1. PDLS © : Psychosocial Issues of Children and Families in Disasters

2. Learning Objectives Review normal psychosocial issues in children. Review normal psychosocial issues in children. Review reactions of children and adolescents to disasters. Review reactions of children and adolescents to disasters. Focus on how the healthcare provider may prepare, assess, and treat children and families in disasters. Focus on how the healthcare provider may prepare, assess, and treat children and families in disasters. Prepare the healthcare provider to assess and address community needs. Prepare the healthcare provider to assess and address community needs. Address specific problems and provide recommendations for disaster assistance in the psychosocial sphere. Address specific problems and provide recommendations for disaster assistance in the psychosocial sphere.

3. It is impossible to separate the effects of disasters on children and their families and the two should be considered as a unit.

4. Case Report A theater filled with children in 1953 was hit by a tornado. A total of 169 children ranging in ages 2 to 15 were involved. A theater filled with children in 1953 was hit by a tornado. A total of 169 children ranging in ages 2 to 15 were involved. The children were evaluated with respect to emotional disturbances: The children were evaluated with respect to emotional disturbances: None113 Mild32 Severe24 A startling total of 30% of the children involved in this catastrophe had mild to severe emotional disturbances following the incident. A startling total of 30% of the children involved in this catastrophe had mild to severe emotional disturbances following the incident.

9. The following events are of the greatest significance with respect to children and their families in a disaster. 1.Death or physical injury to a family member. 2.A loss of home or possessions. 3.Relocation (school changes). 4.Job loss. 5.Parental disorganization or dysfunction.

10. Factors Affecting Responses Perceived or actual life threat. Perceived or actual life threat. Duration of life disruption. Duration of life disruption. Familial and personal property loss. Familial and personal property loss. Parental reactions and extent of family disruption. Parental reactions and extent of family disruption. Child’s predisaster state. Child’s predisaster state. Probability of recurrence. Probability of recurrence.

11. Preexisting Risk Factors Previous physical and/or psychosocial pathology in a child or family member. Previous physical and/or psychosocial pathology in a child or family member. Dysfunctional families secondary to alcohol or drug abuse. Dysfunctional families secondary to alcohol or drug abuse. Children with developmental or physical disabilities. Children with developmental or physical disabilities. Newborns who are in the early stages of bonding. Newborns who are in the early stages of bonding.

12. Cultural, Religious and Ethnic Considerations Outreach by leaders of different cultural groups is essential in all phases. Outreach by leaders of different cultural groups is essential in all phases. Information regarding available services should be provided in all languages appropriate to the community. Information regarding available services should be provided in all languages appropriate to the community. Distribution of such information should be through church and community groups. Distribution of such information should be through church and community groups. Religion (churches, synagogues and clergy) becomes extremely active in the recovery of the community during and after a disaster. Religion (churches, synagogues and clergy) becomes extremely active in the recovery of the community during and after a disaster.

13. Early Vs. Late Effects of Disaster in Children and Adolescents The Three Stages

14. First Stage Time During and immediately after a disaster During and immediately after a disasterReaction Disbelief, denial, anxiety, relief, grief, altruism Disbelief, denial, anxiety, relief, grief, altruism

16. Second Stage Time A few days to several weeks after disaster A few days to several weeks after disasterReaction Clinging, appetite, changes, regressive symptoms, somatic complaints, sleep disturbances, apathy, depression, anger, and hostile delinquent acts Clinging, appetite, changes, regressive symptoms, somatic complaints, sleep disturbances, apathy, depression, anger, and hostile delinquent acts

17. Third Stage Time Months later Months laterReaction Reconstruction Reconstruction

19. Somatic Symptoms These include headaches, abdominal pain, and chest pain and are commonly observed in children and adolescents. These include headaches, abdominal pain, and chest pain and are commonly observed in children and adolescents. Reassurance by the healthcare worker can be of help after evaluation. Reassurance by the healthcare worker can be of help after evaluation. Counseling and mental health intervention may be necessary for the victims as well as the Healthcare workers. Counseling and mental health intervention may be necessary for the victims as well as the Healthcare workers.

20. Regressive Behavior Separation anxiety symptoms which include enuresis, encopresis, thumb-sucking, loss of acquired speech, whining, and fear of darkness are commonly seen in children or toddlers. These are short-lived behaviors following a disaster. Separation anxiety symptoms which include enuresis, encopresis, thumb-sucking, loss of acquired speech, whining, and fear of darkness are commonly seen in children or toddlers. These are short-lived behaviors following a disaster. The Healthcare worker should be reassured of this so that punishment and shame are avoided. The Healthcare worker should be reassured of this so that punishment and shame are avoided. In older children and adolescents, regression takes the form of competing for parental attention and a decline in previously responsible behaviors. Extreme dependency and transient confusion can occur. In older children and adolescents, regression takes the form of competing for parental attention and a decline in previously responsible behaviors. Extreme dependency and transient confusion can occur.

21. Regressive Behavior (continued) Parents should be reassured that this behavior is common and short-lived. If the above symptoms persist more than a few weeks family and child counseling is advised. Parents should be reassured that this behavior is common and short-lived. If the above symptoms persist more than a few weeks family and child counseling is advised. The return of stability in the routine of the home as well as the passage of time rectify the problem. The return of stability in the routine of the home as well as the passage of time rectify the problem.

22. Aggressive/Defiant Behavior Toddlers and preschoolers may exhibit hostile behaviors such as hitting and biting. Toddlers and preschoolers may exhibit hostile behaviors such as hitting and biting. School age children may get involved in peer fights. School age children may get involved in peer fights. Adolescence may become delinquent or rebellious. Adolescence may become delinquent or rebellious.

23. Aggressive/Defiant Behavior (continued) Recommendations Recommendations For the younger child, limit setting may be of help. For the younger child, limit setting may be of help. With adolescents, involving them in the rebuilding of the community or helping with younger children or elderly may aid recovery. With adolescents, involving them in the rebuilding of the community or helping with younger children or elderly may aid recovery.

24. Repetitious Behavior Most commonly seen in toddlers and preschoolers after disaster. Most commonly seen in toddlers and preschoolers after disaster. These children will reenact crucial details of the disaster. These children will reenact crucial details of the disaster. Other repetitive behaviors are recurrent nightmares and frequent flashbacks. Other repetitive behaviors are recurrent nightmares and frequent flashbacks. The Healthcare worker should allow the child or preschooler to reenact the events as these are therapeutic and can help in recovery. The Healthcare worker should allow the child or preschooler to reenact the events as these are therapeutic and can help in recovery.

25. Anxiety Anxiety occurs in all age groups. Anxiety occurs in all age groups. The Healthcare worker should not dismiss or minimize the expression of anxiety. The Healthcare worker should not dismiss or minimize the expression of anxiety. One should discuss with the child or adolescent their fears and anxieties. One should discuss with the child or adolescent their fears and anxieties. Family counseling can be a benefit. Family counseling can be a benefit.

26. Depression A sense of sadness which is not the same as depression is common after disaster. A sense of sadness which is not the same as depression is common after disaster. Sadness is to be expected. If depression is present and persistent psychiatric intervention is warranted. Sadness is to be expected. If depression is present and persistent psychiatric intervention is warranted. This may be manifested by adolescents with suicidal thoughts and teenagers expressing helplessness, hopelessness and suicidal ideation. This may be manifested by adolescents with suicidal thoughts and teenagers expressing helplessness, hopelessness and suicidal ideation. The Healthcare worker should alert parents to signs of depression such as decreased appetite, sleep disturbance, constant sadness and irritability. The Healthcare worker should alert parents to signs of depression such as decreased appetite, sleep disturbance, constant sadness and irritability.

27. Guilt Children and teenagers may feel guilty for surviving or having their families and homes intact. Children and teenagers may feel guilty for surviving or having their families and homes intact. They feel helpless. They feel helpless. Young children may experience “magical thinking” in that they feel they are responsible for the disaster because of something “bad” they did. Young children may experience “magical thinking” in that they feel they are responsible for the disaster because of something “bad” they did. If Litigation is involved, the trauma may persist resulting in disillusionment. If Litigation is involved, the trauma may persist resulting in disillusionment. The Healthcare worker can be of assistance by reassuring the children and adolescents that they were not at fault. The Healthcare worker can be of assistance by reassuring the children and adolescents that they were not at fault. Assignment of blame is counter productive to rebuilding lives, families and communities. Assignment of blame is counter productive to rebuilding lives, families and communities.

28. Posttraumatic Stress Disorder Posttraumatic stress disorder (PTSD) has been a term used in children and adults following traumatic events and disasters. Posttraumatic stress disorder (PTSD) has been a term used in children and adults following traumatic events and disasters. Few children develop the full disorder and they may have a delayed onset. Few children develop the full disorder and they may have a delayed onset. This includes anxiety, depression and conduct disorders. This includes anxiety, depression and conduct disorders. Some children display the symptoms only during the immediate post disaster period. Some children display the symptoms only during the immediate post disaster period.

29. The diagnosis of PTSD has the following criteria in three major categories persisting for more than one month. Reexperiencing of the event through play or trauma specific nightmares. Reexperiencing of the event through play or trauma specific nightmares. Routine avoidance of the reminders of the event or a general lack of responsiveness. Routine avoidance of the reminders of the event or a general lack of responsiveness. Increased sleep disturbances, irritability and poor concentration. Increased sleep disturbances, irritability and poor concentration.

30. The Five Primary Responses of Children and Adolescents to Disasters 1.Increased dependency on parents or guardians. 2.Nightmares 3.Regression in developmental achievements. 4.Specific fears about reminders of the disaster (e.g., a toy airplane if the child was in an airplane crash). 5.Demonstration of the disaster via post-traumatic play and reenactments.

32. Specific Responses of Toddlers and Preschoolers to Disasters Reaction reflects that of parents Reaction reflects that of parents Regressive behaviors Regressive behaviors Decreased appetite Decreased appetite Vomiting, constipation, diarrhea Vomiting, constipation, diarrhea Sleep disorders (insomnia, nightmares) Sleep disorders (insomnia, nightmares) Tics, stuttering, muteness Tics, stuttering, muteness

34. Specific Responses of Toddlers and Preschoolers to Disasters (continued) Clinging Clinging Reenactment via play Reenactment via play Exaggerated startle response Exaggerated startle response Irritability Irritability Posttraumatic stress disorder Posttraumatic stress disorder

35. Specific Responses of School Age Children to Disasters Most marked reaction Most marked reaction Fear, anxiety Fear, anxiety Increased hostility with siblings Increased hostility with siblings Somatic complaints Somatic complaints Sleep disorders Sleep disorders School problems School problems

36. Specific Responses of School Age Children to Disasters (continued) Social withdrawal Social withdrawal Reenactment via play Reenactment via play Apathy Apathy Posttraumatic stress disorder Posttraumatic stress disorder Decreased interest in peers, hobbies, school Decreased interest in peers, hobbies, school

38. Specific Responses of Preadolescents to Disasters Increased hostility with sibs Increased hostility with sibs Somatic complaints Somatic complaints Eating disorders Eating disorders Sleep disorders Sleep disorders Decreased interest in peers, hobbies, school Decreased interest in peers, hobbies, school

39. Specific Responses of Preadolescents to Disasters (continued) Rebellion Rebellion Refusal to do chores Refusal to do chores Interpersonal difficulties Interpersonal difficulties Post-traumatic stress disorder Post-traumatic stress disorder

40. Specific Responses of Adolescents to Disasters Decreased interest in social activities, peers, hobbies, school Decreased interest in social activities, peers, hobbies, school Anhedonia (inability to experience pleasure) Anhedonia (inability to experience pleasure) Decline in responsible behaviors Decline in responsible behaviors Rebellion, behavior problems Rebellion, behavior problems Somatic complaints Somatic complaints Sleep disorders Sleep disorders

41. Specific Responses of Adolescents to Disasters (continued) Eating disorders Eating disorders Change in physical activity Change in physical activity Confusion Confusion Lack of concentration Lack of concentration Risk-taking behaviors Risk-taking behaviors

42. Specific Problems and Recommendations

43. Differences by gender Responses vary by gender. Boys take longer to recover and exhibit aggressive, antisocial and violent behaviors. Responses vary by gender. Boys take longer to recover and exhibit aggressive, antisocial and violent behaviors. Girls are more distressed, have more verbal emotions, ask more questions and have more frequent thoughts concerning the disaster. Girls are more distressed, have more verbal emotions, ask more questions and have more frequent thoughts concerning the disaster.

44. Disruption of Normal Patterns The cardinal effect of disaster and children in adolescents is a disruption of their lives. The cardinal effect of disaster and children in adolescents is a disruption of their lives. Disruption leads to a loss of reliability, cohesion, and predictability. Disruption leads to a loss of reliability, cohesion, and predictability. Toddlers respond with increased dependency. Toddlers respond with increased dependency. School-age children show evidence of trauma with talk and play about trauma and hostility to peers and family. School-age children show evidence of trauma with talk and play about trauma and hostility to peers and family. Adolescents may also withdraw and have decreased interest and experience fatigue, hypertension, hostility and loss of objectivity. Adolescents may also withdraw and have decreased interest and experience fatigue, hypertension, hostility and loss of objectivity.

45. Disruption of normal patterns (continued) Treatment/Recommendations Parents, teachers, and Healthcare workers should create and maintain a predictable schedule for children. Parents, teachers, and Healthcare workers should create and maintain a predictable schedule for children. Night lights, stuffed animals, and reassurance are helpful. Night lights, stuffed animals, and reassurance are helpful. Compassion is helpful but punishment is not. Compassion is helpful but punishment is not. Consultation with psychiatrist or psychiatric social worker may be a benefit. Consultation with psychiatrist or psychiatric social worker may be a benefit.

46. Re-enactment Play Play Home Home Drawings Drawings Nightmares Nightmares Guided play/imagery to take control of scenario and make a happy ending.

58. Care of the Child During Disaster Psychological

59. Psychological Issues PDLS will review general concepts, not age-specific details PDLS will review general concepts, not age-specific details The psychological impact of disasters on children as victims The psychological impact of disasters on children as victims Focus on what to expect and how to help Focus on what to expect and how to help

60. General Principles Children are at a high risk of experiencing psychological consequences before, during, and after a disaster Children are at a high risk of experiencing psychological consequences before, during, and after a disaster Many factors that affect this Many factors that affect this ≈ There is some controversy about these

61. What to Expect? Everyone is affected by a disaster in some way Everyone is affected by a disaster in some way

62. Expected Changes Anxiety, Fears, and Worries about safety of self and others Anxiety, Fears, and Worries about safety of self and others Worries about re-occurrence or consequences such as war Worries about re-occurrence or consequences such as war Hyperactivity, decreased concentration, withdrawal, outbursts, absenteeism Hyperactivity, decreased concentration, withdrawal, outbursts, absenteeism Increased body complaints Increased body complaints ≈ Headache, Stomach-ache, Pains www.apa.org

63. Expected Changes Changes in school performance Changes in school performance Recreating Event through talk, play Recreating Event through talk, play Increased sensitivity to sounds Increased sensitivity to sounds ≈ Sirens, thunder, aircraft Questions about death and injury Questions about death and injury Changes in sleep Changes in sleep Denial of impact Denial of impact Hateful or angry statements Hateful or angry statements www.apa.org

64. Specific Symptoms: Aggression Seen across all age groups Seen across all age groups Verbal and/or physical outbursts towards siblings, adults Verbal and/or physical outbursts towards siblings, adults

65. Specific Symptoms: Regressive Behavior Seen across all age groups Seen across all age groups Crying, clinginess, helplessness Crying, clinginess, helplessness Regression of toileting habits Regression of toileting habits ≈ Bedwetting ≈ Diaper dependence

66. Specific Symptoms: Post-traumatic stress Post-traumatic stress symptoms include: Post-traumatic stress symptoms include: ≈ Nightmares ≈ Flashbacks ≈ Emotional detachment or numbness ≈ Insomnia ≈ Hypervigilance ≈ Irritability ≈ Memory Loss

67. Common Symptoms: Post-traumatic stress The best studied psychological effect The best studied psychological effect Factors affecting development of PTSD: Factors affecting development of PTSD: ≈ Age (older > younger) ≈ Gender (females > males) ≈ Race (black > white) ≈ Parental coping skills and capabilities ≈ Child’s perception of risk (media role?) ≈ Duration of and distance to the danger

68. Examples Buffalo Creek Dam Collapse (1972) Buffalo Creek Dam Collapse (1972) 179 children screened 2 years after 179 children screened 2 years after 37% given “probable diagnosis” PTSD 37% given “probable diagnosis” PTSD

69. Examples Flooding in Bangladesh (1993) Flooding in Bangladesh (1993) 162 children screened 2 years later 162 children screened 2 years later Aggressive behavior went from 0% to 10% Aggressive behavior went from 0% to 10% 34% new onset of enuresis in previously toilet- trained children 34% new onset of enuresis in previously toilet- trained children

70. Examples Wildfires in Australia Wildfires in Australia 808 children screened 808 children screened ≈ 2, 4, 26 months after surviving ≈ Prevalence of post-disaster PTSD did not change Prevalence is % present in population tested ≈ Predicting factors Mother’s response to disaster more predictive compared to patient’s direct exposure

71. Examples Reactions studied in preschoolers exposed to a severe hurricane Reactions studied in preschoolers exposed to a severe hurricane ≈ After 14 months, when compared to unexposed children Higher levels of anxiety and withdrawal Other behavioral issues resolved slowly over 6 months post- disaster Again, mother’s response predictive of resilience in child

72. Examples 9/11 terrorist attacks 9/11 terrorist attacks ≈ National sample 3-5 days after attacks ≈ 35% parents reported one child or more with anxiety- related symptoms ≈ Half of children worried about their safety Factors: –Parental response –Amount of media viewed on the attacks

73. Suicide? Development of PTSD symptoms a link to suicidal behavior Development of PTSD symptoms a link to suicidal behavior In cross-population study of multiple federally declared disasters: In cross-population study of multiple federally declared disasters: ≈ 25% increase in suicide in age group 10-29 years old ≈ Hurricanes, floods, and earthquakes highest risk ≈ Data suggest young men at highest risk

74. How to Help Understand the high rates at which these psychiatric disorders appear in children after disaster Understand the high rates at which these psychiatric disorders appear in children after disaster Understand the time frame Understand the time frame ≈ Many behavioral problems will resolve over weeks to months ≈ Anxiety/PTSD symptoms may persist over years

75. Planning Incorporate Psychologic First Aid information and providers in your planning at all levels Incorporate Psychologic First Aid information and providers in your planning at all levels Utilize the expertise and advice of mental health professionals before, during, and after Utilize the expertise and advice of mental health professionals before, during, and after ≈ Preparation and pre-positioning resources ≈ Expertise in screening, therapy

76. Care of the Child During Disaster Social

77. Overview Children need to be viewed as an integral part of the population, not a “special circumstance” to be dealt with separately Children need to be viewed as an integral part of the population, not a “special circumstance” to be dealt with separately ≈ What happens to adults happens to children Planning, Response, and Recovery must acknowledge this principle to be effective Planning, Response, and Recovery must acknowledge this principle to be effective

78. Influences It is established that outside factors greatly affect a child’s post-disaster psychiatric recovery, especially: It is established that outside factors greatly affect a child’s post-disaster psychiatric recovery, especially: ≈ How parents (especially mother) reacts in the post- disaster environment ≈ Media

79. Influences Exploring the parent-child relationship a little bit more: Exploring the parent-child relationship a little bit more: ≈ Child Abuse ≈ Substance Abuse In general, parental stress and a lack of social services are linked to an increase in child abuse reports In general, parental stress and a lack of social services are linked to an increase in child abuse reports ≈ Is this true after a disaster too?

80. Examples Loma Prieta Earthquke (1989) Loma Prieta Earthquke (1989) Hurricane Hugo (1989) Hurricane Hugo (1989) Hurricane Andrew (1992) Hurricane Andrew (1992) Data suggest that child abuse rates increased in the 3 and 6 month period after these disasters Data suggest that child abuse rates increased in the 3 and 6 month period after these disasters

81. Examples Hurricane Floyd (1999) in North Carolina Hurricane Floyd (1999) in North Carolina ≈ Inflicted traumatic brain injury increased in the 6 months following the hurricane in the most affected counties ≈ After 6 months rates of inflicted injury returned to baseline ≈ Accidental injury rates remained the same

82. Examples A 2001 café fire in the Netherlands wounded 250 adolescents, and killed 14 A 2001 café fire in the Netherlands wounded 250 adolescents, and killed 14 Compared to a control group: ≈ Increased rates of anxiety, depression, and alcohol use ≈ Marijuana, Ecstasy, and sedative use did not increase

83. Expectations Disasters are stressful events to all members of the community Disasters are stressful events to all members of the community ≈ Anticipate problems such as: Increased child abuse Increased substance abuse

84. Media and Society What has been the role of media in recent disasters? What has been the role of media in recent disasters? ≈ Hurricane Katrina ≈ Indian Ocean Tsunami ≈ 9/11 Terrorist Attacks How did children respond to this information, based on what we have already discussed? How did children respond to this information, based on what we have already discussed?

85. Media and Society Many children feared for their own safety, and that of their parents Many children feared for their own safety, and that of their parents Media viewing of disturbing images may exacerbate anxiety, aggression, regression, PTSD Media viewing of disturbing images may exacerbate anxiety, aggression, regression, PTSD What is the responsibility of the media? What is the responsibility of the media? What is the responsibility of parents? What is the responsibility of parents?

86. Suggestions Acknowledge that children do not benefit from the repeated viewing of frightening images Acknowledge that children do not benefit from the repeated viewing of frightening images Photo: National Geographic Channel

87. Suggestions Helping parents in need? Helping parents in need?

88. School The re-establishment of routine may prevent the worsening of symptoms in children and speed the recovery The re-establishment of routine may prevent the worsening of symptoms in children and speed the recovery The ability to recover after a disaster and return to normal is termed resiliency The ability to recover after a disaster and return to normal is termed resiliency

89. School School provides much of what is taken away during a disaster and may be an important part of resiliency School provides much of what is taken away during a disaster and may be an important part of resiliency ≈ Order ≈ Rules ≈ Consistency ≈ Friends ≈ Role Models and Teachers

90. Coping Techniques at Home and School Reinforce the idea of safety and security through self-realization Reinforce the idea of safety and security through self-realization Maintain a routine schedule Maintain a routine schedule Listen to children’s discussions of the events Listen to children’s discussions of the events Discuss how media may be affecting their feelings Discuss how media may be affecting their feelings www.apa.org

91. Coping Techniques at Home and School Validate feelings of anger but discuss how developing hatred towards groups of people does not help Validate feelings of anger but discuss how developing hatred towards groups of people does not help Encourage children to talk about how they have been affected, and explain how these reactions are normal Encourage children to talk about how they have been affected, and explain how these reactions are normal www.apa.org