1. Core Content Lecture 1 Fundamentals of Pediatric Disaster Medicine Andrew L. Garrett, MD Core Content Lecture 1 Fundamentals of Pediatric Disaster Medicine Andrew L. Garrett, MD Pediatric Disaster Life Support

2. The Need is Clear  We have established that disasters affect children at the same time as the rest of the community  We know that children have needs that are different than adults  What tools do we need to properly prepare to treat them?  We have established that disasters affect children at the same time as the rest of the community  We know that children have needs that are different than adults  What tools do we need to properly prepare to treat them?

3. An Approach to Taking Care of Children in Disaster  Taking care of children is a complex process  Multiple factors must be considered  PDLS uses a bio-psycho-social approach  Taking care of children is a complex process  Multiple factors must be considered  PDLS uses a bio-psycho-social approach

4. The Bio-Psycho-Social Model Care of the Child During Disaster Biological Psychological Social

5. The Bio-Psycho-Social Model  No one component is the most important  Excellent care of children requires that all three components be addressed  No one component is the most important  Excellent care of children requires that all three components be addressed

6. Care of the Child During Disaster Biological

7. Biological Needs  Children have unique anatomy and physiology  This creates specific vulnerabilities during disasters  Children have unique anatomy and physiology  This creates specific vulnerabilities during disasters

8. Anatomic Differences  The youngest children have relatively larger and heavier heads  Relatively larger and less protected abdomens  Penetrating injuries  Primary and secondary impact from objects or blast wave  Predisposition to more serious traumatic damage during disasters compared to adult for the same injury  The youngest children have relatively larger and heavier heads  Relatively larger and less protected abdomens  Penetrating injuries  Primary and secondary impact from objects or blast wave  Predisposition to more serious traumatic damage during disasters compared to adult for the same injury

9. Relative Body Proportions

10. Anatomic Differences  Smaller mass may cause children to be thrown further and faster, resulting in greater secondary injuries upon impact

11. Surface to Body Ratio  Higher surface area and thinner skin  Risk of exposure-related injuries  Burns  Hypothermia after decontamination  Toxic exposure to the skin  Dehydration  Higher surface area and thinner skin  Risk of exposure-related injuries  Burns  Hypothermia after decontamination  Toxic exposure to the skin  Dehydration

12. Higher Baseline Metabolism  Faster Respiratory Rate  Dehydration  Ingestion of toxins, smoke, dust  Lower Blood Volume  Shock from bleeding  Greater risk from dehydration  Greater relative metabolic needs  Higher risk for malnutrition sooner than adults  Faster Respiratory Rate  Dehydration  Ingestion of toxins, smoke, dust  Lower Blood Volume  Shock from bleeding  Greater risk from dehydration  Greater relative metabolic needs  Higher risk for malnutrition sooner than adults

13. Behavior  Live Closer to the Floor  Risk of exposure to debris and water  Greater chance of exposure to chemical or radioactive residue  Example: Infant contracts cutaneous anthrax on arm after visiting ABC television studios targeted during the 2001 attack  Live Closer to the Floor  Risk of exposure to debris and water  Greater chance of exposure to chemical or radioactive residue  Example: Infant contracts cutaneous anthrax on arm after visiting ABC television studios targeted during the 2001 attack

14. Behavior  Hand-to-Mouth Activity  Children routinely place hands and objects in mouth, increasing risk of exposure to chemicals, toxins  Increases risk of contracting vomiting and diarrheal illness during unsanitary conditions such as in a shelter or with exposure to contaminated water supply  Hand-to-Mouth Activity  Children routinely place hands and objects in mouth, increasing risk of exposure to chemicals, toxins  Increases risk of contracting vomiting and diarrheal illness during unsanitary conditions such as in a shelter or with exposure to contaminated water supply

15. Immune Systems  Young children do not have the same capacity as adults to respond to infectious disease  Biological agents  Routine infections during sheltering  Young children do not have the same capacity as adults to respond to infectious disease  Biological agents  Routine infections during sheltering

16. How Children Decompensate  Differently than adults  Children rarely have primary cardiac event  Pathway is predictable  Focus is on respiratory problems and shock  To know it is to prevent decompensation  Recognize early signs and symptoms of respiratory distress and shock  Differently than adults  Children rarely have primary cardiac event  Pathway is predictable  Focus is on respiratory problems and shock  To know it is to prevent decompensation  Recognize early signs and symptoms of respiratory distress and shock

18. Care of the Child During Disaster Psychological

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

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

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

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

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

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

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

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

27. Common Symptoms: Post-traumatic stress  The best studied psychological effect  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  The best studied psychological effect  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

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

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

30. Examples  Wildfires in Australia  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  Wildfires in Australia  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

31. Examples  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  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

32. Examples  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  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

33. Suicide?  Development of PTSD symptoms a link to suicidal behavior  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  Development of PTSD symptoms a link to suicidal behavior  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

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

35. Planning  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  Preparation and pre-positioning resources  Expertise in screening, therapy  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  Preparation and pre-positioning resources  Expertise in screening, therapy

36. Care of the Child During Disaster Social

37. Overview  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  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

38. Influences  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  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

39. Influences  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  Is this true after a disaster too?  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  Is this true after a disaster too?

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

41. Examples  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  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

42. Examples  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  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

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

44. Media and Society  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?  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?

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

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

47. Suggestions  Helping parents in need?

48. School  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 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

49. School  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  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

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

51. Coping Techniques at Home and School  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  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 www.apa.org