1. Pediatric Disaster Life Support (PDLS © ) Continuing Medical Education University of Massachusetts Medical School A Course in Caring for Children During Disaster

2. PDLS © : Psychosocial Issues: Children in Disasters

3. Disasters have Significant Psychological Impact on Children

5. PDLS - Psychosocial Issues A “Bio-Psycho-Social” approach to victim management is best A “Bio-Psycho-Social” approach to victim management is best Recognizes that effective preparedness and response requires integration of three realms Recognizes that effective preparedness and response requires integration of three realms Biological Social Psychological

6. PDLS - Psychosocial Issues - Anatomy and Physiology unique to children - Focus on vulnerabilities of children, not on resuscitation - Discuss relationship to: Environmental exposure (heat, cold, entrapment) Decontamination Susceptibility to Chemicals, Toxins Behaviors that increase risk Immature immune systems Lack of verbal skills Lack of self-preservation skills Biological

7. PSYCHOLOGICAL - A child's emotional Response to Disaster - How to anticipate and recognize problems - How long do these disorders last? - Integrating these concepts into disaster preparedness and response plans

8. SOCIAL - Kids are irreversibly integrated into our society If children are not accounted for, parents will not comply with officialsIf children are not accounted for, parents will not comply with officials - Adapting to the concept that children may be intentional targets of terrorism - Role of parents in disaster - Role of media in disaster, a double edged sword - Role of schools, where children spend the bulk of their time away from home - Children routinely cause increased stress in emergency providers

9. Interplay of Medical and Mental Health Triage Separate mental health triage and treatment area may be established Separate mental health triage and treatment area may be established - Once medically cleared - Separate child from adult mental health area Photo Credit: FEMA

10. Interplay of Medical and Mental Health Triage Primary triage: Physical health must take first priority Primary triage: Physical health must take first priority - Walking, crying patients that have good airways are triage category ambulatory Secondary triage: Identify patients with signs of acute distress Secondary triage: Identify patients with signs of acute distress - Panic/fear - Confusion - Disorientation - Anger - Withdrawn or apathetic Photo Credit: FEMA

11. Infants and severely cognitively disabled don’t understand disaster Provide:  Feeding  Comfort  Familiar caretakers Photo Credit: FEMA

12. Toddlers, preschoolers and moderately cognitively disabled Concerned about consequences of disaster Concerned about consequences of disaster Reactions often are behavioral disturbances, mood changes and anxiety Reactions often are behavioral disturbances, mood changes and anxiety Can comprehend absence of parents but not the permanence of death Can comprehend absence of parents but not the permanence of death Photo Credit: FEMA

13. Specific Responses of Toddlers 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

14. Specific Responses of Preschoolers to Disasters Clinging Clinging Reenactment via play Reenactment via play Exaggerated startle response Exaggerated startle response Irritability Irritability Posttraumatic stress disorder Posttraumatic stress disorder

15. Specific Responses of School Age Children to Disasters (5-12) 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

16. 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

17. Adolescents (13–19) Have full understanding of disaster’s causes and consequences Tend to retain sense of omnipotence, boys > girls May suffer depression and anxiety May be aggressive to self or others, risk of suicide May become sullen and withdrawn Photo Credit: FEMA

18. 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

19. Adolescents Response 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

21. Stress response in children “Fight or flight” “Fight or flight” Adrenaline/epinephrine mediated Adrenaline/epinephrine mediated Arousal state Arousal state Increased startle, response, agitation Increased startle, response, agitation Increased heart rate, respiratory rate, blood pressure Increased heart rate, respiratory rate, blood pressure

22. Alternate stress response “Freeze and hide” “Freeze and hide” Vagal nerve stimulus Vagal nerve stimulus Opposite of “fight or flight” Opposite of “fight or flight” Blunted reactions, affect, responses Blunted reactions, affect, responses Lowered heart rate, respiratory rate, blood pressure Lowered heart rate, respiratory rate, blood pressure Syncope may result Syncope may result

23. Short term reactions Disbelief Disbelief Denial Denial Anxiety Anxiety Grief Grief Altruism Altruism Relief Relief

24. Short-term reactions Grief, loss, anger, guilt Grief, loss, anger, guilt Coping strategies Coping strategies - Regression – loss of developmental milestones - Clinging and increased dependency - Helpfulness – more useful in older children - Acting out – competing for attention

26. Second Stage: Immediate Post- Event Period 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

27. 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.

28. 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.

29. 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.

30. 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.

31. Delayed Post-event Period (months) Depression Depression - More likely to manifest sleep, somatic and behavioral symptoms than adults - Family and personal history of depression increase risk - Exacerbated by re-exposure to venue of or media

32. Delayed Post-event Period Post-Traumatic Stress Disorder (PTSD) Post-Traumatic Stress Disorder (PTSD) - An anxiety disorder with psychological and physical symptoms including: Intrusive thoughts, memories and nightmares Exacerbation by anniversaries and reminders of the event Aggression, anger and fear Apathy, numbness

33. Delayed Post-event Period Children have special susceptibility to certain risk factors Children have special susceptibility to certain risk factors - Witnessing terror in parents and loved ones - Repeated exposure to media of the disaster Little data about preventing and treating PTSD in children Little data about preventing and treating PTSD in children Photo Credit: FEMA

34. People with Special Healthcare Needs (PSHCN) Cognitive and/or Emotional Disabilities Reaction to disaster similar to typical children with important differences Reaction to disaster similar to typical children with important differences May be and feel particularly vulnerable due to technology dependence and impaired mobility May be and feel particularly vulnerable due to technology dependence and impaired mobility - Cognitively impaired children may respond similarly to chronologically younger children - Emotionally disabled children are at increased risk for acute and chronic negative disaster responses Photo Credit: FEMA

35. Caring for Disaster Mental Health Adapted mental health first aid: Strategy for identifying children in need of help Introduce yourself in a developmentally appropriate way Introduce yourself in a developmentally appropriate way Explain that you are trying to help Explain that you are trying to help Remain non-threatening but be honest and direct Remain non-threatening but be honest and direct - Preserve credibility - Avoid unrealistic promises or false statements Photo Credit: FEMA

36. Caring for Disaster Mental Health Listen for anxiety, fear about location of care-takers and immediate needs Listen for anxiety, fear about location of care-takers and immediate needs - Acknowledge the child’s emotions - Give reassurance and information If available, guide child to mental health triage/treatment facility If available, guide child to mental health triage/treatment facility Encourage self-help strategies Encourage self-help strategies - Guided imagery - Exercise - Preservation of routine

37. Caring For Disaster Mental Health Play Play Home Home Drawings Drawings Nightmares Nightmares Guided play/imagery to take control of scenario and make a happy ending.

38. Caring For Disaster Mental Health 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.

39. Responding to children’s needs Parents should know age appropriate responses Parents should know age appropriate responses Monitor and limit media exposure to disaster coverage Monitor and limit media exposure to disaster coverage Early counseling may reduce long term negative effects Early counseling may reduce long term negative effects

40. Responding to children’s needs Rehearsal of plan reduces anxiety and gives a sense of control Rehearsal of plan reduces anxiety and gives a sense of control - Rehearsal of plan with a live drill that has children acting out roles Step #1 exercise – school bus accident Step #2 exercise – school evacuation

41. Normal Recovery Talking with others Talking with others Coping mechanisms Coping mechanisms - Learning healthy mechanisms Counseling Counseling