Transcript 4-Psychosocial Issues

©
PDLS :
Psychosocial
Issues of Children and
Families in Disasters
Learning Objectives
 Review normal psychosocial issues in children.
 Review reactions of children and adolescents to
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.
 Address specific problems and provide
recommendations for disaster assistance in the
psychosocial sphere.
It is impossible to separate the effects of
disasters on children and their families
and the two should be considered as a
unit.
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.
 The children were evaluated with respect to emotional
disturbances:
None
Mild
Severe
113
32
24
 A startling total of 30% of the children involved in this
catastrophe had mild to severe emotional disturbances
following the incident.
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.
Factors Affecting Responses
 Perceived or actual life threat.
 Duration of life disruption.
 Familial and personal property loss.
 Parental reactions and extent of family disruption.
 Child’s predisaster state.
 Probability of recurrence.
Preexisting Risk Factors
 Previous physical and/or psychosocial pathology
in a child or family member.
 Dysfunctional families secondary to alcohol or
drug abuse.
 Children with developmental or physical
disabilities.
 Newborns who are in the early stages of bonding.
Cultural, Religious and Ethnic
Considerations
 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.
 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.
Early Vs. Late Effects
of Disaster in Children
and Adolescents
The Three Stages
First Stage
Time
 During and immediately after a disaster
Reaction
 Disbelief, denial, anxiety, relief, grief, altruism
Second Stage
Time
 A few days to several weeks after disaster
Reaction
 Clinging, appetite, changes, regressive
symptoms, somatic complaints, sleep
disturbances, apathy, depression, anger, and
hostile delinquent acts
Third Stage
Time
 Months later
Reaction
 Reconstruction
Somatic Symptoms
 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.
 Counseling and mental health intervention may be
necessary for the victims as well as the
Healthcare workers.
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.
 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.
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.
 The return of stability in the routine of the home as well as
the passage of time rectify the problem.
Aggressive/Defiant Behavior
 Toddlers and preschoolers may exhibit hostile
behaviors such as hitting and biting.
 School age children may get involved in peer fights.
 Adolescence may become delinquent or rebellious.
Aggressive/Defiant Behavior
(continued)
Recommendations
 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.
Repetitious Behavior
 Most commonly seen in toddlers and preschoolers
after disaster.
 These children will reenact crucial details of the
disaster.
 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.
Anxiety
 Anxiety occurs in all age groups.
 The Healthcare worker should not dismiss or
minimize the expression of anxiety.
 One should discuss with the child or adolescent
their fears and anxieties.
 Family counseling can be a benefit.
Depression
 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.
 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.
Guilt
 Children and teenagers may feel guilty for surviving or having
their families and homes intact.
 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.
 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.
 Assignment of blame is counter productive to rebuilding lives,
families and communities.
Posttraumatic Stress Disorder
 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.
 This includes anxiety, depression and conduct
disorders.
 Some children display the symptoms only
during the immediate post disaster period.
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.
 Routine avoidance of the reminders of the event
or a general lack of responsiveness.
 Increased sleep disturbances, irritability and poor
concentration.
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.
Specific Responses of Toddlers and
Preschoolers to Disasters
 Reaction reflects that of parents
 Regressive behaviors
 Decreased appetite
 Vomiting, constipation, diarrhea
 Sleep disorders (insomnia, nightmares)
 Tics, stuttering, muteness
Specific Responses of Toddlers and
Preschoolers to Disasters (continued)
 Clinging
 Reenactment via play
 Exaggerated startle response
 Irritability
 Posttraumatic stress disorder
Specific Responses of School Age
Children to Disasters
 Most marked reaction
 Fear, anxiety
 Increased hostility with siblings
 Somatic complaints
 Sleep disorders
 School problems
Specific Responses of School Age
Children to Disasters (continued)
 Social withdrawal
 Reenactment via play
 Apathy
 Posttraumatic stress disorder
 Decreased interest in peers, hobbies, school
Specific Responses of Preadolescents
to Disasters
 Increased hostility with sibs
 Somatic complaints
 Eating disorders
 Sleep disorders
 Decreased interest in peers, hobbies, school
Specific Responses of Preadolescents
to Disasters (continued)
 Rebellion
 Refusal to do chores
 Interpersonal difficulties
 Post-traumatic stress disorder
Specific Responses of Adolescents to
Disasters
 Decreased interest in social activities, peers,
hobbies, school
 Anhedonia (inability to experience pleasure)
 Decline in responsible behaviors
 Rebellion, behavior problems
 Somatic complaints
 Sleep disorders
Specific Responses of Adolescents to
Disasters (continued)
 Eating disorders
 Change in physical activity
 Confusion
 Lack of concentration
 Risk-taking behaviors
Specific Problems and
Recommendations
Differences by gender
 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.
Disruption of Normal Patterns
 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.
 Toddlers respond with increased dependency.
 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.
Disruption of normal patterns
(continued)
Treatment/Recommendations
 Parents, teachers, and Healthcare workers should create
and maintain a predictable schedule for children.
 Night lights, stuffed animals, and reassurance are helpful.
 Compassion is helpful but punishment is not.
 Consultation with psychiatrist or psychiatric social worker
may be a benefit.
Re-enactment
 Play
 Home
 Drawings
 Nightmares
Guided play/imagery to take control of
scenario and make a happy ending.
Care of the
Child During
Disaster
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
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
What to Expect?
 Everyone is affected by a disaster in some way
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
www.apa.org
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
www.apa.org
Specific Symptoms: Aggression
 Seen across all age groups
 Verbal and/or physical outbursts towards siblings,
adults
Specific Symptoms:
Regressive Behavior
 Seen across all age groups
 Crying, clinginess, helplessness
 Regression of toileting habits
≈Bedwetting
≈Diaper dependence
Specific Symptoms:
Post-traumatic stress
 Post-traumatic stress symptoms include:
≈Nightmares
≈Flashbacks
≈Emotional detachment or numbness
≈Insomnia
≈Hypervigilance
≈Irritability
≈Memory Loss
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
Examples
 Buffalo Creek Dam Collapse (1972)
 179 children screened 2 years after
 37% given “probable diagnosis” PTSD
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 toilettrained children
Examples
 Wildfires in Australia
 808 children screened
≈2, 4, 26 months after surviving
≈Prevalence of post-disaster PTSD did not change
≈Predicting factors
Prevalence is % present in population tested
Mother’s response to disaster more predictive compared to
patient’s direct exposure
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 postdisaster
Again, mother’s response predictive of resilience in child
Examples
 9/11 terrorist attacks
≈National sample 3-5 days after attacks
≈35% parents reported one child or more with anxietyrelated symptoms
≈Half of children worried about their safety
Factors:
– Parental response
– Amount of media viewed on the attacks
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
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
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
Care of the
Child During
Disaster
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
Influences
 It is established that outside factors greatly affect a
child’s post-disaster psychiatric recovery, especially:
≈How parents (especially mother) reacts in the postdisaster environment
≈Media
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?
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
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
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
Expectations
 Disasters are stressful events to all members of the
community
≈Anticipate problems such as:
Increased child abuse
Increased substance abuse
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?
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?
Suggestions
 Acknowledge that children do not benefit from the
repeated viewing of frightening images
Photo: National Geographic Channel
Suggestions
 Helping parents in need?
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
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
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
www.apa.org
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
www.apa.org