Transcript TRAUMA AND A WORLD IN CONFLICT

CHILD AND FAMILY
DISASTER RESEARCH
TRAINING AND EDUCATION
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Federal Sponsors
 NIMH National Institute of Mental
Health
 NINR National Institute of Nursing
Research
 SAMHSA Substance Abuse and
Mental Health Services Administration
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Principal Investigators
 Betty Pfefferbaum, MD, JD
University of Oklahoma Health Sciences
Center
 Alan M. Steinberg, PhD
University of California, Los Angeles
 Robert S. Pynoos, MD, MPH
University of California, Los Angeles
 John Fairbank, PhD
Duke University
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Session 5
Overview Of Disaster Mental
Health In Children
Learning Goal and
Objectives
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Learning Goal
The goal of Session 5 is to:
Understand disaster and terrorism
related child mental health
consequences as a foundation for
disaster mental health research
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Learning Objectives
Upon completion of Session 5, participants will be
able to:
•
Recognize children’s psychological reactions to disaster
and factors that influence reactions
• Identify the factors that promote resilience in children in the
context of disasters
• Appreciate the evidence base for children’s disaster mental
health services and interventions
• Understand the principles of intervention with children and
families following a disaster
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Overview
 Children’s Disaster Mental Health
 Disaster Mental Health Services and
Interventions for Children and Families
 Resilience Among Children Facing
Disaster
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Children’s Disaster
Mental Health
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Topics
 Outcomes
 Factors that influence outcomes
 Interventions
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Buffalo Creek Dam Collapse, 1972
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Outcomes
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Trauma Response
Disaster
Acute Distress
Resilience/
Recovery
Chronic Distress
Risky Behavior
Functional
Impairment
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Trauma Response Trajectories
• Resilience
– No significant distress
• Recovery
– Significant distress, resolves over
time with or without intervention
• Failure to recover
– Significant distress, no recovery,
developmental disruption and
impairment
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Emotional and Behavioral Outcomes
CHILD
CHARACTERISTICS
Demographics
Pre existing disorder
Prior trauma
OUTCOMES
DISASTER EXPOSURE
Objective characteristics
Subjective reaction
PTSD
Anxiety
Depression
Substance Use
Functioning
FAMILY AND
SOCIAL FACTORS
Parent reactions
Social support
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PTSD Outcome: Diagnostic Criteria
 Exposure and reaction
 Reexperiencing (1 or more)
 Avoidance and numbing (3 or
more)
 Arousal (2 or more)
 Duration > one month
 Distress or functional impairment
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Children Can Differ From Adults
 Reaction: disorganized or agitated behavior
 Regression in development: behavior similar to
those exhibited at an earlier age
 Re-experiencing:
- Recollections: repetitive play with themes
- Dreams: generalized dreams without
trauma content
- Acting, feeling, or flashbacks: trauma
reenactment
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Disaster PTSD Rates
70
60
Tsunami
Supercyclone
Earthquake
Wildfire
WTC
WTC
WTC
Ship sinking
Flood
50
40
30
20
10
0
1st Qtr
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Onset of Disorders
• PTSD onset within 6 months for 90%
• Most specific phobia and separation
anxiety onset close in time to the
disaster
• Panic disorder and major depression
later onset
Bolton et al. 2000; Yule et al. 2000
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Survivors With and Without PTSD
Rates of other disorders were higher in survivors with PTSD than in controls
Rates in survivors without PTSD were not higher than in controls
100
82
with PTSD
80
64
62
without PTSD
60
40
20
30
19
12
0
Anxiety
Mood
Any
Bolton et al. 2000
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Psychiatric Effects
>200 young adult survivors: 74% female, 97% Caucasian
Studied 5-8 years after a shipping disaster
60
50
40
30
20
10
0
57
52
41
38
18
35
17
3
survivors
controls
D
S
T
P
y
An
et
i
x
n
A
y
Mean age at disaster = 14.7 yrs.
Mean age at follow up = 21.3 yrs.
y
An
tiv
c
fe
f
A
e
y
An
y
Ps
a
p
o
ch
t
og
l
ho
y
Bolton et al. 2000; Yule et al. 2000
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Elementary School Study
 Sample: 154 school children
– 71 boys, 73 girls
– Mean age 8.2 years (range 6 – 11 years)
 Methodology
– Assessed behavior and emotions besides
posttraumatic stress in hi and lo impact schools
– Longitudinal study (2, 8, and 21 months)
– Multiple sources of information
–Children
–Teachers
–School database
Shaw et al. 1995
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Posttraumatic Stress in Hi-Impact School
Severe posttraumatic stress decreased
70% with moderate to severe posttraumatic stress at 21 months
60
55
51
50
38
40
38
33
30
29
30
no to mild
moderate
20
severe
15
11
10
N = 30
0
2 months
8 months
21 months
Shaw et al. 1996
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Change in Posttraumatic Stress
2 to 21 Months
41
45
40
37
37
35
Significant decrease in
self-reported
posttraumatic stress
was explained by
differences in boys
30
25
25
20
15
2 months
21 months
10
5
0
Boys
Shaw et al. 1996
Girls
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PTSD Over Time: Hurricane Andrew
45
40
35
30
25
PTSD
20
15
10
5
0
3-month
7-month
10-month
Vernberg EM, Silverman WK, La Greca AM, Prinstein MJ. Prediction of posttraumatic stress symptoms in
children after hurricane Andrew. J Abnorm Psychol. 1996;105(2):237-248.
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Parent Reported Behavior Problems
45
40
35
30
25
6-11 years
12-17 years
20
15
10
5
0
Pre 9-11
4 Months
Post
6 Months
Post
Stuber, et al, 2005
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Childhood Traumatic Grief
 Results from violent/sudden loss of a loved
one
 May occur with death from natural causes if
the child’s experience of the death is
sudden, unexpected, or witnessed
 Characterized by the intrusion of trauma
symptoms in bereavement
Cohen et al. 2002
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Traumatic Grief v. Normal Grief
• Intrusive
memories of
manner of death
• Distress at
remembering
• Maladaptive
avoidance
• Positive
memories
• Memories are
comforting
• Yearning
• Sadness
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Factors That Influence Outcome
•Exposure
•Child Characteristics
•Family Factors
•Social Factors
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Direct Versus Indirect Victims
• Direct victims
–
–
–
–
–
Sustained physical injuries
Lost job or possessions
Friend or relative killed
Witnessed event in person
Participation in rescue effort in immediate aftermath
• Indirect victims
–
–
–
–
No property damage or job loss
No personal participation in event rescue efforts
No direct, in person witnessing of event
No deaths or injuries of friends or relatives
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Residents directly vs not directly
affected by September 11 attacks
directly affected by September 11 attacks
not directly affected by September 11 attacks
represents approximately 51,000 people
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PTSD since September 11
directly affected by September 11 attacks
not directly affected by September 11 attacks
PTSD since September 11
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PTSD 6-9 months after
September 11
directly affected by September 11 attacks
PTSD since September 11
not directly affected by September 11 attacks
PTSD 6-9 months after September 11
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Types of Exposure (1)
• Direct
– Physical presence
– Eye witnessing
• Indirect
– Interpersonal relationships
– Community residence
• Remote
– Society membership
– Media
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Types of Exposure (2)
 Characteristics of event
 Dose (severity)
 Subjective Reaction
 Intense fear, helplessness, or
horror
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Exposure
Significantly Different
Exposures
Doors/windows break or come open
Roof blown away or cave in
Anyone with you hurt
Scared a loved one would be hurt/killed
Anyone with you very scared
Get wet from rain/seawater
Pet hurt or killed
Stay out of home after
Still out of home
HI
(%)
LO
(%)
82
57
16
87
87
58
24
39
19
11
5
0
66
68
14
5
9
0
Shaw et al. 1995
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Tsunami Impact
14
12
10
Camps
8
Affected Villages
6
Unaffected
Villages
4
2
0
PTSD
Depress
Thienkrua, et al, 2006
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Posttraumatic Stress at 2 Months
Children in Hi-Impact school were more likely to
have severe posttraumatic stress Hurricane Andrew
60
56
50
41
40
N = 144
57% Hi-Impact
43% Lo-Impact
Mean = 8.2 yrs
39
31
30
21
20
doubtful to mild
13
moderate
10
severe to very severe
0
High
Impact
Low
Impact
Shaw et al. 1995
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Subjective Appraisal of Threat
Variable
Life Threat
Loss
Gender
Age
Mother Severity
Father Severity
Irritable Atmosphere
Depressed
Atmosphere
Violent Atmosphere
Supportive
Atmosphere
R
.21
.01
.19
.16
.25
.25
.29
.18
p
.03
NS
.03
NS
.01
.10
.001
.01
-.03
-.08
NS
NS
Life threat associated
with the number of
PTSD symptoms
Model accounted for 28%
of the variance
N = 179
2 years after Buffalo Creek
Green et al. 1991
PTSD Following Industrial Accident
45
40
35
30
25
Direct Exposure
Indirect Exposure
20
15
10
5
0
11-13 yrs
12-17 yrs
Godeau, et al, 2005
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Child Characteristics
 Demographics
- Sex (female)
- Age
 Pre existing conditions
 Prior trauma
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Pre Event Anxiety Disorder
16
14
Children with pre event anxiety disorder
had significantly more PTSD symptoms
than those without
14
12
10
9
Pre Anxiety
8
No Pre Anxiety
6
4
2
0
Self Report
N = 66 children
1 year after Northridge earthquake
Asarnow et al. 1999
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Prior Trauma
Model explained 60% variance in bombing-related posttraumatic stress
40
36
35
30
25
PTSS-Other
20
793 Nairobi
children
8-14 months
after the 1998
U.S. Embassy
bombing
Peritraumatic reaction
15
10
5
5
0
Pfefferbaum et al. 2003
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Family Characteristics at 8 Months
3
Significant differences between cases and
non cases on all three measures at 8 months
2.8
150 children
8 months after a bushfire
2.5
2.2
2
1.8
1.7
cases
1.4
1.5
non cases
1
0.5
0.5
0
Irritable Distress
Involvement
Overprotection
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Social Support and PTSD
Social support was related to the development of
PTSD and to the duration of PTSD
46
45
44
44
42
41
40
38
PTSD
No PTSD
38
36
34
Development
Duration
Social support measured perceived and received
just after the disaster and at follow up
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Exposure to Television Coverage
443 NYC parents 4 months after September 11
100
90
86 87 87
77
80
70
airplane hit
60
50
48
buildings collapse
40
people running
30
people falling or jumping
20
3 or more images
10
0
Fairbrother et al. 2003
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Assessment: Parent Report
 Parent interview and report provides
objective information in some areas
 Parents may under-estimate children’s
distress
- Parents may be focused on other issues
- Parents may be overwhelmed
themselves
- Children may be especially compliant
- Parents may use denial
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Posttraumatic Stress:
Child and Parent Report
No significant decrease over time on child self report
35
30
29.6
26.3
25.5
25
21.8
19.6
20
18.1
Exposed
13.6
15
Comparison
9.3
10
5
0
3 months
*Exposure significant
+Time significant
9 months
Child report*
3 months
9 months
Parent report*+
Koplewicz et al. 2002
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Event-Related Fear:
Child and Parent Report
No significant decrease over time on child self report
35
30
29.2
28
27.7
26.4
25
23.2
22.6
19.7
20
18.7
Exposed
Comparison
15
10
5
0
3 months
9 months
Child report*
3 months
9 months
Parent report*+
*Exposure significant
+Time significant
Koplewicz et al. 2002
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Predictors for Post-Disaster Distress
•
•
•
•
•
•
•
Disaster severity
Subjective fear
Relocation/disruption
Resource loss
Female
Prior anxiety
Prior trauma
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Child Disaster Mental
Health Services
Assessment
Interventions
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Utilization of Post Disaster Services
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Utilization Rates
•
•
•
•
Oklahoma City = 5%
NYC (young children) = 15%
NYC (Manhattan) = 10%
NYC (lower Manhattan) = 22%
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September 11 Counseling
40
36
35
Of those receiving counseling:
30
30
 47% had severe or very
severe posttraumatic stress
25
20
school teachers
school psychologists/counselors
 50% had moderate
posttraumatic stress
mental health
 3% had mild posttraumatic
stress
20
15
14
10
religious leaders/others
5
 1/3 had received counseling
before 9/11
0
% Receiving
Counseling
NYC parents 4-5 months after incident
- 10% received counseling
- 44% in schools
Fairbrother et al. 2004
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Screening
• Not all children develop
significant problems
• Risk factors identified
• Brief screening measures
available
• Screening well tolerated
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Oklahoma City School-based Screening
190 (49%) of
390 received
counseling
390 (67%) of 586 further screened
586 (9%) of 6,500 identified as
needing further screening
Allen et al. 1999
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Acute Interventions-Triage
• Address immediate
physical/safety/necessity
• Establish stability/security
• Psychological First Aid
– Psychoeducation
– Coping strategies
– Hopefulness
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Assessment
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Individual Assessment and
Treatment
Most necessary for:
 Directly exposed children
 Children whose loved ones were
directly affected
 Children with persistent distress
or impaired functioning
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Individualized Assessment Prior to
Treatment Onset
•
•
•
•
•
•
•
PTSD/sx
Anxiety
Depression
Behavior problems
Functioning
Parent-child relationship
Parental distress
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Tested Therapeutic Interventions
 Trauma-focused therapy
 Traumatic grief-focused therapy
 Eye Movement and
Desensitization and
Reprocessing
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Goals of Interventions
 Goals
 Restore a sense of safety and security
 Reduce sx of PTSD, anxiety and distress
 Restore functioning
 Methods
 Psychoeducation re trauma and impact
 Emotional regulation skills
 Correct maladaptive cognitions
 Resolve trauma related distress and
avoidance
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Psychosocial Intervention (1)
 214 completed treatment
 176 group
 73 individual
 Intervention: 4 weekly sessions




Safety and helplessness
Loss
Competence and anger
Closure and going forward
 Group and individual treatment
 No difference in effectiveness
 Group associated with better completion rates
 Follow-up
 Children maintained treatment gains
Chemtob et al. 2002
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Psychosocial Intervention (2)
25
20
20
15
12
10
treated
untreated
5
0
Posttraumatic Stress
Clinicians rated a random sample
of 21 treated and 16 untreated
Chemtob et al. 2002
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Trauma/Grief Focused Group
Psychotherapy After Earthquake (1)
Participants
 Early adolescents in severely damaged
schools following a massive Armenian
earthquake
 35 received trauma/grief-focused brief
psychotherapy
 29 received no therapy
Goenjian et al. 1997
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Trauma/Grief Focused Group
Psychotherapy After Earthquake (2)
 Intervention
- Sessions delivered over a 3 week period
- 4 ½-hour classroom group psychotherapy sessions
- Average of 2 1-hour individual sessions
 Intervention focused on
- Trauma
- Traumatic reminders
- Post disaster stresses and adversities
- Bereavement and the interplay of trauma and grief
- Developmental impact
Goenjian et al. 1997
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Posttraumatic Stress After
Treatment for Earthquake Disaster
50
47
45
45
Severity Posttraumatic
Stress
- Decreased in treated
41
40
35
32
Treated
Not Treated
- Increased in untreated
30
25
20
20
17
15
16
Severity Depression
- No change in treated
- Increased in untreated
15
10
5
0
1.5 Years
3 Years
Posttraumatic Stress
1.5 Years
3 Years
Goenjian et al. 1997
Depression
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RCT EMDR Hurricane (Chemtob, et al, 2002)
• Children with continuing distress
@ 1 yr
• Randomized to tx v. waitlist
• Intervention = 3 sessions EMDR
• PTSD, anxiety, depression
reduced with tx
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Concerns about Treatment
 Treatment may lead to heightened
arousal and distress
 Avoidance is a core feature of
posttraumatic stress and may impede
treatment
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Treatment Research Status
 Both group and individual shown to be
helpful
 Can be delivered in school settings
 CBT type approaches most tested and
evidence for effectiveness
 Some approaches not tested (e.g,
psychodynamic, play)
 Medication
- Rarely needed
- Adjunctive if used
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Resilience in Children in
the Context of Disasters
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What is Resilience?
 Positive adaptation in spite of
significant life adversities
 The process and outcome of
successfully adapting to difficult or
challenging life experiences,
especially highly stressful or traumatic
events
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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Factors that Contribute to Resilience
Resilient children have:






Optimism
Self efficacy
A sense of mastery
Personal competencies
Cohesive and supportive families
Families that use effective coping skills to
deal with stress
 Hardy families
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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Resources for Fostering Resilience
 Support from parents and family
members
 Support from classmates and close
friends
 Reaffirming ties to such institutions as
social and religious groups
 Providing help and resources to others
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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How Professionals Can Build
Resilience in Children (1)
 Provide children with opportunities to
share and discuss their feelings and
concerns
 Encourage children to resume
normal roles and routines or develop
new routines
 Promote the maintenance of social
connections
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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How Professionals Can Build
Resilience in Children (2)
 Reduce or minimize children's
exposure to disturbing media
information
 Encourage children and teens to stay
healthy and fit
 Encourage children to use positive
strategies for coping with disasterrelated stressors and model positive
coping
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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How Parents Can Build
Resilience in Children
 Take care of themselves
 Promote warmth and nurturance that
establish clear limits
 Establish a safety plan in case of a
traumatic event
 Discuss school safety plans for
potential terrorist events with teachers
and school administrators
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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How Schools Can Build Resilience
in Children (1)
 Identify supportive adults in children’s
lives
 Create positive connections by
developing classroom projects
 Enhance positive attitudes by
developing coping strategies
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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How Schools Can Build Resilience
in Children (2)
 Teach children to relax in the face of
difficulties
 Help children set realistic goals
 Help children identify positive coping
strategies
 Increase children's sense of mastery
and control
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
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How Communities Can Build
Resilience in Children
 Community factors that may be related
to and promote resilience in children and
families include:
- Cohesiveness
- Perceptions of safety
- Perceptions of security
- Effective communication
- Making the needs of children a priority
- Creating a “disaster system of care”
Fact Sheet: Fostering Resilience in Response to Terrorism: For
Psychologists Working With Children, American Psychological Association
Northwest Center for
Public Health Practice
85