Disaster and Trauma Disaster and Trauma During Childhood:During Childhood:The Role of CliniciansThe Role of Clinicians

Stephen J. Cozza, M.D.Professor of PsychiatryUniformed Services University

Child Traumatic ExposuresChild Traumatic Exposures

• Physical and Sexual Abuse

• Domestic and Community Violence

• Medical Trauma• Natural Disasters• Terrorism

• War– Child Soldiering– Displacement/Refugee

Status– Parental Combat

Exposure

• Torture or Kidnapping• Traumatic Grief

Individual Trauma vs. Community DisasterIndividual Trauma vs. Community Disaster

Community Effects of TraumaCommunity Effects of Trauma

• Destruction of infrastructure

• Possible disruption of emergency services

• Permanent effect on community

• Death of loved ones

• Loss of jobs

Community Effects of TraumaCommunity Effects of Trauma

• Parental distraction/preoccupation/

unavailability

• Disruption in schedule and routines

• Separation of families

• Induction of fear and erosion of safety

• Opportunism that

undermines safety

What happens next?What happens next?

Fear of parental death

Separation anxiety

Health facility exposure

Change in parent/family

Change in home/community

CHILD

STRESS LEVEL

T I M E (months)0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

fear of loss of parent

separation from non-injured parent

hospital visits

change in parenting ability

move fromcommunity

Trauma is a Process, Not an EventTrauma is a Process, Not an EventCascade of Events Post Parental InjuryCascade of Events Post Parental Injury

Stages of DisasterStages of DisasterPredisasterPredisaster

IMP

AC

TIM

PA

CT

Rescue and ResponseRescue and Response RecoveryRecovery

T I M E

TreatingTreating

RespondingResponding

PreparingPreparing

TertiaryTertiarySecondarySecondary

PrimaryPrimaryPreventionPrevention

PreparednessPreparednesspredisaster requirementpredisaster requirement

educationeducation

emergency planningemergency planning

drilling for different scenariosdrilling for different scenarios

community relationship buildingcommunity relationship building

“before the fact intervention”“before the fact intervention”

http://www.ready.gov/

http://www.fema.gov/kids/

Disaster Mental Health TrainingDisaster Mental Health Training

http://www.redcross.org/services/disaster/

ResponseResponsePsychological First AidPsychological First Aid

crisis counselingcrisis counseling

psychoeducationpsychoeducation

triagetriage

screeningscreening

risk communicationrisk communication

a non-treatment intervention

calm reassurance

basic information about trauma response

provide comfort and support

establish and ensure safety

connection with community resources

Principles of Psychological First AidPrinciples of Psychological First Aid

Recovery and Social EnvironmentRecovery and Social Environment•Child is contained within layers of support

•Transactional interplay between layers

•Interaction may be mutually constructive or detrimental

•Family is the closest social support

•Encourage recovery by supporting role functioning

National CommunityNational Community

Local Community Local Community

Parents and FamilyParents and Family

IndividualIndividualChildChild

Disaster Recovery and ChildrenDisaster Recovery and Children

• Most dependent are most vulnerable in the process

• Disruption of family equilibrium• Distraction of responsible

parties– many contingencies to address– manage anxiety and personal

stress– potential impairment of role functioning

Disaster Recovery and ChildrenDisaster Recovery and Children

• Disruption of relationships, interpersonal strife, loss of attachments

• Reduction of parental efficacyparental efficacy – influence of parental distress or psychopathology

• Target parental and community efficacyparental and community efficacy as it pertains to child recovery

Developmental ConsiderationsDevelopmental Considerations• Children are subject to many of the

same effects of trauma as adults

• BUT they express their distress differently

• Behavioral manifestations may be misunderstood

• Limited communication skills

• Younger children may harbor cognitive distortions about meaning of trauma

TreatmentTreatment

Understanding riskUnderstanding risk

Diagnostic considerationsDiagnostic considerations

Evidence informed treatmentsEvidence informed treatments

Traumatic GriefTraumatic Grief

Time of trauma

time

fun

ctio

nin

g subject 1

subject 2

subject 3

subject 4

Resilience Variability in Trauma Response

functional illness

Resilience vs. PsychopathologyResilience vs. Psychopathology

• Most disaster victims recover without the development of psychopathology or the need for treatment

• PTSD is not the only psychiatric condition that may result– depression– risk behaviors– substance use disorders

• Variable rates of child PTSD have been reported in the literature after traumatic event (5-75%)

Resilience vs. PsychopathologyResilience vs. Psychopathology

• Difficulty in PTSD diagnosis due to differences in child presentation

• Risk Factors include:– prior history of trauma– preexisting emotional or behavioral problems– severity of stressor and proximity of exposure– psychopathology in the parent– immature familial coping patterns– characteristics of post-disaster environment and

available support

Treatment StrategiesTreatment Strategies

• Psychoeducation

• Parent guidance

• Family intervention

• Supportive services

• Trauma Focused CBT

• Traumatic Grief Treatments

• Pharmacotherapy

Unique Role of Child CliniciansUnique Role of Child Clinicians• Community ConsultantsCommunity Consultants – maintain

ongoing relationships to schools and other agencies that routinely engage children

• Child Development ExpertChild Development Expert – understand the developmental considerations unique to children at all levels of development

• Child AdvocateChild Advocate – highlights the special needs of children when others may not be aware

Unique Role of Child CliniciansUnique Role of Child Clinicians

• ClinicianClinician – treats clinical disorders in children, understanding the importance of interaction with parents and families

• EducatorEducator – communicates information to decision makers and community leaders

• System SpecialistSystem Specialist – effectively coordinates services between different agencies

Available ResourcesAvailable Resources