CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Providing Psychosocial Support toChildren and Families in the Aftermathof Disasters and CrisesDavid J. Schonfeld, MD, FAAP, Thomas Demaria, PhD, the DISASTER PREPAREDNESS ADVISORY COUNCIL AND COMMITTEE ONPSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH

abstract Disasters have the potential to cause short- and long-term effects on thepsychological functioning, emotional adjustment, health, and developmentaltrajectory of children. This clinical report provides practical suggestions onhow to identify common adjustment difficulties in children in the aftermath ofa disaster and to promote effective coping strategies to mitigate the impact ofthe disaster as well as any associated bereavement and secondary stressors.This information can serve as a guide to pediatricians as they offeranticipatory guidance to families or consultation to schools, child care centers,and other child congregate care sites. Knowledge of risk factors foradjustment difficulties can serve as the basis for mental health triage. Theimportance of basic supportive services, psychological first aid, andprofessional self-care are discussed. Stress is intrinsic to many major lifeevents that children and families face, including the experience of significantillness and its treatment. The information provided in this clinical report may,therefore, be relevant for a broad range of patient encounters, even outsidethe context of a disaster. Most pediatricians enter the profession because ofa heartfelt desire to help children and families most in need. If adequatelyprepared and supported, pediatricians who are able to draw on their skills toassist children, families, and communities to recover after a disaster will findthe work to be particularly rewarding.

INTRODUCTION

Disasters are “one-time or ongoing events of human or natural cause thatlead groups of people to experience stressors including the threat of death,bereavement, disrupted social support systems, and insecurity of basichuman needs such as food, water, housing, and access to close familymembers.”1 In a representative sample of more than 2000 US children 2through 17 years of age, nearly 14% were reported to have been exposedto a disaster in their lifetime, with more than 4% of disasters occurring inthe past year.1 Disasters, thereby, affect the lives of millions of children

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2015-2861

DOI: 10.1542/peds.2015-2861

Accepted for publication Jul 30, 2015

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

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every year, whether through naturaldisasters, such as earthquakes,hurricanes, tornadoes, fires, or floods;human-made disasters, such asindustrial accidents, war, orterrorism; or as a result of pandemicsor other naturally occurring diseaseoutbreaks. Children are particularlyvulnerable to the effects of disastersand other traumatic events becauseof a lack of experience, skills, andresources to be able to independentlymeet their developmental, social-emotional, mental, and behavioralhealth needs.2,3 Disasters also havethe potential to cause short- andlong-term effects on thepsychological functioning,emotional adjustment, health, anddevelopmental trajectory ofchildren, which even may haveimplications for their health andpsychological functioning inadulthood; children, as a group, areamong those most at risk forpsychological trauma andbehavioral difficulties aftera disaster.4

Pediatricians and other pediatrichealth care providers are in anexcellent position to (1) encouragefamilies and communities to preparefor potential disasters; (2) providesupport to children and families inthe immediate aftermath of a disaster,as well as throughout the recoveryprocess; (3) share advice andstrategies with caregivers on how topromote and support children’sadjustment, coping, and resilience;(4) provide timely triage to identifyand refer children with or atconsiderable risk of developingadjustment difficulties to appropriateservices; (5) serve as a consultant toschools, child care centers, and otherchild congregate care sites onpreparedness, response, and recoveryefforts; and (6) advocate at the local,state, and national levels for a state ofpreparedness and services to meetthe needs of children affected bydisasters.3 Stress is intrinsic to manymajor life events that children andfamilies face, including the experience

of significant illness and its treatment.The information provided in thisclinical report may, therefore, berelevant for a broad range of patientencounters, even outside the contextof a disaster.

Emotional distress also may interferewith the accurate reporting ofsymptoms and may even mimicphysical conditions. Effectivemanagement of medical conditionsmay be compromised, therebyreducing the quality of pediatric careprovided both in the aftermath ofdisasters and in situations involvingpatient/family distress. Despite theincreased call for psychosocialsupport in the aftermath of a disaster,surveys of practicing pediatriciansconsistently indicate that mostpediatricians perceive themselves tobe unprepared to address the needsof children in such crises.5,6 Thisclinical report presents informationabout children’s common adjustmentreactions to disasters, their riskfactors for addressing and dealingwith challenges, and practicalstrategies to help patients andfamilies increase coping skills andresiliency.

CREATE A SAFE HEALTH CAREENVIRONMENT IN THE AFTERMATH OFA DISASTER

Sites that may deliver care in theaftermath of a disaster should bedesigned to minimize the likelihoodof contributing additional stress tochildren. When delivering medicalcare, attempts should be made tominimize the use of invasive orpainful procedures or treatments andprovide appropriate sedation oranalgesia whenever required. Parentsand family members should remainwith children to the extent possiblethroughout the evaluation andtreatment process, provided that theyare able to cope with their owndiscomfort or distress. Parents maybe guided in supporting theirchildren, such as by using copingstrategies they have found effective in

the past (eg, distraction or attention-refocusing techniques, like a calmingtouch or use of gentle humor).Parents should be allowed totemporarily leave the examinationroom if they are feeling overwhelmed,but should notify the child beforeleaving that they will be in anadjacent area and that thepediatrician or nurse will remain withthem for a few minutes until theyreturn.

Practical steps can be taken tominimize children’s exposure tofrightening images and sounds thatmay compound their distress or serveas triggers or reminders of a disaster.Doors/curtains in the health caresetting should be closed to reduceexposure to others who are injured orin pain. Televisions in waiting,examination, and inpatient rooms canbe turned off if they are broadcastingcoverage of the crisis event. Staffmembers are encouraged toremember that children can oftenoverhear and understand theirconversations.

Parents and doctors can provideexplanations about medicaltreatments and care in positive termsthat emphasize how theseinterventions are intended to keepchildren safe and/or help them feelbetter. Potential risks may bepresented in supportive ways, forexample, “We are going to put thisbelt around your waist so that youremain safe and secure in theambulance,” rather than “We will putthis belt on so that you don’t go flyingout of the ambulance if we have tostop quickly on the way to thehospital.” This advice is relevant evenoutside the context of a disaster.7

COMMON ADJUSTMENT REACTIONS OFCHILDREN TO DISASTERS

The effect of a disaster on eachindividual child varies depending ona number of factors, including (1) thenature of the event and the amount ofdeath, destruction, and disruption;(2) the degree of personal

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involvement of children and theirfamilies; (3) the duration of timebefore children’s daily environment,and that of the overall community,returns to a safe, predictable, andcomfortable routine; (4) whether thestressor is a 1-time or chronic event;(5) the level of coping ability of thechildren’s caregivers; (6) the children’spreexisting mental health,developmental level, and baselineresiliency and coping skills; and (7)the nature of the secondary stressorsand losses that follow the crisis event.In communities recovering froma disaster, it is therefore often helpfulfor pediatricians not only to inquireabout children’s symptoms, but also toask families about what children wereexposed to as a result of the disaster,what they understand about what hashappened to their community, anyongoing stressors that may complicaterecovery, and additional questions thatexplore and identify these risk factors(see Table 1).

Most children who are experiencingadjustment difficulties after a disastermay demonstrate no observablesymptoms. Children might try toavoid revealing concerns andcomplaints to not seem odd and notfurther burden adults in their liveswho are having difficulty coping aswell. Even children suffering fromposttraumatic stress disorder (PTSD)may go undetected unlesspediatricians screen or directlyinquire about symptoms andadjustment. One of the core criteria ofPTSD is an active avoidance ofthinking about or talking about thetriggering event and one’s associatedreactions to that event. Making thediagnostic process even moredifficult, most of the symptoms of anacute stress disorder or PTSD maynot be externally expressed at all(eg, intrusive thoughts). As a result,parents, teachers, and othercaregivers tend to underestimate thelevel of children’s distress aftera disaster and overestimate theirresilience, especially if relying on theobservation of overt behaviors rather

than inquiring specifically aboutfeelings and reactions. The adults’own reactions to the event also maydiminish their ability to identify theirchildren’s needs with optimalsensitivity or reliability.8 Finally, theparents’ own difficulty adjusting to anevent may, in turn, threaten children’ssense of safety and security and serveas a negative model of emotionalregulation.9

Research has shown that aftera major disaster, a large proportion ofchildren in the affected communitywill develop adjustment reactions,with many qualifying for a diagnosisof a mental health condition, oftenrelated to trauma, anxiety, ordepression.10 In a study conducted 6months after the terrorist attacks ofSeptember 11, 2001, involving

a representative sample of more than8000 students in grades 4 through 12attending New York City publicschools, 27% met criteria for 1 ormore probable psychiatric disorderson the basis of self-reporting ofsymptoms and impairment in dailyfunctioning. The study reported thefollowing:

• 11% of students had PTSD;

• 8% of students had major de-pressive disorder;

• 12% of students had separationanxiety disorder;

• 9% of students had panic attacks;and

• 15% of students had agoraphobia(or fear of going outside or takingpublic transportation).

Perhaps of even greater concern, atleast two-thirds of those students whoself-reported mental health symptomsand impairment in daily functioningalso reported that they had not soughtcare, even though free mental healthservices had been available in theirschools. In addition, the vast majority(87%) of all students surveyedreported at least 1 ongoing symptomthat persisted 6 months after theevent, reported as follows:

• 76% of students reported oftenthinking about the attacks;

• 45% of students were actively try-ing to avoid thinking or talkingabout the event;

• 25% of students were experiencingdifficulty concentrating;

• 24% of students were having sleepproblems (including 17% withnightmares); and

• 18% of students stopped going toplaces or doing things thatreminded them of the events ofSeptember 11.11

Because most children experience atleast some long-term reactions toa disaster and because many childrenand families cannot or do not accessmental health services for reasonsincluding cost and perceived stigma,

TABLE 1 Common Symptoms of AdjustmentReactions in Children aftera Disaster24

Sleep problems: difficulty falling or staying asleep,frequent night awakenings or difficultyawakening in the morning, nightmares, orother sleep disruptions.

Eating problems: loss of appetite or increasedeating.

Sadness or depression: may result in a reluctanceto engage in previously enjoyed activities ora withdrawal from peers and adults.

Anxiety, worries, or fears: children may beconcerned about a repetition of the traumaticevent (eg, become afraid during storms aftersurviving a tornado) or show an increase inunrelated fears (eg, become more fearful of thedark even if the disaster occurred duringdaylight). This may present as separationanxiety or school avoidance.

Difficulties in concentration: the ability to learnand retain new information or to otherwiseprogress academically.

Substance abuse: the new onset or exacerbationof alcohol, tobacco, or other substance use maybe seen in children, adolescents, and adultsafter a disaster.

Risk-taking behavior: increased sexual behavior orother reactive risk-taking can occur, especiallyamong older children and adolescents.

Somatization: children with adjustment difficultiesmay present instead with physical symptomssuggesting a physical condition.

Developmental or social regression: children (andadults) may become less patient or tolerant ofchange, revert to bedwetting, or becomeirritable and disruptive.

Posttraumatic reactions and disorders: see Table 2.

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it is important to explore strategiesthat provide interventions andsupport to all children after a majordisaster, rather than relyingexclusively on the traditional clinicalapproach of triage and referral forthose patients identified as needingcare.

Anticipatory guidance and advice canbe provided to families bypediatricians on how to identify andaddress the most commonadjustment reactions that can beanticipated among children aftera disaster (see Table 1). For example,sleep problems are common aftera disaster, and children who havedifficulty sleeping may developproblems with concentration,attention, learning, and academicfunctioning. Promoting sleep hygiene(eg, providing a consistent, quiet, andcomfortable location and time forsleep that is free of noise or otherdistractions, preceded by a quiet andconsistent bedtime ritual), may bedifficult but is nonetheless important,especially when families are living inshelters or other temporary sites.Posttraumatic stress reactions arefrequently observed immediatelyafter a disaster and can be bestexplained to children as the way theirbody automatically responds after anevent frightens them. Less commonly,PTSD may develop a while after thetraumatic event occurred, especiallyamong children who perceived at thetime of the event that their life was injeopardy or experienced intense fear,helplessness, or horror. Table 2includes the diagnostic criteria forPTSD, as outlined in the Diagnosticand Statistical Manual of MentalDisorders, Fifth Edition (DSM-5),12

which include symptoms of intrusion,avoidance, negative alterations incognitions and mood, and increasedarousal that persist for at least 1month and result in significantimpairment in social, academic, orother areas of functioning.

Distress that occurs as a result ofchildren’s involvement in a disaster

often creates an additional burden forthe children who may have hadunresolved predisasterpsychopathology or adjustmentdifficulties. Psychological issues thatchildren have attempted to suppressmay resurface, even if these issuesare not directly related to thedisaster.10,13 As a result, unrelatedevents and experiences (eg, previoustraumatic events or worries about thehealth of parents) may be the causefor what appear to be reactions to thedisaster itself. This distress may beseen among adults, such as parents,as well.

In a related manner, future events andreferences that remind children of thelosses or disturbing images,sensations, and emotions associatedwith the disaster event may serve aslater triggers of their grief or traumasymptoms. Some examples include

anniversaries of the disaster, severeweather that reminds a child ofa natural disaster, persistent signs ofdestruction in the community, soundsof emergency vehicles, allusions tosimilar events on television or inclassroom lessons, or visits to healthcare facilities. These reminders mayresult in an unanticipated, acuteresurgence of some of the feelingsassociated with the loss or crisis andcatch children off guard. Parents,educators, and others who work withchildren should anticipate that suchtriggers may occur and help childrenanticipate and plan for how toaddress these feelings.

BEREAVEMENT AND SECONDARYSTRESSES

Whereas the adjustment difficulties(as outlined in Table 1) that childrenexperience after a disaster may be

TABLE 2 Symptoms of Posttraumatic Stress Disorder24

Exposure: The child is exposed to actual or threatened death, serious injury, or sexual violence. This may bethrough the child’s direct experience; by witnessing the traumatic event, especially when involvinga caretaker; or by the child learning that the traumatic event occurred involving a close family memberor friend without any direct experience or witnessing of the event by the child.

The following symptoms must occur for more than 1 month’s time:1. Intrusion• The child has repeated distressing memories and/or dreams (nightmares) about the traumatic

event; it is not required for children to remember the content of these distressing dreams. Forsome children, repetitive play activities may involve themes or aspects of the traumatic event.

• The child may display a loss of awareness of present surroundings (dissociation) and act as if thetraumatic event is reoccurring (flashbacks).

• The child may experience intense or prolonged psychological distress and/or physiologic reactionsat exposure to internal or external cues that symbolize or resemble the traumatic event.

2. Avoidance• The child attempts to avoid distressing memories, thoughts, feelings, activities, and/or places that

remind him or her of the traumatic event.3. Negative alterations in cognitions and mood• The child has problems remembering important aspects of the traumatic event.• The child maintains negative beliefs or expectations about oneself, others, or the world.• The child has thoughts about the cause or consequences of the traumatic event that lead to blame

of self/others.• The child experiences negative emotional states, such as depression, and has trouble experiencing

and expressing positive emotions.• The child shows a markedly diminished interest or participation in significant activities, including

play.• The child feels distant from others, which may lead the child to become socially withdrawn and

avoid people, conversations, or interpersonal situations.4. Increased arousal and reactivity associated with the traumatic event• Irritable and angry outbursts (extreme temper tantrums).• Reckless or self-destructive behavior.• Hypervigilance.• Exaggerated startle response.• Problems with concentration.• Sleep disturbance.

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related to posttraumatic reactions,many will not be directly attributableto the disaster itself. Disasters mayworsen preexisting problems, such asfinancial strain, parental depression,parenting challenges, or childbehavior problems, which may havebeen adequately compensated oraddressed in a setting of less stress.14

Disasters often also initiate a cascadeof secondary losses and stressors thatmay become the primary concern fora particular child or family. A childpresenting with sleep problemsmonths after a flood may beresponding to marital conflict orparental distress related to financialconcerns instead of solely strugglingto cope with the flooding itself. Aftera major natural disaster, it is commonto see increased unemployment orunderemployment resulting infinancial stress on families; a need forfamilies to relocate resulting inchanges in schools or peer groups forthe children; temporary livingsituations that are suboptimal orcauses of interpersonal conflict; ordepression, substance use, or maritalconflict among parents. Such anincrease in marital stress, domesticviolence, and parental mental healthproblems was demonstrated in theGulf Coast region after HurricaneKatrina.15,16 Child abuse has alsobeen reported to increase after majordisasters.17 Pediatricians may seechildren and families dealing withsuch issues even if the children oradults in the family did notexperience the disaster itself astraumatic but instead are reacting tosecondary losses or stressors.Management of these concernsrequires a different approach thantrauma treatment; pediatricians needto adopt a more holistic approach toassessing adjustment and promotingcoping and resiliency among childrenand families after a disaster.Assessments need not only to explorehow children are adjusting with thedisaster event itself, but also to seekinformation about their current lifecircumstances and how they are

dealing with the challenges thesecircumstances may pose. Given thatchildren may withhold voicing theirconcerns in the presence of theirparents or other family members soas not to further burden the adultswho may be in distress themselves, itis important to interview the childrenalone with the parents’ permissionand child’s assent when trying toassess fully their level of coping.

Given that these secondary losses andstressors may continue for evenseveral years after a major disaster,children’s adjustment difficulties maypersist for a similarly extended time.Children’s adjustment should not beexpected before the restoration andstabilization of the home, school,and community environments andsupports for children, which may notreturn to being fully functional forseveral years.

If children experience the deaths offamily members or friends as a resultof the disaster, bereavement mayemerge as their predominantconcern. In most situations,bereavement in the context ofa disaster is not dissimilar frombereavement occurring in othercontexts; when children haveobserved a violent death of a lovedone, grief may be compounded bytrauma reactions requiring treatmentof trauma in addition to bereavementsupport. Children, like adults, willstruggle with understanding andaccepting the death and the effect ithas on them and their family and thechallenge of a life devoid of someonethey loved.18 Parents, teachers, andother caring adults are often reluctantto talk with children who are grievingor even to raise the topic out of a fearof causing further distress by sayingthe “wrong thing.” Yet, the distress iscaused by the reaction to the deathitself, rather than any question orinvitation to talk. Talking mayprovide some relief if not coerced.Avoiding discussion is rarely helpfuland often isolates children at a time

when they are most in need ofsupport and assistance.

Pediatricians and other pediatrichealth care providers can serve asa useful resource for children whohave recently experienced the deathof a close family member or friend byhelping their caregivers understandthe importance of inviting andanswering their questions, providinginformation to help guide them inunderstanding and adjusting to theloss, and helping them identifystrategies for coping with theassociated distress. Timelyinformation about how to involvechildren in the funeral or othermemorialization activities, how toenlist the support of schoolpersonnel, and bereavement supportservices available within thecommunity are helpful to provide,through in-person meetings, phonecalls, or psychoeducational material.Practical and free resources areavailable for this purpose19 (seewww.aap.org/disasters/adjustmentand www.achildingrief.com). Aresource offering free multimediatraining materials on how to supportgrieving children is available throughthe Coalition to Support GrievingStudents at www.grievingstudents.org. Practical guidance on how toapproach notification of childrenabout the death of a family memberor friend,20 including within theunique context of a disaster,21 can befound elsewhere.

RISK FACTORS FOR ADJUSTMENTDIFFICULTIES AND GUIDELINES FORREFERRAL

In the immediate aftermath ofa disaster, pediatricians need toassess both the physical and mentalhealth of children. The primary focusis, of necessity, medical stabilizationand evaluation, but a secondarymental health triage should followshortly thereafter. Table 3 outlinesthe factors to be assessed during thismental health triage to identifychildren most in need of mental

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health services or other immediateattention to their mental healthneeds. The following factors, inparticular, suggest the need forimmediate mental health services: (1)dissociative symptoms, such asdetachment, derealization, ordepersonalization, which may presentin children as appearing confused,distant, daydreaming, or aloof (suchdissociation at the time of exposurehas been found to be the mostsignificant predictor of later PTSD);(2) extreme confusion or inability toconcentrate or make even simpledecisions; (3) evidence of extremecognitive impairment or intrusivethoughts; (4) intense fear, anxiety,panic, helplessness, or horror; (5)depression at the time of the event13;(6) uncontrollable and intense grief;(7) suicidal ideation or intent; and (8)

marked physical complaints resultingfrom somatization.22 When children’scaregivers are struggling themselvesto cope with the event, helping thecaregivers access services forthemselves and/or providinga referral to a mental health providerto assist with children’s coping alsomay be indicated.

Children’s adjustment and resiliencydepend on a number of factors thatrelate to the nature of the event itself(such as how much damage or deathresulted from the event); the degreeof personal effects on children orthose close to them in terms of death,disability, injury, or loss of propertyor damage to housing; the level ofexposure involving direct witnessingor viewing graphic coverage throughthe media or online; the degree andduration of secondary losses andstressors; the disruption caused tochildren’s extended support systemand the level of adaptation ofcaregivers and the degree to whichthey are able to create a safe andnurturing environment that promotesrecovery for the children; and thenature of children’s preexistingcoping abilities.23,24 Table 3 outlinesthe factors before, during, and aftera disaster that are associated with anincreased risk of difficulty adjustingafter a disaster.

Separation from parents or otherimportant caregivers is associatedwith increased difficulty adjusting toa disaster. Efforts to reunite childrenwho are separated from their familyby the event are a high priority.25,26

In those situations in which childrenrequire medical treatment orobservation before reunification ispossible, individual volunteers can beassigned to provide consistent andongoing support to individualchildren until reunification isachieved. When parents, guardians, orother family members are available,guidance by the health care team canhelp them serve an active andappropriate role in the evaluation and

treatment process and can help toreduce their children’s distress.3

BASIC SUPPORTIVE SERVICES ANDPSYCHOLOGICAL FIRST AID

Attention to the basic needs ofindividuals affected by a disaster isa top priority for the immediateresponse. Basic needs include food,shelter, safety, supervision,communication, and reunificationwith loved ones. Ensuring that thesebasic needs are addressed is the firststep to providing emotional support.

In addition, all individuals directlyaffected by a disaster should beprovided psychological first aid,which involves psychoeducation andsupportive services to accelerate thenatural healing process and promoteeffective coping strategies.Psychological first aid includesproviding timely and accurateinformation to promote anunderstanding that will facilitateadjustment, offering appropriate(but not false) reassurance thatcorrects misconceptions andmisperceptions that might otherwiseunnecessarily increase the appraisalof risk, supplying information aboutlikely reactions and practicalstrategies to facilitate coping withdistress, and helping people identifysupports in their family and usefulresources in their community.27 Onesuch model for psychological first aidthat is readily accessible to thoseoutside the mental health field isListen, Protect, and Connect.28

Pediatricians and other pediatrichealth care providers should ensurethat all staff in their practice setting,including front office and supportstaff, are familiar with psychologicalfirst aid and ready to provide suchsupport to children and adults in theaftermath of a disaster. Given thatchildren and families who present tohealth care settings are often indistress, these are useful skills thatcan be used on a daily basis evenoutside the context of a disaster. Inaddition, having other adults who

TABLE 3 Factors Associated With anIncreased Risk of AdjustmentProblems After a Disaster24

1. Preexisting factors• Previous psychopathology, significant losses,attachment disturbances, limited copingskills, or other traumatic events.

• Socioeconomic differences that result inlower levels of postdisaster resources andsupport.

2. Nature of disaster experience• Injury of the child or death or injury of thoseclose to the child.

• Nature and extent of exposure, includingnumber of deaths, physical proximity todisaster, and extent of personal loss. Human-made disasters, especially terrorist attacksthat have a high degree of intentionality,generally create reactions that are moreprevalent and long-lasting.

• Extent of exposure to horrific scenes(including indirectly through the media).

• Child’s perception (at the time of the event)that his or her life was in jeopardy.

3. Subsequent factors• Personal identification with the disaster orvictims.

• Separation of child from parents or otherimportant caregivers as result of event.

• Loss of property or belongings; need torelocate or other disruption in daily routineor environment.

• Parental difficulty in coping, substance abuse,mental illness.

• Lack of supportive family communicationstyle.

• Lack of community resources and support.

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care for children, such as staff withinchild care facilities and schools, alsobe familiar with these strategies isimportant to create resilientcommunities that are able to supportchildren in the aftermath ofa disaster.

NOTIFICATION AND MEDIA COVERAGE

Children should be informed abouta disaster as soon as informationbecomes available. Children cansense when critical information isbeing withheld and when trustedadults are not being genuine; this, inturn, undermines their trust andsense of safety and compromises theability of these adults to be laterviewed as a source of support andassistance. Even very young childrenor those with developmentaldisabilities can sense the distress oftrusted adults. Children also oftenoverhear or otherwise learninformation about the events, suchas through the Internet or socialmedia or from conversations withother children.

The amount of information to sharewith individual children may vary bythe developmental level of thechildren or their typical copingstrategies. In general, older childrenseek and benefit from moreinformation. Irrespective of their age,children who generally cope bylearning more and understandingmore about a threat will often seekand benefit from a deeperunderstanding. But no matter thedevelopmental level or usual copingstyle, it is best to start with simpleand basic facts about the event andthen take the lead from children’squestions that follow about whatfurther information or explanationswill be helpful. If some time haspassed since the event, children canbe asked what they may have alreadyheard or learned about the event andwhat questions they now have. In thisway, misunderstandings andmisconceptions can be identified andaddressed. The goal is to help

children feel they understand what isgoing on enough for them to knowhow best to deal with the situation.

Media coverage often containsgraphic images and details, evocativepictures or stories, or strongemotional content that is not helpfulfor children or adults. Technologicaladvances and changes in the massmedia landscape now offer a stageunlike any in history, from whichdisaster events can reach anenormous audience in real-time.Continuous news coverage, broadcastover the ubiquitous presence oftelevisions, personal computers, theInternet, and smartphones, and anincreasingly sophisticated technologyfor live broadcasts has resulted in theunprecedented coverage of disastersin real-time and exquisite detail,allowing viewers to experience theevent almost as if they werephysically present. This expandedmedia presence has led to a broaderpopulation of children and youth witheither primary or secondary exposureto an event.8,29,30

Parents should, therefore, limit theamount of media coverage in theimmediate aftermath of a disasterfor children and all members of thefamily, including television, radio,Internet, and social media, andremember that children oftenoverhear and pick up on mediacoverage being viewed by adults. Ifmedia coverage is going to beviewed by children, parents maywant to record and view it first and/or watch along with children. Indiscussions, avoid graphic detailsand excessive information that is nothelpful to understand what hashappened or learn what to do tokeep safe or to cope. If no furtherunderstanding is resulting fromcontinued viewing of coverage of theevent, then it is best for even adultsto discontinue such viewing. Rightafter a disaster occurs is a good timeto turn off electronic devices that arebeing used for entertainment andcome together physically and

emotionally as a family unit toprovide support to one another.

PROMOTING EFFECTIVE COPINGSTRATEGIES

Advocating specific coping strategiesfor children after a disaster can bechallenging because of theinteraction among a number offactors, including a child’s personalcharacteristics, preexistingfunctioning, and developmentallevel.10 Research on stressmanagement has demonstrated thatdirectly facing a problem isassociated with better outcomes, andavoiding the situation or onlyreacting emotionally can be moreproblematic, but outcomes may varydepending on the nature of thestressors. Problem-focused copingmay be most beneficial whenstressors can be controlled by thechild. Avoidant or emotion-focusedcoping might be more productivewhen stressors cannot beremoved.31 The influence of a child’scaregivers is also important toconsider; parents and other caringadults may be so overwhelmedthemselves after a disaster that theyare unable to appreciate the distressin their children. Adults often hidetheir own distress to protect theirchildren or provide them falsereassurance; they may intentionallyor unintentionally imply thatchildren should not be upset. Inreality, if children feel worried, thenthey are worried. Telling them thatthey should not be worried is usuallyineffective and undermines thepotential for children to own theirfeelings and learn strategies to dealwith them.

Although it is important for childrento be encouraged to express theirfeelings and concerns, it is equallyimportant that adults help fostera range of coping skills in children sothat they have strategies they can useto address distress and troublingfeelings. If parents can communicatesome of their own distress, with an

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emphasis on sharing personalstrategies they have used to copeeffectively with that distress (thatmay be applicable to the children),they provide opportunities forchildren to learn coping strategies.For example, a parent can share thathe was upset about the destruction oftheir home and loss of personalproperty and that this interfered withhis sleep or caused some sadness, andthen discuss how talking to anothertrusted adult, getting some exercise,meditating, helping others who werealso affected, and so forth, helped himfeel better. Pediatricians can supportfamilies by providing examples ofa variety of coping strategies (eg, bothproblem focused and emotionfocused, approach and avoidance)while modeling emotional regulationand a positive attitude. Suggestingthat children contribute to a food orclothing drive for those who lost theirhomes or draw hopeful pictures forvictims in hospitals can help childrenfeel like they are contributing.Adolescents may wish to writepositive comments in social media toencourage those who may be isolatedand distressed after a disaster.Children may also benefit from thepediatrician sharing his or her ownunderstanding of the disaster andrecovery process which will helpchildren better interpret all that isgoing on (eg, “The tornado createda big mess, but we are pullingtogether as a community,” or “Livingin a shelter with all the other childrenin the neighborhood must have beena real adventure”). Communicatingwith children in this manner aftera disaster may help them begin tomake sense of all that has occurredand increase their self-confidencebecause they have coped with anevent that once appearedoverwhelming.

Children may feel guilt or shameassociated with the disaster, evenwhen they have no objective reasonto feel responsible. They mayquestion what they did or failed to dothat led to or contributed to the

impact of the disaster; they maywonder what they could have done tohave improved the outcome. It isoften helpful to reassure childrenabout their lack of responsibility.When children persist in beliefs thattheir inadvertent comments oractions were somehow contributory(eg, a child has an argument witha parent just before the parent iskilled in a car accident duringa severe storm), it may be helpful toclarify that their behavior orconversation was in no way intendedto cause such harm and did not do so.Although such guilt and shame maybe common in the aftermath ofa disaster, if left unaddressed, thesepainful self-incriminating emotionsmay cause significant distress andlong-term adjustment problems. Self-blame and survivor’s guilt mayremain with children and can lead tolong-term difficulties.32

Children, just as do adults, often feelpowerless in the aftermath ofa disaster; this may be improved ifthey are able to help others. It is,therefore, beneficial to help childrenidentify practical actions they cantake to aid others, whether victims ofthe disaster or others in need in thefamily or broader community.

Psychotropic medications shouldgenerally be avoided in themanagement of children’s distressafter a disaster. Children need todevelop an understanding of theevent and learn to express and copewith their reactions. Medicationshould, therefore, not be used tosuppress reactions such as crying orfeelings such as sadness and shouldnot be used to blunt children’sawareness of the event. Referral to orconsultation with a child mentalhealth professional with expertise inthe management of childhood traumais recommended for primary careproviders when considering use ofpsychotropic medications forpersistent or severe posttraumaticreactions.21

CONSULTATION TO SCHOOLS

Pediatricians can work with localschools to assist in recovery effortsfor students. After a disaster, schoolsare likely to see negative effects onlearning among their students, andstaff may find it difficult to teach ormanage their classes unless adequatesupports are put in place immediatelyafter the disaster and maintaineduntil recovery has been completed.Schools can serve as an effectivemeans to reach the broad populationof children and families affected bythe disaster and a cost-effective andaccessible site for the delivery ofbasic and supportive services byprofessionals already familiar to thestudents and trusted by the families.Schools are also sites that areamenable to psychoeducation,psychological first aid, and groupsupportive services. Schools areparticularly well suited to monitoringchildren’s adjustment over time andcan be used to provide additionalmental health services or referral tocommunity services.

Schools should have well-establishedguidelines for crisis response andwell-trained crisis responseteams.33,34 All school staff shouldhave basic skills in psychological firstaid28 and basic bereavementsupport.18,35 Resources for trainingand guidance for schools respondingto crisis and loss can be found at theWeb site for the National Center forSchool Crisis and Bereavement (www.schoolcrisiscenter.org) and theCoalition to Support GrievingStudents (www.grievingstudents.org).

SHORT- AND LONG-TERMINTERVENTIONS

The goal of short-term intervention isto address immediate physical needsand to keep children safe andprotected from additional harm; tohelp children understand and beginto accept the disaster; to identify,express, validate, and cope with theirfeelings and reactions; to reestablisha sense of safety through routines and

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family connections; to start to regaina sense of mastery and control overtheir life; and to return to child careor school and other developmentallyappropriate activities.21,36 Childrenwho are grieving the loss of a familymember or friend may benefit frombereavement counseling or support.Those experiencing or at high-risk ofdeveloping PTSD should be offeredreferral to a mental healthprofessional experienced in cognitive-behavioral therapy that addressestrauma. School-based grouptreatment using cognitive-behavioraltreatment approaches, such asCognitive-Behavioral Intervention forTrauma in Schools, also has beenshown to be effective.37 Children withmultiple stressors and/or chronic andongoing trauma and those withlimited external supports within theirfamily, school, and broadercommunity are more likely to requirecounseling or other formal support.

In general, children are helped byreturning to their routine, such aschild care, school, organized activities,and sports, as soon as practical aftera disaster, as long as the necessarysupport systems andaccommodations (such astemporarily reducing or providingmore time for homeworkassignments or tests) are in place.Expectations for children’s classroomperformance and behavior may needto be modified until their adjustmentdifficulties no longer interfere withtheir cognitive, emotional, and socialfunctioning. Parents and educatorsmay be falsely reassured, however, bya return to routine, misinterpretingthat children are more resilient thanthey may be and are no longer inneed of support or assistance oncethey have begun the process ofrecovery. Children often need ongoingsupport for months or longer aftera major disaster, and some willrequire more intensive interventions.If supports and assistance arewithdrawn before full recovery hasoccurred, some children will fail toreturn to their baseline level of

adjustment and coping and may showcontinued impairment for anextended period of time.

In the immediate aftermath ofa disaster, communities often becomemore cohesive for a time period, withmembers of the community providingand receiving support that had notbeen expressed before the disaster.This “honeymoon phase” is oftencharacterized by some initialimprovement in coping amongmembers of the community but isoften not sustained. Some vulnerableindividuals, despite an initialimprovement, may be challengedwithout ongoing support; they maycome to feel hopeless about theirability to return to their baselinefunctioning or doubt they will everrecover fully. Depression andsuicidality, especially among adults,may therefore be seen later, such asseveral months after the disasterevent, despite initial improvementbut before substantial recoveryoccurs. These observations have beennoted among communities affectedby major disasters and represent animportant vulnerability.38,39

In contrast, if children and adultsreceive sufficient and sustainedsupport, and have the internalresources to adjust to the event, theymay emerge with new skills that theycan use to cope with future adversity.In this way, disasters may result inposttraumatic growth among bothchildren and adults. Suchposttraumatic growth is more likelyto occur when children are providedsupport of sufficient intensity andduration.24

Schools also can provideopportunities for students to helpothers as they and their communitiesrecover from the event and itsaftermath. Having the opportunity tohelp others often assists in theadjustment and coping of thestudents providing such assistance.Schools also can help studentsidentify appropriate mechanisms formemorialization and

commemoration. These activitiesprovide a means for expressing griefand loss in a shared fashion, therebydecreasing isolation and promotingcohesion. When deaths have occurredas a result of the disaster, thesemeans of remembrance can reaffirmthe personal attachment to theindividual(s) who died and reassurethe bereaved that the loved one willbe remembered. Any such activitiesshould involve the activeparticipation of children andadolescents both in the planning andimplementation to ensure that theyare developmentally appropriate andpersonally relevant for them. Simplyput, a memorial planned by adults forchildren is most likely to betherapeutic for the adults.18

PROFESSIONAL SELF-CARE

Pediatricians, when they aremembers of the community affectedby a disaster, also experience theirown personal effects as well as theeffects on family and friends. Despitethis, they must contend with theincreased needs of their patientsduring a time when conditions maybe austere and the supportsavailable for the practice of medicinemay be significantly compromised.Physicians may find that they need toprovide more direct mental healthservices and basic medical serviceswhile also helping families navigatethe process to obtain social services.The “emotional labor” duringdisasters can be highly strenuous. Inaddition, it can be difficult to witnessthe distress of patients and theirfamilies (as well as that of otherstaff); vicarious traumatization canresult from repeated exposure to theevocative stories of patients andtheir families. Reminding oneselfthat one is making a positive impact,when surrounded by enormousneeds that seem beyond one’scontrol, can be challenging.Establishment of flexible routines,monitoring oneself for negativethoughts, creating realistic

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professional expectations, settinghealthy boundaries betweenpersonal time and professionalhours, practicing daily personalstress management, makinga conscious attempt to reducecompassion fatigue, and use of bothprofessional and social supports,including counseling, will increasethe likelihood that pediatricians willremain able to attend to the needsand feelings of their patients as wellas their own.6

Pediatricians, as a group, need toacknowledge that it is acceptable tobe upset when situations areparticularly distressing, need tobecome willing to ask for and acceptassistance whenever it may be helpful(as opposed to only when it is“absolutely needed”), and need toactively take steps to care for theircolleagues and themselves. TheAmerican Academy of Pediatrics hasidentified a range of resources thatpediatric health care providers canuse to promote the recovery ofchildren, families, and communities(www.aap.org/disasters/adjustment).As a professional organization, theAmerican Academy of Pediatrics hasidentified professional self-care as animportant priority and has focusedfunding, strategic planning efforts,and continuing education initiativesin this area.

Most pediatricians enter theprofession because of a heartfeltdesire to help children and familiesmost in need. If adequately preparedand supported, pediatricians who areable to draw on their skills to assistchildren, families, and communities torecover after a disaster will find thework to be particularly rewarding,although at times exhausting. Thereare few other opportunities to havesuch a dramatic effect on the lives ofchildren, their families, and thecommunity.

LEAD AUTHORS

David J. Schonfeld, MD, FAAPThomas Demaria, PhD

DISASTER PREPAREDNESS ADVISORYCOUNCIL, 2014-2015

Steven Elliot Krug, MD, FAAP, ChairpersonSarita Chung, MD, FAAPDaniel B. Fagbuyi, MD, FAAPMargaret C. Fisher, MD, FAAPScott Needle, MD, FAAPDavid J. Schonfeld, MD, FAAP

LIAISONS

John James Alexander, MD, FAAP – US Food and Drug

Administration

Daniel Dodgen, PhD – Office of the Assistant Secretary

for Preparedness and Response

Andrew L. Garrett, MD, MPH, FAAP – Office of the

Assistant Secretary for Preparedness and Response

Georgina Peacock, MD, MPH, FAAP – Centers for

Disease Control and Prevention

Sally Phillips, RN, PhD – Department of Homeland

Security, Office of Health Affairs

Erica Radden, MD – US Food and Drug Administration

David Alan Siegel, MD, FAAP – National Institute of

Child Health and Human Development

STAFF

Laura Aird, MSSean DiederichTamar Magarik Haro

COMMITTEE ON PSYCHOSOCIAL ASPECTS OFCHILD AND FAMILY HEALTH, 2014-2015

Michael W. Yogman, MD, FAAP, ChairpersonThresia B. Gambon, MD, FAAPArthur Lavin, MD, FAAPLTC Keith M. Lemmon, MD, FAAPGerri Mattson, MD, FAAPLaura Joan McGuinn, MD, FAAPJason Richard Rafferty, MD, MPH, EdMLawrence Sagin Wissow, MD, MPH, FAAP

LIAISONS

Sharon Berry, PhD, LP – Society of Pediatric

Psychology

Terry Carmichael, MSW – National Association of

Social Workers

Edward R. Christophersen, PhD, FAAP – Society of

Pediatric Psychology

Norah L. Johnson, PhD, RN, CPNP-BC – National

Association of Pediatric Nurse Practitioners

Leonard Read Sulik, MD, FAAP – American Academy

of Child and Adolescent Psychiatry

CONSULTANT

George J. Cohen, MD, FAAP

STAFF

Stephanie Domain, MS, CHESTamar Magarik Haro

ABBREVIATION

PTSD: posttraumatic stressdisorder

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