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Psychosocial Psychosocial Consequences of Disaster Consequences of Disaster
in Childrenin Children
PDLS version 2PDLS version 2
draftdraft
Gretchen K. Lipke, MDGretchen K. Lipke, MD
ObjectivesObjectives
The student will be able to describe:The student will be able to describe: Expected reactionsExpected reactions Unhealthy reactionsUnhealthy reactions Coping mechanismsCoping mechanisms Family role in child’s responseFamily role in child’s response
It is impossible to separate the It is impossible to separate the effects of disaster on children and effects of disaster on children and their families and the two should be their families and the two should be considered as a unit.considered as a unit.
Children in DisasterChildren in Disaster
Mass casualty events affect childrenMass casualty events affect children• Directly, as victimsDirectly, as victims• Indirectly, as families are affected Indirectly, as families are affected
Children as Direct VictimsChildren as Direct Victims
Children as indirect victimsChildren as indirect victims
Oklahoma CityOklahoma City
3200 high school students in city 3200 high school students in city given screening questionnaire 7 given screening questionnaire 7 weeks after bombingweeks after bombing
1/3 knew someone killed1/3 knew someone killed Retrospective scores of initial arousal Retrospective scores of initial arousal
and fear predictive of PTSD at 7 wksand fear predictive of PTSD at 7 wks Raised concerns about TV impact on Raised concerns about TV impact on
traumatized youthtraumatized youth
Children as VictimsChildren as Victims
Psychological reactionsPsychological reactions• Immediate Immediate • Short-termShort-term• Long-termLong-term
OverlapOverlap Normal variation by ageNormal variation by age
Jupiter shipping disasterJupiter shipping disaster
Boat sank – 217 teenaged survivorsBoat sank – 217 teenaged survivors At 5-8 year follow-up:At 5-8 year follow-up:
• 111 (52%) had PTSD at some point111 (52%) had PTSD at some point• Control group 3.4% incidenceControl group 3.4% incidence• 90% onset within 6 months90% onset within 6 months• 1/3 recovered within 1 year1/3 recovered within 1 year• 1/3 still have PTSD 8 year after incident1/3 still have PTSD 8 year after incident
Immediate ReactionsImmediate Reactions
Shock, grief, lossShock, grief, loss Helping, as coping mechanismHelping, as coping mechanism AngerAnger Guilt at surviving, at preserving Guilt at surviving, at preserving
material possessions or family when material possessions or family when friends and neighbors did notfriends and neighbors did not
Short-term reactionsShort-term reactions
During and immediately after eventDuring and immediately after event Continuum with immediate and into Continuum with immediate and into
long-termlong-term Overlap; no clear delineation of Overlap; no clear delineation of
changes, and it may differ among changes, and it may differ among survivors, even within family unit.survivors, even within family unit.
BUT children model the adult BUT children model the adult behavior within their family unitbehavior within their family unit
Short term reactionsShort term reactions
DisbeliefDisbelief DenialDenial AnxietyAnxiety GriefGrief AltruismAltruism ReliefRelief
Short-term reactionsShort-term reactions
Grief, loss, anger, guiltGrief, loss, anger, guilt Coping strategiesCoping strategies
• Regression – loss of developmental Regression – loss of developmental milestonesmilestones
• Clinging and increased dependencyClinging and increased dependency• Helpfulness – more useful in older Helpfulness – more useful in older
childrenchildren• Acting out – competing for attentionActing out – competing for attention
RegressionRegression
Common after traumaCommon after trauma Short-lived behavior –few weeksShort-lived behavior –few weeks Not intentional – child needs Not intentional – child needs
reassurancereassurance Thumb sucking, whining, fear of the Thumb sucking, whining, fear of the
dark, loss of toilet training and dark, loss of toilet training and speech patternsspeech patterns
Loss of previous dependability, Loss of previous dependability, confusion, attention seekingconfusion, attention seeking
Short term reactionsShort term reactions
1 week after Armenian earthquake 1 week after Armenian earthquake (12/88), survey of Armenian (12/88), survey of Armenian adolescents in Los Angeles showedadolescents in Los Angeles showed• Strong identification with victimsStrong identification with victims• Felt personally affectedFelt personally affected• Group activities to escape grief Group activities to escape grief
reactionsreactions
Armenian earthquake resultsArmenian earthquake results
• Group pressure to accelerate helping Group pressure to accelerate helping effortsefforts
• Group cohesion improvedGroup cohesion improved• Preference to preserve communal Preference to preserve communal
values, even over helping earthquake values, even over helping earthquake victimsvictims
• ““participation envy” – survivor guilt, participation envy” – survivor guilt, envy and resentment over being envy and resentment over being excluded from a unique and rallying excluded from a unique and rallying communal experience communal experience
Long term reactionsLong term reactions
Coping mechanismsCoping mechanisms• RegressionsRegressions• Acting outActing out• Replaying eventReplaying event• ClinginessClinginess• Attention seeking behaviorAttention seeking behavior
Long term reactionsLong term reactions
Other Other • Somatic complaints – headache and Somatic complaints – headache and
stomach aches commonstomach aches common• Repetitive re-enactment – drawings, Repetitive re-enactment – drawings,
role-playing, dolls and puppetsrole-playing, dolls and puppets• Risk-taking behaviors – thrill seeking, Risk-taking behaviors – thrill seeking,
drug usedrug use• Withdrawal – from school, friends, usual Withdrawal – from school, friends, usual
activitiesactivities
The diagnosis of PTSD The diagnosis of PTSD
Three categories lasting over a Three categories lasting over a month:month:• Re-experiencing of the event through Re-experiencing of the event through
play or trauma specific nightmares.play or trauma specific nightmares.• Routine avoidance of the reminders of Routine avoidance of the reminders of
the event or a general lack of the event or a general lack of responsiveness.responsiveness.
• Increased sleep disturbances, irritability Increased sleep disturbances, irritability and poor concentration.and poor concentration.
Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder
Interpersonal violence or life-Interpersonal violence or life-threatening accidents or disastersthreatening accidents or disasters
More likely after direct exposureMore likely after direct exposure Also if trauma witnessed or loved Also if trauma witnessed or loved
ones involved with associated horror ones involved with associated horror and shockand shock
PTSD factorsPTSD factors
Degree of controllability, Degree of controllability, predictability and perceived threatpredictability and perceived threat
Relative success of attempts to Relative success of attempts to minimize injury to oneself or othersminimize injury to oneself or others
Actual lossActual loss Intensified if wounded, exposed to Intensified if wounded, exposed to
heat, cold or painheat, cold or pain
Symptoms of PTSDSymptoms of PTSD
Stressor/triggerStressor/trigger Re-experiencing the eventRe-experiencing the event Avoidance of remindersAvoidance of reminders Unwanted recollectionsUnwanted recollections At least one month’s durationAt least one month’s duration
Age and developmentAge and development
Infants to teens – broad range of Infants to teens – broad range of abilitiesabilities
Similar responses will manifest Similar responses will manifest differently at different agesdifferently at different ages
Differences by genderDifferences by gender Responses vary by gender. Boys Responses vary by gender. Boys
take longer to recover and exhibit take longer to recover and exhibit aggressive, antisocial and violent aggressive, antisocial and violent behaviors.behaviors.
Girls are more distressed, have more Girls are more distressed, have more verbal emotions, ask more questions verbal emotions, ask more questions and have more frequent thoughts and have more frequent thoughts concerning the disaster.concerning the disaster.
Parental InvolvementParental Involvement Chernobyl follow-up study: 11 years after Chernobyl follow-up study: 11 years after
evacuation, comparison of 300 children evacuation, comparison of 300 children aged 10-12 at time of study evacuated (as aged 10-12 at time of study evacuated (as infants or in utero) with 300 homeroom infants or in utero) with 300 homeroom classmates never in radiation affected classmates never in radiation affected area.area.
Evac moms rated child’s well-being as Evac moms rated child’s well-being as signif worse, esp somatic despite normal signif worse, esp somatic despite normal PE and blood work.PE and blood work.
Evac kids rated their mental health similar Evac kids rated their mental health similar to classmates except for Chernobyl-related to classmates except for Chernobyl-related anxietyanxiety
Chernobyl and adolescentsChernobyl and adolescents
50 adolescents 9 years after accident50 adolescents 9 years after accident Uncertainty about radiation exposureUncertainty about radiation exposure Frequent thoughts about accidentFrequent thoughts about accident Worried about radiation exposure as Worried about radiation exposure as
a cause of any health problemsa cause of any health problems
PTSD in adolescentsPTSD in adolescents
217 young adults who survived 217 young adults who survived shipping disaster in adolescence shipping disaster in adolescence followed for 5-8 yearsfollowed for 5-8 years
Duration and severity of PTSD most Duration and severity of PTSD most strongly related not to disaster-strongly related not to disaster-related factors, but pre-disaster related factors, but pre-disaster vulnerability and whether survivors vulnerability and whether survivors received school-based supportreceived school-based support
Hurricane AndrewHurricane Andrew
92 492 4thth -6 -6thth graders graders 15 months prior – self reports of 15 months prior – self reports of
anxiety, behavior assessment by anxiety, behavior assessment by peers and teachers and academic peers and teachers and academic skillsskills
Repeated testing at 3 and 7 months Repeated testing at 3 and 7 months post-disasterpost-disaster
At 7 months, exposure and pre-At 7 months, exposure and pre-disaster anxiety predictive of PTSDdisaster anxiety predictive of PTSD
Attention seekingAttention seeking
Infants – crying and irritabilityInfants – crying and irritability Toddlers – regression from Toddlers – regression from
developmental milestonesdevelopmental milestones Preschool – hitting and bitingPreschool – hitting and biting School – defiance of home and school School – defiance of home and school
rulesrules Adolescents – truancy, risk-taking Adolescents – truancy, risk-taking
behaviorsbehaviors
Disruption of Normal PatternsDisruption of Normal Patterns The cardinal effect of disaster and children in The cardinal effect of disaster and children in
adolescents is a disruption of their lives adolescents is a disruption of their lives which leads to a loss of reliability, cohesion, which leads to a loss of reliability, cohesion, and predictability.and predictability.
Toddlers respond with increased Toddlers respond with increased dependency.dependency.
School-age children show evidence of trauma School-age children show evidence of trauma with talk and play about trauma and hostility with talk and play about trauma and hostility to peers and family.to peers and family.
Adolescents may also withdraw and have Adolescents may also withdraw and have decreased interest and experience fatigue, decreased interest and experience fatigue, hypertension, hostility and loss of objectivity.hypertension, hostility and loss of objectivity.
Disruption RecommendationsDisruption Recommendations
Parents, teachers, and healthcare workers Parents, teachers, and healthcare workers should create and maintain a predictable should create and maintain a predictable schedule for children.schedule for children.
Night lights, stuffed animals, and Night lights, stuffed animals, and reassurance are helpful.reassurance are helpful.
Compassion is helpful but punishment is Compassion is helpful but punishment is not.not.
Consultation with psychiatrist or Consultation with psychiatrist or psychiatric social worker may be a benefit.psychiatric social worker may be a benefit.
Stress response in childrenStress response in children
““Fight or flight”Fight or flight” Adrenaline/epinephrine mediatedAdrenaline/epinephrine mediated Arousal stateArousal state Increased startle, response, agitationIncreased startle, response, agitation Increased heart rate, respiratory Increased heart rate, respiratory
rate, blood pressure.rate, blood pressure.
Alternate stress responseAlternate stress response
““Freeze and hide”Freeze and hide” Vagal nerve stimulusVagal nerve stimulus Opposite of “fight or flight”Opposite of “fight or flight” Blunted reactions, affect, responsesBlunted reactions, affect, responses Lowered heart rate, respiratory rate, Lowered heart rate, respiratory rate,
blood pressureblood pressure Syncope may resultSyncope may result
Responding to children’s needsResponding to children’s needs
Parental cues most importantParental cues most important Acknowledge danger and frightAcknowledge danger and fright Calm reassurance provides a sense Calm reassurance provides a sense
of safetyof safety Let children know that feeling upset Let children know that feeling upset
is normalis normal Extra time and attention.Extra time and attention.
Responding to children’s needsResponding to children’s needs
Parents should know age appropriate Parents should know age appropriate responsesresponses
Monitor and limit media exposure to Monitor and limit media exposure to disaster coveragedisaster coverage
Early counseling may reduce long Early counseling may reduce long term negative effectsterm negative effects
Rehearsal of plan reduces anxiety Rehearsal of plan reduces anxiety and gives a a sense of controland gives a a sense of control
Responding to children’s needsResponding to children’s needs
Talking through what happenedTalking through what happened Replaying, for younger children, Replaying, for younger children,
similar to talking throughsimilar to talking through Perspective on family impactPerspective on family impact Probability of recurrence or (for Probability of recurrence or (for
distant events) personal impactdistant events) personal impact
Normal RecoveryNormal Recovery
Talking with othersTalking with others Coping mechanismsCoping mechanisms
• Learning healthy mechanismsLearning healthy mechanisms CounselingCounseling
Post disaster interventionsPost disaster interventions
School based group sessions have School based group sessions have worked wellworked well• Kauai 2 years after Hurricane InikiKauai 2 years after Hurricane Iniki• 4200 children grades 2-6 screened for 4200 children grades 2-6 screened for
trauma related psychosocial symptomstrauma related psychosocial symptoms• 248 with highest levels of symptoms 248 with highest levels of symptoms
randomly assigned to individual randomly assigned to individual counseling or groups sessions.counseling or groups sessions.
• Equal improvement maintained at 1 Equal improvement maintained at 1 year follow-upyear follow-up
Hurricane Hugo blew down the Hurricane Hugo blew down the broccolibroccoli
Role-playingRole-playing DrawingsDrawings Expressing the child’s fears through Expressing the child’s fears through
another characteranother character