1 Current Issues in Disaster Mental Health: Clinical Applications Betty Pfefferbaum, M.D., J.D. University of Oklahoma Health Sciences Center May 2007

2 Learning Objectives Appreciate the importance of child disaster mental health Identify children’s reactions to disasters and the factors that influence their reactions Comprehend the rationale in intervention approaches Recognize the limitations in children’s disaster interventions

3 Through Children’s Eyes, WHO

4 Definition – A severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the altered community World Health Organization, 1992 Disaster

5 Are Disasters Increasing?

6 Reasons for Increase in Disasters Poverty and Vulnerability Climate Change Urbanization Poor Building and Land Use

7 Children’s Reactions and the Factors that Influence Their Reactions

8 Hurricanes 2004 Charley (August 13) – Category 4 Florida’s Southwest coast – $15 billion Frances (September 5) – Category 2 Florida’s East coast – $9 billion Ivan (September 16) – Category 3 Alabama near Florida border – $14 billion Jeanne (September 26) – Category 3 Florida’s East coast – $7 billion Blake et al. NOAA/NWS/NCEP/TPC/NHC April, 2007; Sallenger et al. 2006

9 Hurricane Katrina August 29, 2005 Category 3 80 mph winds >90 mph gusts $81 billion Knabb et al & National Hurricane Center, 2005;NOAA’s Technical Report,

10 Hurricane Andrew 1992 August 1992 Category 5 (Winds > 160 mph) 61 deaths 135,000 single family and mobile homes destroyed or damaged $26 billion dollars

11 Model Primary predictors of posttraumatic stress – Exposure – Perceived life threat – Life-threatening experiences – Loss and disruption – Child characteristics – Sex – Age – Ethnicity – Social environment – Access to social support – Child coping Vernberg et al. 1996

12 % PTSD Symptom Severity Vernberg et al school children grades 3 to 5 3 months after Hurricane Andrew Overall mean in moderate range

13 Predictors of PTSD Symptoms: 3 Months Vernberg et al % variance explained by: Exposure Child characteristics Access to social support Coping Perceptions of support from Parents Classmates Teachers Close friends

14 Access to Social Support * ** Support from teachers and classmates accounted for small but significant variance in PTSD symptoms Vernberg et al Model with exposure, demographics, access to social support, and coping explained > 60%

15 Exposure at 7 Months La Greca et al rd to 5 th graders 3 schools Southern Dade County

16 Posttraumatic Stress: Hurricane Andrew La Greca et al No grade or sex differences Children with moderate to very severe reactions early were at risk for persistent stress reactions

17 Posttraumatic Stress: 7 and 10 Months Model accounted for 39.1% variance at 7 months 24% variance at 10 months La Greca et al. 1996

18 Posttraumatic Stress La Greca et al Mean RI Score% Level PTSD n = 92 Grades 4-6

19 Predictors of Posttraumatic Stress La Greca et al. 1998

20 Emotional/Behavioral Outcome Predictors – Exposure – Child characteristics – Demographics – Pre-existing conditions – Coping – Recovery environment

21

22 Posttraumatic Stress at 2 Months Shaw et al Children in Hi-Impact school were more likely to have severe posttraumatic stress N = % Hi-Impact 43% Lo-Impact Mean = 8.2 yrs

23 Posttraumatic Stress in Hi-Impact School Shaw et al N = 30 Severe posttraumatic stress decreased 70% with moderate to severe posttraumatic stress at 21 months

24 Disruptive Behavior at 8 Months There was a marked decrease in disruptive behavior in the Hi-Impact school initially followed by a return to the level of the previous year Disruptive behavior in the Lo-Impact school remained at much higher levels for longer returning to the level of the previous year at the end of the academic year Shaw et al. 1995

25 Hi-Impact Disruptive Behaviors  The initial decrease in disruptive behaviors in Hi-Impact school was followed by  A rebound (3-5 months) and  A relatively quick return to normalcy (9 months)  The effects may be associated with  Increased mental health professionals, mobile crisis teams, and crisis intervention Shaw et al. 1995

26 Lo-Impact Disruptive Behaviors  The increase in disruptive behaviors in Lo- Impact school  Remained higher for longer  Returned to level of the previous year at the end of the academic year  This may be related to  Relocation of students from more directly affected schools and  Increased demand for and shift of resources to directly affected schools Shaw et al. 1995

27 Interventions Early Interventions Assessment General Therapeutic Principles Evidence Base for Interventions

28 Goals of Early Intervention  Restore a sense of safety and security  Protect from excessive exposure to reminders  Validate experiences and feelings  Restore equilibrium and routine  Open and enhance communication  Provide support

29 Recognize Hierarchy of Needs Survival, safety, security Food, shelter Health (physical and mental) Triage Orient to immediate service needs Communicate with family, friends, and community NIMH 2002

30 Assumptions and Principles In the immediate post-event phase, expect normal recovery Presuming clinically significant disorder in the early post-event phase is inappropriate except in those with a pre-existing condition NIMH 2002

31 Psychological First Aid First aid is “the first aid received by a person in trouble” American Psychiatric Association

32 Psychological First Aid Protect survivors from further harm Reduce physiological arousal Mobilize support for those who are most distressed Keep families together and facilitate reunion of loved ones Provide information and foster communication and education Use effective risk communication techniques NIMH 2002

33 Psychological First Aid Manuals to guide the delivery of PFA – National Child Traumatic Stress Network and National Center for PTSD – American Red Cross – International Federation of Red Cross and Red Crescent Societies

34

35 Core Actions and Goals - 1 Make contact and engage – Respond to contacts initiated by survivors – Initiate contacts in a non-intrusive, compassionate, and helpful manner Provide safety and comfort – Enhance immediate and ongoing safety – Provide physical and emotional comfort NCTSN & NCPTSD 2006

36 Core Actions and Goals - 2 Stabilize – Calm and orient emotionally overwhelmed or disoriented survivors Gather information – Identify immediate needs and concerns – Gather additional information NCTSN & NCPTSD 2006

37 Core Actions and Goals - 3 Offer practical assistance – Help survivors with immediate needs and concerns Connect with social supports – Help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources NCTSN & NCPTSD 2006

38 Core Actions and Goals - 4 Provide information on coping – Provide information about stress reactions and coping to promote adaptive functioning Link with collaborative services – Link survivors with available services needed at the time or in the future NCTSN & NCPTSD 2006

39 Assessment  Parent report provides objective information in some areas  It is essential to assess children directly as parents may under-estimate their distress  Parents may be focused on other issues  Parents may be overwhelmed themselves  Parents may use denial  Children may be especially compliant

40 World Trade Center 1993 February 26, killed > 1,000 injured Thousands trapped CNN (1997) & The Joint Terrorism Task Force

41 Children’s Symptoms at 3 and 9 Months Exposure – 9 trapped in elevator – 13 on observation deck – 27 controls Measures – Child and parent report Koplewicz et al

42 Posttraumatic Stress and Fear Posttraumatic StressIncident Fear Koplewicz et al Parent report: significant decrease Child report: no decrease

43 General Therapeutic Principles  Therapy must provide a safe environment to process painful and overwhelming experiences  Treatment involves transforming the child’s self concept from victim to survivor  Avoidance is a core feature of posttraumatic stress and may impede treatment  Treatment may lead to heightened arousal and distress

44 Treatment Approaches  Supportive psychodynamic approaches  Play therapy  Cognitive-behavioral approaches  Family therapy  Group therapy  Medication  Rarely needed  Adjunctive if used

45 Family Interventions  Identify and address parental reactions and needs  Educate parents about the effects of their own reactions on their children  Inform parents about children’s disaster reactions in general and about their own child’s experiences and reactions  Assist families with secondary stresses  Help families anticipate the needs of children

46 Small Group Interventions  Promote sense of order, control, and security  Accommodate more children  Provide opportunities for children to - Share with and reassure each other - Practice new skills  Educate children about trauma responses  Assess coping and its effectiveness  Identify those needing more intense interventions

47 School-based Interventions - 1 Disaster reactions may emerge in the context of school School settings provide access to children and the potential for enhanced compliance Schools are a natural support system where stigma associated with treatment is diminished Services in schools help normalize children’s experiences and reactions Wolmer et al. 2003; Wolmer et al. 2005

48 School-based Interventions - 2 School personnel are familiar with, and deal with, situational and developmental crises School curricula already address prevention in other mental health areas School personnel have opportunities to observe children Supervision, feedback, and follow-up are possible Wolmer et al. 2003; Wolmer et al. 2005

49 School-based Interventions - 3 Classroom settings are developmentally-appropriate Classroom settings provide – Predictable routines – Consistent rules – Clear expectations – Immediate feedback – Stimulus for curiosity and engaging learning skills School-based interventions facilitate peer interactions and support which may prevent withdrawal and isolation Wolmer et al. 2003; Wolmer et al. 2005

50 Content of Interventions Trauma – Emotional distress – Arousal – Reminders Loss and grief Anxiety Depression Safety Anger Conduct problems Concentration problems Coping Social support

51 Intervention Techniques Interventions use – Psycho-education – Emotional processing – Projective techniques – Cognitive-behavioral approaches – Anxiety-reduction and management techniques – Exposure – Coping skills enhancement – Social support – Resilience building Interventions use individual, group, or mixed format

52 Limitations in General Convenience samples of modest size – Not able to generalize to – Other groups of children – Other types of disaster – Other settings (geographic or clinical/community) Lack comparison groups including comparison to natural recovery – Not able to determine – If the intervention was better than another intervention or even natural recovery – What aspect of the intervention was effective Lack long term follow up

53 QUESTIONS