1. P-FLASH with Kids: PRACTICAL FRONT LINE ASSISTANCE & SUPPORT FOR HEALING Betty Pfefferbaum, MD, JD 1 Carol S. North, MD 2 Robin H. Gurwitch, PhD 1 Barry Hong, PhD 2 University of Oklahoma Health Sciences Center 1 Washington University School of Medicine 2

2. I NTRODUCING... Y OUR P RESENTERS I NTRODUCING... Y OUR P RESENTERS

3. P URPOSE To provide a tool kit for practical, front line postdisaster mental health interventions with children following the 9/11 terrorist attacks

4. G OALS OF THE T RAINING 1) Differentiate normative and pathological responses 2) Review disaster responses, assessment, and treatment 3) Provide disaster mental health education and skill-building

5. Please introduce yourself to the group What issues do you face? I NTRODUCTIONS

6. T OPICS Part 1: Reactions to disaster Part 2: Assessment Part 3: Intervention

7. Reactions P ART 1

8. R EACTIONS  Posttraumatic stress disorder  Other disorders  Reactions  Factors affecting response

9. D ISASTERS  Overwhelming events  Affect many individuals and entire communities  Result in:  Property damage  Disruption of daily life  Human suffering, injury, and/or loss of life

10.  Innocent people targeted  Unpredictable T ERRORISM AS U NIQUE T RAUMA  Intentional human design - to undermine sense of safety and trust in government and social institutions

11. T IMING: P HASES OF D ISASTER Disaster phases:  Pre-disaster  Acute impact  Early post-disaster  Long-term post-disaster

12.  Normal reactions  Most children significantly exposed to a disaster will manifest some distress, but most do not develop psychiatric illness  Pathological reactions  Some children will develop a diagnosable mental disorder after a disaster R EACTIONS TO D ISASTER

13. D IAGNOSIS VS. D ISTRESS Subdiagnostic distress: - Deserves recognition and intervention (just because it is not PTSD does not mean it is not significant) Psychiatric diagnosis: not just a label - Need for professional evaluation and treatment - Need for professional evaluation and treatment - Has implications for prognosis - Has implications for prognosis - Used to select appropriate interventions - Used to select appropriate interventions

14. PTSD D OESN'T C APTURE I T A LL Comorbidity with PTSD in adolescents  Population adolescents: 6% PTSD (lifetime) - 80% of those with PTSD had another disorder  Adolescents in cruise ship sinking: 52% PTSD - Few or no delayed-onset cases - 1/3 of those with PTSD recovered within 1 year and another 1/3 recovered by 5-8 years

15. C OMMON N ORMAL R EACTIONS PTSD FEATURES: Intrusive re-experience  Re-enactment in play  Group B  Group C Emotional constriction  Group D Heightened arousal  Increased sensitivity to sounds  Increased activity  Irritability  Concentration problems  Sleep disturbance

16. C OMMON N ORMAL R EACTIONS Fear and anxiety  Disaster-specific fears  Fear of recurrence  Concerns about safety  Separation anxiety

17. C OMMON N ORMAL R EACTIONS Depressive symptoms are common. They may:  Pre-date the trauma exposure  Occur in the context of:  PTSD and other disorders  Intervening stressors  Bereavement

18. I NFANTS  Sleeping problems  Feeding problems  Irritability  Failure to meet developmental milestones

19. P RESCHOOL C HILDREN  Behavioral regression  Separation anxiety, clinging, and dependence  Irritability, temper tantrums, and behavior problems  Sleep disturbance; nightmares  Repetitive play re-enactment  Withdrawal: subdued or even mute

20. S CHOOL C HILDREN  Excessive questions or discussion about the incident  Irritability  Increased negative behaviors  Somatic complaints  Changes in school performance

21. A DOLESCENTS  Irritability  Isolation and withdrawal  Guilt and self-blame  Anger and hate  Anxiety about the world and their future  Fascination with death and dying  Absenteeism  Risk for substance abuse/alcohol use  Poor impulse control and high-risk behaviors

22. B EREAVEMENT AND T RAUMATIC G RIEF  Bereavement is a normal process that may be a focus of clinical attention; traumatic grief is complicated  Bereavement may complicate recovery from traumatic events, and traumatic circumstances may complicate the grief process  Bereavement and traumatic grief are distinct from, but share common features with, psychiatric disorders, most notably major depression and PTSD

23. F ACTORS A FFECTING R ESPONSE  Disaster characteristics  Exposure  Child factors  Family factors  Community factors

24. C HARACTERISTICS OF THE D ISASTER Man-made disasters may be more traumatizing than natural disasters because:  they are intentional  their purpose is to create fear, mistrust, and societal disruption

25. T YPE OF E XPOSURE  Physical presence and witnessing  Proximity  Subjective experience  Interpersonal relationship with those directly exposed

26. E LEMENTS OF E XPOSURE  Separation  Property damage  Secondary adversities  Traumatic reminders

27. M EDIA C OVERAGE  Exposure to media coverage absent other means of exposure does not meet the PTSD stressor criterion  Research connecting media exposure and PTSD symptoms does not imply causality  Cognitive processing of media coverage depends on the child's developmental level

28. C HILD F ACTORS  Age and development  Gender  Ethnicity  Pre-existing conditions and prior trauma

29. F AMILY F ACTORS  Association between child and parent reactions  Risk:  Disruption of routine  Parent symptoms  Family stressors  Impaired family functioning  Strained parent-child relationship  Interpersonal awareness

30. C OMMUNITY F ACTORS  Pre-disaster characteristics of communities  Post-disaster changes  Property damage  Community disruption  Competition for resources  Community response