1. Northwest Center for Public Health Practice 1 CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION

2. Northwest Center for Public Health Practice 2 Federal Sponsors  NIMH National Institute of Mental Health  NINR National Institute of Nursing Research  SAMHSA Substance Abuse and Mental Health Services Administration

3. Northwest Center for Public Health Practice 3 Principal Investigators  Betty Pfefferbaum, MD, JD University of Oklahoma Health Sciences Center  Alan M. Steinberg, PhD University of California, Los Angeles  Robert S. Pynoos, MD, MPH University of California, Los Angeles  John Fairbank, PhD Duke University

4. Session 5 Overview Of Disaster Mental Health In Children

5. Northwest Center for Public Health Practice 5 Learning Goal and Objectives

6. Northwest Center for Public Health Practice 6 Learning Goal The goal of Session 5 is to: Understand disaster and terrorism related child mental health consequences as a foundation for disaster mental health research

7. Northwest Center for Public Health Practice 7 Learning Objectives Upon completion of Session 5, participants will be able to: Recognize children’s psychological reactions to disaster and factors that influence reactions Identify the factors that promote resilience in children in the context of disasters Appreciate the evidence base for children’s disaster mental health services and interventions Understand the principles of intervention with children and families following a disaster

8. Northwest Center for Public Health Practice 8 Overview  Children’s Disaster Mental Health  Disaster Mental Health Services and Interventions for Children and Families  Resilience Among Children Facing Disaster

9. Northwest Center for Public Health Practice 9 Children’s Disaster Mental Health

10. Northwest Center for Public Health Practice 10 Topics  Outcomes  Factors that influence outcomes  Interventions

11. Northwest Center for Public Health Practice 11 Buffalo Creek Dam Collapse, 1972

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17. Northwest Center for Public Health Practice 17 Outcomes

18. Northwest Center for Public Health Practice 18 Disaster Acute Distress Chronic Distress Risky Behavior Functional Impairment Resilience/ Recovery Trauma Response

19. Northwest Center for Public Health Practice 19 Trauma Response Trajectories Resilience – No significant distress Recovery – Significant distress, resolves over time with or without intervention Failure to recover – Significant distress, no recovery, developmental disruption and impairment

20. Northwest Center for Public Health Practice 20 Emotional and Behavioral Outcomes CHILD CHARACTERISTICS Demographics Pre existing disorder Prior trauma FAMILY AND SOCIAL FACTORS Parent reactions Social support DISASTER EXPOSURE Objective characteristics Subjective reaction OUTCOMES PTSD Anxiety Depression Substance Use Functioning

21. Northwest Center for Public Health Practice 21 PTSD Outcome: Diagnostic Criteria  Exposure and reaction  Reexperiencing (1 or more)  Avoidance and numbing (3 or more)  Arousal (2 or more)  Duration > one month  Distress or functional impairment

22. Northwest Center for Public Health Practice 22 Children Can Differ From Adults  Reaction: disorganized or agitated behavior  Regression in development: behavior similar to those exhibited at an earlier age  Re-experiencing: - Recollections: repetitive play with themes - Dreams: generalized dreams without trauma content - Acting, feeling, or flashbacks: trauma reenactment

23. Northwest Center for Public Health Practice 23 Disaster PTSD Rates

24. Northwest Center for Public Health Practice 24 Onset of Disorders PTSD onset within 6 months for 90% Most specific phobia and separation anxiety onset close in time to the disaster Panic disorder and major depression later onset Bolton et al. 2000; Yule et al. 2000

25. Northwest Center for Public Health Practice 25 Survivors With and Without PTSD Bolton et al. 2000 Rates of other disorders were higher in survivors with PTSD than in controls Rates in survivors without PTSD were not higher than in controls

26. Northwest Center for Public Health Practice 26 Psychiatric Effects Bolton et al. 2000; Yule et al. 2000 >200 young adult survivors: 74% female, 97% Caucasian Studied 5-8 years after a shipping disaster Mean age at disaster = 14.7 yrs. Mean age at follow up = 21.3 yrs.

27. Northwest Center for Public Health Practice 27 Elementary School Study  Sample: 154 school children – 71 boys, 73 girls – Mean age 8.2 years (range 6 – 11 years)  Methodology – Assessed behavior and emotions besides posttraumatic stress in hi and lo impact schools – Longitudinal study (2, 8, and 21 months) – Multiple sources of information – Children – Teachers – School database Shaw et al. 1995

28. Northwest Center for Public Health Practice 28 Posttraumatic Stress in Hi-Impact School Shaw et al. 1996 N = 30 Severe posttraumatic stress decreased 70% with moderate to severe posttraumatic stress at 21 months

29. Northwest Center for Public Health Practice 29 Change in Posttraumatic Stress 2 to 21 Months Significant decrease in self-reported posttraumatic stress was explained by differences in boys Shaw et al. 1996

30. Northwest Center for Public Health Practice 30 PTSD Over Time: Hurricane Andrew Vernberg EM, Silverman WK, La Greca AM, Prinstein MJ. Prediction of posttraumatic stress symptoms in children after hurricane Andrew. J Abnorm Psychol. 1996;105(2):237-248.

31. Northwest Center for Public Health Practice 31 Parent Reported Behavior Problems Stuber, et al, 2005

32. Northwest Center for Public Health Practice 32 Childhood Traumatic Grief  Results from violent/sudden loss of a loved one  May occur with death from natural causes if the child’s experience of the death is sudden, unexpected, or witnessed  Characterized by the intrusion of trauma symptoms in bereavement Cohen et al. 2002

33. Northwest Center for Public Health Practice 33 Traumatic Grief v. Normal Grief Intrusive memories of manner of death Distress at remembering Maladaptive avoidance Positive memories Memories are comforting Yearning Sadness

34. Northwest Center for Public Health Practice 34 Factors That Influence Outcome Exposure Child Characteristics Family Factors Social Factors

35. Northwest Center for Public Health Practice 35 Direct Versus Indirect Victims Direct victims – Sustained physical injuries – Lost job or possessions – Friend or relative killed – Witnessed event in person – Participation in rescue effort in immediate aftermath Indirect victims – No property damage or job loss – No personal participation in event rescue efforts – No direct, in person witnessing of event – No deaths or injuries of friends or relatives

36. Northwest Center for Public Health Practice 36 Residents directly vs not directly affected by September 11 attacks represents approximately 51,000 people directly affected by September 11 attacksnot directly affected by September 11 attacks

37. Northwest Center for Public Health Practice 37 PTSD since September 11 directly affected by September 11 attacks not directly affected by September 11 attacks PTSD since September 11

38. Northwest Center for Public Health Practice 38 PTSD 6-9 months after September 11 directly affected by September 11 attacksnot directly affected by September 11 attacks PTSD since September 11PTSD 6-9 months after September 11

39. Northwest Center for Public Health Practice 39 Types of Exposure (1) Direct – Physical presence – Eye witnessing Indirect – Interpersonal relationships – Community residence Remote – Society membership – Media

40. Northwest Center for Public Health Practice 40 Types of Exposure (2)  Characteristics of event  Dose (severity)  Subjective Reaction  Intense fear, helplessness, or horror

41. Northwest Center for Public Health Practice 41 Exposure Significantly Different Exposures HI (%) LO (%) Doors/windows break or come open8211 Roof blown away or cave in575 Anyone with you hurt160 Scared a loved one would be hurt/killed8766 Anyone with you very scared8768 Get wet from rain/seawater5814 Pet hurt or killed245 Stay out of home after399 Still out of home190 Shaw et al. 1995

42. Northwest Center for Public Health Practice 42 Tsunami Impact Thienkrua, et al, 2006

43. Northwest Center for Public Health Practice 43 Posttraumatic Stress at 2 Months Shaw et al. 1995 Children in Hi-Impact school were more likely to have severe posttraumatic stress Hurricane Andrew N = 144 57% Hi-Impact 43% Lo-Impact Mean = 8.2 yrs

44. Subjective Appraisal of Threat VariableRp Life Threat.21.03 Loss.01NS Gender.19.03 Age.16NS Mother Severity.25.01 Father Severity.25.10 Irritable Atmosphere.29.001 Depressed Atmosphere.18.01 Violent Atmosphere-.03NS Supportive Atmosphere -.08NS Green et al. 1991 N = 179 2 years after Buffalo Creek Life threat associated with the number of PTSD symptoms Model accounted for 28% of the variance

45. Northwest Center for Public Health Practice 45 PTSD Following Industrial Accident Godeau, et al, 2005

46. Northwest Center for Public Health Practice 46 Child Characteristics  Demographics - Sex (female) - Age  Pre existing conditions  Prior trauma

47. Northwest Center for Public Health Practice 47 Pre Event Anxiety Disorder Asarnow et al. 1999 Children with pre event anxiety disorder had significantly more PTSD symptoms than those without N = 66 children 1 year after Northridge earthquake

48. Northwest Center for Public Health Practice 48 Prior Trauma 793 Nairobi children 8-14 months after the 1998 U.S. Embassy bombing Model explained 60% variance in bombing-related posttraumatic stress Pfefferbaum et al. 2003

49. Northwest Center for Public Health Practice 49 Family Characteristics at 8 Months Significant differences between cases and non cases on all three measures at 8 months McFarlane 1987 150 children 8 months after a bushfire

50. Northwest Center for Public Health Practice 50 Social Support and PTSD Udwin et al. 2000 Social support was related to the development of PTSD and to the duration of PTSD Social support measured perceived and received just after the disaster and at follow up

51. Northwest Center for Public Health Practice 51 Exposure to Television Coverage Fairbrother et al. 2003 443 NYC parents 4 months after September 11

52. Northwest Center for Public Health Practice 52 Assessment: Parent Report  Parent interview and report provides objective information in some areas  Parents may under-estimate children’s distress - Parents may be focused on other issues - Parents may be overwhelmed themselves - Children may be especially compliant - Parents may use denial

53. Northwest Center for Public Health Practice 53 Posttraumatic Stress: Child and Parent Report Child report*Parent report* + *Exposure significant + Time significant Koplewicz et al. 2002 No significant decrease over time on child self report

54. Northwest Center for Public Health Practice 54 Event-Related Fear: Child and Parent Report Child report*Parent report* + Koplewicz et al. 2002 *Exposure significant + Time significant No significant decrease over time on child self report

55. Northwest Center for Public Health Practice 55 Predictors for Post-Disaster Distress Disaster severity Subjective fear Relocation/disruption Resource loss Female Prior anxiety Prior trauma

56. Northwest Center for Public Health Practice 56 Child Disaster Mental Health Services Assessment Interventions

57. Northwest Center for Public Health Practice 57 Utilization of Post Disaster Services

58. Northwest Center for Public Health Practice 58 Utilization Rates Oklahoma City = 5% NYC (young children) = 15% NYC (Manhattan) = 10% NYC (lower Manhattan) = 22%

59. Northwest Center for Public Health Practice 59 NYC parents 4-5 months after incident - 10% received counseling - 44% in schools Of those receiving counseling:  47% had severe or very severe posttraumatic stress  50% had moderate posttraumatic stress  3% had mild posttraumatic stress  1/3 had received counseling before 9/11 Fairbrother et al. 2004 September 11 Counseling

60. Northwest Center for Public Health Practice 60 Screening Not all children develop significant problems Risk factors identified Brief screening measures available Screening well tolerated

61. Northwest Center for Public Health Practice 61 Oklahoma City School-based Screening 190 (49%) of 390 received counseling 390 (67%) of 586 further screened 586 (9%) of 6,500 identified as needing further screening Allen et al. 1999

62. Northwest Center for Public Health Practice 62 Acute Interventions-Triage Address immediate physical/safety/necessity Establish stability/security Psychological First Aid – Psychoeducation – Coping strategies – Hopefulness

63. Northwest Center for Public Health Practice 63 Assessment

64. Northwest Center for Public Health Practice 64 Individual Assessment and Treatment Most necessary for:  Directly exposed children  Children whose loved ones were directly affected  Children with persistent distress or impaired functioning

65. Northwest Center for Public Health Practice 65 Individualized Assessment Prior to Treatment Onset PTSD/sx Anxiety Depression Behavior problems Functioning Parent-child relationship Parental distress

66. Northwest Center for Public Health Practice 66 Tested Therapeutic Interventions  Trauma-focused therapy  Traumatic grief-focused therapy  Eye Movement and Desensitization and Reprocessing

67. Northwest Center for Public Health Practice 67 Goals of Interventions  Goals  Restore a sense of safety and security  Reduce sx of PTSD, anxiety and distress  Restore functioning  Methods  Psychoeducation re trauma and impact  Emotional regulation skills  Correct maladaptive cognitions  Resolve trauma related distress and avoidance

68. Northwest Center for Public Health Practice 68 Psychosocial Intervention (1)  214 completed treatment  176 group  73 individual  Intervention: 4 weekly sessions  Safety and helplessness  Loss  Competence and anger  Closure and going forward  Group and individual treatment  No difference in effectiveness  Group associated with better completion rates  Follow-up  Children maintained treatment gains Chemtob et al. 2002

69. Northwest Center for Public Health Practice 69 Psychosocial Intervention (2) Clinicians rated a random sample of 21 treated and 16 untreated Chemtob et al. 2002

70. Northwest Center for Public Health Practice 70 Trauma/Grief Focused Group Psychotherapy After Earthquake (1) Participants  Early adolescents in severely damaged schools following a massive Armenian earthquake  35 received trauma/grief-focused brief psychotherapy  29 received no therapy Goenjian et al. 1997

71. Northwest Center for Public Health Practice 71 Trauma/Grief Focused Group Psychotherapy After Earthquake (2 )  Intervention - Sessions delivered over a 3 week period - 4 ½-hour classroom group psychotherapy sessions - Average of 2 1-hour individual sessions  Intervention focused on - Trauma - Traumatic reminders - Post disaster stresses and adversities - Bereavement and the interplay of trauma and grief - Developmental impact Goenjian et al. 1997

72. Northwest Center for Public Health Practice 72 Posttraumatic Stress After Treatment for Earthquake Disaster Severity Posttraumatic Stress - Decreased in treated - Increased in untreated Severity Depression - No change in treated - Increased in untreated Goenjian et al. 1997 Posttraumatic StressDepression

73. Northwest Center for Public Health Practice 73 RCT EMDR Hurricane (Chemtob, et al, 2002) Children with continuing distress @ 1 yr Randomized to tx v. waitlist Intervention = 3 sessions EMDR PTSD, anxiety, depression reduced with tx

74. Northwest Center for Public Health Practice 74 Concerns about Treatment  Treatment may lead to heightened arousal and distress  Avoidance is a core feature of posttraumatic stress and may impede treatment

75. Northwest Center for Public Health Practice 75 Treatment Research Status  Both group and individual shown to be helpful  Can be delivered in school settings  CBT type approaches most tested and evidence for effectiveness  Some approaches not tested (e.g, psychodynamic, play)  Medication - Rarely needed - Adjunctive if used

76. Northwest Center for Public Health Practice 76 Resilience in Children in the Context of Disasters

77. Northwest Center for Public Health Practice 77 What is Resilience?  Positive adaptation in spite of significant life adversities  The process and outcome of successfully adapting to difficult or challenging life experiences, especially highly stressful or traumatic events Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

78. Northwest Center for Public Health Practice 78 Factors that Contribute to Resilience Resilient children have:  Optimism  Self efficacy  A sense of mastery  Personal competencies  Cohesive and supportive families  Families that use effective coping skills to deal with stress  Hardy families Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

79. Northwest Center for Public Health Practice 79 Resources for Fostering Resilience  Support from parents and family members  Support from classmates and close friends  Reaffirming ties to such institutions as social and religious groups  Providing help and resources to others Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

80. Northwest Center for Public Health Practice 80 How Professionals Can Build Resilience in Children (1)  Provide children with opportunities to share and discuss their feelings and concerns  Encourage children to resume normal roles and routines or develop new routines  Promote the maintenance of social connections Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

81. Northwest Center for Public Health Practice 81 How Professionals Can Build Resilience in Children (2)  Reduce or minimize children's exposure to disturbing media information  Encourage children and teens to stay healthy and fit  Encourage children to use positive strategies for coping with disaster- related stressors and model positive coping Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

82. Northwest Center for Public Health Practice 82 How Parents Can Build Resilience in Children  Take care of themselves  Promote warmth and nurturance that establish clear limits  Establish a safety plan in case of a traumatic event  Discuss school safety plans for potential terrorist events with teachers and school administrators Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

83. Northwest Center for Public Health Practice 83 How Schools Can Build Resilience in Children (1)  Identify supportive adults in children’s lives  Create positive connections by developing classroom projects  Enhance positive attitudes by developing coping strategies Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

84. Northwest Center for Public Health Practice 84  Teach children to relax in the face of difficulties  Help children set realistic goals  Help children identify positive coping strategies  Increase children's sense of mastery and control How Schools Can Build Resilience in Children (2) Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association

85. Northwest Center for Public Health Practice 85 How Communities Can Build Resilience in Children  Community factors that may be related to and promote resilience in children and families include: - Cohesiveness - Perceptions of safety - Perceptions of security - Effective communication - Making the needs of children a priority - Creating a “disaster system of care” Fact Sheet: Fostering Resilience in Response to Terrorism: For Psychologists Working With Children, American Psychological Association