Helping Children and Families Prepare and Cope with Disasters

Deanna Dahl Grove, M.D.Associate Professor of Pediatrics

Objectives

• To differentiate factors that contribute to coping psychologically in disasters

• To understand stages of child development and impact upon response to disasters

• To understand means of coping with children in disasters to promote positive recovery

• To identify some resources to assist the community

“Preparing and Coping with Disasters will assist to prevent long term effects: of emotional and behavioral disorders from antisocial behavior to PSTD”

Why helping children is so important

Factors that affected Mental Health - Katrina

• Parental mental distress

• Informal social support

•Minimal sense of community

•Unstable housing

• Loss of household income

David Abramson, IOM June 11, 2013

Factors that affected Mental Health - Katrina

•Food insecurity

•Poor family functioning

•Social disorder (gangs, drug sales)

David Abramson, IOM June 11, 2013

Influences on Psychological well-

being

•Type and intensity of exposure

•Availability of family support during and after the event

•Degree of disruption to routine

•Amount of social chaos

Resilience•Good cognitive abilities

•Positive self construct (self efficacy and self control)

•Attitude and beliefs the incorporate - hopefulness, faith, positive world view

•Ability to form sustainable relationships with others

Factors the contribute to Vulnerability• Age and developmental stage

• Dependency upon caregivers (emotional availability of individuals)

• Gender (males have externalizing behavior- aggression and females may internalize more risk for depression)

• Previous physical or mental health

• Baseline family or community problems - compounded by disaster

Initial Stages of Response

•Fear

•Denial

•Confusion

•Daze

•Numbness

Potential Response Days or Weeks Later

• Regressive behavior

• Anguish

• Fear

• Sadness

• Depression

• Hostility

• Aggression

• Apathy

• Withdrawal

• Sleep disturbance

• Somatization

• Pessimism

Potential Response Days or Weeks later

(continued)

•If some of the symptoms listed on the previous slide persist and impair return to normal function, then indication that help is needed.

PTSD “Arises as a delayed or protracted response to a stressful event of exceptionally threatening

nature which is likely to cause pervasive distress in almost

everyone”

•Exposure to traumatic event

•Persistent re-experiencing of event

PTSD (Continued)

•Avoidance of stimuli associated with trauma and symptoms of numbing

•Symptoms of increased arousal

•Persistent for one month, and impair normal activity

Children’s potential contributors to

PTSD• Separation from parent (fear that parent will

die)

• Physical injury and related pain

• Caregivers inability to meet child’s needs due to their own distress (prior maladaptive behaviors are exaggerated)

• Over-exposure to mass media images

• Lack of cohesive community response

Depression•Sleep disturbance

•Eating too little or too much

•Feelings of hopelessness, and helplessness

•Frustration, emotional outbursts

•Despondency

Depression (continued)

•Loss of interest in play or peers

•Regression

•School performance

•Somatic complaints

•Suicidal ideation

Anxiety

•Fear (of the dark is common)

•Irritable

•Restless

•Recurrent thoughts/feelings/images

•Concentration or memory problems

•Somatic disorders: Shaking, chest pain, GI disorders

How to help•Return to normal routine (meals,

sleep)

•Opportunities to play, interact with peers

•Encourage patience by caregivers to be supportive of distress (healthy coping skills)

•Listen

How to help (continued)

•Set normal limits and expectations

•Do not overestimate child’s ability to cope - lack of communication may be due to not wanting to add to stress

Communication tips

• Use clear simple language

• Answer questions directly, do not use graphic detail or speculate

• Acknowledge cultural bias and differences - physical contact

• Acknowledge emotions - empathy (hiding your own emotions due to being overwhelmed is acceptable)

• Do not ignore suicidal or homicidal thoughts or statements

Classic Stages (Theory)

Infancy Toddler PreschoolSchool

AgeTeen

Piaget SensorimotorSensorimoto

rPre

operational

Concrete operatio

ns

Formal operations

EriksonBasic trust

and mistrust

Autonomy vs

shame

Initiative vs guilt

Industry vs

inferiority

Identity vs. role diffusion

Normal Behavior 0-2 years

•Night awakening (4 mo)

•Stranger anxiety (9 mo)

•Aggression - biting (12 mo)

•Need for limit setting (18 mo)

•Tantrums (18 mo)

•Toilet training (24 mo)

Care by Age - 0-24 months

•Feeding, sleep

•Nurturing care

•Developmental stimulation - play, cuddling etc.

Normal Behavior Preschool

•Parallel play (3 years old)

•Interactive play (domestic type 5 years old)

•Stubborn behavior

•Compliant behavior

•Magical thinking

Care by age - preschool

•Food, sleep (toy or blanket for assisting with sleep disturbance)

•Play - drawing, other children their age

•Answer questions truthfully, acknowledge feelings

•Magical thinking

School Age•Latency

•Seek acceptance from others beyond parents

•Self-esteem (cognitive ability to evaluate and see how others perceive them)

•Conformity - fairness

•Concrete logical thinking - rules

Care of School age•Acknowledge feelings

•Listen

•Reassure that it is not their fault, if they express this concern

•Minimize media exposure

•Socialization with other children

•Structured play- i.e. cleaning, gathering food

•Coping: distraction

Teenagers

• Abstract thought (formal operations)

• Future implications perceived but may not apply decision making

•Concern for attractiveness (fitting in)

• Idealism

•Conflicts over independence and autonomy

• Emerging sexuality

• Peer influence intense

• Separation from family

Care Adolescent•Behavior may be adult like or child

•Listen in on peer group participation

•Acting out behavior (substance abuse etc.)

•Revenge thoughts - discourage behavior and talk about consequences

•Coping strategies: guided imagery, distraction

For additional information about the following, see Pan American Health Organization reference at end of presentation:

•Reactions by age group•Recommendations for psychological care in disaster•Further Recommendations for psychological care in disaster

When to refer• Suicidal thoughts or

ideation

• Symptoms that interfere with everyday life and persist for >1 month

• Threatening behavior to self or others

• Behavior that interferes with school/ADL

•Withdrawal > 1 month (confused, aloof, distant)

•Nightmares that persist

• Explosive behavior

• Substance abuse

• Previous physical or emotional trauma at higher risk

Planning for Anticipated Situations in the

Community• Education of behavioral and emotional

needs by age: with community members (schools, daycares, first responders, many others)

• Planning programs for detection of emotional problems (acute and chronic) in daycares and schools

• Planning and education for families

Lessons from Joplin•Tight community (schools have

relationships with everyone)

•Set clear goal to start school

•Summer school

•Temporary facilities, not temporary education

•Take care of adults too

•Celebrations frequently

Protectors and Promoters

• Positive self identity

• Executive control and self regulation

•Coping skills

• Supportive relationships

• Ability to help others

• Positive world view

• Stability of home, community and social routines

National Children’s Disaster Mental Health

COP•Pre-event - community gap analysis

•Listen, protect and connect concept

•Use of PsySTART

•Children’s Response and Coordination Group/Operations Section

•Developed by Merritt Scheiber, PhD

Family Reunification

Options• Patient Connection

• Safe and Well Online Registry (two registry) www.redcross.org/safeandwell or 1-800-733-2767

• International Tracing

• Armed Forces Emergency Services and Communication

• Facebook and Twitter

• Google missing persons

Currently being tested in Chicago

Save the Children

• Save the Children’s Focus:

• Immediate Response

• Recovery

• Strengthening

• Child-Focused Community Resilience

• Create Child centered space

• Work with community to have child focused preparedness (partner with local agencies)

• Partnership with Columbia University to create child-focused preparedness assessment tool

Resources• http://www.aap.org/en-us/advocacy-and-policy/aap-health-

initiatives/Children-and-Disasters/Pages/default.aspx (google aap and disasters)

• http://ncdmph.usuhs.edu/Learn/PsySoc/NC_PI_T01_040.htm#

• http://ncdmph.usuhs.edu/

• Schreiber, M. (2011) National Children’s Disaster Mental Health Concept of Operations, Oklahoma City. OK (Terrorism and disaster Center at the Univ. of OK. Health Sciences Center)

• Pan American Health Organization, Practical Guide of Mental Health in Disaster Situations, Washington 2006