the emotional impact of disaster on children and families · the family or caregivers infants,...

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M O D U L E 9

The Emotional Impact of Disaster on Children and Families

Brian Stafford | David Schonfeld | Lea Keselman | Carmen López Stewart

INTRODUCTION

In addition to their disastrous effects on the life and infrastructure of communi-

ties, these events produce a massive collective stress exceeding the ability of the

affected population to cope with the physical, emotional, and financial burdens.

Disaster episodes affect millions of people and exert a collective social suffering

that requires a monumental effort by individuals, communities, societies, and the

world community to overcome.

Classically, relief efforts focus on the physical consequences of disasters by

providing immediate medical attention and addressing health and environmental

services (water supply, sewage disposal, and shelter). Only in recent years have

the short and long-term emotional and mental health consequences among

exposed individuals been taken into consideration. By definition, coping with a

disaster challenges the individual's adaptive capacity.

Children and adolescents are emotionally vulnerable to their experiences

during a disaster. However, a child's reaction to a disaster varies widely depending

on circumstances such as: (1) the extent of exposure to the event, (2) the amount

of support during the disaster and its aftermath, and (3) the amount of personal

loss and social disruption. In addition, the child's response and adaptation are influ-

enced by the child's developmental stage, degree of dependency on adults, unique

individual characteristics, and the child's previous experiences. In most cases the

child's emotional response after a disaster represents an "expected" adaptive

The Emotional Impact of Disasters on Children and their Families

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Brian Stafford, MD, FAAPDavid Schonfeld MD, FAAP

Dr. Lea KeselmanDr. Carmen López Stewart

behavior. However, this "expected" adaptive behavior can become a significant

mental health problem that will chronically impair a child's social and emotional

development when it is too intense or persistent. Therefore, the early identifica-

tion of intense and problematic responses requires adequate support and treat-

ment, according to the emotional needs and developmental stage of each child. It

is essential to educate adults who provide care (parents, teachers, pediatricians)

about stress symptoms, and normal and abnormal adaptive reactions. Knowing

when to intervene promptly is important, because traumatic experiences during

childhood are associated with a higher risk of later emotional and behavioral

disorders, including antisocial behaviors. It is also important to prevent these

more serious disorders and behaviors with anticipatory guidance and early inter-

vention since the availability of pediatric mental health professionals is quite

limited, especially in developing countries and rural frontier parts of our state.

Training pediatricians and school based staff has the potential to greatly enhance

the effective management, early intervention, and support for children and

families affected by a disaster, so that the majority of impacted children will adjust

and recover functioning.

This module provides information on the emotional consequences of

exposure to massive incidents among children and adolescents, describes the cri-

teria for the identification of more serious mental health disorders, and pro-

poses strategies for the referral and management of children at different devel-

opmental stages.

EMOTIONAL VULNERABILITY INCHILDREN AND ADOLESCENTS INDISASTER SITUATIONS

OBJECTIVES

� Describe the types of childhoodexperiences that impact the vulnerabilityof children and adolescents.

� Identify the major factors that influencethe emotional impact of disasters onchildren and adolescents.

SECTION I / EMOTIONAL VULNERABILITY

The human impact of a disaster is affect-ed by the vulnerability of the children andadolescents involved in the event.Although disasters impact almost every-one in the area, certain populations havecharacteristics that predispose to having ahigher risk of negative consequences.The psychological well-being of individ-

ual children is influenced by the following:1) the type and intensity of exposure tothe event, 2) the availability of family support during the event and duringrecovery, 3) the degree of day-to-day lifedisruption, and 4) the amount of socialdisorganization and chaos. In addition, vul-nerability depends on individual charac-teristics of the child, the social and eco-nomic circumstances of the family andcommunity, and the available resources inthe surrounding environment and com-munity.

Individual Characteristics thatInfluence VulnerabilityEmotional reactions in children vary accord-ing to the personal characteristics of thechild or adolescent:� Age or developmental stage(physical, psychological, andsocial)

� Degree of dependency on adultsin the family or caregivers

� Gender� Previous physical and mentalhealth

� Resilience

Age or Developmental Stage of the ChildA child's age and developmental stagewill modulate the emotional response toa disaster (See Appendix on page 42). Ifnot physically impaired by the trauma, achild's intrinsic adaptive capacity willallow the resumption of normal play,educational, and other developmentallyappropriate activities.

Degree of Dependency on Adults inthe Family or CaregiversInfants, toddlers, and preschoolers arenearly completely dependent on adultsfor their care. School-age children arealso very dependent on adults.

Vulnerability alsodepends onindividualcharacteristics ofthe child, the socialand economiccircumstances ofthe family,community, andthe availableresources in thesurroundingenvironment.

SECTION 1 / EMOTIONAL VULNERABILITY

Adolescents, while less dependent, may lackexperience and cognitive ability to under-stand and anticipate the immediate orlonger-term consequences of the disaster.On the other hand, adolescents may bemore self-sufficient and react in a mannersomewhat independent from their care-givers. The adaptive capacity of nearly all chil-dren is influenced by the physical and emo-tional availability of their caregivers, but thisis especially true for younger children. Theymay experience intense feelings of abandon-ment when separated from adults in thefamily who have been injured, dislocated,killed, or who are doing community work.

GenderCultural and biological differences betweengirls and boys make it more likely for boysto have more disruptive or externalizingbehavioral symptoms and longer recoveryperiods than girls. Boys tend to react withaggressive behavior, violence, and antisocialattitudes, which can expose them to addi-tional trauma. Girls, on the other hand, aremore at risk for internalizing disorderssuch as depression and anxiety. Girls arealso at risk for interpersonal violence(rape) during and following a disaster. Insome cultures, girls may be more willingand able to verbalize their experiences.

Previous Physical and Mental HealthHaving a chronic physical disease is a riskfactor for poor adaptation following a dis-aster. In addition, a previous history oftrauma, loss, family distress, or emotion-al/behavioral problems increases the like-lihood of a more intense and persistentemotional disturbance after disasters.

ResilienceResilience is an adaptive capacity thatallows an individual to cope more effec-tively with adverse circumstances. In spiteof their vulnerability, many girls and boyshave inner resources that enable them tobe resilient in disaster situations.Resilience may be related to inheritedtemperament, but it is more likely influ-enced by having had a nurturing caregiverwho helped them develop self-confidenceand adaptive skills to cope with traumaticcircumstances.More resilient children are able to focustheir energy on developmentally appropri-ate activities such as play, friendships, andlearning. To the extent possible it is best tominimize the degree to which children aremade to assume parental roles that areinconsistent with their own developmentaland emotional needs.

Factors that Influence theEmotional Impact on Childrenin Disaster SituationsEvents that cause a great deal of damageor long-lasting disruptions, or occur withlittle warning, tend to cause a greaterdegree of distress. Factors that influencethe type and intensity of the emotionalimpact experienced by affected childrenare shown in Box 1.

Type, Extent, and Duration of DisasterAcute situations of short duration that gen-erate few changes in everyday life cause lesspsychological damage than those that areprolonged and cause extensive damage tothe social environment.

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In spite of theirvulnerability, manygirls and boys haveinner resources thatenable them to bemore resilient thanmany adults indisaster situations.


Physical Injury Physical injury and related pain is associ-ated with chronic PTSD symptoms.

Effects on Parents or CaregiversChildren are sensitive to how a disasterhas affected families and community.Adults, who normally provide support,protection, and stability, may be unable toprovide shelter, food, or safety. They mayfail to respond appropriately to theirchild's emotional distress because theyare incapacitated by their own emotionalresponse. Children are affected by theircaregiver's response to an event. An over-whelmed caregiver frequently leads to adistressed child. Emotional or behavioraldisorders manifested by caregiversincrease a child's feelings of insecurityand fear; making long-term emotional andbehavioral disorders more likely.

Family Inner Resources: Relationshipsand Communication among FamilyMembersFamilies characterized by tense and con-flicting relationships prior to the disasterare more likely to react in nonadaptiveand disorganized manners. This reinforcesfeelings of helplessness and insecurity inchildren.

Exposure of Children to Mass MediaRepetitive exposure of children to terri-fying images on television has an emo-tional impact on them. Children may mis-understand these images and believe thatthe event is ongoing. Graphic images canoverwhelm and frighten younger chil-dren, and impact older children and ado-

Direct Exposure to DisasterWhen children are direct witnesses tothe impact of a disaster, the emotionalconsequences are more severe.

Perception of Life-threat to Self orSignificant OtherA perceived threat to an individual's life isas important to assess as any objectiverisk, since the perception of a life-threat isa strong risk factor for developing an emo-tional disorder. In children, their belief thattheir parent might die is also a significantrisk factor for developing PTSD.

Separation From Caregivers Children who suffer trauma are morelikely to develop PTSD if they are notwith their parents –or are separatedfrom their parents– immediately after theevent.

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The emotionalconsequences ofman-made eventsare more severethan those that arisefrom naturaldisasters.

BOX 1. Factors that influence theemotional impact on children indisaster situations

� Characteristics, extent and duration of thedisaster

� Direct exposure to disaster� Perception of life-threat to self orsignificant other

� Separation from caregivers� Physical injury� Effects on parents or caregivers� Inner resources of the family, and relationand communication patterns among thefamily members

� Exposure of children to mass media� Cultural differences� Degree of disorganization and loss ofsocial control in the community

� Community response


lescents as well. Indirect exposure to dis-aster through TV images is associatedwith anxiety and other emotional distur-bances in children not directly exposedto the disaster. Adults should monitorand restrict images that their children areexposed to through all media, but espe-cially through television.

Cultural DifferencesChildren and families who have previouslyendured traumatic experiences, includingviolence, abuse, and separation from care-givers have a greater risk of experiencingserious adverse emotional reactions todisaster. A strong and extensive social net-work may serve as a protective buffer.Likewise, some religious beliefs may serveas protective factors for children and theirfamilies.

Degree of Disruption and Loss ofSocial Control in the CommunityDisasters may generate situations of chaosand disruption that undermine the normalrule of law and lead to desperate and crim-inal behavior such as looting, robbery, andvandalism. The frequency of interpersonalviolence including rape of women and sex-ual abuse of children increases in these cir-cumstances.

Community Response to the Needsof Children Affected by DisasterThe more social cohesiveness the commu-nity retains, the quicker that society willgain a sense of stability, normalcy, or, atleast, hope. Communities recover quicker ifprior to the disaster they have prepared aplan for responding and rebuilding. Having acommunity response and recovery planthat is implemented in a prompt, effective,and coherent manner will create a moresupportive environment that lessens therisk for long-term emotional disorders.

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Disasters maygenerate situations ofchaos and disruptionthat undermine thenormal rule of lawand lead to desperateand criminal behavior.

CHILDREN'S EMOTIONALRESPONSE TO DISASTER

OBJECTIVES

� Know the stages of the emotional

response to a disaster.

� Know the most common emotional

disorders in children exposed to disaster

situations.

� Recognize the cases that require referral

for mental health professional assistance.

SECTION II / EMOTIONAL RESPONSE

Normal Emotional ResponseWhen a child is exposed to a disaster,the emotional responses can range fromminimal distress to inattention, fear, lackof enjoyment (anhedonia), anxiety,depression, and grief to symptoms of re-experiencing, avoidance, hypervigilance,and disruptive behavior.In many instances these symptomatic

reactions are considered normal respon-ses to a traumatic experience and aretime-limited. Children, however, may alsohave significant impairment and chronicsymptomatology.

Stages of Normal EmotionalResponse of Children toDisasterThe emotional response to traumaticstress can be viewed in stages. There area range of emotional responses or reac-

tions that can be seen, some of whichare more likely to occur during orimmediately after the disaster and somewhich are more likely to be seen at alater time.The first stage, occurring immediately

after the traumatic experience, mayinclude reactions of fear, denial, confu-sion, and sorrow as well as feelings ofrelief if loved ones are unharmed. It mayalso include dissociative symptoms: feel-ings of emotional numbing, being in adaze, a sense of what has occurred is notreal or that one doesn't feel like oneself,or lack of memory for some aspects ofthe experience (amnesia).The second stage occurs days or

weeks after the disaster. In many childrenit is characterized by regressive behaviorand signs of emotional stress such asanguish, fear, sadness, and depressivesymptoms; hostility and aggressivenessagainst others; apathy, withdrawal, sleepdisturbance, somatization, pessimisticthoughts about the future, and repetitiveplay enactment of the trauma. As long asthese symptoms do not impair normalchildhood activities, they are consideredpart of the normal recovery process andthey can be expected to lessen or disap-pear after some weeks.Emotional responses that are persistent

and impair a return to normal functioningshould be considered pathologic. These

The most frequentchildhood disordersfollowing a disasterare in the areas ofanxiety, mood, andbehavior

responses may be related to bereavementand grief or to a new or pre-existing emo-tional disorder.Although grief is not a mental disorder,

it may require or benefit from profession-al attention, especially if it is complicatedby an emotional disorder such as depres-sion or PTSD. Traumatic deaths are ofparticular concern for precipitatingsevere grief reactions in disasters.Five factors that increase the risk of

"traumatic grief" are:� Sudden, unanticipated deaths.� Deaths involving violence, mutilation,and destruction.

� Deaths that are perceived as random orpreventable, or both.

� Multiple deaths.� Deaths witnessed by the survivor thatare associated with a significant threat topersonal survival or a massive or con-frontation with death and mutilation.

The most frequent childhood disordersfollowing a disaster are in the areas of anx-iety, mood, and behavior (Box 2). Thesedisorders are reviewed below.

Severe Stress Reaction andAdaptive Disorders (F43), Acute Stress Reaction, andPost-traumatic Stress Disorder(F43.1)Post-traumatic stress disorder (PTSD) is aclinical entity that commonly occurs afterexposure to a traumatic event. A traumaticevent threatens the physical or psychologi-cal integrity of the affected person, and isassociated with feelings of confusion, inse-curity, terror, and bewilderment.Data on the prevalence of PTSD in

childhood vary widely, reflecting the indi-vidual experience of the children and fam-ilies as well as the amount of personal andcommunal loss.The International Classification of

Diseases (ICD-10) defines PTSD as a dis-order that "arises as a delayed or pro-tracted response to a stressful event orsituation (of either brief or long duration)of an exceptionally threatening or cata-strophic nature, which is likely to causepervasive distress in almost anyone." TheDiagnostic and Statistical Manual ofMental Disorders, 4th ed., Text Revision(DSM IV-TR), requires a number of crite-ria to be met by the individual to establisha diagnosis of PTSD (Box 3).

Re-experiencing the Traumatic EventChildren may experience recurrent,intrusive, and pervasive thoughts regar-ding the traumatic event. This occurs asflashbacks or repetitive dreams, or night-

BOX 2. Most common emotionaldisorders in the childhoodpopulation exposed to disaster(ICD-10)

� Severe stress reaction and adaptivedisorders (F43)

� Acute stress reaction and post-traumaticstress disorder (F43.1)

� Depressive episode (F32) and recurrentdepressive disorder (F33)

� Separation anxiety disorder of childhood(F 93.0),

� Phobic anxiety disorder of childhood(F93.1),

� Social anxiety disorders of childhood(F93.2)

� Conduct disorder confined to the familycontext (F91)

SECTION 1I / EMOTIONAL RESPONSE10

SECTION 1I / EMOTIONAL RESPONSE 11

mares. These dreams may not necessa-rily contain images drawn from the trau-matic event; in fact, the frightening dre-ams may have no recognizable content.Younger children may act out what theyhave witnessed —in all of its intensity—or they may engage in joyless repetitiveplay in which themes or aspects of thetraumatic experience are re-enacted.Other symptoms include emotional andphysiological reactivity to certain remin-ders (cues) of the event such as smells,images, sounds, or similar emotional trig-gers.

Avoidance and Numbing Affected individuals frequently avoidpassing through places, conversations, orsituations that trigger any painful recol-lection of the traumatic event. Avoidancein children may take the form of closingor covering their eyes when in proximityto the traumatic scene or otherreminder. They may also have tantrumsprior to returning to a site of traumati-zation. Numbing behavior is recognizedwhen children often lose interest inactivities they used to enjoy. A child, whoonce had a full range of emotionalexpression, may look withdrawn,restricted, and indifferent. Affected chil-dren may also seem emotionallydetached from significant others. Someolder children and adolescents mayreport a sense of not caring or doomabout the future.

Symptoms of Increased ArousalHyperarousal is manifested throughsleep disturbance that can include night-mares, fear of sleeping alone, or difficul-

ty initiating or staying asleep. Difficultiesin concentration make learning difficult.Hypervigilance and an exaggerated star-tle response may lead to excessive irri-

BOX 3. DSM IV-TR diagnosticcriteria for PTSD

� Exposure to a traumatic event� Persistent re-experiencing of the event, as

evidenced by:

—Distressing recollections

—Dreams

—Flashback

—Distress at cues

—Physiological reactivity to cues

� Avoidance of stimuli associated with

trauma and symptoms of numbing of

general responsiveness, as evidenced by:

—Avoidance of thoughts and feelings

—Avoidance of activities, places, people

—An inability to recall aspects of the event

—Decreased interest/participation in social

activities

—Emotional detachment

—Restricted affect

—Foreshortened sense of future

� Symptoms of increased arousal, as

evidenced by:

—Insomnia

—Irritability

—Difficulty concentrating

—Hypervigilance

—An exaggerated startle

To establish the diagnosis, symptoms must

be present for al least one month and

should be associated with considerable

impairment of child’s normal activity

SECTION 1I / EMOTIONAL RESPONSE

tability or angry outbursts and maymake interpersonal relations quite diffi-cult, especially within the family.

Other SymptomsOther associated symptoms that fre-quently co-occur include regressive beha-viors, such as thumb-sucking, enuresis, andencopresis, as well as other phobias andanxieties, multiple somatic symptoms(stomachaches and headaches), and dis-ruptive behavior.PTSD manifestations vary according tothe development stage of the affectedchild, making it possible to describe themin three groups: preschool-age children,school-age children, and adolescents.

PTSD in Preschool-ageChildrenToddlers and preschool-age children canexperience PTSD symptoms but theyoften cannot verbally communicate theirdistress. Instead, they frequently lookwithdrawn, silent, indifferent, quiet, fear-ful, demonstrate regressive behaviorsand fears especially increased separationanxiety. They may re-enact intrusivememories through repetitive play of thetrauma.

PTSD in School-age ChildrenOlder children can manifest all of thesymptoms of post-traumatic stress dis-order, including irritability as well asemotional constriction. They often sufferfrom difficulties in attention that impairtheir concentration at school. In addi-tion, somatic symptoms, such asheadaches and stomachaches, are typical.

Their worries about the disaster mightbecome pervasive. They may attempt toprevent future dangers by asking ques-tions about aspects of the event, includ-ing minor details that may seem obses-sional. They may also re-enact troublingrecollections through play or drawing.

PTSD in AdolescentsAdolescents can experience all of thesymptoms of PTSD that adults can. Theymay have recurrent thoughts or dreamsabout the incident that may lead to feelingsof anxiety, depression, helplessness, andguilt, and suicidal ideation. Occasionally, inan attempt to relieve their distress, theymay increase their use of illicit substances.In addition, they may demonstrate rebe-llious and antisocial behavior.

Depressive DisordersSigns of depression such as sadness, hope-lessness, and sleep disturbance are commonmanifestations after a catastrophic event.This is especially true when the return tonormal routines and settings is delayed orimpossible. Symptoms of depression can betemporary or chronic and may requireintervention of medical and mental healthprofessionals. Pediatricians and generalpractitioners who care for children exposedto disaster should identify the appearanceand persistence of the following symptomsof depression: � Sleep disturbance: insomnia, hypersom-nia, nightmares

� Eating pattern disturbances: rejectionof food or excessive feeding/eating

� Feelings of hopelessness and helplessness� Feelings of frustration, irritability, rest-lessness, emotional outbursts.

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Younger childrenmay “act out” thetraumaticexperience in all itsintensity or enactthe trauma throughrepetitive play.

Symptoms ofanxiety may appearat all ages and affectuniformly the adultand childhoodpopulation.

SECTION 1I / EMOTIONAL RESPONSE 13

� Reduced or no interest in usual every-day activities, feelings of discourage-ment (despondency)

� Reduced or no capacity for enjoymentof activities that were usually pleasant

� Loss of interest in playing� Loss of interest in relating with peers� Loss of friends� Regressive behaviors (going back toearlier developmental stages)

� Tendency towards withdrawal andannoyance

� School performance problems� Somatic symptoms since they aresometimes equivalent to depressivesymptoms (e.g. headaches, stom-achaches among the most frequent)

� Suicidal thoughts or suicidal ideation inadolescents and older children, requir-ing immediate attention by mentalhealth professionals

Anxiety DisordersSymptoms of anxiety may appear at allages. Among the most frequent include:

� Fears (often of the dark)� Irritability� Restlessness� Avoidance behavior� Recurrent stressful thoughts or feelingof being in danger

� Recurrent images� Attention, concentration, and memorydisturbances

� Shaking� Dizziness, instability 1 Tachycardia,dyspnea, chest pain

� Muscle contractures

� Gastrointestinal disorders (diarrhea,constipation)

� Sweating

Conduct Disorders of Defiantand Aggressive BehaviorAggressive behavior is also a frequentoutcome among children and adoles-cents, especially males. Whereas youngerchildren may hit or bite others, olderchildren may get quite violent, especiallywith their peers, and pushing and fightingbecomes common. Rebellious, antisocial,and even criminal behavior can alsooccur.When greatly distressed, children and

adolescents may enact their distressthrough emotional outbursts, and otherdisruptive behavior. Parents may betempted to over-react to somatic symp-toms or pardon disruptive behavior dueto feelings of guilt related to an inabilityto protect their children. Parents shouldattempt to sensitively provide consistentlimits and to provide opportunities todiscuss their child's fears, anger, sadnessand other emotions without relyingupon the child for their own comfort.

Other ManifestationsChildren and adolescents frequentlyexpress emotional distress through soma-tic symptoms. The most common includeheadaches, stomachaches, chest pain, andnausea. These symptoms typically improvewhen kids are given the chance toexpress their feelings in an appropriatemodality –play, drawing, talking. It is

Signs of depressionsuch as sadness,hopelessness, andsleep disturbanceare commonmanifestations aftera disaster.

It is necessary thatchildren understandthat they are notresponsible for whathappened in orderto preventinappropriatefeelings of guilt.

SECTION 1I / EMOTIONAL RESPONSE14

important to be alert to these symptomsand make the corresponding consultationif they persist.Special mention is needed for sleep

disturbances. Insomnia, refusal to go tosleep, frequent waking, nightmares, nightterrors, and fears of sleeping alone arevery common. Adults should be sensitivethat this is related to a child's sense ofsecurity and respond appropriately andflexible. Bedtime rituals should resume; inaddition, spending more time with chil-dren near bedtime, providing a soothingtransitional object (doll, stuffed animal),leaving a light on, and staying with themuntil they are asleep are possibilities.Younger children have cognitive

processes that are egocentric, and maybelieve that they are to blamed for notbehaving or for negative thoughts and

fantasies. Excessive feelings of guilt andinappropriate self-blame may also arisein older children and adolescents forhaving survived or for being unable toprevent their loved ones from beinginjured or killed. It is necessary that children understand that they are not responsible for what happened inorder to prevent inappropriate feelingsof guilt.Regressive behavior is very common,

especially among younger children whosedevelopmental achievements are not aswell consolidated. They become moredependent on adults, perhaps even cling-ing to them, and symptoms of separationanxiety or school refusal may appear. Theymay often regress to thumb-sucking, fear-ing the dark, wetting the bed, and evenhave encopretic episodes.

SPECIFIC INTERVENTIONS FORDEVELOPMENTAL STAGES

OBJECTIVES

� Describe the different types ofinterventions for emotional responsesseen in children at differingdevelopmental stages.

� Be aware of recommendations torestore routines and child and familyfunctioning.

� Be acquainted with the possibleinterventions aimed at lessening theemotional impact of disasterschildhood.

SECTION III / SPECIFIC INTERVENTIONS FOR DEVELOPMENTAL STAGES

Interventions for emotionaldisorders in children exposed to a situation of disas-terChildren with adverse reactions to

stress and behavioral symptoms for morethan 1 month are at higher risk of develop-ing PTSD or violent or criminal behaviorsin the future. They should, therefore,receive psychological support within thefirst month after the episode.Most children present first to primary

care clinicians or to non-mental healthprofessionals. Primary care clinicians playan important role in educating familiesabout prevention and support strategies,providing early intervention, screening foremotional disturbance, providing lessintensive interventions, and referring formental health and community-based treat-ment (Box 4). Pediatricians have thecapacity to provide appropriate anticipato-ry guidance and manage emotional condi-tions early on when these conditions maybe ameliorated. Prompt measures to mini-

CASE 1.An important part of the population inyour city has been affected by a flood,prompting an evacuation plan thatinvolves displacement of most people toshelters. You have been summoned aspart of the multidisciplinary rescue teams.

� As a pediatrician, what do youconsider to be your role in hel-ping families during the firstdays?

CASE 2.After an earthquake the population ofyour town is progressively returning tonormal. Children are gradually returningto school.

� What do you think should beyour role in this phaseregarding school and schoolteachers?

BOX 4. Pediatrician’s role

� Anticipatory guidance� Manage early disturbance� Screen for disorders� Provide less intensive intervention� Refer for mental health and community-based treatment


notifying the family of a death, whether achild or parent has died. It is best to dothis in person and not in a telephone callwhenever possible, regardless of the timeof day. It will also be preferable to deliverthis news in a private place, away from thedistractions of ongoing care to patients.The manual entitled Pediatric Terrorismand Disaster Preparedness: A Resourcefor Pediatricians describes the notificationprocess as follows:

"After notifying the survivor(s) of thedeath, pause to allow both the informa-tion to be processed and emotions tobe expressed. Do not try to fill thesilence, even though it may seem awk-

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Adolescents mayreact withwithdrawal, apathy,behavioral changes,substance abuse andrisk-taking behaviors,but also feelings ofguilt, hopelessness,helplessness andsadness.

BOX 5. How can we help children?

Recommendations for promotingadjustment to stressful and traumaticevents

A. Understand emotional reactions� Pay attention to behaviors at home andat school or daycare

� Acknowledge and accept behavior asnormal adaptations to stress

B. Reduce the emotional impact� Provide support, comfort, and time forplay and discussion

� Model healthy coping behavior� Have parents seek help if needed

C. Facilitate recovery� Normalize routines as soon as possible� Listen to children and validate their feelings � Encourage activities that help them expresstheir feelings: different type of games, art-related activities, etc.

mize fear and anxiety in children exposedto a traumatic event are essential. Thesemeasures should give children the certain-ty that adults are in control and respond-ing appropriately, and that previous familyand community routines are returning.Following a disaster, the primary mental

health goals in the initial 1 to 2 months areto restore stability, improve social net-works, decrease hyperarousal, and helpnatural recovery seeking. Anticipatoryguidance for post-trauma emotional symp-toms includes describing the types of dis-tress, explaining that many symptoms are anormal response, and describing measuresto help the child and family adapt to thestressor and return to previous function-ing. This guidance can be given to individualfamilies, to educators, and to the media. Ingeneral, these universal recommendationsinclude the following:� Return to normal routines� Be patient and supportive and give chil-dren time to adapt to his/her distress

� Continue to set normal and appropriatelimits on the child's behavior

� Allow children to talk about his/herworries and feelings if desired

� Encourage the child to spend time withfriends

� Encourage children to return to his/herprevious developmental tasks

� Parents are encouraged to deal withtheir own feelings and get support andtreatment if indicated

More in-depth individual counseling andanticipatory guidance should be develop-mentally based (Box 5).

Notification of DeathOne of the most difficult experiences thata pediatrician will have during a disaster is


ward. Listen more than you speak.Silence is often better than anything youcan say. Stay with the family members asthey are reacting to the news, even ifthey are not talking. � Use clear and simple language. Avoideuphemisms such as terminated,expired, or passed away. State that theindividual died or is dead.

� Don't provide unnecessary graphicdetails. Begin by providing basic infor-mation and allow the individual to askquestions for more details.

� Don't lie or speculate. If you do notknow the answer to a question, say so.Try to get the answer if possible.

� Be conscious of nonverbal communi-cation and cues, both those of thefamily as well as your own.

� Be aware of and sensitive to culturaldifferences. If you do not know how aparticular culture deals with a death, itis fine to ask the family.

� Consider the use of limited physicalcontact (e.g., placing a hand on thefamily member's shoulder or provid-ing a shoulder to cry on). Monitor theindividual's body language and if at allin doubt whether such contact wouldbe well received, ask first.

� Realize that the individual may initiallyappear to be in shock or denial. Expectadditional reactions, such as sadness,anger, guilt, or blame. Acknowledge emo-tions and allow them to be expressedwithout judgment.

� Do not ignore or dismiss suicidal orhomicidal statements or threats.Investigate any such statements (oftenthis will be facilitated by the involvementof mental health professionals) and if con-cerns persist, take appropriate action.

� Just before and during the notification

process, try to assess if the survivorshave any physical (e.g., severe heartdisease) or psychological (e.g., majordepression) risk factors, and assesstheir status after notification has beencompleted.

� If possible, write down your name andcontact information in case the familywants further information at a latertime. If the situation is not appropri-ate for providing your name and con-tact information, then consider howthe family may be able to obtain addi-tional information in the future (evenmonths later).

� Do not try to "cheer-up" survivors bymaking statements such as "I know ithurts very much right now, but I knowyou will feel better within a shortperiod of time." Instead, allow themtheir grief. Do not encourage them tobe strong or to cover up their emo-tions by saying "You need to be strongfor your children; you don't wantthem to see you crying, do you?" Feelfree to express your own feelings andto demonstrate empathy, but do notstate you know exactly how familymembers feel. Comments such as "I

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The best way toreduce theemotional impact ofdisaster is to try tokeep the familytogether and theparents functioningwell.


realize this must be extremely difficultfor you" or "I can only begin to imag-ine how painful this must be to hear"can demonstrate empathy. Avoidstatements such as "I know exactlywhat you are going through" (youcan't know this) or "You must beangry" (let the individual express hisor her own feelings; don't tell the per-son how to feel) or "Both my parentsdied when I was your age" (don'tcompete with the survivor for sympa-thy). Provide whatever reassuringinformation you may be able to, suchas "It appears your husband diedimmediately after the explosion. It isunlikely he was even aware of whathappened and did not suffer before hedied." However, do not use such infor-mation as an attempt to cheer up fam-ily members (e.g.,"You should behappy, many people suffered painfulburns or were trapped under rubblefor an hour before they died. At leastyour husband didn't experiencethat.")

� Feel free to demonstrate that you areupset as well—it is fine to cry orbecome tearful. If you feel, though,that you are likely to become over-whelmed (e.g., sobbing or hysterical),then try to identify someone else todo the notification.

� After you have provided the informa-tion to the family and allowed ade-quate time for them to process theinformation, you may wish to askquestions to verify comprehension.

� Offer the family the opportunity toview the body of the deceased and tospend some time with their loved one.Before allowing the family to view thebody, the health care team should pre-pare it for viewing by others. A member

of the healthcare team should escortthe family to the viewing and remainpresent, at least initially.

� Help families figure out what to donext. Offer to help them notify addi-tional family members or closefriends. Tell them what needs to bedone regarding the disposition of thebody. Check to see if they have ameans to get home safely (if they havedriven to the notification, they maynot feel able to drive back safely), andinquire if they have someone they canbe with when they return home.

� Help survivors identify potentialsources of support within the com-munity (e.g., member of the clergy,their pediatrician, family members, orclose friends).

� Take care of yourself. Death notifica-tion can be very stressful to healthcare providers.

Counseling Interventions according to AgeThe general recommendations providedby the Pan American Health Organizationfor children and adolescent psychosocialcare in a disaster situation can be found inthe Appendix page 43. The chart describesthe recommendations for parents andteachers for sleep disorders, excessiveclinging, incontinence, regressive behav-iors, school problems, anxiety, aggressive-ness, rebellious, hostile and recklessbehavior, pain and somatic complaints, andbereavement.An understanding of how children may

view death and adjust to loss is critical toproviding psychosocial counseling andcare. As described in Pediatric Terrorism andDisaster Preparedness: A Resource for

18

Pediatricians, children's understanding ofdeath may be very different from that ofadults. Children have had far less person-al experience of loss and have accumulat-ed less information about death. They canalso have difficulty understanding whatthey have seen and what they are toldunless the basic concepts related to deathare explained to them. Adults will need toprovide especially young children withboth the basic facts about what happensto people after they die, as well as theconcepts that help them to explain thosefacts. For example, young children may betold that after people have died, theirbody is buried in a cemetery or turned toashes that can then be buried or scat-tered. Children can be very distressed bythese facts unless they are helped tounderstand the concept that at the timeof death, all life functions end completelyand permanently—the body can nolonger move, and the person is no longerable to feel pain. That is why it is okay tobury or cremate the body.Children need to understand four con-

cepts about death to comprehend whatdeath means and to adjust to a personalloss: irreversibility, finality, inevitability, andcausality (Table 1). Most children willdevelop an understanding of these con-cepts between ages 5 and 7, but this varieswidely among children of the same age ordevelopmental level, based in part on theirexperience and what others have taughtthem. When faced with a personal loss,some children 2 years old or younger maydemonstrate at least some comprehensionof these concepts. Adults should notunderestimate the ability of young children

to understand what death means if it isexplained to them properly. Therefore, it isbest to ask children what they understandabout death, instead of assuming a level ofcomprehension based on their age. As chil-dren explain what they already understand,it will be possible to identify their misun-derstandings and misinformation and tocorrect them accordingly.When providing explanations to chil-

dren, use simple and direct terms. Be sureto use the words "dead" or "died" insteadof euphemisms that children may find con-fusing. If young children are told that theperson who died is in "eternal sleep," theymay expect the deceased to later awakenand be afraid to go to sleep themselves.This description does little to help childrenunderstand death and may cause moreconfusion and distress.Religious explanations can be shared with

children of any age, but adults should appre-ciate that religious explanations are general-ly very abstract and therefore difficult foryoung children to comprehend. It is best topresent both the facts about what happensto the physical body after death, as well asthe religious beliefs that are held by the fam-ily. Even when children are given appropriateexplanations, they still may misinterpretwhat they have been told. For example,some children who have been told that thebody is placed in a casket worry aboutwhere the head has been placed. Afterexplanations have been given to children, itis helpful to ask them to review what theynow understand about the death.It is also helpful for children to find their

own unique way of saying goodbye tosomeone they have lost; this can be

SECTION III / SPECIFIC INTERVENTIONS FOR DEVELOPMENTAL STAGES 19

Adolescents need aspace to talk aboutthe events, withfreedom to ask allthe questions theyhave.


achieved through painting, planting and car-ing for a tree, praying, lighting a candle, orany other suitable expression. The perma-nence of the situation can be supportedover time.

Children Younger than 12 Months Focus the care of infants on the fulfillmentof their basic needs, such as feeding, sleep-ing, and general care, and sheltering themduring the caregiver's difficult adaptation to

20

TABLE 1. Concepts of death and implications of incomplete understanding foradjustment to loss

Concept Example of incompleteunderstanding

Implication

Irreversibility

Death is seen as a permanentphenomenon from whichthere is no recovery orreturn.

Finality (Nonfunctionality)

Death is seen as a state inwhich all life functions ceasecompletely.

Inevitability (Universality)

Death is seen as a naturalphenomenon that no livingbeing can escape indefinitely.

Causality

A realistic understanding ofthe causes of death isdeveloped.

Child expects the deceased toreturn, as if from a trip.

Child worries about a buriedrelative being in pain or tryingto dig himself or herself outof the grave; child wishes tobury food with the deceased.

Child views significantindividuals (i.e., self, parents)as immortal.

Child who relies on magicalthinking is apt to assumeresponsibility for death of aloved one by assuming badthoughts or unrelated actionswere causative.

Failure to comprehend thisconcept prevents child fromtaking the first step in themourning process, that ofappreciating the permanenceof the loss and the need toadjust ties to the deceased.

Can lead to preoccupationwith physical suffering of thedeceased and may impairreadjustment; serves as thebasis for many horror storiesand films directed at childrenand youth (e.g., zombies,vampires, and other “livingdead”).

If child does not view death asinevitable, he or she is likelyto view death as a punishment(either for actions or thoughtsof the child or the deceased),leading to excessive guilt andshame.

Tends to lead to excessiveguilt that is difficult for childto resolve.

Adapted from Schonfeld D. Crisis intervention for bereavement support: a model of intervention in the children’s school. ClinPediatr 1989;28(1):27-33. Reprinted with permission of Sage Publications, Inc.


the event. Appropriate nurturing care anddevelopmental stimulation (e.g., singing,cuddling, playing) is desirable. Resume dailyroutines to the extent possible.

Preschool-age ChildrenThe best way to reduce the emotionalimpact of disaster is to try to keep thefamily together and the parents function-ing well. In this way, children can get thesupport and care they need.The most important thing for the emo-

tional health of children who experiencedisaster situations is to feel loved, caredfor, and protected by their parents orcaregivers.The intervention for preschool-age

children depends on their symptoms:� If they become passive and listless, pro-vide them with a routine safe place,where they can feel emotionally con-nected and have suitable materials fordrawing, playing, or other activities.Encourage them to draw people theywould like to be with, put names tothose people, create a story about thedrawing, and make a poster where newelements can be added.

� If they feel scared, provide supportiveopportunities for them to express theirfears and emotions.

� If the child is having sleep disturbance(nightmares and or fear of being aloneat night), try routine calming activitiesbefore bedtime, such as reading a com-forting book or telling a hopeful story.

These disturbances are usually tempo-rary and fluctuate in severity. It is impor-tant for parents to provide gentle struc-ture, reassurance, and some flexibility inroutines.

� Regressive behaviors (e.g., thumb-sucking,bed-wetting, and baby-talk) are commonresponses to stress. They provide somesort of comfort to the child, are not inten-tional, and usually are transitory. The bestmanner for parents to respond is toaccept this as a measure of how distressedthe child is by the situation and to gentlyencourage her/him to return to theirdevelopmental achievements. Parentsshould avoid criticism, mockery, or annoy-ance, and should reward developmentallyappropriate behavior through praise.

� Give them all the information theyneed, without unnecessarily alarmingthem. Answer questions in a truthfulbut plain and simple way. Do not sharedescriptions of specifics of loss andtrauma with them at this age as it maylead to further traumatization. If theydo not understand what is going on andcannot discern their own feelings, helpthem understand what they feelthrough playing or drawing, especially ifit is shared with parents or caregivers.Caregivers should also share some oftheir similar feelings and explain howthey feel safer now. This helps the childto understand that their feelings arecommon responses and that they arenot alone in having them.

� Children may attribute magical quali-ties to certain objects or situations(magical thinking) through their ego-centric cognitive capacity. They maybelieve that seeing an object related tothe emergency may cause the event tobe repeated. Avoid exposing the chil-dren to the news media, especially TV.Images can be retraumatizing, and thechildren may not understand that theimages shown are from a past discreteevent rather than new disasters.

� Children separated from close rela-tives, even for a short period of time,

21


may feel distressed, anxious, and irrita-ble. It is important for parents tounderstand that this is also likely to betransient, and that they should try tospend more time together as a family,providing the children a safe space toexpress themselves.

School-age ChildrenThe emotional impact of disaster on chil-dren of school age is also strongly relatedto the adaptation of their caregivers. Theycomprehend the notion of good and bad,and as they develop, they can verballyexpress their feelings and emotions.However, disasters typically surpass theability of many people to cope and it iscommon for children to feel confused andworried about their own reactions.An appropriate response for school-

age children is to provide them a safespace where they can share their experi-ence and fears. A dialogue with caregiverscan be very helpful, especially if the care-giver is adapting well.School-age children frequently worry

about their behavior during the disaster.They may feel responsible for not havingdone enough and may blame themselves.It is important to create conditions wherethey can express their feelings and emo-tions, and to reassure them that whathappened was nobody's fault (particularlyin natural disasters), and especially nottheir fault. Children of all ages (and evenadults) may worry that something theydid or failed to do, or even just thought orwished about, may have caused or con-tributed to the disaster or the death ofloved ones, even if there is no logical rea-son for such feelings. Children are natu-

rally reluctant to disclose such feelings ofguilt, which may significantly impair theiradjustment to the disaster.When traumatic reminders trigger spe-

cific fears, it is important to help themidentify and verbalize the setting and/oremotion that elicited those feelings.Although they may be able to understandwhat occurred, repeated graphic imagesof the disaster can trigger and exacerbatefeelings of fear and anxiety. One way tominimize the impact of media exposure isto watch TV together and mutually sharetheir emotions about the images and theevent. Some children will repeatedly re-enact a traumatic situation with obsessivedetail, cognitive distortions, and occasion-ally with an absence of specific informa-tion. Frequently the intensity of the emo-tions is so extreme that children maybecome overwhelmed. It is important toallow them to cry and express anger andsadness. If this occurs in the presence ofsupportive parents or caregivers, it can bequite therapeutic. If they are unable toverbally express themselves, art and playmaterial can assist them.Encourage continued socialization of

children, but without making it burden-some. Plan structured activities for thediffering developmental stages and inter-ests. These activities are beneficial for chil-dren and for the community. For example,children can help with cleaning the schoolif it was affected or gathering food forthose who had been displaced to shelters.Provide additional supports, both at

home and at school, to assist children inlearning and meeting other academicdemands.

22


AdolescentsProvide adolescents with a space to dis-cuss the event and their initial and ongo-ing response to it. It can also be helpfulfor a reliable adult to share valid informa-tion with them.Adolescents are frequently self-con-

scious about their emotions, especiallyfears generated by the traumatic event.Fears can sometimes create a sense ofvulnerability and shame. It may be benefi-cial for them to share these feelings with-in a group of peers.Adolescents may "act-out" what they

cannot verbally express. Substance abuse,criminal behaviors, and sexual promiscuityare some possible behaviors. These pose achallenge for the parents and should beaddressed by the family, school, and thecommunity.In addition, abrupt shifts in interperson-

al relationships can occur during times ofcrisis. Changes in familial, peer, and other(teacher) relationships may occur. Providea safe place for parents and adolescentsto talk about these changes and how theyaffect them. Reflecting on abrupt losses orchanges in relationships and how to adaptto these changes may result in a plan onhow to redesign the family structure.Typically adolescents place a high value

on the sense of justice. This may lead cer-tain individuals to a strong desire forrevenge. Man-made disasters are the idealsituation for feelings of revenge to arise. Itis important for adults to acknowledgethese emotions discourage this kind ofretaliatory behavior. Discuss the real con-

sequences of following these emotions todiscourage impulsive revenge.Adolescents may also need a space to

talk about the events, with freedom to askall the questions they have. Adolescentsshould be invited to talk about their feel-ings, but should not be forced by parentsto engage in discussions when they arenot yet ready. They can also participate infamily decisions and help in reconstruc-tion tasks; being provided opportunitieswhere they can help others may assistadolescents in coping with their own dis-tress.

School-based InterventionsPediatricians should work with schools(and sites that provide daycare) in disasterplanning as well as during the post disasterresponse, because schools are often thebest (and sometimes only) setting to deliv-er mental health services to children aftera disaster. Getting children back to schoolas soon as possible encourages a morenormal routine and provides access toemotional support from both teachers andpeers. Abnormal grief reactions and mentalhealth disorders such as PTSD are likely toemerge in the school setting. For example,intrusive thoughts and difficulty concen-trating may interfere with academic per-formance and social adaptation. Therefore,school programs that deal with the conse-quences of trauma and the recoveryprocess may be helpful. These programsshould integrate efforts to identify andrefer children in need of more intensiveindividual evaluation and treatment.

23


Early Intervention and CrisisResponse for Children and Families(from the Pediatric Terrorism and DisasterPreparedness: A Resource for Pediatricians,Foltin et al., 2006) Unfortunately, there is no clear empiricalevidence for the effectiveness of any crisisresponse intervention. In fact, the fre-quently used and previously heraldedCritical Incident Stress Debriefing orManagement (CISD or CISM) strategieshave not demonstrated effectiveness, andin some studies they have proved detri-mental. Indeed, it has been recommendedthat compulsory debriefing of victims oftrauma should cease. However, it is possi-ble that an alternative method of earlycrisis intervention may be helpful forassisting people who may be recentlytraumatized. The following recommenda-tions and guidelines for early interventionstrategies are based on evidence fromresearch on the risk factors for PTSD aswell as some intervention research. Thus,they provide an empirical foundation forappropriate and useful approaches toassist potentially traumatized individuals.Currently, there is no evidence that glob-al intervention for all trauma survivorsserves a function in preventing subse-quent psychopathology. However, there isconsensus that providing comfort, infor-mation, and support, and meeting theimmediate practical and emotional needsof affected individuals can help peoplecope with a highly stressful event. Thisintervention should be conceptualized assupportive and non interventional butdefinitely not as a therapy or treatment.This suggestion recognizes that most

people do not develop PTSD and otherposttraumatic symptoms immediately.Instead, they usually will experience tran-sient stress reactions that will abate withtime. The goal of early intervention is tocreate a supportive (but not intrusive)relationship that will result in the exposedindividual being open to follow up, furtherassessment, and referral to treatmentwhen necessary. Inherent in this earlyintervention is the recognition that inter-pretation or directive interventions arenot to be provided. After assuring thatbasic necessities are available and are nota pressing concern, the basic principles ofintervention should be followed. Theseprinciples should ensure that no harm isbeing done in the intervention processand hopefully prevent or reduce sympto-matology and impairment. � Interventions should be grounded inthe basic principles of child develop-ment, and providers should be experi-enced in working with children of dif-ferent ages and levels of development.

� Mental health providers should havecollaborative relationships with com-munity providers to ensure access andcommunity support for children andfamilies.

� Children and families should beassessed for risk factors and symptoms,and interventions should be crafted toaddress the findings. An essential objec-tive is to improve parental attentionand family cohesion through assess-ment, psychoeducation, and treatment,when necessary, to parents and primarycaregivers.

� Providers should make concertedefforts to prevent social disruption anddisplacement.

24


� Providers should identify, assess, andattempt to ameliorate or remove chil-dren and families from the continuedthreat of danger.

� Providers should have continued con-tact and monitor children for symp-toms or impairment.

Handouts or flyers that describe trau-ma, what to expect, and where to get help

should be made available. Individualsshould be given an array of interventionoptions that may best meet their needs.The goal is not to maximize emotionalprocessing of horrific events, as in expo-sure therapy, but rather to respond to theacute need that arises in many to sharetheir experience, while at the same timerespecting those who do not wish to dis-cuss what happened.

25

PREVENTION ANDDETECTION OF MENTALHEALTH PROBLEMS

OBJECTIVES

� Understand how pediatricians can

provide a perspective on children and

adolescents in relation to their families,

schools, and communities.

� Be acquainted with the activities that

may be effective before, during, and after

a disaster, in the direct care of children

and their families.

SECTION IV / PREVENTION AND DETECTION

How can Pediatricians DetectConditions, Intervene and HelpReduce the Emotional Impactof Disaster on Children andAdolescents?Pediatricians have a fundamental role inthe assessment of the emotional impactof disasters on children and adolescents.By detecting conditions that can increasethe emotional impact and by identifyingthe most vulnerable, pediatricians canadvise families, teachers, and the commu-nity on ways to minimize the emotionalconsequences of the disaster.The pediatrician is a very significant fig-

ure for parents because they haveentrusted the care of their child to thisphysician. The pediatrician is also an

important link in the child-family-school-community chain. Part of the pediatri-cian's role is to encourage communica-tion between families, schools, and leadersin the community, and to develop a jointplan that aims to reduce or avoid long-term emotional consequences, and returnchildren to a sense of routine and securi-ty. The first aspect pediatricians shouldaddress is a plan for their own securityand the security of their family. Lack ofplanning and intense worry about one'sown and family's security will underminethe ability to assist others.

Pre-disaster InterventionEnsure that the emotional needs of chil-dren are adequately considered andaddressed as part of the anticipatory plan-ning of disasters.Because the pediatrician understands

the physical and emotional needs of chil-dren throughout their different develop-mental stages, the active engagement ofpediatricians in all phases of planning isneeded to create a plan that addressesthe psychosocial aspects of children andfamilies.With this knowledge, one can advise

parents, teachers, police officers, fire-fighters, and others on some of the basicelements needed to prevent or reducethe expected emotional impact on chil-dren, and to identify children at high risk

Pediatricians have afundamental role inthe assessment ofthe emotionalimpact of disasterson children andadolescents.

for an intense and immediate emotionaldisturbance and chronic mental healthproblems.Pediatricians can give advice on the

emotional needs of children at eachdevelopmental stage, and can assist incommunity collaboration. One way toprepare the community is by giving talks,distributing leaflets or other informa-tional material, and educating the localmedia.A pediatrician can also assist in the

planning for the placement of availableresources and structure of the rescueteams in pediatric hospitals, shelters, andemergency rooms.Pediatricians should also work togeth-

er with school personnel in the prepara-tion of programs aimed at early andongoing detection of emotional distur-bances among the students. It is impor-tant to train teachers and personnel incharge about the specific emotionalneeds and typical reactions to a disaster.The pediatrician should talk with par-

ents about the reactions they mightexpect from their children according totheir developmental stage (see SectionIII). Implementation of this kind of antic-ipatory planning is especially crucial inthose communities considered to be athigh risk for being exposed to earth-quakes, hurricanes, floods, and other nat-ural disasters.

During the DisasterPediatricians should help community lea-ders identify the existing resources todeal with the disaster and make sure thatthose resources are distributed equitably.It is important to participate in disaster-related call centers and educate the massmedia in order to educate broader seg-

ments of the population. It is also crucialto become integrated into an organizedrelief and recovery program. It should bekept in mind that children spend manyhours at school, and disasters often occurwhile they are there. Hence, if teachersand school personnel are trained to iden-tify the most frequent emotional manifes-tations of students and know how to dealwith them, the school can provide an ade-quate place for children and adolescentsto feel safe and confident enough toexpress their concerns and carry on acti-vities appropriate for their age. This willlikely reduce the emotional impact and itsconsequences.

After the Disaster It is important for pediatricians to beavailable for consultation to families,schools, and the community in recogni-zing the different long-term emotionalreactions that appear among the child-hood/adolescent population.Once the event is over and the threat

has abated, they should give emotionalsupport and guidance to families, especial-ly the parents. Consider referring parentsfor support when needed, since the par-ents are the main vehicle by which chil-dren recover. They should listen andadvise parents on how to respond totheir child's emotional distress. Clarifyingnormal reactions and those reactions thatare more concerning can be very helpfulto parents. If intact, the pediatrician'soffice should remain a safe place for chil-dren and families to feel comfortable, andfree to ask for guidance and support. It isideal to have an adequate place wheremeetings with the whole family can be

If teachers and schoolpersonnel are trainedto identify the mostfrequent emotionalmanifestations ofstudents and how todeal with them, theschool can provide anadequate place forchildren andadolescents to feel safe and confident.

SECTION 1V / PREVENTION AND DETECTION 27

SECTION 1V / PREVENTION AND DETECTION28

Once the event isover and the threathas abated,pediatricians shouldgive emotionalsupport and guidanceto families, especiallythe parents.

held. Encourage dialogue between parentsand their children that can be modeled bythe pediatrician.The pediatrician should continue to

provide emotional support and facilitatecommunication among family members.He/she should help rebuild a normal rou-tine so children can regain a sense ofsecurity. He/she should be alert to thosechildren with special needs, e.g. thosewho have been direct witnesses of thedisaster, children with previous diseases,or orphans. It is imperative to follow upon children in order to establish the needfor specialist referral.The role of the pediatrician also

includes being an advisor to school per-sonnel, helping to screen children forimpairing symptoms, and being availablefor further assessment with treatment orreferral of children who have more severeor chronic symptoms.In addition to providing information

that the observed emotional disturbanceis transitory, the pediatrician should alsocounsel families, educators, and themedia, that a certain percentage of chil-dren will develop long-term symptoma-tology and impairment benefiting fromtreatment.The pediatrician should also be aware of

the criteria for a child or adolescent referralto a mental health professional, a specialist,or community-based treatment. Many pedia-tricians believe it is their responsibility toscreen for emotional distress and makereferrals after trauma and disaster. Formalscreening of all individual can be veryhelpful and is more suitable than informalscreening or routine surveillance

(http:/massgeneral.org/schoolpsychi-atry/checklists_ table.asp).The identification of mental health dis-

turbance can be complicated by an indi-vidual's reluctance to discuss symptoms,and ongoing fears for safety, and byshame and guilt associated with the trau-ma. It may be difficult for medicalproviders to inquire about symptomssince they may be affected by the disas-ter and are uncomfortable with the sub-ject. Those who believe it is not theirresponsibility or lack suitable training orconfidence can still provide suitableanticipatory guidance and counseling, andcan identify those vulnerable individualsmost at risk for persistent or severeemotional impact. In this regard, specialattention should be paid to children whohave been direct witnesses of terroristattacks or slaughter or who have suf-fered significant losses.

When should ProfessionalHelp be Sought?In most cases, expressions of emotionalimpact are transient and children goprogressively back to normal activities.However there are cases that requirereferral to a mental health professional.Mental health professional intervention

has the following goals: � To offer the child a safe setting wherehe/she can talk about his/her feelingsand emotions with respect to the situa-tion he/she is undergoing.

� To prevent the symptoms from beco-ming chronic and interfering witheveryday performance.

SECTION 1V / PREVENTION AND DETECTION 29

� To implement the needed measuresto lessen the potential impact on thedeveloping personality of the child.

Refer if the child presents:� Suicidal thoughts or suicidal ideation.� Symptoms that persist for more than 1 to 3 months and interfere with every-day life.

� Aggressive behavior, threatening his/herown or other people's life.

� Behavioral school problems that inter-fere with acceptable functioning.

� Persistent (longer than 1 month) with drawal behavior that interfereswith social life.

� Frequent nightmares that persist overtime.

� Frequent outbursts of anger, annoyan-ce, explosive behavior.

� Persistent (longer than 1 month) soma-tic complaints.

� Avoiding behavior or anxiety symptomsthat interfere with everyday life.

� Alcohol or substance abuse.� Preexisting problems and risk factorswhich should be taken into special con-sideration, since traumatic situationscan reactivate previous conflicts withover-whelming effects (Box 6).

Some communities lack a formal mentalhealth system or are overwhelmed by theneeds of the populace. In these instances,innovative community-based treatmentscan be effective. After a major flood andlandslide in Venezuela, specialized treat-ments for parents and children weredeveloped to address the significant preva-lence of post-traumatic stress disorder

symptoms. This included summer campsfor children to address their ongoing fearsand other symptoms, and it also allowedcaregivers to receive treatment concur-rently.The pediatrician can also help mental

health professionals by describing localidioms for emotional symptoms, and cul-tural patterns of distress as well as localstigma associated with mental disordertreatment. The pediatrician should informparents that many individuals have chronicemotional disturbance after disaster, butthat treatment is helpful. The pediatriciancan also be helpful to mental health pro-fessionals by identifying suitable volun-teers in the community. Mature individualswho are motivated, adapting well, andtrusted within the community can betrained by mental health professionals tohelp implement community-based pro-grams.

BOX 6. Children with high riskfor poor emotional outcome

� Wounded children� Children separated from parents for anextended period of time

� Children with previous illnesses, physicalor mental

� Children with poor family emotionalsupport

� Children whose parents have recentlydivorced

� Children who have been direct witnessesof terrorist attacks or slaughter or thoughtthey would not survive

� Children with a history of child abuse

It is reccommendedto implement theneeded measures tolessen the potentialimpact of theexperienced disastersituations on thedevelopingpersonality of the child.

SUMMARY / SUGGESTED READING30

SUMMARYDisasters place affected populations in great danger. Only in recent years have werecognized the importance of emotional impact and its short, median, and long-term consequences.Children and adolescents are an especially vulnerable group, since the reaction todisaster in these age groups depends on their psychosocial developmental stage,individual characteristics, degree of emotional and affective dependency on adults,and previous experiences.In the aftermath of a disaster, an emotional response is expected in the pediatricpopulation that can be considered a "normal reaction to an abnormal situation."However, if the response becomes very intense or persistent, or the child has anincreased vulnerability, more immediate specific support is necessary.The role of the pediatrician as part of the child-family-school-community chain iscrucial, for he/she knows the physical and emotional needs of children in each deve-lopmental stage and represents an important source of information, support andhelp for the community, school, families, and children.Acknowledging and addressing emotional disturbances in the childhood populationat an early stage is, to a great extent, the most effective way to prevent persistentand long-term disorders.

SUGGESTED READING

American Academy of Pediatrics. Committee on PsychosocialAspects of Child and Family Health. How Pediatricians canRespond to The Psychosocial Implications of Disasters. Pediatrics1999;103:521-523.

American Psychiatry Association. Diagnostic and StatisticalManual of Mental Disorders, 4a ed. Washington DC: AmericanPsychiatry Association 1994;424-429.

American Academy of Pediatrics. Pediatric Education for PrehospitalProfessionals. 2nd ed. Children in Disasters. 2006;173-189.

ACEP and American Academy of Pediatrics. APLS: The PediatricEmergency Medicine Resource. 4th ed. 2004;542-563.

Breslau N, Davis GC, Andreski P, Peterson E. Traumatic Eventsand Posttraumatic Stress Disorder in an urban population ofyoung adults. Arch Gen Psychiatry 1991;48:216-222.

Caffo E, Belaise C. Psychological aspects of traumatic injury in childrenand adolescents. Child Adolesc Psychiatr Clin Am 2003;12(3):493-535.

Carr A. Interventions for Posttraumatic Stress Disorder inchildren and adolescents. Pediatr Rehab 2004;7(4):231-24.

Crane PA, Clements PT. Psychological response to disasters: focus inadolescents. J Psychosoc Nurs Ment Health Serv 2005; 43(8):31-38.

Ferguson SL. Preparing for disasters: Enhancing the rol ofpediatric nurses in wartime. J Pediatr Nurs 2002;17(4):307-38.Groome D, Soureti A. Posttraumatic Stress Disorder and anxietysymptoms in children exposed to the 1999 Greek earthquake.Br J Psychol 2004;95(pt 3):387-397.

Gurwitch RH, Kees M, Becker SM, Schreiber M, Pfefferbaum B,Diamond D. When disasters strikes: responding to the needs ofchildren. Prehospital Disaster Med 2004;19(1):21-28.

SUGGESTED BIBLIOGRAPHY 31

Hagan JF Jr. American Academy of Pediatrics Committee onPsychosocial Aspects of Child and Family Health. Task Force onTerrorism. Psychosocial implications of disaster or terrorism onchildren: a guide for the pediatrician. Pediatrics 2005;116(3):787-795.

Hohenhaus SM. Practical considerations for providing pediatriccare in mass casuality incident. Nurs Clin North Am2005;40(3):523-533.

Hoven CW, Duarte CS, Mandell DJ, Children´s mental health afterdisasters: the impact of the World Trade Center attack. CurrPsych Rep 2003;5(2):95-100.

Hagan JF Jr and the Committee of Psychosocial Aspects of Childand Family Health and The Task Force on Terrorism.Implications of disaster or terrorism on children: a guide forthe pediatrician.

Laraque D, Boscarino JA, Battista A, et al. Reactions and needsof tristate-area pediatricians after the events of September11th: implications for children’s mental health services.Pediatrics 2004;113(5):1357-66.

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SUGGESTED READING

CASE RESOLUTION

Case resolution

Case 1. It is important to convey the message that emotional manifestations following situations ofdisaster are the expected adaptive reactions to a chaotic unexpected situation.The emotional impact on children is related to a great extent to parent's or caregiver's

reactions, so it is essential to first listen to them and give them support to minimize theadults' distress.It is important for parents to know the potential emotional reactions of their children,

according to their developmental stage. In the same way, it is important to identify the dif-ference between an expected reaction and one that requires attention.

Case 2. Children spend a great part of the day at school in contact with their teachers. Therefore,it is essential for teachers to be familiar with the different emotional needs of theirstudents according to their specific developmental stage. Also, teachers need to know thedifferent reactions and symptoms that may develop among their students.

It is important that the pediatrician work together with the school to implement pro-grams aimed at early detection of emotional disturbances.

The role of the pediatrician as an advisor for school personnel is crucial, and he or sheshould be available whenever required for the assessment of certain students.

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MODULE REVIEW

SECTION I - EMOTIONAL VULNERABILITY IN CHILDREN AND

ADOLESCENTS IN DISASTER SITUATIONS

1.What individual conditions influence vulnerability in children?2.What factors influence the emotional impact of disasters on children?3.What are the coping resources families can count on to deal with a situation of disaster?

SECTION II - CHILDREN’S EMOTIONAL

RESPONSE TO DISASTER

1.What are the most frequent emotional disturbances in the childhood populationexposed to disaster?

2.What are the characteristics of post-traumatic stress disorder?3.What are the major symptoms in depressive disorders?

SECTION III - SPECIFIC INTERVENTIONS FOR

DEVELOPMENTAL STAGES

1.What are the most common reactions in pre-school children?2.What are the most frequent reactions in school children? 3.How can adverse reactions in adolescents be dealt with?

SECTION IV - PREVENTION AND DETECTION

OF MENTAL HEALTH PROBLEMS

1.What is the role of the pediatrician in helping reduce the emotional impact inthe childhood population?

2.How should the pediatrician intervene before a disaster takes place?3.What is the role of the pediatrician during the disaster?4.What contributions can the pediatrician make after the disaster?

MODULE REVIEW

APPENDIX34

Agegroup

Reactions within the first 72 hours

Reactions within the first month

Reactions during thesecond and third months

0 - 2 years

3 - 5 years

6 - 11 years

• Agitated state• Frequent shouting and crying• Excessive clinging to parents (cannotbear separation)

• They cannot fall asleep or they oftenwake up

• They overreact to any kind of stimuliand it is difficult to reassure them

• Behavioral changes, passivity,irritability, restlessness

• Excessive fear of any stimuli,especially of those reminiscent of the event

• Spatial disorientation (cannot tellwhere they are)

• Sleep disturbances: insomnia, wakingup in a state of anxiety, etc.

• Behavioral changes: passivity• Aggressiveness, irritability• Confusion (they look puzzled) anddisorientation (they cannot tell date,place, etc.)

• Frequent crying• Regressive behavior• Language impairments

• Sleep disorders • Loss of appetite • Excessive clinging to parents• Apathy• Regressive behavior

• Regressive behavior: bed-wetting,baby talk, thumb-sucking

• They cannot bear being alone • Appetite loss or increase• Sleep disorders • Loss of powers of speech orstammering

• Specific fears: of real people orsituations (animals or darkness) orof imaginary ones (witches, etc).

• Unjustified fear• Difficulty keeping still• Difficulty focusing attention• Headaches and other somaticcomplaints

• Repetitive play enactment of thetraumatic event

• Sleep disturbance• Greater tolerance to physicalseparation

• Unjustified crying

• School or day care center refusal• Headaches and bodily pain• Food refusal or excessive eating• Repetitive play enactment of thetraumatic event

• Difficulty concentrating at school• School refusal• They feel guilty or assume thedisaster is a consequence ofsomething they have done orthought

• They look withdrawn or shy• Repetitive play enactment of thetraumatic event

Summary of the main psychological reactions of children and adolescents in disaster and emergency situations

APPENDIX 35

Agegroup

Reactions within the first 72 hours

Reactions within the first month

Reactions during thesecond and third months

12 - 18 years • Confusion and disorientation

• Withdrawal, refusal to speak

• They look distracted or as if theirmind were elsewhere

• Loss of appetite

• Loss of sleep

• Headaches and bodily pain

• Loss of interest in usual activities

• Rebellious behavior against theirfamily or any kind of authority

• Behavioral problems

• Escaping from home

• School refusal

Observeddisturbance

Recommendations for parents Recommendations for teachers

Sleep disorders

Excessive clinging

Incontinence

Other regressivebehaviors

• Reassure them• Be firm about sleeping time• Stay with them for a while• Leave a night-light on• If they wake up fully and are scared (nightmare),reassure them; should they recall the event the followingday, talk about the cause of their fears. If they are notfully awaken (night terror), do not wake them, sincethey will not recall the event the following day

• Reassure them• Encourage physical contact and cuddle them• In case of separation, tell them where you are going, andwhen you are coming back. Have somebody stay with them

• Avoid punishments and mockery• Change their clothes and reassure them• Limit liquids at night• Take them to the bathroom before they go to bedand during the night

• Show them how pleased you are when they do notwet the bed (tell them so; register the days they havenot wet the bed in a calendar, etc.)

• Leave a night-light on

• Do not punish them (ignore these behaviors)• Make them focus on something else

• Identify the problem (for instance, if you notice thechild is exhausted)

• Allow parents to be in the classroom for some time,reducing it gradually

• Do not allow mockery or rejection from classmates • Resume school activities as soon as possible

• Make them focus on something else• Ignore these behaviors

General recommendations for children and adolescent psychosocial care in a disaster situation

From: PAHO, Practical guide of mental health in disaster situations. Washington D.C., 2006

APPENDIX36

Observeddisturbance


School problems

Anxiety

Aggressiveness

Rebellious, hostileand recklessbehavior

• Seek rapid school reintegration• Do not punish them for their faults; instead, rewardany progress

• Seek a return to normal routines at home• Be firm about a reasonable study schedule

• Reassure them• Do not transmit them adults’ anxiety• Give clear and honest explanations about the past andcurrent situation (avoid making assumptions about anuncertain future)

• Explore management strategies with them (breathingtechniques, physical activity, etc.)

• Help them face fears gradually; be with them• Set an example as regards self-control• Do not use either corporal or verbal punishment; thebest punishment is indifference or a neutral attitude(still lovingly)

• Make it clear that aggression to others shall not beallowed

• Declare a truce: ignore the aggression while demandingisolation in a supervised place for a short time–“until you are able to control yourself”

• Let them know what the desirable and expectedbehavior is

• Encourage channeling of excessive energy, anxiety andanger through non-harmful strategies

• Reward self-control achievements (hugs, picture cards,stickers, etc.)

• Be patient• Be firm and object to unacceptable behaviors• Set clear rules in the family environment • Encourage communication

• Rapid school reintegration • Partial parental presence (in the case of theyoungest children)

• Special support in case of poor performance: sit thechild in the first row; provide individualized attentionat the end of school-day, etc.

• Encourage participation• Reward achievements• Prevent discrimination

• Bear in mind that anxiety interferes with attentionand concentration and causes restlessness

• Reward positive behaviors: staying seated, followinginstructions, etc

• Make periodic evaluations of achievements with them(acknowledgment and reinforcement of positivebehaviors) and ignore negative behaviors

• Do not allow aggressive behaviors.• Declare a truce• Explain what the desirable and expected behavior is• Reward achievements• Punish through indifference

• Behavior model• Consider possible external assistance for the family

APPENDIX 37

Observeddisturbance


Pain and somaticcomplaints

Bereavement

• Rule out any medical condition; if necessary, resort tohealth services

• Establish the relationship between what happens andthe symptoms

• Do not allow manipulation through symptoms

• Let them perceive their own sadness• Let them express their feelings and memories freely(sadness, anger, guilt) and talk about it in the familygroup

• Provide company and manifest affection• Do not conceal reality• Do not encourage denial; talk about losses and theirpermanent nature, despite which it is necessary to“carry on”, and try to return to normal life as soonas possible, including individual and collective socialactivities

• Allow their participation in funeral rites (burial,religious services in case of death, etc.)

• Counteract possible feelings of anger and guiltexplaining the real circumstances of the loss (ordeath)

• Allow adolescents to deal with mourning before theyassume new responsibilities

• Warn parents and facilitate medical aid

• Inform classmates before the child starts attendingclasses. Briefly explain what normal reactions thechild will have

• Provide emotional support• Facilitate spaces to talk with the child individually,but do not focus all your attention on him/her

• Encourage participation in regular educational andrecreational activities

• Check the child’s evolution and identify red flags(growing sadness, death or suicidal thoughts, etc.)

• Contact parents and coordinate actions

From: PAHO, Practical guide of mental health in disaster situations. Washington D.C., 2006

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