Psychosocial Consequences of Disaster in Children

1. Psychosocial Consequences of Disaster in Children PDLS version 2 draft Gretchen K. Lipke, MD

2. Objectives • The student will be able to describe: • Expected reactions • Unhealthy reactions • Coping mechanisms • Family role in child’s response

3. It is impossible to separate the effects of disaster on children and their families and the two should be considered as a unit.

5. Children in Disaster • Mass casualty events affect children • Directly, as victims • Indirectly, as families are affected

6. Children as Direct Victims

7. Children as indirect victims

8. Oklahoma City • 3200 high school students in city given screening questionnaire 7 weeks after bombing • 1/3 knew someone killed • Retrospective scores of initial arousal and fear predictive of PTSD at 7 wks • Raised concerns about TV impact on traumatized youth

9. Children as Victims • Psychological reactions • Immediate • Short-term • Long-term • Overlap • Normal variation by age

10. Jupiter shipping disaster • Boat sank – 217 teenaged survivors • At 5-8 year follow-up: • 111 (52%) had PTSD at some point • Control group 3.4% incidence • 90% onset within 6 months • 1/3 recovered within 1 year • 1/3 still have PTSD 8 year after incident

11. Immediate Reactions • Shock, grief, loss • Helping, as coping mechanism • Anger • Guilt at surviving, at preserving material possessions or family when friends and neighbors did not

16. Short-term reactions • During and immediately after event • Continuum with immediate and into long-term • Overlap; no clear delineation of changes, and it may differ among survivors, even within family unit. • BUT children model the adult behavior within their family unit

17. Short term reactions • Disbelief • Denial • Anxiety • Grief • Altruism • Relief

19. Short-term reactions • Grief, loss, anger, guilt • Coping strategies • Regression – loss of developmental milestones • Clinging and increased dependency • Helpfulness – more useful in older children • Acting out – competing for attention

20. Regression • Common after trauma • Short-lived behavior –few weeks • Not intentional – child needs reassurance • Thumb sucking, whining, fear of the dark, loss of toilet training and speech patterns • Loss of previous dependability, confusion, attention seeking

21. Short term reactions • 1 week after Armenian earthquake (12/88), survey of Armenian adolescents in Los Angeles showed • Strong identification with victims • Felt personally affected • Group activities to escape grief reactions

22. Armenian earthquake results • Group pressure to accelerate helping efforts • Group cohesion improved • Preference to preserve communal values, even over helping earthquake victims • “participation envy” – survivor guilt, envy and resentment over being excluded from a unique and rallying communal experience

23. Long term reactions • Coping mechanisms • Regressions • Acting out • Replaying event • Clinginess • Attention seeking behavior

24. Long term reactions • Other • Somatic complaints – headache and stomach aches common • Repetitive re-enactment – drawings, role-playing, dolls and puppets • Risk-taking behaviors – thrill seeking, drug use • Withdrawal – from school, friends, usual activities

26. The diagnosis of PTSD • Three categories lasting over a month: • Re-experiencing of the event through play or trauma specific nightmares. • Routine avoidance of the reminders of the event or a general lack of responsiveness. • Increased sleep disturbances, irritability and poor concentration.

27. Post-Traumatic Stress Disorder • Interpersonal violence or life-threatening accidents or disasters • More likely after direct exposure • Also if trauma witnessed or loved ones involved with associated horror and shock

28. PTSD factors • Degree of controllability, predictability and perceived threat • Relative success of attempts to minimize injury to oneself or others • Actual loss • Intensified if wounded, exposed to heat, cold or pain

29. Symptoms of PTSD • Stressor/trigger • Re-experiencing the event • Avoidance of reminders • Unwanted recollections • At least one month’s duration

30. Age and development • Infants to teens – broad range of abilities • Similar responses will manifest differently at different ages

31. Differences by gender • Responses vary by gender. Boys take longer to recover and exhibit aggressive, antisocial and violent behaviors. • Girls are more distressed, have more verbal emotions, ask more questions and have more frequent thoughts concerning the disaster.

32. Parental Involvement • Chernobyl follow-up study: 11 years after evacuation, comparison of 300 children aged 10-12 at time of study evacuated (as infants or in utero) with 300 homeroom classmates never in radiation affected area. • Evac moms rated child’s well-being as signif worse, esp somatic despite normal PE and blood work. • Evac kids rated their mental health similar to classmates except for Chernobyl-related anxiety

33. Chernobyl and adolescents • 50 adolescents 9 years after accident • Uncertainty about radiation exposure • Frequent thoughts about accident • Worried about radiation exposure as a cause of any health problems

34. PTSD in adolescents • 217 young adults who survived shipping disaster in adolescence followed for 5-8 years • Duration and severity of PTSD most strongly related not to disaster-related factors, but pre-disaster vulnerability and whether survivors received school-based support

35. Hurricane Andrew • 92 4th -6th graders • 15 months prior – self reports of anxiety, behavior assessment by peers and teachers and academic skills • Repeated testing at 3 and 7 months post-disaster • At 7 months, exposure and pre-disaster anxiety predictive of PTSD

36. Attention seeking • Infants – crying and irritability • Toddlers – regression from developmental milestones • Preschool – hitting and biting • School – defiance of home and school rules • Adolescents – truancy, risk-taking behaviors

37. Disruption of Normal Patterns • The cardinal effect of disaster and children in adolescents is a disruption of their lives which leads to a loss of reliability, cohesion, and predictability. • Toddlers respond with increased dependency. • School-age children show evidence of trauma with talk and play about trauma and hostility to peers and family. • Adolescents may also withdraw and have decreased interest and experience fatigue, hypertension, hostility and loss of objectivity.

38. Disruption Recommendations • Parents, teachers, and healthcare workers should create and maintain a predictable schedule for children. • Night lights, stuffed animals, and reassurance are helpful. • Compassion is helpful but punishment is not. • Consultation with psychiatrist or psychiatric social worker may be a benefit.

40. Stress response in children • “Fight or flight” • Adrenaline/epinephrine mediated • Arousal state • Increased startle, response, agitation • Increased heart rate, respiratory rate, blood pressure.

41. Alternate stress response • “Freeze and hide” • Vagal nerve stimulus • Opposite of “fight or flight” • Blunted reactions, affect, responses • Lowered heart rate, respiratory rate, blood pressure • Syncope may result

42. Responding to children’s needs • Parental cues most important • Acknowledge danger and fright • Calm reassurance provides a sense of safety • Let children know that feeling upset is normal • Extra time and attention.

45. Responding to children’s needs • Parents should know age appropriate responses • Monitor and limit media exposure to disaster coverage • Early counseling may reduce long term negative effects • Rehearsal of plan reduces anxiety and gives a a sense of control

49. Responding to children’s needs • Talking through what happened • Replaying, for younger children, similar to talking through • Perspective on family impact • Probability of recurrence or (for distant events) personal impact