CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION

1. CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION

2. Research on Children’sDisaster Mental HealthGaps and Challenges Randal Beaton, PhD, EMT University of Washington Adopted/adapted from Gilbert Reyes, PhD Terrorism and Disaster Center University of Oklahoma Health Sciences Center Northwest Center for Public Health Practice

3. Federal Sponsors • NIMH National Institute of Mental Health • NINR National Institute of Nursing Research • SAMHSA Substance Abuse and Mental Health Services Administration

4. Principal Investigators • Betty Pfefferbaum, MD, JD University of Oklahoma Health Sciences Center • Alan M. Steinberg, PhD University of California, Los Angeles • Robert S. Pynoos, MD, MPHUniversity of California, Los Angeles • John Fairbank, PhDDuke University

5. Learning Objectives Participants will learn to: • Identify significant gaps in knowledge about harmful effects of disasters on children’s psychosocial functioning. • Identify significant gaps in knowledge about variables that influence the differential effects of disasters on children’s psychosocial functioning.

6. Learning Objectives(Continued) Participants will learn to: • Identify significant gaps in knowledge about the effectiveness of psychosocial services and interventions for children affected by disasters. • Identify significant challenges to extending and elaborating knowledge about the effects of disasters on children’s psychosocial functioning and the effectiveness of disaster mental health interventions.

7. General Research Questions • What are the psychosocial effects of disasters? • What factors influence those effects? • What can be done to alter those effects?

8. What are the psychosocial effects of disasters? • Where are the effects found (location)? • Who is affected (populations)? • How much are they affected (caseness)? • When are they affected (time course)? • Do the effects unfold in phases as conditions change? • How do the effects differ as a function of children’s development?

9. What are the psychosocial effects of disasters? • Pathogenesis: • What are the pathogens? • Exposure to what? • Under what conditions? • At what levels? • Severity • Frequency • Chronicity • Duration

10. What are the psychosocial effects of disasters? • What pathologies are generated or exacerbated? • Trauma symptoms? PTSD? • Depression? • Anxiety? • Substance Abuse? • Social Disadvantages; e.g. stigma • At what levels? • Among whom? • By what mechanisms?

11. What are the psychosocial effects of disasters? Categories of studies found in the (adult) literature: • Empirical Epidemiological • Study entire population • Define and describe psychopathology • Prevalence and incidence rates • Clinical Descriptive • Selected samples • Case study methods • Assess symptom levels • More descriptive than inferential Rubonis & Bickman, 1991

12. What are the psychosocial effects of disasters? Findings from a meta-analysis of the empirical literature Rubonis & Bickman, 1991, p.391:

13. What are the psychosocial effects of disasters? Findings from an empirical review of the empirical literature (a) specific psychological problems (disorders in the DSM-IV) (b) nonspecific distress (i.e., subclinical elevation of symptoms associated with reactions to extreme stress), (c) health problems and concerns (e.g., somatic complaints, substance abuse) Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002

14. What are the psychosocial effects of disasters? Findings from an empirical review of the empirical literature(continued) (d) chronic problems in living (e.g., increased daily hassles secondary to the disaster) (e) psychosocial resource loss (e.g., deterioration of personal hardiness and social support) (f) problems specific to youth (e.g., separation anxiety, developmental regression, and externalizing behavior problems) Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002

15. What are the psychosocial effects of disasters? • Findings from Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002: • Levels of Impairment in studied samples: • 51% (of 160) empirical studies reported moderate impairment among disaster survivors • 39% reported severe to very severe impairment • Suggests that a very substantial proportion of disaster survivors could benefit from psychosocial interventions Comparable specification of effects on children is not evident in the literature Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002

16. What are the significant gaps in knowledge about the harmful effects of disasters on children’s psychosocial functioning?

17. Gap 1: Descriptive EpidemiologyHow are the psychosocial effects of disastersdistributed among the exposed children? • Populations at risk (i.e., exposed) are inadequately defined. • Children are particularly overlooked. • Minority groups are underrepresented. • Exposure is inconsistently defined. • Case definitions are inconsistently defined. • Reporting (data) sources are inconsistently selected. • Biased sampling methods (representativeness) distort incidence and prevalence estimates (validity/reliability). • The instruments of measurement are not standardized.

18. Gap 1: Descriptive EpidemiologyHow are the psychosocial effects of disastersdistributed among the exposed children? • Change over time is seldom studied: • Lack of longitudinal investigations • Delayed onset latency is poorly studied. • Periodicity (e.g., phases, anniversaries) is poorly studied. • “Natural” attenuation (i.e., tincture of time) goes unmeasured.

19. Challenges To Accurately Assessing Of The Psychosocial Effects Of Disasters On Children • Defining the populations at risk with sufficient breadth and specificity to ensure that children at all levels and types of exposure are properly screened. • Employing unbiased sampling methods that yield results representative of the populations at risk.

20. Challenges To Accurately Assessing Of The Psychosocial Effects Of Disasters On Children • Adopting a standardized: • set of instruments and protocols to be employed with consistency across studies. • set of adequately differentiated (not just trauma) and specified case definitions to be employed with consistency across studies. • protocol of data sources to be employed with consistency across studies. • Overcoming the lack of baseline information. • Difficulty distinguishing disaster effects from preexisting pathology.

21. Challenges To Accurately Assessing Of The Psychosocial Effects Of Disasters On Children • Decreasing the time-lag between precipitating events and the initial point of measurement (time 1). • Advanced preparation. • Funding. • Permissions and access. • Persuading and training researchers to adopt epidemiological standards. • Replacing static snapshot studies with longitudinal designs that account for change over time.

22. Which Factors Influence Those Effects? • Factors that increase risk (risk factors). • Factors that reduce risk (protective factors). • Factors that amplify or attenuate the translation of exposure into pathology (moderators)? • Affects the strength of the relationship. • Factors that are necessary for the translation of exposure into pathology (mediators)? • Explains a mechanism of the relationship. • These are the keys to resilience.

23. Which Factors Influence Those Effects? • Vulnerability (Mediators and Moderators): • What are the risk factors? • Female gender • Early or advanced age • Low SES • Pre-existing conditions • Degree of exposure • Unique event characteristics; e.g. terrorism & media • What are the protective factors? • Opposites of risk factors? • Training and experience? • Hardiness? • Self-efficacy? • Social support?

24. Which Factors Influence Those Effects? Risk factors for more severe psychosocial impairment • Conditions of mass violence or massive casualties • Severity and level of exposure • Severity and pervasiveness of the financial & social effects • Threat of or actual loss of life • Physical injuries • Pre-disaster psychosocial functioning • Post-disaster (secondary) stressors • Low Socioeconomic Status (SES) • Fewer social and economic resources (e.g., social support) • Higher risk among women, youth, disadvantaged “minority” groups, and residents of less developed countries Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002

25. What are the significant gaps in knowledge about variables that influence the psychosocial effects of disasters on children?

26. Gap 2: Differential Impact FactorsWhich variables influence the psychosocial effectsof disasters children? • Risk and protective factors are poorly specified and inconsistently operationalized. • Personal attributes • Social/Cultural attributes • Environmental conditions and operators • Stressors & buffers

27. Gap 2: Differential Impact FactorsWhich variables influence the psychosocial effectsof disasters in children? • Utility of risk and protective factors for screening is insufficiently examined • sensitivity • specificity • Mediating and moderating relationships are insufficiently examined.

28. Challenges To Assessing Variables That Influence The Psychosocial Effects Of Disasters On Children • Hastily prepared research designs lead to: • Over reliance on small samples and convenience samples. • No power to examine complexity between variables (e.g., mediation and moderation) • Over reliance on categorical variables. • Inability to examine complexity within variables (e.g., threshold effects). • Over reliance on immutable variables; e.g. gender • Poor utility for interventions. • Settling for descriptive results with poor explanatory power. • Inability to study change over time.

29. Challenges To Assessing Variables That Influence The Psychosocial Effects Of Disasters On Children • Risk and protective factors need to be conceptualized in ways that better inform prevention, intervention, and public policy. • Examine relationships among risk and protective factors to distinguish between direct effects, mediators, and moderators. • Increase reliance on theory-driven models that move from mere description to explanatory mechanisms. • Examine the evolving influence of risk and protective factors over time. • Employ more sophisticated modeling techniques to clarify complex interactions of predictors and outcomes.

30. What can be done to alter those effects? • Which interventions will proactively reduce risk (prevention)? • Which interventions will reduce manifest pathology? • Which factors amplify or attenuate the translation of exposure into pathology (moderators)? • Affect the strength of the relationship. • Which factors are necessary for the translation of exposure into pathology (mediators)? • Explain a mechanism of relationship.

31. What can be done to alter those effects? • Conceptual and Design Issues • Targets of Intervention? • Scope of Intervention? • Modes of Intervention? • Timing of Intervention? • Levels of Intervention? • Method of Evaluation? • Timing of Evaluation? • Indices of Response to Intervention (outcomes)?

32. What can be done to alter those effects? • Needs Assessment • What is needed? • When is it needed? • Where is it needed? • Needed by whom? • What works? • What works with whom? • Individuals • Adults • Children • Families • Institutions (e.g., schools) • Communities

33. What can be done to alter those effects? • Modes of Service Delivery • Provided by whom? • In what amounts? • When? • For how long? • At what locations?

34. What can be done to alter those effects? • Barriers to Care: What facilitates or discourages the seeking of treatment? • Accessibility? • Financial concerns? • Logistical Concerns? • Competing priorities? • Acceptability? • Stigma? • Credibility?

35. What can be done to alter those effects? Direct Psychosocial Interventions • Debriefing (prophylactic crisis intervention). • EMDR (Chemtob, Nakashima, & Carlson, 2002). • Stress Management (coping skills). • Crisis Intervention (arousal reduction, problem solving). • Grief Counseling (loss and bereavement). • Psychotherapy (clinical disorders).

36. What can be done to alter those effects? Indirect Interventions with Psychosocial Targets • Psychological First Aid • Reduction of unnecessary stressors • Respite care for caregivers • Advocacy to reduce “bureaucratic” frustration • Psycho-education to inform effective coping • Parenting education • Teacher education • Leadership training in the fire service • Community mobilization

37. What are the significant gaps in knowledge about the effectiveness of psychosocial interventions for children exposed to disasters?

38. Gap 3: Characteristics of Effective InterventionsWhich characteristics influence the effectiveness of psychosocial interventions for children exposed to disasters? • Inadequate scientific evidence to support use of popularized interventions in the early post-disaster environment. • Treatment samples don’t represent the population. • Therapists in studies differ from counterparts in field settings. • Tested interventions not employed in field settings • Commonly used disaster interventions with children go untested under field conditions.

39. Gap 3: Characteristics of Effective InterventionsWhich characteristics influence the effectiveness of psychosocial interventions for children exposed to disasters? • Tested interventions are poorly disseminated and seldom adopted for field use, and field interventions are seldom tested. • Modes of service delivery differ substantially between clinical settings and field settings. • Barriers to care go unexamined

40. Challenges In Assessing the Effectiveness OfPsychosocial Interventions for Disaster Exposed Children • Competing priorities during the early phases of disasters. • Political and social concerns about unintended consequences and implications. • Community resistance. • Limitations on access. • Ethical concerns. • IRB approval barriers. • Funding barriers.

41. Conclusion The existing research literature on disaster mental health, while rich and useful in many ways, is inadequate in the following ways: • Inadequate basic epidemiology. • Unrepresentative samples. • Delay between precipitant and measurement (decay) • Neglect of time as a variable. • Unsubstantiated extrapolation and generalization of weak findings. • Inadequately systematic and precise examination of variables and relationships. • Untested effectiveness of interventions.

42. Impediments • Lackof Prediction and Preparation • Lack of Funding and Human Resources • Slow funding process • Lack of Access to Affected Populations • Proximity • Competing Agendas & Priorities • Stigma and negative bias towards research • Ethical Objections

43. Proposed Solutions • Prepare for predictable events and aspects. • Alter funding mechanisms to promote rapid response protocols. • Integrate research designs into governmental and non-governmental relief efforts. • Form geographically distributed research networks to facilitate access and cut response times. • Integrate research with other agendas & priorities. • Target stigma, ignorance and negative biases towards research with public education campaigns. • Promote policy reforms that raise the priority of children’s disaster mental health research.

44. Proposed Solutions • Adopt a public health approach to studying the psychosocial effects of disasters on children. • Adopt a developmental psychopathology approach that examines the the risk and protective factors related to the psychosocial effects of disasters • Promote the use of longitudinal designs that assess change over time. • Adhere to scientific standards of evidence. • Develop and test approaches to interventions that are congruent with local cultural values and expectations; e.g. community action research • Confront pseudo-ethical objections: “We already know it works so…”

45. Sustainability of Pacific NW LMRT: Next Steps • Listserv- notify of future projects • Access to Regional Mentoring Consultants • All the DRT Newsletter • Invitation to describe and chronicle this technological training effort in an article • Specific Research Projects-brainstorm