Comprehensive Approach to Pediatric Disaster Care

1. Pediatric Disaster Life Support Core Content Lecture 1 Fundamentals of Pediatric Disaster Medicine Andrew L. Garrett, MD

2. The Need is Clear • We have established that disasters affect children at the same time as the rest of the community • We know that children have needs that are different than adults • What tools do we need to properly prepare to treat them?

3. An Approach to Taking Care of Children in Disaster • Taking care of children is a complex process • Multiple factors must be considered • PDLS uses a bio-psycho-social approach

4. Biological Care of the Child During Disaster Psychological Social The Bio-Psycho-Social Model

5. The Bio-Psycho-Social Model • No one component is the most important • Excellent care of children requires that all three components be addressed

6. Biological Care of the Child During Disaster

7. Biological Needs • Children have unique anatomy and physiology • This creates specific vulnerabilities during disasters

8. Anatomic Differences • The youngest children have relatively larger and heavier heads • Relatively larger and less protected abdomens • Penetrating injuries • Primary and secondary impact from objects or blast wave • Predisposition to more serious traumatic damage during disasters compared to adult for the same injury

9. Relative Body Proportions

10. Anatomic Differences • Smaller mass may cause children to be thrown further and faster, resulting in greater secondary injuries upon impact

11. Surface to Body Ratio • Higher surface area and thinner skin • Risk of exposure-related injuries • Burns • Hypothermia after decontamination • Toxic exposure to the skin • Dehydration

12. Higher Baseline Metabolism • Faster Respiratory Rate • Dehydration • Ingestion of toxins, smoke, dust • Lower Blood Volume • Shock from bleeding • Greater risk from dehydration • Greater relative metabolic needs • Higher risk for malnutrition sooner than adults

13. Behavior • Live Closer to the Floor • Risk of exposure to debris and water • Greater chance of exposure to chemical or radioactive residue • Example: Infant contracts cutaneous anthrax on arm after visiting ABC television studios targeted during the 2001 attack

14. Behavior • Hand-to-Mouth Activity • Children routinely place hands and objects in mouth, increasing risk of exposure to chemicals, toxins • Increases risk of contracting vomiting and diarrheal illness during unsanitary conditions such as in a shelter or with exposure to contaminated water supply

15. Immune Systems • Young children do not have the same capacity as adults to respond to infectious disease • Biological agents • Routine infections during sheltering

16. How Children Decompensate • Differently than adults • Children rarely have primary cardiac event • Pathway is predictable • Focus is on respiratory problems and shock • To know it is to prevent decompensation • Recognize early signs and symptoms of respiratory distress and shock

18. Care of the Child During Disaster Psychological

19. Psychological Issues • PDLS will review general concepts, not age-specific details • The psychological impact of disasters on children as victims • Focus on what to expect and how to help

20. General Principles • Children are at a high risk of experiencing psychological consequences before, during, and after a disaster • Many factors that affect this • There is some controversy about these

21. What to Expect? • Everyone is affected by a disaster in some way

22. Expected Changes • Anxiety, Fears, and Worries about safety of self and others • Worries about re-occurrence or consequences such as war • Hyperactivity, decreased concentration, withdrawal, outbursts, absenteeism • Increased body complaints • Headache, Stomach-ache, Pains www.apa.org

23. Expected Changes • Changes in school performance • Recreating Event through talk, play • Increased sensitivity to sounds • Sirens, thunder, aircraft • Questions about death and injury • Changes in sleep • Denial of impact • Hateful or angry statements www.apa.org

24. Specific Symptoms: Aggression • Seen across all age groups • Verbal and/or physical outbursts towards siblings, adults

25. Specific Symptoms: Regressive Behavior • Seen across all age groups • Crying, clinginess, helplessness • Regression of toileting habits • Bedwetting • Diaper dependence

26. Specific Symptoms: Post-traumatic stress • Post-traumatic stress symptoms include: • Nightmares • Flashbacks • Emotional detachment or numbness • Insomnia • Hypervigilance • Irritability • Memory Loss

27. Common Symptoms: Post-traumatic stress • The best studied psychological effect • Factors affecting development of PTSD: • Age (older > younger) • Gender (females > males) • Race (black > white) • Parental coping skills and capabilities • Child’s perception of risk (media role?) • Duration of and distance to the danger

28. Examples • Buffalo Creek Dam Collapse (1972) • 179 children screened 2 years after • 37% given “probable diagnosis” PTSD

29. Examples • Flooding in Bangladesh (1993) • 162 children screened 2 years later • Aggressive behavior went from 0% to 10% • 34% new onset of enuresis in previously toilet-trained children

30. Examples • Wildfires in Australia • 808 children screened • 2, 4, 26 months after surviving • Prevalence of post-disaster PTSD did not change • Prevalence is % present in population tested • Predicting factors • Mother’s response to disaster more predictive compared to patient’s direct exposure

31. Examples • Reactions studied in preschoolers exposed to a severe hurricane • After 14 months, when compared to unexposed children • Higher levels of anxiety and withdrawal • Other behavioral issues resolved slowly over 6 months post-disaster • Again, mother’s response predictive of resilience in child

32. Examples • 9/11 terrorist attacks • National sample 3-5 days after attacks • 35% parents reported one child or more with anxiety-related symptoms • Half of children worried about their safety • Factors: • Parental response • Amount of media viewed on the attacks

33. Suicide? • Development of PTSD symptoms a link to suicidal behavior • In cross-population study of multiple federally declared disasters: • 25% increase in suicide in age group 10-29 years old • Hurricanes, floods, and earthquakes highest risk • Data suggest young men at highest risk

34. How to Help • Understand the high rates at which these psychiatric disorders appear in children after disaster • Understand the time frame • Many behavioral problems will resolve over weeks to months • Anxiety/PTSD symptoms may persist over years

35. Planning • Incorporate Psychologic First Aid information and providers in your planning at all levels • Utilize the expertise and advice of mental health professionals before, during, and after • Preparation and pre-positioning resources • Expertise in screening, therapy

36. Social Care of the Child During Disaster

37. Overview • Children need to be viewed as an integral part of the population, not a “special circumstance” to be dealt with separately • What happens to adults happens to children • Planning, Response, and Recovery must acknowledge this principle to be effective

38. Influences • It is established that outside factors greatly affect a child’s post-disaster psychiatric recovery, especially: • How parents (especially mother) reacts in the post-disaster environment • Media

39. Influences • Exploring the parent-child relationship a little bit more: • Child Abuse • Substance Abuse • In general, parental stress and a lack of social services are linked to an increase in child abuse reports • Is this true after a disaster too?

40. Examples • Loma Prieta Earthquke (1989) • Hurricane Hugo (1989) • Hurricane Andrew (1992) • Data suggest that child abuse rates increased in the 3 and 6 month period after these disasters

41. Examples • Hurricane Floyd (1999) in North Carolina • Inflicted traumatic brain injury increased in the 6 months following the hurricane in the most affected counties • After 6 months rates of inflicted injury returned to baseline • Accidental injury rates remained the same

42. Examples • A 2001 café fire in the Netherlands wounded 250 adolescents, and killed 14 Compared to a control group: • Increased rates of anxiety, depression, and alcohol use • Marijuana, Ecstasy, and sedative use did not increase

43. Expectations • Disasters are stressful events to all members of the community • Anticipate problems such as: • Increased child abuse • Increased substance abuse

44. Media and Society • What has been the role of media in recent disasters? • Hurricane Katrina • Indian Ocean Tsunami • 9/11 Terrorist Attacks • How did children respond to this information, based on what we have already discussed?

45. Media and Society • Many children feared for their own safety, and that of their parents • Media viewing of disturbing images may exacerbate anxiety, aggression, regression, PTSD • What is the responsibility of the media? • What is the responsibility of parents?

46. Suggestions • Acknowledge that children do not benefit from the repeated viewing of frightening images Photo: National Geographic Channel

47. Suggestions • Helping parents in need?

48. School • The re-establishment of routine may prevent the worsening of symptoms in children and speed the recovery • The ability to recover after a disaster and return to normal is termed resiliency

49. School • School provides much of what is taken away during a disaster and may be an important part of resiliency • Order • Rules • Consistency • Friends • Role Models and Teachers

50. Coping Techniques at Home and School • Reinforce the idea of safety and security through self-realization • Maintain a routine schedule • Listen to children’s discussions of the events • Discuss how media may be affecting their feelings www.apa.org