PSYCHOSOCIAL CARE FOR CHILDREN IN DISASTER

1. PSYCHOSOCIAL CARE FOR CHILDREN IN DISASTER Dr. K. Sekar Professor of PSW NIMHANS, BANGALORE sekar@nimhans.kar.nic.in 098452 14397

2. Disaster is a severe disruption of ecological and psycho social which greatly exceeds the coping capacity of affected community. WHO, 1992 DISASTER Some visuals in the presentation could be disturbing for certain viewers

3. PSYCHOSOCIAL CARE Psychosocial programming consists of structured activities designed to advance children's psychological and social development and to strengthen protective factors that limit the effects of adverse influences. WHO, 2001

4. NEED FOR PSYCHOSOCIAL CARE • Mitigate effect of trauma • Alleviate psychological distress • Strengthen resiliency • Re-establish normal development process

5. PS CARE IN DISASTERSNIMHANS EXPERIENCES 1981 -2011

6. Two and half decades of work in disaster mental health and psycho social care work by NIMHANS. Recognised by Ministry of Health of GOI as the nodal centre for psycho social care in disasters in India. NIMHANS – NODAL CENTRE FOR PSYCHO SOCIAL CARE IN DISASTERS

7. Development Rehabilitation Response Reconstruction Development Event Prevention Warning Mitigation Preparedness Development PHASES OF DISASTER

8. PSYCHOSOCIAL EFFECTS OF DISASTER PSYCHOSOCIAL EFFECTS Rescue and Recovery Personnel Acute Phase7 days Friends of Primary Victims Primary Victims Disaster Community Relatives of Primary Victims Community Members Reconstruction 38 weeks-3 years Immediate Post-Disaster 1 week-12weeks Rehabilitation 12 weeks-36 weeks TIME

9. A B C PS NEEDS AFTER DISASTER • 7-14 days – Psychological support • 2 weeks - 6 month – Psycho social support • > 6 months – Psycho social rehabilitation • Lifetime – rebuilding of the survivor population SOURCE: Disaster Mental health model, in Disaster mental health in India, pp243

10. Estimates of the prevalence of trauma in the population world over are projected to be between 33% and 90% during various phases of disaster recovery. APA. 1980. Helzer JE, Robins LN, McEvoy L. 1987. .Davidson JRT, Hughes D, Blazer DG. 1991. .Breslau N, Davis GC, Andreski P et al. 1991. .Kessler RC, Sonnega A, Bromet E et al. 1995. PREVALENCE OF TRAUMA

11. Giddiness / instability Panic attacks Generalised Anxiety Somatic symptoms Emotional problems – irritability, _ apprehension, _ numbness Increased alcohol use Grief PTSD sx - flashbacks Survivor guilt Depression REACTIONS TO DISASTER REACTIONS Duration

12. Prolonged continuation of biological responses following stress may lead to an inappropriate pairing of the traumatic memory with distress, and then initiate a cascade of secondary biological alterations, including structural changes of the brain. BIOLOGICAL RESPONSES

13. Displacement of the individual Unemployment Change in marital status Single parent families Orphans Disruption in the social fabric Breakdown of the traditional forms of Social Support SOCIAL ISSUES

14. DISASTER LIFESTYLE CHANGES • Worse change in lifestyle might be associated with high PTSD score (Fukuda et al, 1999) subsequent to a disaster • Cigarette smoking • Consuming alcohol • Family violence • Wife battering • Child neglect • Mental stress

15. SURVIVORS AT RISK

16. SINGLE PARENT CHILDREN • Children who have lost either one of their parents, find it difficult to accept the loss of the parent. • They should be encouraged to speak about their loss and reassured with support from the remaining parent and siblings, instead of avoiding the issue totally.

17. ORPHAN CHILDREN It is important that such children remain with immediate family members who can look after them. A secure and non-threatening environment can provide a space where they can explore their grief, come to terms with their loss and begin to relate to their new surroundings.

18. RIGHTS OF CHILDREN FOR PSC The psychosocial care and protection of children is recognized by Article 39 of the Convention on the Rights of the Child, which deals with the child’s right to psychological recovery and social reintegration. In recent years emphasis has increasingly been on providing activities for children to create a safe and ‘normal’ environment, rather than focusing on psychological analysis and treatment. Specific targeted programmes are needed in order to ensure that psychological recovery and social reintegration can take place at the earliest (UNICEF 1999).

19. IMPACT OF DISASTER ON CHILDREN AND ADOLESCENTS 1.   Loss of familiar environment 2.   Fear and insecurity 3.   Struggle for food, shelter and other amenities 4.   Witnessed death 5.  Continued threat to their sense of well-being 6.  Injury to self 7.  Being tortured (in human made disaster) 8.  Witnessing violence and destruction.

20. ·         Temper tantrums ·         Crying ·         Clinging and demanding ·         Scary nightmares ·         Helplessness ·         Regressive behaviour (thumb sucking, wanting to be carried, bed-wetting) ·         Moodiness, irritation ·         Fear of darkness or sleeping alone ·         Easily frightened and then anger ·         Increased aggression specially in boys PRE-SCHOOLERS UPTO 6 Yrs

21. SCHOOL GOING CHILDREN ·         Physical complaints – headache, stomach aches ·         Aggression ·         Fear of darkness/ghost / sleeping alone / separation from parents ·         Lack of self competency ·         Understand loss and become very anxious ·         Regression to behaviours like thumb sucking etc ·         Nightmares and inability to sleep ·         Fear of recurrence ·         Difficulty in following routines

22. ADOLESCENTS ·  Seeks isolation, becomes less communicative ·  Sleeplessness or increased sleep ·  Feel different or alienated because of their experiences ·  Irritability ·  Increased risk taking behaviours ·  Increase substance abuse ·  Avoidance of trauma related thoughts, feelings and activities ·  Aggression – fights, destructive, arguments ·  Feelings of hopelessness, feeling of neglect and isolation

23. SPECIAL CHILDREN • Orphaned children • Single parent children • Children who are disabled or injured • Children who are handicapped • Children who have seen violence • Children who have lost close family members

24. BANGALORE CIRCUS TRAGEDY • Bangalore Circus tragedy(1981) • Home based care through simple emotional support • Beneficial to survivors H.S. NARAYAN et al.

25. “I have treated phosgene poisoning. But methyl isocyanate is something else. I don’t think anyone in India is even competent to handle MIC poisoning” Dr. R.K. Rajnarayan Industrial Health Expert Bhopal plant 1978-1981 GAS AFFECTED CHILDREN HAMIDIA HOSPITAL

26. Born on the day of the gas leak. This girl was named Gas Devi, ‘gas goddess’, by her parents. GAS GODDESS

27. Children get in through broken boundary walls to play in the contaminated grounds. Tank E610, which contained the deadly MIC, lies just a few yards away in the back ground. ABANDONED FACTORY SITE

28. Commonly encountered reactions in children are: Regressive problems Bodily reactions Suicidal ideas Emotion and conduct problems Illness modeled after others BHOPAL DISASTER MENTAL HEALTH MANUAL

29. MANAGEMENT

30. MARATHWADA EARTHQUAKE • Marathwada Earthquake ( Sep. 1993) • Getting attracted to substances especially gutka and alcohol • Schooling affected as post earthquake rebuilt schools are far off from their houses • Decline in social contact due to geographical distancing

31. PSYCHOSOCIAL CARE WITH CHILDREN - ORISSA • Orphan children • Single parent children • Single children • Step children • Child trafficking • School refusals • Sneha karmis are vital in the care process.

32. Have nightmares or talk about cyclone repeatedly Regress and develop bedwetting School refusal Decline in scholastic performance Disturbed and angry Teachers need to be sensitive and sensitized on the above issues SCHOOL GOING CHILDREN

33. EVALUATION OF CHILDREN • The highest percentage of symptoms • elicited among the children were • slow learning; getting scared • sleep problems; wetting of clothes.

34. IMPACT OF CYCLONE ON CHILDREN IN THE CONTROLLED AND INTERVENTION AREAS

35. PS INTERVENTIONS REDUCES SYMPTOMS AMONG CHILDREN • The interventions with the children in terms of formation of small groups and introduction of mediums have played a vital part in the study area. • This is evident from the lowest mean distribution of the symptoms in the study area in comparison to the control and community samples studied. • The presence of the mean number of symptoms ranging from 1.2 to 3.8 among children in the total population studied reveals the higher psychological morbidity in the disaster affected area even at the end of two and a half years.

36. GUJARAT EARTHQUAKE • 26th January 2001 • About 1000 students were killed in Kutch alone. • An estimated 400,000 children enrolled in the districts affected by earthquake affected.

37. INTERVENTIONS AT SCHOOLS • 17,000 teachers were directly affected. • Psychosocial interventions initiated in the primary schools of four worst affected blocks covering 78 school clusters extending services to 721 villages.

38. UNICEF, GCERT, GMHA, NIMHANS INITIATIVE • Psychosocial support programme in school settings • Development of manual of care for school teachers. • Training of DIET personnel as TOTs • Establishment of a training team for psychosocial interventions in the State. • More than 1500 teachers trained on psychosocial interventions in 728 schools.

39. IMPACT ASSESSMENT • Impact assessment survey on 800 trained teachers. • 90% reported that training had been helpful • Effective in dealing with their own trauma. • Capacity building and facilitation was felt. • Need for continued support to teachers for filed level implementation.

40. LONG TERM PSYCHOSOCIAL SUPPORT • Psychosocial intervention need to be universal as opposed to being available for only those who show disorder. • Need to be culture sensitive by focusing on helping the local resource pool evolve • Psychosocial programme developed as an immediate response to the disaster need to evolve into a long term PSS programme.

41. Potentially life-threatening events, such as the mass-violence, physical attack, sexual attack on women and children in Gujarat since February 27 2002, in many ways has resulted in major psychological trauma both among the victims and those who witnessed the same. GUJARAT RIOTS & CHILDREN

42. Resulted in the death of nearly 1000 persons Many of them, being women and children. Houses and commercial establishment have been looted and gutted across the state. Nearly one lakh people were in makeshift camps run largely by self-help efforts of the affected communities. THE GUJARAT VIOLENCE

43. Impact of events like Loud noises, shouting, Running, panic and anxiety, Separation from loved ones, Loss of the comfortable environment, Depravation of food and drink Impact a child much more than an adult. IMPACT OF EVENTS ON CHILDREN

44. The children do not have the mind or the emotional state to solve problems like an adult. A child needs to discuss and sort out his/ her fears with an adult because they do not probably realize that there are other options. They are dependent on adults physically and emotionally. Often they cannot comprehend what has happened to them. EMOTIONAL STATE OF CHILDREN

45. “I do not want to go to school. If something happens, I will die there, my father will die somewhere”. “Whenever I come to school, I remember the way we were running the other day”. “I feel fearful about that day, it may happen any time” “I see my mother’s face in the examination sheet” SCHOOL CHILDREN’S REACTION

46. “I will kill as many as possible, I am waiting for the day”. “I am afraid, everybody tells it will occur again”. “I see my brother shouting for help, his body is full of blood, crying and shouting with pain”. “I wanted to be Sachin. I cannot play cricket anymore”. COMMUNITY ADOLESCENTS REACTION

47. “I used to open and show the clothes with the same hands. How can I do with this maimed fingers”. “I was shouting at you, but you never saw me. I realized later that there was no sound coming from my throat”. “I used to open the wheels in no time. Now I cannot even hold the spanner”. YOUNG ADOLESCENTS REACTIONS

48. “She is very stubborn now a days, wants things immediately, wets clothes” - 5 years old. “She does not want to meet anyone, stays by herself” - 8 years old. “Suddenly gets up at night, feels very scared” - 9 years old. “Doesn’t concentrate in school, has become very disobedient” -12 years old. GIRLS REACTION

49. “He is very angry and fights with everyone” 13 years. “He is smoking now a days and keeps saying that he could not save his sister” 17 years. “I am expecting my next child. This one does not get down of my hip” 3 years old. “Both these kids get shouting and beatings from him every day”. PARENTS REACTIONS

50. “Doctor saab, would this 90,000 rupees bring back my son”. “He was pretty and loveliest of the lot, look at his face today”. “I do not want my son to go to that school”. “The teachers are prejudiced” “They have a specific mind set and borders in their mind”. PARENTS REACTIONS