CHILD AND FAMILY

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CHILD AND FAMILY DISASTER RESEARCH TRAINING AND
EDUCATION
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Research on ChildrensDisaster 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
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Federal Sponsors

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

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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

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Learning Objectives

• Participants will learn to
• Identify significant gaps in knowledge about
  harmful effects of disasters on childrens
  psychosocial functioning.
• Identify significant gaps in knowledge about
  variables that influence the differential effects
  of disasters on childrens psychosocial
  functioning.

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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 childrens psychosocial functioning
  and the effectiveness of disaster mental health
  interventions.

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General Research Questions

• What are the psychosocial effects of disasters?
• What factors influence those effects?
• What can be done to alter those effects?

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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
  childrens development?

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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

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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?

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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
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What are the psychosocial effects of disasters?

• Findings from a meta-analysis of the empirical
  literature

Rubonis Bickman, 1991, p.391
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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
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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
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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
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• What are the significant gaps in knowledge about
  the harmful effects of disasters on childrens
  psychosocial functioning?

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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.

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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.

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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.

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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.

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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.

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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.

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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?

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

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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

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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.

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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.

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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.

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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.

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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)?

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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

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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?

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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?

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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).

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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

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

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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 dont 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.

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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

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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.

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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.

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Impediments

• Lack of 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

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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
  childrens disaster mental health research.

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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

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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