TRAUMA AND A WORLD IN CONFLICT

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CHILD AND FAMILY DISASTER RESEARCH TRAINING AND
EDUCATION
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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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Session 5
Overview Of Disaster Mental Health In Children
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Learning Goal and Objectives
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Learning Goal

• The goal of Session 5 is toUnderstand
  disaster and terrorism related child mental
  health consequences as a foundation for disaster
  mental health research

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Learning Objectives

• Upon completion of Session 5, participants will
  be
• able to
• Recognize childrens psychological reactions to
  disaster
• and factors that influence reactions
• Identify the factors that promote resilience in
  children in the context of disasters
• Appreciate the evidence base for childrens
  disaster mental health services and interventions
• Understand the principles of intervention with
  children and families following a disaster

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Overview

• Childrens Disaster Mental Health
• Disaster Mental Health Services and Interventions
  for Children and Families
• Resilience Among Children Facing Disaster

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Childrens Disaster Mental Health
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Topics

• Outcomes
• Factors that influence outcomes
• Interventions

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Buffalo Creek Dam Collapse, 1972
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• Outcomes

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Trauma Response
Resilience/ Recovery
Chronic Distress
Acute Distress
Disaster
Risky Behavior
Functional Impairment
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Trauma Response Trajectories

• Resilience
• No significant distress
• Recovery
• Significant distress, resolves over time with or
  without intervention
• Failure to recover
• Significant distress, no recovery, developmental
  disruption and impairment

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Emotional and Behavioral Outcomes
CHILD CHARACTERISTICS Demographics Pre existing
disorder Prior trauma
OUTCOMES PTSD Anxiety Depression Substance
Use Functioning
DISASTER EXPOSURE Objective characteristics Subje
ctive reaction
FAMILY AND SOCIAL FACTORS Parent
reactions Social support
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PTSD Outcome Diagnostic Criteria

• Exposure and reaction
• Reexperiencing (1 or more)
• Avoidance and numbing (3 or more)
• Arousal (2 or more)
• Duration gt one month
• Distress or functional impairment

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Children Can Differ From Adults

• Reaction disorganized or agitated behavior
• Regression in development behavior similar to
  those exhibited at an earlier age
• Re-experiencing
• - Recollections repetitive play with themes
• - Dreams generalized dreams without
• trauma content
• - Acting, feeling, or flashbacks trauma
• reenactment

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Disaster PTSD Rates
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Onset of Disorders

• PTSD onset within 6 months for 90
• Most specific phobia and separation anxiety onset
  close in time to the disaster
• Panic disorder and major depression later onset

Bolton et al. 2000 Yule et al. 2000
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Survivors With and Without PTSD
Rates of other disorders were higher in survivors
with PTSD than in controls Rates in survivors
without PTSD were not higher than in controls
Bolton et al. 2000
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Psychiatric Effects
gt200 young adult survivors 74 female, 97
Caucasian Studied 5-8 years after a shipping
disaster
Mean age at disaster 14.7 yrs. Mean age at
follow up 21.3 yrs.
Bolton et al. 2000 Yule et al. 2000
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Elementary School Study

• Sample 154 school children
• 71 boys, 73 girls
• Mean age 8.2 years (range 6 11 years)
• Methodology
• Assessed behavior and emotions besides
  posttraumatic stress in hi and lo impact schools
• Longitudinal study (2, 8, and 21 months)
• Multiple sources of information
• Children
• Teachers
• School database

Shaw et al. 1995
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Posttraumatic Stress in Hi-Impact School
Severe posttraumatic stress decreased 70 with
moderate to severe posttraumatic stress at 21
months
N 30
Shaw et al. 1996
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Change in Posttraumatic Stress 2 to 21 Months
Significant decrease in self-reported posttraumat
ic stress was explained by differences in boys
Shaw et al. 1996
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PTSD Over Time Hurricane Andrew
Vernberg EM, Silverman WK, La Greca AM, Prinstein
MJ. Prediction of posttraumatic stress symptoms
in children after hurricane Andrew. J Abnorm
Psychol. 1996105(2)237-248.
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Parent Reported Behavior Problems
Stuber, et al, 2005
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Childhood Traumatic Grief

• Results from violent/sudden loss of a loved one
• May occur with death from natural causes if the
  childs experience of the death is sudden,
  unexpected, or witnessed
• Characterized by the intrusion of trauma symptoms
  in bereavement

Cohen et al. 2002
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Traumatic Grief v. Normal Grief

• Intrusive memories of manner of death
• Distress at remembering
• Maladaptive avoidance

• Positive memories
• Memories are comforting
• Yearning
• Sadness

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Factors That Influence Outcome

• Exposure
• Child Characteristics
• Family Factors
• Social Factors

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Direct Versus Indirect Victims

• Direct victims
• Sustained physical injuries
• Lost job or possessions
• Friend or relative killed
• Witnessed event in person
• Participation in rescue effort in immediate
  aftermath
• Indirect victims
• No property damage or job loss
• No personal participation in event rescue efforts
• No direct, in person witnessing of event
• No deaths or injuries of friends or relatives

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Residents directly vs not directly affected by
September 11 attacks
directly affected by September 11 attacks
not directly affected by September 11 attacks
represents approximately 51,000 people
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PTSD since September 11
directly affected by September 11 attacks
not directly affected by September 11 attacks
PTSD since September 11
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PTSD 6-9 months after September 11
directly affected by September 11 attacks
not directly affected by September 11 attacks
PTSD since September 11
PTSD 6-9 months after September 11
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Types of Exposure (1)

• Direct
• Physical presence
• Eye witnessing
• Indirect
• Interpersonal relationships
• Community residence
• Remote
• Society membership
• Media

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Types of Exposure (2)

• Characteristics of event
• Dose (severity)
• Subjective Reaction
• Intense fear, helplessness, or horror

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Exposure
Significantly Different Exposures HI () LO ()
Doors/windows break or come open 82 11
Roof blown away or cave in 57 5
Anyone with you hurt 16 0
Scared a loved one would be hurt/killed 87 66
Anyone with you very scared 87 68
Get wet from rain/seawater 58 14
Pet hurt or killed 24 5
Stay out of home after 39 9
Still out of home 19 0
Shaw et al. 1995
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Tsunami Impact
Thienkrua, et al, 2006
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Posttraumatic Stress at 2 Months
Children in Hi-Impact school were more likely to
have severe posttraumatic stress Hurricane Andrew
N 144 57 Hi-Impact 43 Lo-Impact Mean 8.2
yrs
Shaw et al. 1995
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Subjective Appraisal of Threat
Variable R p
Life Threat .21 .03
Loss .01 NS
Gender .19 .03
Age .16 NS
Mother Severity .25 .01
Father Severity .25 .10
Irritable Atmosphere .29 .001
Depressed Atmosphere .18 .01
Violent Atmosphere -.03 NS
Supportive Atmosphere -.08 NS
Life threat associated with the number of PTSD
symptoms
Model accounted for 28 of the variance
N 179 2 years after Buffalo Creek
Green et al. 1991
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PTSD Following Industrial Accident
Godeau, et al, 2005
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Child Characteristics

• Demographics
• - Sex (female)
• - Age
• Pre existing conditions
• Prior trauma

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Pre Event Anxiety Disorder
Children with pre event anxiety disorder had
significantly more PTSD symptoms than those
without
N 66 children 1 year after Northridge earthquake
Asarnow et al. 1999
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Prior Trauma
Model explained 60 variance in bombing-related
posttraumatic stress
793 Nairobi children 8-14 months after the
1998 U.S. Embassy bombing
Pfefferbaum et al. 2003
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Family Characteristics at 8 Months
Significant differences between cases and non
cases on all three measures at 8 months
150 children 8 months after a bushfire
McFarlane 1987
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Social Support and PTSD
Social support was related to the development of
PTSD and to the duration of PTSD
Social support measured perceived and received
just after the disaster and at follow up
Udwin et al. 2000
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Exposure to Television Coverage
443 NYC parents 4 months after September 11
Fairbrother et al. 2003
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Assessment Parent Report

• Parent interview and report provides objective
  information in some areas
• Parents may under-estimate childrens distress
• - Parents may be focused on other issues
• - Parents may be overwhelmed themselves
• - Children may be especially compliant
• - Parents may use denial

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Posttraumatic Stress Child and Parent Report
No significant decrease over time on child self
report
Child report
Parent report
Exposure significant Time significant
Koplewicz et al. 2002
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Event-Related FearChild and Parent Report
No significant decrease over time on child self
report
Child report
Parent report
Exposure significant Time significant
Koplewicz et al. 2002
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Predictors for Post-Disaster Distress

• Disaster severity
• Subjective fear
• Relocation/disruption
• Resource loss
• Female
• Prior anxiety
• Prior trauma

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Child Disaster Mental Health
Services Assessment Interventions
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Utilization of Post Disaster Services
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Utilization Rates

• Oklahoma City 5
• NYC (young children) 15
• NYC (Manhattan) 10
• NYC (lower Manhattan) 22

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September 11 Counseling

• Of those receiving counseling
• 47 had severe or very severe posttraumatic
  stress
• 50 had moderate posttraumatic stress
• 3 had mild posttraumatic stress
• 1/3 had received counseling before 9/11

• NYC parents 4-5 months after incident
• - 10 received counseling
• - 44 in schools

Fairbrother et al. 2004
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Screening

• Not all children develop significant problems
• Risk factors identified
• Brief screening measures available
• Screening well tolerated

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Oklahoma City School-based Screening
Allen et al. 1999
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Acute Interventions-Triage

• Address immediate physical/safety/necessity
• Establish stability/security
• Psychological First Aid
• Psychoeducation
• Coping strategies
• Hopefulness

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Assessment
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Individual Assessment and Treatment

• Most necessary for
• Directly exposed children
• Children whose loved ones were directly affected
• Children with persistent distress or impaired
  functioning

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Individualized Assessment Prior to Treatment Onset

• PTSD/sx
• Anxiety
• Depression
• Behavior problems
• Functioning
• Pa rent-child relationship
• Parental distress

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Tested Therapeutic Interventions

• Trauma-focused therapy
• Traumatic grief-focused therapy
• Eye Movement and Desensitization and Reprocessing

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Goals of Interventions

• Goals
• Restore a sense of safety and security
• Reduce sx of PTSD, anxiety and distress
• Restore functioning
• Methods
• Psychoeducation re trauma and impact
• Emotional regulation skills
• Correct maladaptive cognitions
• Resolve trauma related distress and avoidance

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Psychosocial Intervention (1)

• 214 completed treatment
• 176 group
• 73 individual
• Intervention 4 weekly sessions
• Safety and helplessness
• Loss
• Competence and anger
• Closure and going forward
• Group and individual treatment
• No difference in effectiveness
• Group associated with better completion rates
• Follow-up
• Children maintained treatment gains

Chemtob et al. 2002
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Psychosocial Intervention (2)
Clinicians rated a random sample of 21 treated
and 16 untreated
Chemtob et al. 2002
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Trauma/Grief Focused Group Psychotherapy After
Earthquake (1)

• Participants
• Early adolescents in severely damaged schools
  following a massive Armenian earthquake
• 35 received trauma/grief-focused brief
  psychotherapy
• 29 received no therapy

Goenjian et al. 1997
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Trauma/Grief Focused Group Psychotherapy After
Earthquake (2)

• Intervention
• - Sessions delivered over a 3 week period
• - 4 ½-hour classroom group psychotherapy
  sessions
• - Average of 2 1-hour individual sessions
• Intervention focused on
• - Trauma
• - Traumatic reminders
• - Post disaster stresses and adversities
• - Bereavement and the interplay of trauma and
  grief
• - Developmental impact

Goenjian et al. 1997
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Posttraumatic Stress After Treatment for
Earthquake Disaster

• Severity Posttraumatic Stress
• - Decreased in treated
• - Increased in untreated
• Severity Depression
• - No change in treated
• - Increased in untreated

Goenjian et al. 1997
Posttraumatic Stress
Depression
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RCT EMDR Hurricane (Chemtob, et al, 2002)

• Children with continuing distress _at_ 1 yr
• Randomized to tx v. waitlist
• Intervention 3 sessions EMDR
• PTSD, anxiety, depression reduced with tx

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Concerns about Treatment

• Treatment may lead to heightened arousal and
  distress
• Avoidance is a core feature of posttraumatic
  stress and may impede treatment

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Treatment Research Status

• Both group and individual shown to be helpful
• Can be delivered in school settings
• CBT type approaches most tested and evidence for
  effectiveness
• Some approaches not tested (e.g, psychodynamic,
  play)
• Medication
• - Rarely needed
• - Adjunctive if used

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• Resilience in Children in
• the Context of Disasters

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What is Resilience?

• Positive adaptation in spite of significant life
  adversities
• The process and outcome of successfully adapting
  to difficult or challenging life experiences,
  especially highly stressful or traumatic events

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
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Factors that Contribute to Resilience

• Resilient children have
• Optimism
• Self efficacy
• A sense of mastery
• Personal competencies
• Cohesive and supportive families
• Families that use effective coping skills to deal
  with stress
• Hardy families

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
79
Resources for Fostering Resilience

• Support from parents and family members
• Support from classmates and close friends
• Reaffirming ties to such institutions as social
  and religious groups
• Providing help and resources to others

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
80
How Professionals Can Build Resilience in
Children (1)

• Provide children with opportunities to share and
  discuss their feelings and concerns
• Encourage children to resume normal roles and
  routines or develop new routines
• Promote the maintenance of social connections

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
81
How Professionals Can Build Resilience in
Children (2)

• Reduce or minimize children's exposure to
  disturbing media information
• Encourage children and teens to stay healthy and
  fit
• Encourage children to use positive strategies for
  coping with disaster-related stressors and model
  positive coping

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
82
How Parents Can Build Resilience in Children

• Take care of themselves
• Promote warmth and nurturance that establish
  clear limits
• Establish a safety plan in case of a traumatic
  event
• Discuss school safety plans for potential
  terrorist events with teachers and school
  administrators

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
83
How Schools Can Build Resilience in Children (1)

• Identify supportive adults in childrens lives
• Create positive connections by developing
  classroom projects
• Enhance positive attitudes by developing coping
  strategies

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
84
How Schools Can Build Resilience in Children (2)

• Teach children to relax in the face of
  difficulties
• Help children set realistic goals
• Help children identify positive coping strategies
  
• Increase children's sense of mastery and control

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association
85
How Communities Can Build Resilience in Children

• Community factors that may be related to and
  promote resilience in children and families
  include
• - Cohesiveness
• - Perceptions of safety
• - Perceptions of security
• - Effective communication
• - Making the needs of children a priority
• - Creating a disaster system of care

Fact Sheet Fostering Resilience in Response to
Terrorism For Psychologists Working With
Children, American Psychological Association