Current Issues in Disaster Mental
Health: Clinical Applications
Betty Pfefferbaum, M.D., J.D.
University of Oklahoma Health Sciences Center
May 2007
1
Learning Objectives
• Appreciate the importance of child disaster
mental health
• Identify children’s reactions to disasters
and the factors that influence their
reactions
• Comprehend the rationale in intervention
approaches
• Recognize the limitations in children’s
disaster interventions
2
Through Children’s Eyes, WHO
3
Disaster
• Definition
– A severe disruption, ecological
and psychosocial, which greatly
exceeds the coping capacity of
the altered community
World Health Organization, 1992
4
Are Disasters Increasing?
5
Reasons for Increase in Disasters
• Poverty and Vulnerability
• Climate Change
• Urbanization
• Poor Building and Land Use
6
Children’s Reactions and
the Factors that Influence
Their Reactions
7
Hurricanes 2004
• Charley (August 13)
– Category 4 Florida’s Southwest
coast
– $15 billion
• Frances (September 5)
– Category 2 Florida’s East coast
– $9 billion
• Ivan (September 16)
– Category 3 Alabama near Florida
border
– $14 billion
• Jeanne (September 26)
http://www.nhc.noaa.gov/2004atlan.shtml
– Category 3 Florida’s East coast
– $7 billion
Blake et al. NOAA/NWS/NCEP/TPC/NHC April, 2007; Sallenger et al. 2006
8
Hurricane Katrina August 29, 2005
• Category 3
• 80 mph winds
• >90 mph gusts
• $81 billion
http://www.nhc.noaa.gov/2005atlan.shtml
Knabb et al & National Hurricane Center, 2005;NOAA’s Technical Report, 2005
9
Hurricane Andrew 1992
• August 1992
• Category 5 (Winds > 160
mph)
• 61 deaths
• 135,000 single family and
mobile homes destroyed or
damaged
• $26 billion dollars
http://scijinks.jpl.nasa.gov/weather/people/disaster/hurricane_andrew_large.jpg
http://www.nhc.noaa.gov/1992andrew.html
10
Model
• Primary predictors of posttraumatic stress
– Exposure
– Perceived life threat
– Life-threatening experiences
– Loss and disruption
– Child characteristics
– Sex
– Age
– Ethnicity
– Social environment
– Access to social support
– Child coping
Vernberg et al. 1996
11
% PTSD Symptom Severity
35
Overall mean in moderate range
30
30
26
25
25
Few or no symptoms
20
15
Mild
14
Moderate
Severe
10
5
Very severe
5
0
568 school children grades 3 to 5
3 months after Hurricane Andrew
Vernberg et al. 1996
12
Predictors of PTSD Symptoms: 3 Months
40
62% variance explained by:
Exposure
Child characteristics
Access to social support
Coping
35
35
30
25
21
Exposure
20
Support
15
10
5
5
0
%
variance
Coping
Perceptions of support from
Parents
Classmates
Teachers
Close friends
Vernberg et al. 1996
13
Access to Social Support
Support from teachers and classmates accounted
for small but significant variance in PTSD symptoms
1.6
1.4
1.4 *
1.2
1
**
1
0.8
Parents
0.6
Classmates
0.4
Teachers
0.2
0.2
0.1
Close friends
0
PTSD
symptoms
Model with exposure, demographics, access
to social support, and coping explained > 60%
Vernberg et al. 1996
14
Exposure at 7 Months
50
44
45
442 3rd to 5th graders
3 schools Southern Dade County
40
35
30
27
23
25
20
15
10
10
5
0
Home damage
Alternate housing
1-2 other
3 or more other
La Greca et al. 1996
15
Posttraumatic Stress: Hurricane Andrew
Children with moderate to very severe reactions
early were at risk for persistent stress reactions
35
30
30
25
27
25
24
23
21
21
20
3 months
15
15
11
7 months
10 months
10
4
5
3
No grade or sex differences
2
0
Mean Symptom
Score
% Moderate
PTSD
% Severe
PTSD
% Very severe
PTSD
La Greca et al. 1996
16
Posttraumatic Stress: 7 and 10 Months
16
15
Model accounted for
39.1% variance at 7 months
24% variance at 10 months
14
12
10
9
8
7
6
6
5
4
4
4
3
33
3
2
2
Life threat
Loss and disruption
Demographics
Life events
Social support
Coping
0
7 months
10 months
La Greca et al. 1996
17
Posttraumatic Stress
60
54
50
40
40
35
30
20
20
3 months
7 months
27
20
18
13
8
10
3
n = 92
Grades 4-6
0
Posttraumatic
Stress
Mean RI Score
Severe/Very
Severe
Moderate
Mild
Doubtful
% Level PTSD
La Greca et al. 1998
18
Predictors of Posttraumatic Stress
35
32
30
25
20
20
15
14
1112
12
Exposure
Pre anxiety
Pre attention
Pre academic
10
5
0
3 months
7 months
La Greca et al. 1998
19
Emotional/Behavioral Outcome
• Predictors
– Exposure
– Child characteristics
–Demographics
–Pre-existing conditions
–Coping
– Recovery environment
20
http://www.publicaffairs.noaa.gov/photos/1992andrew2.gif21
Posttraumatic Stress at 2 Months
60
56
Children in Hi-Impact school were more likely
to have severe posttraumatic stress
50
41
40
39
N = 144
57% Hi-Impact
43% Lo-Impact
Mean = 8.2 yrs
31
30
21
20
doubtful to mild
13
moderate
10
severe to very severe
0
High
Impact
Low
Impact
Shaw et al. 1995
22
Posttraumatic Stress in Hi-Impact School
Severe posttraumatic stress decreased
70% with moderate to severe posttraumatic stress at 21 months
60
55
51
50
38
40
38
33
30
29
30
no to mild
moderate
20
severe
15
11
10
N = 30
0
2 months
8 months
21 months
Shaw et al. 1996
23
Disruptive Behavior at 8 Months
• There was a marked decrease in disruptive
behavior in the Hi-Impact school initially
followed by a return to the level of the
previous year
• Disruptive behavior in the Lo-Impact school
remained at much higher levels for longer
returning to the level of the previous year at
the end of the academic year
Shaw et al. 1995
24
Hi-Impact Disruptive Behaviors
 The initial decrease in disruptive behaviors
in Hi-Impact school was followed by
 A rebound (3-5 months) and
 A relatively quick return to normalcy (9
months)
 The effects may be associated with
 Increased mental health professionals, mobile
crisis teams, and crisis intervention
Shaw et al. 1995
25
Lo-Impact Disruptive Behaviors
 The increase in disruptive behaviors in LoImpact school
 Remained higher for longer
 Returned to level of the previous year at the
end of the academic year
 This may be related to
 Relocation of students from more directly
affected schools and
 Increased demand for and shift of resources to
directly affected schools
Shaw et al. 1995
26
Interventions
Early Interventions
Assessment
General Therapeutic Principles
Evidence Base for Interventions
27
Goals of Early Intervention
 Restore a sense of safety
and security
 Protect from excessive
exposure to reminders
 Validate experiences and
feelings
 Restore equilibrium and
routine
 Open and enhance
communication
 Provide support
28
Recognize Hierarchy of Needs
• Survival, safety, security
• Food, shelter
• Health (physical and mental)
• Triage
• Orient to immediate service
needs
• Communicate with family,
friends, and community
NIMH 2002
29
Assumptions and Principles
• In the immediate post-event phase, expect
normal recovery
• Presuming clinically significant disorder in the
early post-event phase is inappropriate
except in those with a pre-existing condition
NIMH 2002
30
Psychological First Aid
• First aid is “the first aid
received by a person
in trouble”
www.oklahomacitybombing.com
American Psychiatric Association 1954
31
Psychological First Aid
• Protect survivors from further harm
• Reduce physiological arousal
• Mobilize support for those who are most
distressed
• Keep families together and facilitate reunion of
loved ones
• Provide information and foster communication and
education
• Use effective risk communication techniques
NIMH 2002
32
Psychological First Aid
• Manuals to guide the delivery of PFA
– National Child Traumatic Stress Network and
National Center for PTSD
– American Red Cross
– International Federation of Red Cross and
Red Crescent Societies
33
34
Core Actions and Goals - 1
• Make contact and engage
– Respond to contacts initiated by survivors
– Initiate contacts in a non-intrusive,
compassionate, and helpful manner
• Provide safety and comfort
– Enhance immediate and ongoing safety
– Provide physical and emotional comfort
NCTSN & NCPTSD 2006
35
Core Actions and Goals - 2
• Stabilize
– Calm and orient emotionally overwhelmed or
disoriented survivors
• Gather information
– Identify immediate needs and concerns
– Gather additional information
NCTSN & NCPTSD 2006
36
Core Actions and Goals - 3
• Offer practical assistance
– Help survivors with immediate needs and
concerns
• Connect with social supports
– Help establish brief or ongoing contacts with
primary support persons or other sources of
support, including family members, friends,
and community helping resources
NCTSN & NCPTSD 2006
37
Core Actions and Goals - 4
• Provide information on coping
– Provide information about stress reactions
and coping to promote adaptive functioning
• Link with collaborative services
– Link survivors with available services needed
at the time or in the future
NCTSN & NCPTSD 2006
38
Assessment
 Parent report provides objective
information in some areas
 It is essential to assess children directly
as parents may under-estimate their
distress




Parents may be focused on other issues
Parents may be overwhelmed themselves
Parents may use denial
Children may be especially compliant
39
World Trade Center 1993
•
•
•
•
February 26, 1993
6 killed
> 1,000 injured
Thousands trapped
http://www.talkingproud.us/ImagesEagle/AttacksonUS/WTC1993.jpg
CNN (1997) & The Joint Terrorism Task Force
40
Children’s Symptoms at 3 and 9 Months
• Exposure
– 9 trapped in
elevator
– 13 on observation
deck
– 27 controls
• Measures
– Child and parent
report
http://www.cnn.com/US/9609/05/terror.plot/trade.center.large.jpg
Koplewicz et al. 2002
41
Posttraumatic Stress and Fear
Parent report: significant decrease
Child report: no decrease
35
30
29.6
26.3
25
28
27.7
29.2
26.4
25.5
21.8
20
3 months
15
9 months
10
5
0
Child
Parent
Posttraumatic Stress
Child
Parent
Incident Fear
Koplewicz et al. 2002
42
General Therapeutic Principles
 Therapy must provide a safe environment
to process painful and overwhelming
experiences
 Treatment involves transforming the child’s
self concept from victim to survivor
 Avoidance is a core feature of
posttraumatic stress and may impede
treatment
 Treatment may lead to heightened arousal
and distress
43
Treatment Approaches
 Supportive psychodynamic approaches
 Play therapy
 Cognitive-behavioral approaches
 Family therapy
 Group therapy
 Medication
 Rarely needed
 Adjunctive if used
44
Family Interventions
 Identify and address parental reactions and
needs
 Educate parents about the effects of their own
reactions on their children
 Inform parents about children’s disaster
reactions in general and about their own child’s
experiences and reactions
 Assist families with secondary stresses
 Help families anticipate the needs of children
45
Small Group Interventions
 Promote sense of order, control, and security
 Accommodate more children
 Provide opportunities for children to
- Share with and reassure each other
- Practice new skills
 Educate children about trauma responses
 Assess coping and its effectiveness
 Identify those needing more intense interventions
46
School-based Interventions - 1
• Disaster reactions may emerge in the context of school
• School settings provide access to children and the potential
for enhanced compliance
• Schools are a natural support system where stigma
associated with treatment is diminished
• Services in schools help normalize children’s experiences
and reactions
Wolmer et al. 2003;
Wolmer et al. 2005
47
School-based Interventions - 2
• School personnel are familiar with, and deal with,
situational and developmental crises
• School curricula already address prevention in other
mental health areas
• School personnel have opportunities to observe children
• Supervision, feedback, and follow-up are possible
Wolmer et al. 2003;
Wolmer et al. 2005
48
School-based Interventions - 3
• Classroom settings are developmentally-appropriate
• Classroom settings provide
–
–
–
–
–
Predictable routines
Consistent rules
Clear expectations
Immediate feedback
Stimulus for curiosity and engaging learning skills
• School-based interventions facilitate peer interactions
and support which may prevent withdrawal and isolation
Wolmer et al. 2003;
Wolmer et al. 2005
49
Content of Interventions
• Trauma
•
•
•
•
•
•
•
•
•
– Emotional distress
– Arousal
– Reminders
Loss and grief
Anxiety
Depression
Safety
Anger
Conduct problems
Concentration problems
Coping
Social support
50
Intervention Techniques
• Interventions use
–
–
–
–
–
–
–
–
–
Psycho-education
Emotional processing
Projective techniques
Cognitive-behavioral approaches
Anxiety-reduction and management techniques
Exposure
Coping skills enhancement
Social support
Resilience building
• Interventions use individual, group, or mixed
format
51
Limitations in General
• Convenience samples of modest size
– Not able to generalize to
– Other groups of children
– Other types of disaster
– Other settings (geographic or clinical/community)
• Lack comparison groups including
comparison to natural recovery
– Not able to determine
– If the intervention was better than another intervention or
even natural recovery
– What aspect of the intervention was effective
• Lack long term follow up
52
QUESTIONS
53