PSYCHOSOCIAL CARE FOR CHILDREN IN DISASTER Dr. K. Sekar Professor of PSW NIMHANS, BANGALORE...

PSYCHOSOCIAL CARE FOR CHILDREN IN DISASTER

Dr. K. Sekar

Professor of PSW

NIMHANS, BANGALOREsekar@nimhans.kar.nic.in 098452 14397

DISASTER

• Disaster is a severe disruption of ecological and psycho social which greatly exceeds the coping capacity of affected community.

WHO, 1992

Some visuals in the presentation could be disturbing for certain viewers

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

NEED FOR PSYCHOSOCIAL CARE

• Mitigate effect of trauma

• Alleviate psychological distress

• Strengthen resiliency

• Re-establish normal development process

PS CARE IN DISASTERSNIMHANS EXPERIENCES 1981 -2011

NIMHANS – NODAL CENTRE FOR PSYCHO SOCIAL CARE IN DISASTERS

• 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.

PHASES OF DISASTER

Acute Phase7 days

Immediate Post-Disaster

1 week-12weeks

Rehabilitation12 weeks-36 weeks

Reconstruction38 weeks-3 years

PSYCHOSOCIAL EFFECTS

Primary Victims

Rescue and

Recovery Personnel

Community Members

Disaster Community

Relatives of Primary

Victims

Friends of Primary Victims

PSYCHOSOCIAL EFFECTS OF DISASTER

TIME

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

A B C

SOURCE: Disaster Mental health model, in Disaster mental health in India, pp243

PREVALENCE OF TRAUMA• 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.

• Giddiness / instabilityGiddiness / instability

• Panic attacksPanic attacks

• Generalised AnxietyGeneralised Anxiety

• Somatic symptomsSomatic symptoms

• Emotional problems Emotional problems

– – irritability, irritability,

_ apprehension, _ apprehension,

_ numbness_ numbness

• Increased alcohol useIncreased alcohol use

• GriefGrief• PTSD sx - PTSD sx -

flashbacks flashbacks • Survivor Survivor

guilt guilt • DepressionDepression

• GriefGrief• PTSD sx - PTSD sx -

flashbacks flashbacks • Survivor Survivor

guilt guilt • DepressionDepression

Duration

REACTIONS

REACTIONS TO DISASTERREACTIONS TO DISASTER

BIOLOGICAL RESPONSES

• 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.

SOCIAL ISSUES

• 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

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

SURVIVORS AT RISK

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.

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.

RIGHTS OF CHILDREN FOR PSCThe 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).

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.

PRE-SCHOOLERS UPTO 6 Yrs         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

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

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

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

BANGALORE CIRCUS TRAGEDY

• Bangalore Circus tragedy(1981)

• Home based care through simple emotional support

• Beneficial to survivors

H.S. NARAYAN et al.

GAS AFFECTED CHILDREN HAMIDIA HOSPITAL

• “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 GODDESS

• Born on the day of the gas leak.

• This girl was named Gas Devi, ‘gas goddess’, by her parents.

ABANDONED FACTORY SITE

• 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.

BHOPAL DISASTER MENTAL HEALTH MANUAL

• Commonly encountered reactions in children are:– Regressive problems– Bodily reactions– Suicidal ideas– Emotion and conduct

problems– Illness modeled after

others

MANAGEMENT

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

PSYCHOSOCIAL CARE WITH CHILDREN - ORISSA

1.Orphan children

2.Single parent children

3.Single children

4.Step children

5.Child trafficking

6.School refusals

Sneha karmis are vital in the care process.

SCHOOL GOING CHILDREN• 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

EVALUATION OF CHILDREN

•The highest percentage of symptoms

elicited among the children were

• slow learning; getting scared

•sleep problems; wetting of clothes.

IMPACT OF CYCLONE ON CHILDREN IN THE

CONTROLLED AND INTERVENTION AREAS

2.1

1.41.2

3.8

0

0.5

1

1.5

2

2.5

3

3.5

4

Balikuda

Bodabellary

Kendrapara

Erasam

ma

Controled Intervention

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.

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.

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.

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.

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.

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.

GUJARAT RIOTS & CHILDREN

• 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.

THE GUJARAT VIOLENCE• 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.

IMPACT OF EVENTS ON CHILDREN

• 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.

EMOTIONAL STATE OF CHILDREN • 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.

SCHOOL CHILDREN’S REACTION

• “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”

COMMUNITY ADOLESCENTS REACTION

• “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”.

YOUNG ADOLESCENTS REACTIONS• “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”.

GIRLS REACTION• “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.

PARENTS REACTIONS

• “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

• “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”.

MEDIA STATEMENTS• ‘Trauma haunts

children’• ‘Nobody’s children’• ‘Crying need for heeling

touch’• ‘Sleep and the innocent’• ‘Children play with

sand - making graves’• These statements clearly

indicate the impact of the riots in Gujarat on the children.

MEDIA STATEMENTS• “I feel like my mind has been

destroyed”

Javeed, 14

• “I feel scared to talk to people. What if they are killers in disguise”

Reshma Bano, 11

• “If I see a policeman, now, I start running away”

Sohrab Khan, 13

POST TRAUMATIC STRESS AMONG CHILDREN IN CAMPS

314

54 59

40

213 1

0

10

20

30

40

50

60

None Subclinical Moderate Severe

Shah Alam

DKG

IMPACT OF THE RIOT ON THE YOUNGER AND OLDER CHILDREN

• Significant differences were observed in the overall impact, intrusion and avoidance among the older children of Shah-e-Aalam camp

centre

Dhariyakhan GummatShah e Aalam

Mea

n IE

S_TO

TAL

36

34

32

30

28

26

AGE OF THE CHILDREN

5-9 YEARS

10-15 YEARS

DIFFERENTIAL IMPACT OF RIOT ON

THE GENDER OF THE CHILDREN

• Male and female children residing in Shah-e-Aalam and female children of Dhariya Khan Gummat had higher mean scores on intrusion.

centre

Dhariyakhan GummatShah e Aalam

Mea

n IE

S_IN

TRUS

ION

19

18

17

16

15

14

13

Gender

Male

Female

TSUNAMI IN INDIA

TSUNAMI IMPACT ON CHILDREN CHENNAI

12.37

12.1612.16

12.78

11.811.9

1212.112.212.312.412.512.612.712.812.9

Avoidance Intrusion

Male

Female

61

39

0

10

20

30

40

50

60

70

Mild Moderate

Impact

11.97

12.23

12.712.85

11.4

11.6

11.8

12

12.2

12.4

12.6

12.8

13

Avoidance Intrusion

<=10

>10

•There was no significant difference on the impact, age or gender of the children

TSUNAMI IMPACT ON CHILDREN NAGAI

3

5146

0

10

20

30

40

50

60

Subclinical Mild to Moderate Severe

10.1

12.6

10.8

14.1

0

2

4

6

8

10

12

14

16

Avoidance Intrusion

Male

Female

97% of the children affected. No difference in impact and the age. Intrusion and overall impact higher among girls in comparison to boys.

9.7

13.5

10.7

13.3

0

2

4

6

8

10

12

14

16

Avoidance Intrusion

<=10

>10

FIELD REFLECTIONS

• “Children in my place now play make believe games based on tsunami. One of the child will lie like a corpse and others will carry the body of the child”.

• “I lost my interest in education as many of friends died in tsunami and when I open the book it reminds me my friends. Many of friends thought that I was dead.

A&N ISLANDS IMPACT ON CHILDREN

5

28

67

0

10

20

30

40

50

60

70

80

Mild Mooderate Severe

`

Teachers report

Child, parent and teachers

Parental report

Children report IMPACTED CHILDREN 1120

MILD- 403 (35.98%)

MODERATE- 538 (48.04%) SEVERE- 179 (15.98%)

MENTAL HEALTH REPORT

PROBABLE- 874 (78.05%)NON-PROBABLE- 246 (21.96%)

BEHAVOURIAL PROBLEM

ANTISOICAL- 81 (7.23%)

IMPACT & PROBABILITY 152 (13.57%)

IMPACT & BEHAVIOURAL -12 (1.07%)

SEVERE- 10(0.89%)

Child and parent

Child and teacher

1

2

3

4

5

6

TSUNAMI NEED ASSESSMENT-CHILDREN

REBUIDING STRUCTURE IS POSSIBLE

HEALING OF MIND IS IT POSSIBLE ?

WHAT NEEDS TO BE DONE Actions that provide the child

with a sense of control – allow them to talk about the event and listen to them without giving any advice.

Encourage them to play – mostly they will play out what happened let them do it, then discuss what happened and how he people were feeling.

PAINTING IS HEALING

• Give them opportunities for painting and drawing where they can express their emotions, this is very healing.

HEALING TOUCHES

Story telling, singing songs and other games involving physical movement are some of the healing touches that can be provided.

GIVE ATTENTION TO…

Give attention and praise a child’s coping behaviour like for following a routine, reducing their anger etc.

Pay more attention and spend time on their studies once they return to school.

VOLUNTEERS ACTIVITIES• Volunteers activities

included working with small groups for short duration

• Drama, story telling, art work, play activities

• Child to child alliance – distribution of school kits

• Knitting work for young girls.

TRAINING COMMUNITY VOLUNTEERS

MEDIUMS USEFUL FOR PSC AMONG CHILDREN

• Children can be aided in recovery through the use of various mediums suiting their age group,

• Drawing

• Story telling

• Clay modeling

• Games

• Worksheets

• Puppetry

Child’s present feelings

Child’s feelings about Child’s feelings about the eventthe event

Child’s feelings about Child’s feelings about future lifefuture life

I lost my sister in Tsunami-I am sad.

My sister never eats food, my father feeds her.

Me and my brother-I lost him in Tsunami.

Me and my father-he loves me a lot.

FAMILY PORTRAIT

DRAWINGTsunami Loss in Tsunami

PLASTICINE - CLAY

FAMILY OF DOGS/ DOLLS

• Sharing in group • Individual sharing

OBSERVATIONS

• Children interested in doing activity

• Comfortable with mediums

• Children ventilated their feelings and emotions very well

• Decrease in stress level• Brought down the

distressing experiences in Tsunami

AN OVERVIEW OF HOW PLAY & OTHER ACTIVITIES HELP CHILDREN

To gain mastery over events

Play helps children express their feelings and emotions.This release helps childrenfeel lighter. Repeated expressions also lighten the power negative emotions haveover children’s lives and help them move forward.

In development of understanding

Children can change their way of thinking, modify their behaviour or learn new healthy ways of interacting, behaving, or coping by reacting to concepts presented through stories, listening and observing other children, etc.

WRITING EXERCISE

Aim: Express disturbing events

Five phases

-Identify the event that bothers

-Bring out what they miss a lot

-Saddest event

-Happiest event

-What I should do to make my life happy

AN OVERVIEW OF HOW PLAY & OTHER ACTIVITIES HELP CHILDREN

In skill development

While interacting and playing,the children learn to take turns, share things play by the rules, learn to talk in a group, make friends, etc.These skills are developed during the process of play.

Develop self-esteem

Opportunities to present their creations, talk aboutthemselves, get praised by others for their work or behaviour, make new friends etc., help the children feel good.

SPECTRUM OF CARE

DEPROFESSIONALISE SKILLS

WHICH MEDIUM SUITS WHICH AGE GROUP

Adapted from Geldart et al: 1 indicates it will work very well 2 that is okay and 3 that it is the least medium.

ACTIVITY KEY INDICATING THE PURPOSE AND SUITABILITY FOR

VARIOUS AGE GROUPS.

ACTIVITES USED TO HELP CHILDREN DEVELOP UNDERSTANDING

Activity Can be used to….

1. Question bag or box Answer their queries and concerns

2. Misinterpretations How something can be hurtful because of how we look at it.

3. Opposing emotions What helps them cope with situations.

4. Opposing emotions How to move from a negative to positive emotions.

5. Happy memories We need to move on in life

ROLE OF DIFFERENT CAREGIVERS

HEALING IS POSSIBLE

SUGGESTION

• Children activity brings out the hidden feelings in the children as well as in adult’s.

• Continuation of the psychosocial care programme

• Developing a clear understanding about the Psychosocial care among the NGOs and other community level leaders

• Children to be trained on disaster preparedness

• Life skills and social skills

WHAT WILL HELP IS TO

  Let the child be close to adults they know and like. Re-establish some sort of a routine for them like

eating, sleeping, going for programs like ‘Bal Muskaan’.

 Actions that are security giving by actions like touching, hugging, reassuring them verbally.

 Actions that provide the child with a sense of control – allow them to talk about the event and listen to them without giving any advice.

WHAT WILL HELP IS TO

• Encourage them to play – mostly they will play out what happened let them do it, then discuss what happened and how he people were feeling.

• Give them opportunities for painting and drawing where they can express their emotions, this is very healing.

• Story telling, singing songs and other games involving physical movement should be done.

WHAT WILL HELP IS TO

• Give attention and praise a child’s coping behaviour like for following a routine, reducing their anger etc.

• Work with other caregivers in the environment to help the child recover like getting medicines if necessary working with the Bal Muskaan facilitator.

• Pay more attention and spend time on their studies once they return to school

HOW TO SUPPORT A CHILD’S RECOVERY FROM A TRAUMATIC EVENT

DISASTER Can lead to CONFUSION AND INSECURITY

HELP THE CHILD RECOVER

A. Understand his/her emotionalreactions by:• Observing behaviour• Monitoring progress at school/home• Accepting and acknowledging the changes

B. Decrease the physical and emotional effects by:• Listening• Reassuring• Modeling healthy coping behaviour

C. Facilitate recoveryby:

• Normalising life routines• Talking• Playing and other activities

All the above three can lead to:

ADJUSTMENT OR MASTERY OVER EMOTIONAL DISTRESS

CONCLUSION

• The psychosocial needs of the disaster affected children are real. It is imperative that the ‘healing of minds’ is taken up as an essential part of rebuilding the lives of the children.

DISASTERS KEEP OCCURING

THERE IS A NEED FOR PERSONAL, PROFESSIONAL, POLICY MAKERS & PUBLIC

COMMITMENT TO EMERGING ISSUES

THANK

YOU