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Current Issues in Disaster Mental Health: Clinical Applications. Betty Pfefferbaum, M.D., J.D. University of Oklahoma Health Sciences Center May 2007. Learning Objectives. Appreciate the importance of child disaster mental health - PowerPoint PPT Presentation
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1
Current Issues in Disaster MentalHealth: Clinical Applications
Betty Pfefferbaum, M.D., J.D.University of Oklahoma Health Sciences Center
May 2007
2
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
3Through Children’s Eyes, WHO
4
• Definition– A severe disruption, ecological
and psychosocial, which greatly exceeds the coping capacity of the altered community
World Health Organization, 1992
Disaster
5
Are Disasters Increasing?
6
Reasons for Increase in Disasters
• Poverty and Vulnerability
• Climate Change
• Urbanization
• Poor Building and Land Use
7
Children’s Reactions and the Factors that Influence
Their Reactions
8
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)– Category 3 Florida’s East coast– $7 billion
http://www.nhc.noaa.gov/2004atlan.shtml
Blake et al. NOAA/NWS/NCEP/TPC/NHC April, 2007; Sallenger et al. 2006
9
Hurricane Katrina August 29, 2005
• Category 3
• 80 mph winds
• >90 mph gusts
• $81 billion
Knabb et al & National Hurricane Center, 2005;NOAA’s Technical Report, 2005
http://www.nhc.noaa.gov/2005atlan.shtml
10
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://www.nhc.noaa.gov/1992andrew.html
http://scijinks.jpl.nasa.gov/weather/people/disaster/hurricane_andrew_large.jpg
11
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
12
% PTSD Symptom Severity
14
30
2625
5
0
5
10
15
20
25
30
35
Few or no symptoms
Mild
Moderate
Severe
Very severe
Vernberg et al. 1996
568 school children grades 3 to 5 3 months after Hurricane Andrew
Overall mean in moderate range
13
Predictors of PTSD Symptoms: 3 Months
35
5
21
0
5
10
15
20
25
30
35
40
%variance
Exposure
Support
Coping
Vernberg et al. 1996
62% variance explained by:Exposure
Child characteristicsAccess to social support
Coping
Perceptions of support fromParents
ClassmatesTeachers
Close friends
14
Access to Social Support
0.2
1.4
1
0.1
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
PTSDsymptoms
Parents
Classmates
Teachers
Close friends
*
**
Support from teachers and classmates accounted for small but significant variance in PTSD symptoms
Vernberg et al. 1996
Model with exposure, demographics, access to social support, and coping explained > 60%
15
Exposure at 7 Months
2723
44
10
0
5
10
15
20
25
30
35
40
45
50
Home damage Alternate housing 1-2 other 3 or more other
La Greca et al. 1996
442 3rd to 5th graders3 schools Southern Dade County
16
Posttraumatic Stress: Hurricane Andrew
30
2725
4
24 23
15
3
21 21
11
2
0
5
10
15
20
25
30
35
Mean SymptomScore
% ModeratePTSD
% SeverePTSD
% Very severePTSD
3 months
7 months
10 months
La Greca et al. 1996
No grade or sex differences
Children with moderate to very severe reactions early were at risk for persistent stress reactions
17
Posttraumatic Stress: 7 and 10 Months15
9
5
34
332
7
4
6
3
0
2
4
6
8
10
12
14
16
7 months 10 months
Life threat
Loss and disruptionDemographics
Life eventsSocial support
Coping
Model accounted for39.1% variance at 7 months24% variance at 10 months
La Greca et al. 1996
18
Posttraumatic Stress
20
13
20
27
40
18
3
8
35
54
0
10
20
30
40
50
60
PosttraumaticStress
Severe/VerySevere
Moderate Mild Doubtful
3 months
7 months
La Greca et al. 1998
Mean RI Score % Level PTSD
n = 92Grades 4-6
19
Predictors of Posttraumatic Stress
32
20
11 121214
0
5
10
15
20
25
30
35
3 months 7 months
Exposure
Pre anxiety
Pre attention
Pre academic
La Greca et al. 1998
20
Emotional/Behavioral Outcome
• Predictors– Exposure– Child characteristics
– Demographics– Pre-existing conditions– Coping
– Recovery environment
21http://www.publicaffairs.noaa.gov/photos/1992andrew2.gif
22
Posttraumatic Stress at 2 Months
13
21
31
41
56
39
0
10
20
30
40
50
60
High Impact
Low Impact
doubtful to mild
moderate
severe to very severe
Shaw et al. 1995
Children in Hi-Impact school were more likely to have severe posttraumatic stress
N = 14457% Hi-Impact 43% Lo-Impact Mean = 8.2 yrs
23
Posttraumatic Stress in Hi-Impact School
1511
29
55
3833
51
38
30
0
10
20
30
40
50
60
2 months 8 months 21 months
no to mild
moderate
severe
Shaw et al. 1996
N = 30
Severe posttraumatic stress decreased70% with moderate to severe posttraumatic stress at 21 months
24
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
25
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
26
Lo-Impact Disruptive Behaviors
The increase in disruptive behaviors in Lo-Impact 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
27
Interventions
Early InterventionsAssessment
General Therapeutic PrinciplesEvidence Base for Interventions
28
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
29
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
30
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
31
Psychological First Aid
• First aid is “the first aid received by a person in trouble”
American Psychiatric Association 1954
www.oklahomacitybombing.com
32
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
33
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
34
35
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
36
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
37
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
38
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
39
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
40
World Trade Center 1993
• February 26, 1993• 6 killed• > 1,000 injured• Thousands trapped
CNN (1997) & The Joint Terrorism Task Force
http://www.talkingproud.us/ImagesEagle/AttacksonUS/WTC1993.jpg
41
Children’s Symptoms at 3 and 9 Months
• Exposure– 9 trapped in
elevator– 13 on observation
deck– 27 controls
• Measures– Child and parent
report
Koplewicz et al. 2002
http://www.cnn.com/US/9609/05/terror.plot/trade.center.large.jpg
42
Posttraumatic Stress and Fear
29.6
25.528
29.2
26.3
21.8
27.726.4
0
5
10
15
20
25
30
35
Child Parent Child Parent
3 months
9 months
Posttraumatic Stress Incident Fear
Koplewicz et al. 2002
Parent report: significant decreaseChild report: no decrease
43
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
44
Treatment Approaches
Supportive psychodynamic approaches Play therapy
Cognitive-behavioral approaches
Family therapy
Group therapy
Medication Rarely needed Adjunctive if used
45
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
46
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
47
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
48
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
49
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
50
Content of Interventions
• Trauma– Emotional distress– Arousal– Reminders
• Loss and grief• Anxiety• Depression• Safety• Anger• Conduct problems• Concentration problems• Coping• Social support
51
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
52
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
53
QUESTIONS