1 Current Issues in Disaster Mental Health: Clinical Applications Betty Pfefferbaum, M.D., J.D. University of Oklahoma Health Sciences Center May 2007.

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


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


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


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


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


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


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


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

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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

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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

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• 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


• 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


• Stabilize– Calm and orient emotionally overwhelmed or

disoriented survivors

• Gather information– Identify immediate needs and concerns– Gather additional information

NCTSN & NCPTSD 2006

37


• 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


• 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 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


• 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

1 Current Issues in Disaster Mental Health: Clinical Applications Betty Pfefferbaum, M.D., J.D. University of Oklahoma Health Sciences Center May 2007.

Documents

moderate range slide

land use slide

months vernberg

childrens reactions

months model

persistent stress reactions

severe reactions

ptsd symptoms vernberg