Childhood Trauma in the Aftermath of a Natural D isaster

Childhood Trauma in the Aftermath of a Natural Disaster

Wednesday 28th May 201412:30pm - 2:00pm AEST

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PRESENTERS:Dr Susie BurkePsychologistAustralian Psychological Society

Dr Rowena ConroyClinical psychologistRoyal Children’s Hospital

Facilitator: Jan-Louise Godfrey, APS

Childhood trauma in the aftermath of a natural disaster

Susie BurkeAPS

Agenda• Introduction

Recent disasters in Australia

• Perth Fires 2014– 50 homes destroyed

• Blue Mountain Fires Oct 2013– 248 homes destroyed– 2 died

• Dunalley (TAS) Fires Jan 2012– 100 properties destroyed

• Cyclone Yasi– 1 died, – 150 homes, + 650 uninhabitable, 2000 + damaged

• QLD Floods– 35 died, – 70 towns– 200,000 people affected

• Victorian floods 2010• 83 towns

• Black Saturday Fires 2009– 173 died– 2000 homes destroyed

Current and future threats

• Climate change is expected to underpin a steady increase in climate related disasters

• Worldwide, children have the greatest risk of harm from climate change impacts

• Our health system is under-prepared for increased weather-related disaster service demand

Children in disasters• “whilst it is extremely

common for children to experience some symptoms of traumatic stress after a natural disaster, most do not experience a serious mental health syndrome”

• Children’s responses are different to adult responses• Reactions will be different for each individual • There is no ‘one way’ to respond• Responses range from mild stress reactions to more

serious responses• Resilience is the norm• Most recover well with the support of family and friends• The path of recovery is not smooth• Setbacks are part of normal recovery• Children’s needs often go up over time• A minority (10-20%) of survivors are at risk of

developing significant mental health problems

Children’s reactions by age

Behavioural signs0 to 5 years

Clinginess and separation difficultiesEasily frightenedChanges to eating & sleeping patternsRegressionsCrying easilySearching for the person or thing that has been lost as a result of the traumatic eventNeed for routine, consistency and familiarityStruggling to communicate in words

0 to 5 years

Common feelingsConfusion and uncertaintyChallenges to ‘basic trust’Being confused or frightened by intense feelings and reactionsSensitive to trigger reminders and changes in mood of primary caregiversLong-lasting perceptual memories

5-12 yearsBehavioural signsDifficulty concentrating, vagueness or acting ‘hyper’Poor relationships at home or school, or poor performance at schoolPreoccupation with other traumatic events or disastersLack of interest in new activitiesPersistent sleep disturbances or nightmaresReenactments Personality changesRegressions

5 to 12 years

Common thoughts and feelings:Fear of recurrenceDistress at remindersConcern about personal responsibilityMood or personality changesIncreased self focusing or withdrawalLowered self esteemWish for revenge

How to help children?

3 tiered framework

• Level 1 - Simple practical, emotional & informational support

• Level 2 – Simple psychological strategies

• Level 3 – Formal mental health interventions

3 - Formal mental health interventions

2 - Simple psychological

strategies

1 - Simple practical, emotional & informational support

Stepped care for children

Evidence-basedMust include familiesStarting with least intrusive, population levelEnding with clinical consultation if needed

Level 1 typeContinuity of schoolingActivities for recoveryCreativity (play, art)Books, workbooksPsycho-education – (e.g., information for parents re helping children feel safe)Classroom programsResilience building

Level 2 typeSkills for Psychological recovery

Level 3Psychological therapies

Five Empirically-Supported Early Intervention PrinciplesAustralian Centre for Post Traumatic Mental Health (ACPMH)

Self-Efficacy

Calming

SafetyHope

Connectedness

What is psychological first aid

• Human, caring, compassionate response• Basic common sense principles of

support• DO NO HARM• Evidence informed• Focus on:

– Practical needs– Basic comfort– Connection to necessary supports

PFA for children• ‘PFA is probably

the most immediate and useful method of assisting children and young people whether it is directly or via caregiver’.

• (Ursano et al., 2007)

LISTEN with your ears and eyesdon’t force talkingask questions like: • what do you think has

happened? • what are you most worried

about?

PROTECT – keep the child safe, be patient, try and keep routines, monitor media exposure CONNECT – reach out to family, friends, community resources etc.

(UCLA Centre for Public Health & Disasters)

Supporting children aged 0 to 5

Maintain routines Reassure them that they are safe Keep a calm atmosphere in children’s presenceAvoid unnecessarily separating children from their important caregiversTolerate children’s clinginess and lack of independenceListen to children’s retelling of eventsRespect children’s fears and give them time to copeProtect children from re-exposure Accept and help children to name strong feelings during brief conversationsExpect uncharacteristic behaviour but maintain basic rulesRuth Wraith

Supporting children aged 5 to 12Listen to what children say, think and feelCorrect any misperceptions about the disaster, help them to understand what has happenedKeep to normal routinesProtect children from re-exposure, monitor amount of media exposure Ask you child what you could do to help them Watch how they play, monitor how they are coping at school and in community activities Expect uncharacteristic behaviour but maintain basic rules Remain aware of your own reactions to children’s distress Provide opportunities for children to experience controlEncourage children to explore ways of helping othersDiscuss your feelings openly and honestly and explain how you feelUse creative outlets

Treating moderate distress

• Some children will experience ongoing reactions that will cause enough distress to interfere with adaptive coping.

• These children do NOT have severe mental health problems

• These children do NOT have long-term difficulties in recovery

• Research suggests that a skills building approach is more effective than supportive counseling

Skills for Psychological Recovery

Developed in US post Hurricane KatrinaAdapted for Australian use in 2009Model for facilitating recovery following disasters For anyone effected by disasterDesigned to reduce distress, regain control, increase self-efficacy, accelerate recoveryIn weeks and months, after PFAPractical, skills-building approachDoes not assume pathology

Components of SPR• gathering information & prioritising

assistance• building problem-solving skills • promoting positive activities• managing reactions • promoting helpful thinking • rebuilding healthy social connections

Problem-Solving

Disasters often result in many practical problemsProblem-solving helps the child to manage the problem actively and move on; improves feelings of control and self efficacy(Considered most useful of all SPR skills)Steps

what is the problem? (how often, who is involved, how do you feel, rank, decide ownership)

What do you need, want? Brainstorm (go for at least 10!)Choose best options (rate each option)

Managing Emotional Reactions“when something bad has happened there are lots of ways that you might be reminded of it afterwards. Eg…Your reactions to these reminders can get in the way of what you are doing at home, at school, or when you are with your friends. It is really good to learn some skills that can help you deal with these reactions so that they don’t get in your way. Each time you practice them you will find that you get a little better at it. Also, you learn that you have more control than you think”. Toolkit: Identifying body reactionsCalming skills

Breathing exerciseSelf talkSocial support

Naming feelings and concerns to better understand and to communicate with others

Helpful Thinking

Disasters can change the way we think about ourselves and our worldDistressing disaster-related thoughts can maintain negative emotions (fear, anger)Focus on helpful thoughts improves mood and paves way for more effective copingChildren rely heavily on caregivers/adults in their environment when forming thoughtsWork with caregivers to identify their unhelpful thoughts as well

• Games and activities to discuss thoughts:

• Go fish• Good coach, bad

coach

• Children maintain social connection through play

• Often after a disaster children may slow down, disengage from play, mimic the ‘energy and posture’ of their caregivers (slowed down, slumped, depressed)

• Adults need to remember how helpful play is

• Caregivers can practice giving permission for children to play

• Caregivers can help to organise plays for children

Social connections

Positive activities“Since the disaster you may

have felt like you were filled up with a lot of icky feelings. Now, I can’t just make those feelings go away! I wish it were that easy! What we can do is work on filling up some of your time with activities that will fill you with positive, happy feelings”

(From ACPMH 2009, SPR manual, 2009)

Psychological assessment and intervention with children and

adolescents after natural disastersAPS Webinar, May 28th 2014

Rowena Conroy M.Psychol(Clin.), PhD, MAPS (CCLlN)

The Royal Children’s Hospital, MelbourneThe University of Melbourne

Murdoch Children’s Research Institute

Recovery Trajectories• Initial distress for most

• Most recover without formal mental health intervention

• A significant minority have ongoing difficulties; course can be chronic if untreated

Common psychological difficulties

Affective: fear; worry; irritability; sadness; anger; guilt

Cognitive: concentration; intrusions; nightmares; thoughts (about event/symptoms/self/world/future)

Behavioural: avoidance; school refusal; substance use; self-harm; suicidal behaviours; vigilance; safety-seeking; regression; tantrums; aggression; non-compliance

Physical: stomach aches; headaches; sleep; “jumpiness”

Functional Impairments: academic; social; physical

Developmental considerations

Where there is a history of Type II Trauma (“Complex Trauma”)• Dysregulation (affective, behavioural,

cognitive)– Emotional reactivity– Numbing– Dissociation– Self-harm

• Attachment difficulties– Other relationship difficulties– Prominent shame– (Sexual behaviour)

Mental Health Disorders• Post-traumatic Stress Disorder (PTSD)

• Other Anxiety Disorders

• Depression

• Oppositional Defiant Disorder (ODD)

• Attention Deficit Hyperactivity Disorder (ADHD)

• Substance Abuse (Adolescents)

Risk Factors: Event-related• Proximity/Exposure

• Subjective fear/Perceived life threat

• Pain

• Separation from parents

• Interpersonal

• Repeated

• Subsequent stressors

Risk Factors: Individual• Prior trauma exposure

• Prior emotional/behavioural difficulties

• Female gender (for “internalising” presentations)

• Post-event avoidance, rumination

Risk Factors: Family/Other Systems

• Parent mental health

• Parental trauma history

• Family functioning difficulties

• Low social support

Assessment Considerations • Always assess for trauma exposure

• Consider multiple outcomes

• Multiple informants

• Developmental considerations

• Hallmark avoidance

Assessment Considerations, cont.

• Assessment of current coping strategies

• Consider standardised measures

• Assess functioning of family system (& other systems)

• Risk assessment

• Assessment is ongoing

Australian Centre for Posttraumatic Mental Health (ACPMH; 2013)

www.acpmh.unimelb.edu.au/resources

American Academy of Child & Adolescent Psychiatry (AACAP; 2010)

www.aacap.org

National Institute for Clinical Excellence (NICE; 2005) (UK)

www.nice.org.uk

Intervention for PTSD• Trauma-Focussed Cognitive Behaviour Therapy

(TF-CBT):– Strongest empirical support– Endorsed by national “best-practice” guidelines

• Substantial reductions in severity of PTSD symptoms after:– Natural disasters– Terrorist attacks– Motor vehicle accidents– Witnessed violence– Sexual & nonsexual assaults– Sexual abuse

Trauma-Focussed CBT: Components

• Psychoeducation• Parenting• Relaxation• Affective expression & modulation• Cognitive coping• Trauma narrative (imaginal exposure)• In vivo exposure• Conjoint parent-child sessions• Enhancing safety and future

developmentCohen, J. A., Mannarino, A. P. & Deblinger, E. (2006). Treating trauma and traumatic grief in children & adolescents. New York: Guilford Press.Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2012). Trauma-focused CBT for children and adolescents: Treatment applications. New York: Guilford Press.

Psychoeducation• Enhancing understanding of

– Reactions– Triggers– Role of coping strategies– Role of family

• Normalises reactions

• Opportunity to correct misconceptions

• Engendering hope

Affect Labelling/Modulation• Immediate symptom relief

• Replacing less adaptive coping strategies

• Groundwork for other therapy components

• May need plenty of attention if history of repeated trauma

Cognitive Therapy

• Addressing cognitions that are causing distress/impairment

– “Our house will burn down again”– “Nowhere is safe anymore”– “I’m never going to be happy again”– “If I hadn’t gone back to get my bag, our

house would have been ok”

Exposure (Graded, Prolonged)• May be indicated when intrusive trauma-related

symptomatology is prominent

• Exposure to memories (trauma narrative) (imaginal)

• Exposure related to situations (in vivo)• Going outside when it’s hot(/stormy/windy/raining/….)• Going to barbeques• Sleeping in own bed

• With care, consent, and appropriate clinician training

Caregiver Involvement

• Consider barriers and strengths

• Parenting behaviour as the target

• Parents as “coaches”

• Referrals for caregivers

“Process” considerations• Formulation-driven intervention

• Hallmark avoidance (can be subtle)

• Consider longer sessions (habituation/arousal reduction)

• Developmentally-appropriate adaptations

“Process”, cont.

• Home-based tasks

• Rewards

• Impact of heightened arousal on therapy

• Control

TF-CBT & Complex PTSD• Modifications may be needed when Type II

trauma history present– Attachment and the therapeutic relationship– Initial engagement & stabilisation– Affect regulation/distress tolerance– Pace– Length– Crisis management “derailing” TF-CBT

Resources• National Child Traumatic Stress Network (USA)

www.nctsnet.org• Australian Child & Adolescent Trauma, Loss & Grief

Network (ACATLGN)www.earlytraumagrief.anu.edu.au

• Australian Centre for Posttraumatic Mental Healthwww.acpmh.unimelb.edu.au

• National Center for PTSD (USA) www.ncptsd.va.gov

• Australian Psychological Society www.psychology.org.au/topics/disasters/bushfires

• International Society for Traumatic Stress Studieswww.istss.org

Resources, cont.• Tulane Institute of Infant and Early Childhood

Mental Healthwww.infantinstitute.org

• Australian Centre for Grief and Bereavementwww.grief.org.au

• Psychosocial Support in Disasterswww.psid.org.au

• Children and War Foundationwww.childrenandwar.org

• Online TF-CBT traininghttp://tfcbt.musc.edu

QUESTIONS & ANSWERS

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• One more webinar on the treatment of attachment disorders in June – See the ATAPS Clinical Support Service web portal for details.

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