Rocky Mountain Region Disaster Mental Health Conference
February 11-14, 1999
Laramie, Wyoming
CONFERENCE PROCEEDINGS
DAY 3
Children And Families In Disasters
Day Three was devoted to Children and Families in Disasters. The tone for the day and
the theme session was set by Annette M. La Greca, Ph.D. The title of her presentation was
"Children's Reactions to Disasters: Lessons Learned from Andrew and Other Disasters".
Her presentation was followed by Russell Jones, Ph.D. who presented information about
his NIMH Residential Fire Study involving children and their parents. Dr. Alan Delamater
presented a study examining PTSD, behavioral adjustment, and developmental outcomes in
preschool children exposed to Hurricane Andrew. Merritt Schreiber, Ph.D. described the
Laguna Beach, CA firestorm and a FEMA supported program which provided services for
children and parents over 17 months. The final presentation of the day was by Robin
Gurwitch, Ph.D. who provided a description and personal account of her work with children
following the Oklahoma City bombing.
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PRESENTER: Annette M. La Greca, Ph.D.
Professor of Psychology and Pediatrics
Director, Clinical-Child and Pediatric Health Programs
Co-Director, Child Division
Department of Psychology
University of Miami
alagreca@miami.edu
Dr. La Greca began her presentation with a brief literature review and background of
children and disasters. Following natural disasters such as Hurricanes Andrew and
Hugo, the Northridge Earthquake, the Oakland fires, and the Loma Prieta Earthquake,
and man-made disasters such as crashes of TWA Flight 800 and Valuejet, bombings and
terrorist activities, there has been tremendous interest and concern about the impact
of such disasters on children and adolescents. Her review of recent work by a number
of investigators who have studied children's reactions to disasters indicates that
disasters represent traumatic events for children. These can result in post-traumatic
stress reactions. Dr. La Greca's review suggested that findings indicate that children's
reactions to disasters can be severe. They are not merely fleeting, transitory events
that dissipate quickly. Children's reactions appear to linger and persist. As a result,
they are likely to cause much distress for children and their families. Due to the
severe and persistent reactions children might have to disasters, efforts to provide
effective services and interventions for children and adolescents following a disaster
are an important, and frequently overlooked, mental health need.
Dr. La Greca discussed a number of factors surrounding children's reactions following
disasters. PTSD in children can result from exposure to Trauma. A re-experiencing of
the event can cause reactions which include, over time, Avoidance/Numbing, Hyperarousal,
and/or other symptoms of PTSD. She discussed the challenges in identifying post traumatic
stress reactions in children. These have implications for post disaster interventions.
Describing which children are most likely to be at risk for severe and persistent
post traumatic stress reactions is one challenge. Others include understanding factors
(at home and in school) that promote children's coping after a major disaster. There
are developmental aspects which need to be taken into account. There is also the need
for matching intervention strategies with the phase of post disaster recovery (acute,
short-term, or long-term).
Recent studies of children's reactions to disasters has suggested that the disasters
represent traumatic events for children that can result in the emergence of post-traumatic
reactions. Dr. La Greca discussed the prevalence of PTSD in children at three stages -
Initial prevalence; Prevalence over time and its developmental course; and the Prevalence
of different symptom clusters. The conceptual framework she discussed places considerable
emphasis on the importance of characteristics of the individual (e.g. ethnicity, pre-
disaster functioning); of the disaster (e.g. degree of exposure, life threat); and of
the recovery environment (e.g. availability of social support, intervening life events)
in understanding children's short-term and long-term reactions. Dr. La Greca talked about
differentiating immediate, short-term, and long-term disaster reactions, especially in
terms of the types of intervention strategies which might be needed at different points
in time.
Some of the other types of reactions Dr. La Greca discussed included Anxiety, Fears,
Sleep Disturbances, Depression, Problems with academic functioning or school, Vigilance
and Security concerns, and how these may vary among types of disasters or traumas.
In discussing the implications of the reactions children have, Dr. La Greca listed a
number of factors which contribute, including:
* Exposure - Life threat does not mean that the actual loss of life needs to
have occurred.
Loss and disruption of one's life can be immediate and ongoing.
* Predisaster characteristics of the individual -
~ Demographics including age, gender (are girls more vulnerable?),
and ethnicity (are minority youth affected differently?)
~ Levels of pre-disaster functioning. This includes psychological
functioning as well as pre-disaster academic functioning.
* Aspects of the recovery environment -
~ Intervening life events can affect the recovery process.
~ The social support systems available can facilitate or impede
effective recovery (e.g. family, friends, teachers).
* Children's ability to cope with stress -
~ Children have difficulty coping with novel and intense stressors.
~ Over time, the negative strategies seem to be most predictive of
problems.
The conceptual model put forward by Dr. La Greca was suggested as useful in predicting
short-term (3 months) and longer-term (7-10 months) reactions. It was also suggested
as being useful in identifying children who are slow to recover.
The implications Dr. La Greca spoke about are that high risk children (and others) should
be monitored. Some of the things she suggested looking for include:
* They are at risk for greater life threat during the event.
* They experience a greater number of loss/disruption events post
disaster.
* Members of ethnic minorities are at higher risk.
* They may experience more major life events post disaster.
* Less social support may be available from family and friends.
* They may use negative coping styles in dealing with disaster
related stress.
* They may have lower levels of pre-disaster academic achievement.
* They may present with attention problems.
* They may experience higher levels of pre-disaster anxiety.
Dr. La Greca suggested monitoring children whoe show the above characteristics in order
to provide more effective interventions.
In discussing interventions, Dr. La Greca pointed out a number of factors to be aware of:
* There are a number of obstacles which can hinder effective intervention.
~ The lack of a disaster plan, or one including mental health leaves
a gap in how to provide such services effectively.
~ The disorganization and chaos immediately following a disaster can
make it difficult to provide effective interventions.
~ The lack of coordination among services and providers makes it difficult
to implement plans and interventions.
~ There is often competition and/or a lack of coordination between
various community agencies and groups.
~ Adults are pre-occupied with other phases of the disaster recovery
efforts. They may find it difficult to provide the needed support
for children as a result.
~ Adults may deny problems in children or "miss" the problems.
* The impact phase is the phase of the disaster which begins when the
disaster event begins and it lasts until the end of the disaster.
It is over when there has been an initial assessment of the number
of casualties or other losses. When this is communicated to the people
who are directly affected, the impact phase can be said to have
concluded. Dr. La Greca stated that the goals following the impact
phase are to restore children's sense of normalcy or routine and their
sense of personal safety.
* The next phase Dr. La Greca discussed was the short term recovery or
Adaptation Phase. This generally lasts up to 3 months post disaster.
During this phase, she suggests targeting all children within the
affected areas. Some methods she discussed included:
~ Classroom and small group activities
~ Family approaches in which expression is encouraged.
~ Provide information to helping professionals. These could include
fact sheets, web sites, telephone, mass media, etc. Similar
information should be provided to the general public as well.
Dr. La Greca suggested monitoring children who are at high risk and providing individual and
family interventions for those who are highly distressed. The goals she recommended for the
Adaptation Phase include:
~ Normalize day to day routines as much as possible.
~ Make sure that children return to their daily routines such as
school, sports and friends.
~ Encourage emotional processing of the event by creating an
environment which allows children to discuss and express their
feelings.
~ Provide opportunities for some fun and distraction.
~ Help parents, teachers, and other adults identify trauma
related behaviors.
* The next phase that Dr. La Greca discussed was the medium to long
term phase which lasts from about 3 months to a year or longer.
During this phase, continued assistance is provided to the most
affected communities, those who are experiencing persistent
symptoms or difficulties are targeted; family, small group and
individual interventions are done; and public ceremonies and
other disaster related rituals are accomplished. The goals that
Dr. La Greca suggested for this phase include:
~ Continue to create a "normal" environment.
~ Continue with the processing of the event.
~ Work to help strengthen social support networks with friends,
family and school.
~ Help to facilitate positive coping with the ongoing stressors.
Finally, Dr. La Greca discussed the importance of pre disaster preparedness. She noted
that this preparedness and the levels of preparation vary tremendously from community
to community. There are many high risk areas she said that are not prepared. She suggested
Miami and Japan as examples. There are some things that can be accomplished locally. Every
family should be encouraged to develop their own disaster plan. FEMA has a web site for
kids that can help with this.
Another suggestion that Dr. La Greca made was to provide distractions for children other
than TV. Quite often the media uses "scare" tactics to mobilize preparations. Finally, she
said that preparation efforts stop at "the event". There is a need to prepare for the aftermath.
She likened this to pregnancy. After the event, one needs to act.
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References
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PRESENTER: Russell T. Jones, Ph.D.
Professor of Psychology
Specialty in Clinical Child Psychology and Community Psychology
Virginia Polytechnic Institute and State University
jones@vt.edu
There has been relatively little research focusing on residential fires. Russell Jones, Ph.D.
briefly reviewed the literature in this area. His review leads to conclusions that potential
negative consequences associated with fire on survivors' psychological functioning suggests
the need for systematic study in this area. Dr. Jones suggested that the identification of
predictors of post disaster functioning would be helpful in determining possible treatment
interventions. Additionally, he pointed out that previous research suggests that parents'
reactions and their own psychological states are related to their children's adjustment
following major disasters.
Dr. Jones went on to describe an ongoing study examining the impact of residential fire on
children and their parents. The study he discussed is a controlled, cross-sectional,
longitudinal study which assesses children's levels of psychological distress using a
multi-method assessment strategy. The study he described was also designed to ascertain
the effects of family atmosphere and parental functioning on children's levels of
psychological distress after residential fire. It used a stress and coping model to help
identify predictors of psychological distress in children.
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References
DISCUSSION AND COMMENTS (If you wish to make comments or enter
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PRESENTER: Alan M. Delamater, Ph.D.
Director of Clinical Psychology
Mailman Center for Child Development
Department of Pediatrics
University of Miami School of Medicine
Professor of Pediatrics and Psychology
adelamat@peds.med.miami.edu
Alan Delamater, Ph.D. presented a study which examined post-traumatic stress disorder
(PTSD), behavioral adjustment, and developmental outcomes in preschool children who
had been exposed to Hurricane Andrew in 1992. His study measured mothers' PTSD,
depression, and optimism as predictors of children's responses. His study presents
useful conclusions of major interest to clinicians and practitioners in the field of Disaster
Mental Health. He concluded that many young children can be expected to exhibit PTSD
symptoms and other behavioral disruptions for at least 18 months following exposure
to a natural disaster. He also concludes that the symptoms are related to previous
trauma, levels of stress during and following the event, and mothers' PTSD. He suggests
that maternal optimism is associated with the emotional responses to the disaster.
Finally, Dr. Delamater concluded that children with PTSD are at risk for developmental
delay and suggested that interventions be provided soon following exposure and should
target both the children and their mothers.
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References
DISCUSSION AND COMMENTS (If you wish to make comments or enter
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PRESENTER: Merritt D. Schreiber, Ph.D.
Clinical Psychologist
County of Orange Health Care Agency
Behavioral Health Care/Children and Youth Services
chipzhz@aol.com
Schreiber (1999) describes a firestorm which struck Laguna Beach, CA on October 30, 1993
in which 400 homes were lost. He describes a FEMA supported program which provided
services for affected children and parents over a 17 month period. The results he reports
found that levels of PTSD and comorbid depression were significantly higher in children
whose homes were destroyed. Current dissatisfactions with living arrangements and
perceptions of greater difficulty in school were seen as being strong correlates of distress.
Factors related to sustained vulnerability, post disaster stresses, adversities and traumatic
reminders are discussed. The findings presented were suggested as confirming the need for
extended mental health services beyond the initial event as the risk from disaster exposure
continued to accrue over time. This article presents information about a large-scale traumatic
event, its assessment of needs, treatment and outcome data with important implications for
disaster mental health professionals in other high risk areas.
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References
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PRESENTER: Robin Gurwitch, Ph.D.
Assistant Professor
Department of Pediatrics
University of Oklahoma Health Sciences Center
Oklahoma City, OK
robin-gurwitch@ouhsc.edu
Robin Gurwitch, Ph.D. presented a description and personal account of her work following
the Oklahoma City bombing an April 19, 1995.
168 people died in the bombing of the Alfred P. Murrah Federal Building at 9:02 AM on
that morning. Nineteen of the victims were children. Hundreds of people were injured and
800 structures and windows were shattered up to a mile away. There were 52 children and a
staff of nine at the YMCA which was located near the federal building. All were injured as
glass windows shattered. Dr. Gurwitch said that the children had just come inside after
playing in the yard, "If the children had been outside, they would have died."
A "Compassion Center" was set up at the First Christian Church. A mental health escort
person was assigned to each family awaiting information about the status of loved ones.
Media were not allowed inside. Within a few days, death notifications began. Dr. Gurwitch
said that teams were set up for death notices. Families were escorted up to a room by
military personnel along with a psychologist and a member of the clergy for support. The
military guarded the door from unauthorized personnel. The psychologist/psychiatrist and
clergy were with the Medical Examiner when the family arrived. The medical examiner
notified the family that their loved one was found.
Dr. Gurwitch noted that during this process, the teams noticed that families asked questions
about what to tell children. As a result, an additional mental health professional specializing
in children's issues was added to the team.
Dr. Gurwitch said that mental health professionals conducted intervention services at the
schools. The local school board agreed to conduct a needs assessment test for the children.
In some schools this was not allowed. She attributed this to a case of "teachers/principals
underestimating children's needs. This affected everybody."
There were some 6000 children in the schools, of which about 500 were determined to be at
risk. Training for dealing with children's trauma was provided for school counselors.
Counselors decided that, of the 500 at risk, 300 "don't need extra help and the 200 -
nobody has ever figured out what happened to them." Dr. Gurwitch said that in the final
place, 53 students received "intensive services". These students were placed into small
groups, were debriefed, and did art therapy. Many hundreds of children had contact with
mental health specialists over the next months and the following year. Due to FEMA
guidelines, many of these children received only crisis intervention. Therapy services
were available if requested and continue to be available to all children impacted by
the bombing in Oklahoma City.
In planning for future disasters and related children's services, Dr. Gurwitch suggested the
following question be addressed: "How do we help the helpers know what children's needs
are?"
In her presentation, Dr. Gurwitch spoke about the children who had survived and how they
dealt with post-traumatic play or the re-experiencing of the event. She provided a number
of examples.
One child who was at the re-located YMCA hung Barbie Dolls upside down from the
dollhouse.
Another child who had survived the explosion created, for many weeks, Lego people with
missing upper bodies and lower bodies who lay in beds in the hospital - "legless, armless
and headless people".
Dr. Gurwitch reported that she saw this boy change over time. "The Lego people were full
bodies in the hospital bed, with someone next to the bed and everyone had a Lego Christmas
tree."
Another situation she discussed accurred at the re-located YMCA. The children were in a
"nice room". However, it was located in a weight room. Whenever there was a "thunk!" the
children started crying, setting off a "chain reaction".
Dr. Gurwitch talked about one four year old boy who explained how he had gotten a scab on
his head. He said it was because he had been shot in the head. For him, getting shot was
the worst thing that could happen to him. It happened and he concluded that he must have
been shot. He was unable to grasp the bombing.
Some of the other children Dr. Gurwitch reported on showed symptoms of what she termed
"diminished interest". The mother of a three year old girl at the YMCA described her
daughter by saying "the sunshine had come out of her eyes."
The initial recovery process lasted many weeks. The final two bodies were not found until
the building was imploded on May 23, 1995 at 7 AM. Dr. Gurwitch reported that people who
watched relived the smells, sound and sights of the explosion. She said that the parents
who had taken their children to watch had "spiked a reaction" in them.
Dr. Gurwitch said there was a good deal of survival guilt among some children. One five
year old girl who had recently moved from the "Stars and Stripes" Day Care Center to the
YMCA told her "I should have stayed where I was, because I know I could have gotten all my
friends out." The mother of this child couldn't drive down a road with any glass buildings
without her daughter "going ballistic".
In concluding remarks, Dr. Gurwitch said that she hopes Mental Health Professionals can
use what they learned from this disaster and that the skills they developed for interacting
with children of trauma can be used for any type of disaster - "a shooting, a flood, and,
God forbid, a bomb." She also stressed that they should also recognize that children have
the same unique issues as their parents.
In a final comment, Dr. Gurwitch, in addressing how life in Oklahoma City has changed,
said that "Thanksgiving has changed, but there are still things to be thankful for."
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