Children are likely involved in disasters wherever they occur. For example, the much-studied 1972 Buffalo Creek flood in West Virginia left 125 dead, 52 of them children. Thousands of children were affected by the tsunami that devastated Southeast Asia in December 2005 and the terrorist attacks in the United States on September 11, 2001. Children are passengers on planes when they crash, are located in buildings when they burn, and live in areas that are flooded. They may even be specifically targeted because of the emotional impact that their victimization has on the community, as evidenced by the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, which killed 168, 19 of whom were infants and young children.
Although children have always been involved in disasters, the study of disasters and their impact on children is relatively young. Until the early 1980s, it was commonly believed that little, if any, treatment was needed after a traumatic event touched the lives of children. Following groundbreaking work by Robert Pynoos and others, it is now understood that children have significant reactions and that they need mental health services to improve overall outcome. Unfortunately, children’s lives are affected regularly by traumatic events, including child maltreatment, domestic violence, and community violence. When large-scale events occur, such as terrorist attacks or natural disasters like recent hurricanes Katrina and Rita on the Gulf Coast, calamities that directly affect thousands indirectly affect many times that number through the media, and that increases children’s awareness of the horrors that can accompany large-scale disasters. Children are considered one of the highest-risk groups for adverse reactions and consequences. However, the mental health needs of children do not seem to be addressed adequately in the preparedness, response, or recovery phases of planning for disasters. This finding is highlighted in a recent report by the National Advisory Committee on Children and Terrorism.
Children’s Responses to Disasters
Children’s responses to disaster can be viewed in four categories: cognitive, emotional, physiological, and behavioral. The cognitive reactions include problems with attention and concentration. This difficulty may be coupled with problems with impulse control and decision-making abilities. Problems with memory also may arise. Unfortunately, the professional and the lay communities have been sensitized to interpret the combination of many of these problems as evidencing attention deficit/hyperactivity disorder (AD/HD). Therefore, following disasters or other traumatic events, children may be referred for AD/HD assessment and medication. It is important to evaluate onset of the problems and exposure to trauma in making the diagnosis. (Note: children with AD/HD can be affected by trauma, and their AD/HD will need to be taken into account when assessing their responses.) Another common cognitive reaction is the presence of intrusive thoughts. Children may have images or thoughts of the disaster coming unbidden, often disrupting concentration in school. There may be an increased focus on the event. This will be evident in their repeated discussions of or questions about the disaster. Decreases in self-esteem and ideas of self-blame are two other cognitive reactions seen in children following disaster.
There are many emotional reactions after disaster, with worries, anxieties, and fears related to the event and its aftermath among the most common. Children’s worries generally revolve around issues of safety and security for themselves and for others. The sphere of worry expands with a child’s age. Very young children may worry about the security of themselves and their immediate family. As children develop empathy, they may worry about those in their school system, neighborhoods, and community. Older children’s and adolescents’ worries may include concern about those they may not know who could be touched by the disaster or future similar events. For example, many in this age group may be concerned about children living in Afghanistan and Iraq impacted by the global war on terrorism or about soldiers serving overseas. Anxiety about a reoccurrence of the disaster is extremely common after an event. This anxiety may be exacerbated by trauma reminders. For example, children who experienced Hurricane Katrina may have feelings of worry, fear, and anxiety with thunderstorms and with each new hurricane season, and children living in new and perhaps strange locations may experience loss reminders on a daily basis after the disaster.
Emotional reactions can include a sense of helplessness, guilt, and grief related to the disaster. Children, like adults, may experience emotional numbing, but this appears to be seen more in older than in younger children. Mood swings and irritability, often the hallmark of childhood, may increase after a disaster. Therefore, such reactions should not be viewed merely as a function of the “terrible twos” or the teenage years. Clinicians should look for a change in mood and irritability with friends and family from before to after the disaster.
Physiological effects after disaster can be thought of as bodily reactions. These often include changes in sleep patterns, with problems either falling asleep or staying asleep. Nightmares are common. Unfortunately, when children are not sleeping well, it can impact other areas of their lives, such as learning. Appetite also may be affected by disasters, resulting in either weight gain or weight loss. Many children experience somatic complaints after a disaster, including headaches, stomachaches, fatigue, and flu-like symptoms. Concerned parents may seek medical consultation related to these physical symptoms. It is, therefore, important for mental health professionals and their medical colleagues to work together to assure a comprehensive understanding of common reactions after disaster. Agitation may increase after disaster. For school age children, this response may look like fidgeting at their desks, increasing adults’ concerns related to a diagnosis of AD/HD. Children may become hypervigilant after a disaster, with their bodies preparing to respond to any perceived threat. Finally, an increased startle response may be experienced after a disaster; it can be triggered by loud noises (e.g., sirens, thunder, a car backfiring) or similar unexpected, unpredictable happenings. Once startled, children may have difficulty settling back down and refocusing their attention.
Behavioral effects of disaster are, perhaps, the most observable reactions. Young children may show more separation anxiety. They may be more clingy and whiny than before the disaster. A regression in behaviors also may be noticed: They may have toileting accidents despite being reliably potty trained, make demands for pacifiers given up long ago, or use baby talk that had been abandoned. Although young children are very proud of self-care skills such as dressing themselves, they may request more help from caregivers and teachers. Older children and adolescents may show a change in social relationships. They may become more irritable and argumentative with family and friends than they were before the disaster. Increased aggression also may be seen. Withdrawal behaviors may be noticed; for example, children of all ages may wish to avoid activities that they once enjoyed, including time with friends, extracurricular activities, or family outings.
Behaviorally, impairments in meeting responsibilities at home and at school may be seen. For example, children may not complete chores as they did prior to the disaster. A brief decline in school performance may occur, such as a failure to complete in-class assignments or homework, a drop in grades, or frustration with learning new material. Although the brief decline is common, clinicians also should be mindful of children who show a significant improvement in their academic performance after a disaster. Generally, these children will become wholly focused on schoolwork to the exclusion of their friends, extracurricular activities, and hobbies. While this focus may seem positive from an academic standpoint (improvement in grades, increased commitment to study and to excel), it should be viewed as problematic if all other activities are avoided or ignored and their importance minimized by the child.
Special attention should be shown to adolescents in the aftermath of a disaster. Adolescents are at risk for experiencing a sense of foreshortened future. Because of this, they may seek new experiences, including those considered high-risk, such as substance use, promiscuity, and reckless driving. Adolescents may become fascinated with death. Depression may be experienced. This combination, coupled with diminished impulse control, poor decision-making, and withdrawal, places this age group at increased risk for suicide after a disaster.
Children’s responses to disaster can be mediated by a number of factors. Perhaps one of the strongest predictors is exposure to the event. The greater the child’s exposure, the more likely the adverse reactions will be. Exposure includes being a direct witness to the disaster, including injury and exposure to injury or loss sustained by family members, and perception of the disaster as a threat to the child’s life or the lives of family members. Exposure also includes destruction by the disaster of the child’s or the child’s family’s personal property. Loss is a unique category after disaster. Loss includes death of a family member or a pet. When a child experiences the death of a family member due to traumatic circumstances, he or she is at risk for child traumatic grief—the trauma experience may interfere with how grief is processed. With media coverage of disasters being constant and intense, the relationship between media exposure and posttraumatic symptoms has been examined. Results from research studies indicate a strong correlation; however, causation is not clear.
Children of all ages feel more secure in times of crisis when they are with parents or caregivers. The longer children are separated from these important adults in their lives, the greater the risk that the children will have difficulties. Therefore, connecting children with family as soon as possible after a disaster is important. Children also benefit from routine. Disasters disrupt routine, including routines of school, home, extracurricular activities, and community service. Disrupted routine is positively correlated with posttraumatic symptoms (the greater the disruption, the greater the symptoms reported). Routine includes day-to-day activities as well as rules of behavior. Children generally find comfort and stability in order and consistency, so the randomness of disasters or the malicious intent of terrorism may be incomprehensible to them, and they may feel confused and respond with fear and heightened anxiety. It is important to remember that while a return to routine is necessary, it is generally not sufficient to help children in the aftermath of disaster.
When considering which children may be at greatest risk for difficulties after a disaster, it is important to consider which children have previously been identified as being at risk. Preexisting conditions, whether psychiatric or physical, and limitations, such as mental and educational capacity, condition the child’s response to the disaster and postdisaster symptoms. Children who have a history of special services in school or are involved in therapy services should be considered at risk. Similarly, children with a prior history of traumatic events in their lives are also included in this at-risk group. As prior history of the child can help in determining risk, so too can prior history of the family. Factors that can contribute to problems after disaster include how the family was functioning prior to the event. Consider stressors in the family (financial and emotional). Stressors can be both positive and negative. The loss of a job can be stressful, and so too can a move to a new home, especially if this involves a change in school and friends for the child. One of the best predictors of how well children cope after a disaster is how well their parents or caregivers adjust to the event. Adults who are having problems coping with the disaster may not be able to continue fulfilling their appropriate roles as guide, moral compass, and interpreter of the outside world; the child is then unclear about how he or she is expected to behave in a situation. Therefore, when assessing the emotional well-being of children after disaster, it is also important to assess how the family is faring.
Taking a developmental perspective with children in the aftermath of disaster can increase understanding of how children understand, react, and cope with what has happened. The child’s developmental level helps predict his or her physical, cognitive, and emotional capacities. For example, preschool children may believe that thinking about something will cause it to happen and so believe that they caused the tornado or the plane crash or the shooting, and the resulting guilt can be overwhelming for them. Young children may not understand “replay,” and seeing media coverage of a disaster may give them the impression that the event is happening over and over again, increasing their fears and anxieties. Older children may have a greater appreciation for the unpredictability of disasters and can understand the extent of loss and devastation, leading to concerns about their future, also increasing fears, anxieties, and depressive feelings. Adolescents, because they are closely aligned with friends, view any disruption in being able to see them or talk with them as very distressing. They may, therefore, “overreact” to the closing of their school, the inability to get together with friends, and the possibility of relocating, further contributing to their emotional responses to the disaster. Biological sex, in and of itself, is relevant only insofar as it relates to the expectations the children learned from their culture; for example, girls may have learned to express emotional reactions, such as crying, and boys may have learned to express cognitive and behavioral reactions, such as behaving stoically or acting out.
Culture, which includes the language, values, beliefs, traditions, and customs that bind people together, provides the context both for interpreting the cause of a disaster and for how to respond to it. Cultures vary in the emphasis they place on the importance of privacy, whether an individual or group perspective is “right,” how to comfort others, which emotions are appropriate to express under different conditions, how adults and children are supposed to interact, and whether asking for help is acceptable—and all are involved in predicting a child’s reaction to a disaster.
Perhaps the most well-known—certainly the most well-publicized—reaction following a disaster is posttraumatic stress disorder (PTSD). This adult-oriented diagnosis has few reactions that are specific to children. As a result, children may be underrepresented in having this disorder.
For example, an investigation of children’s reactions to Hurricane Andrew found PTSD symptoms 44 months after the hurricane in 40% of the children studied, with re-experiencing, hyperarousal, and avoidance or psychic numbing symptoms the most prominent ones. Although PTSD is one disorder that is common after disaster, anxiety disorders, depression, and behavioral problems should also be considered. While a formal diagnosis may be present, it is more likely that symptoms rather than a full diagnosis will exist.
Just as symptoms and pathology may exist, it is also important to focus on strengths. Consider that children have factors that can enhance their ability to bounce back after a disaster. Resilience is this ability to bounce back quickly and effectively after a crisis. This can be enhanced or taught. While many, if not most, children may be resilient in the face of adversity, this does not mean that interventions are not needed. Children may be resilient in one situation but not in others. While any one of the numerous factors—characteristics of the disaster, dimensions of risk and resiliency, the child’s developmental level, and so on—can provide the basis for predicting how a particular child may respond to a particular disaster, the best predictions take into account as many factors as possible.
A full discussion of interventions with children in the aftermath of disaster is beyond the scope of this entry. The appropriateness of individual interventions will depend on how long it has been since the disaster occurred. Consider a mental health triage assessment to determine the need for various levels of intervention. A promising model for this is PsySTART, which helps determine need for as well as allocation of mental health resources following a disaster. In the immediate aftermath of a disaster, Psychological First Aid (PFA) may be useful. There are several models for this, including one sponsored by the American Red Cross and another titled Listen, Protect, and Connect.
Cognitive behavioral treatment approaches to interventions with children after disaster are the most promising for effective outcomes. An intervention for young children after disaster that can be delivered in a group format in various settings is Healing After Trauma Skills. An evidenced-based treatment to be delivered in a school setting to older children who have been exposed to violence or disasters is Cognitive Behavioral Intervention for Trauma in Schools (CBITS). The intervention with the strongest empirical findings for use with children after trauma is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). Originally developed for children who have been abused, it has been successful with children who have experienced other traumas, including disasters. If loss is present, TF-CBT has been adapted for this circumstance and it is strongly recommended. A 10-hour free Web-based training in TF-CBT and more information are available at the TF-CBT Web site.
Mental health professionals are instrumental in bringing about overall positive outcomes for children and families after a disaster. To maximize the role of mental health providers, their involvement should begin with all stakeholders in the community in the preparedness phase and continue through the response and recovery phases. Continuous training on this topic is important, as potential events and state-of-the art responses are always changing.
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