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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

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Current issues in disaster mental health clinical applications

Current Issues in Disaster MentalHealth: Clinical Applications

Betty Pfefferbaum, M.D., J.D.

University of Oklahoma Health Sciences Center

May 2007

Learning objectives
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


  • Definition

    • A severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the altered community

World Health Organization, 1992

Reasons for increase in disasters

Poverty and Vulnerability

Climate Change


Poor Building and Land Use

Reasons for Increase in Disasters

Children s reactions and the factors that influence their reactions

Children’s Reactions and the Factors that Influence Their Reactions

Hurricanes 2004
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

Blake et al. NOAA/NWS/NCEP/TPC/NHC April, 2007; Sallenger et al. 2006

Hurricane katrina august 29 2005
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

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

Hurricane Andrew 1992


  • 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

Ptsd symptom severity
% PTSD Symptom Severity

Overall mean in moderate range

568 school children grades 3 to 5

3 months after Hurricane Andrew

Vernberg et al. 1996

Predictors of ptsd symptoms 3 months
Predictors of PTSD Symptoms: 3 Months

62% variance explained by:


Child characteristics

Access to social support


Perceptions of support from




Close friends

Vernberg et al. 1996

Access to social support
Access to Social Support

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%

Vernberg et al. 1996

Exposure at 7 months
Exposure at 7 Months

442 3rd to 5th graders

3 schools Southern Dade County

La Greca et al. 1996

Posttraumatic stress hurricane andrew
Posttraumatic Stress: Hurricane Andrew

Children with moderate to very severe reactions

early were at risk for persistent stress reactions

No grade or sex differences

La Greca et al. 1996

Posttraumatic stress 7 and 10 months
Posttraumatic Stress: 7 and 10 Months

Model accounted for

39.1% variance at 7 months

24% variance at 10 months

La Greca et al. 1996

Posttraumatic stress
Posttraumatic Stress

n = 92

Grades 4-6

Mean RI Score

% Level PTSD

La Greca et al. 1998

Emotional behavioral outcome
Emotional/Behavioral Outcome

  • Predictors

    • Exposure

    • Child characteristics

      • Demographics

      • Pre-existing conditions

      • Coping

    • Recovery environment

Posttraumatic stress at 2 months
Posttraumatic Stress at 2 Months

Children in Hi-Impact school were more likely

to have severe posttraumatic stress

N = 144

57% Hi-Impact

43% Lo-Impact

Mean = 8.2 yrs

Shaw et al. 1995

Posttraumatic stress in hi impact school
Posttraumatic Stress in Hi-Impact School

Severe posttraumatic stress decreased

70% with moderate to severe posttraumatic stress at 21 months

N = 30

Shaw et al. 1996

Disruptive behavior at 8 months
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

Hi impact disruptive behaviors
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

Lo impact disruptive behaviors
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



Early Interventions


General Therapeutic Principles

Evidence Base for Interventions

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

Goals of Early Intervention

Recognize hierarchy of needs
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

Assumptions and principles
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

Psychological first aid
Psychological First Aid

  • First aid is “the first aid received by a person in trouble”

American Psychiatric Association 1954

Psychological first aid1
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

Psychological first aid2
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

Core actions and goals 1
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


Core actions and goals 2
Core Actions and Goals - 2

  • Stabilize

    • Calm and orient emotionally overwhelmed or disoriented survivors

  • Gather information

    • Identify immediate needs and concerns

    • Gather additional information


Core actions and goals 3
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


Core actions and goals 4
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



  • 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

World trade center 1993
World Trade Center 1993

  • February 26, 1993

  • 6 killed

  • > 1,000 injured

  • Thousands trapped

CNN (1997) & The Joint Terrorism Task Force

Children s symptoms at 3 and 9 months
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

Posttraumatic stress and fear
Posttraumatic Stress and Fear

Parent report: significant decrease

Child report: no decrease

Posttraumatic Stress

Incident Fear

Koplewicz et al. 2002

General therapeutic principles
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

Treatment approaches
Treatment Approaches

  • Supportive psychodynamic approaches

  • Play therapy

  • Cognitive-behavioral approaches

  • Family therapy

  • Group therapy

  • Medication

    • Rarely needed

    • Adjunctive if used

Family interventions
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

Small group interventions
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

School based interventions 1
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

School based interventions 2
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

School based interventions 3
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

Content of interventions
Content of Interventions

  • Trauma

    • Emotional distress

    • Arousal

    • Reminders

  • Loss and grief

  • Anxiety

  • Depression

  • Safety

  • Anger

  • Conduct problems

  • Concentration problems

  • Coping

  • Social support

Intervention techniques
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

Limitations in general
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