Disaster Responses Often Ignore Kids With Psychological Injuries
Publication: Psychiatric News
Identifying children who need help after disasters may be more efficient at hospitals or schools, but those institutions must be prepared to take on that crucial role, said speakers at the American Academy of Child and Adolescent Psychiatry's annual meeting in Honolulu in October.
Often children without obvious physical injuries are marginalized, even though they may be suffering the psychological aftereffects of the event in silence.
Possible reactions to trauma include behavior familiar to classroom teachers—lack of concentration, disorganization, hyperactivity—which “everybody knows” are symptoms of attention-deficit/hyperactivity disorder (ADHD). “But they are also the symptoms for posttraumatic stress,” said Robin Gurwitch, Ph.D., of the Cincinnati Children's Hospital Medical Center. “Children don't wake up one morning with ADHD.”
Most children are resilient in the face of trauma, but many children have reactions that show up in school settings, Gurwitch noted. They may have cognitive, behavioral, or emotional problems; display anger or withdrawal; or report physical symptoms such as headache, stomach ache, or fatigue. Trauma can increase absenteeism or lead to lower grades and graduation rates.
Not all children who have experienced a trauma develop PTSD, although some without apparent symptoms soon after the event “do have symptoms that may show up in time,” she said.
Thus, schools can be important venues for identifying and beginning to care for children who have been through some disaster, while balancing the needs of education against the need to recover. Schools represent a safe, familiar setting to children. For mental health personnel, schools are where the children are and where large numbers can be screened and treated. School settings increase parents' willingness to permit access to services. “If it's in school, it must be OK, and my child's not crazy,” runs the parental logic.
Start With Psychological First Aid
The first step in helping children is psychological first aid—emotional support and practical coping to help children get through the next minutes, hours, and days. In the phrase used by the Red Cross: “Listen, protect, connect.”
“However, psychological first aid is not a cure-all or a substitute for other psychosocial interventions,” she emphasized.
Reducing children's exposure to media that are discussing the trauma is another helpful step. Seeing disasters replayed again and again on television may heighten anxiety, and watching repeated coverage of the events may also be an expression of anxiety, she said. Educating families to turn off the TV can help in either case.
“If you help and inform parents, you are helping their children,” she said. That can begin by directly addressing the event and correcting any inaccurate or maladaptive attributions, like blaming themselves for the disaster.
Trauma-focused cognitive-behavioral therapy has been tested in six randomized controlled trials that showed it alleviated PTSD symptoms and decreased behavioral problems. Reopening schools closed after a disaster can also help reestablish the social networks that support children. Regular classroom attendance, along with sports and other extracurricular activities, helps create stability in children's lives, Gurwitch said.
Schools are not the only places that can help children after disasters. Hospitals inevitably play a role, but they have to be prepared, said Jon Shaw, M.D., of Miami's Jackson Memorial Hospital, a professor of psychiatry and behavioral sciences and chief of the Division of Child and Adolescent Psychiatry at the Miller School of Medicine at the University of Miami.
Mental Health Casualties Ignored
Hospitals are required to hold mass-casualty exercises, but they often ignore behavioral and mental health casualties, even though they are the ones likely to overwhelm doctors when disaster strikes.
“Three out of four hospitals do not have a behavioral-readiness plan in place, and psychological casualties can outnumber medical casualties by a ratio of 4 to 1 or worse,” said Shaw.
He cited the extreme case of exposure to radioactive cesium-137 in Goiania, Brazil, in 1987. When word got out, 112,000 people presented themselves for screening, about 9,000 had symptoms consistent with radiation poisoning, but only 249 were actually exposed to the cesium.
After terrorists bombed a Madrid train in 2004, area hospital emergency departments efficiently evaluated and treated the injured or sent them to other departments. All was quiet for a while, said Shaw. “Then the relatives arrived”—a wave of anxious, physically uninjured people needing attention.
When planning for disasters, the hospital patient-reception area should include mental health specialists on the triage team: a senior psychiatrist and psychiatric nurse, along with administrative and computer support, said Shaw. Screening tools should be available to assess trauma exposure, life-threatening injuries, and bereavement reactions, if known at the time.
Some children may be asymptomatic but others may be crying, trembling, or clinging or exhibiting withdrawal or regressive behavior. Mobilizing psychological first aid and any available family or community support is an appropriate first step, and if those measures aren't sufficient, referral to an acute crisis center is appropriate, said Shaw.
He noted as well that clinicians should allow some time to pass before considering medications for the children, and then only when severe symptoms or comorbidities are present, not just stress.
Logistical support is crucial to registering individuals and families when they arrive and to helping families who may be searching for relatives, who may or may not be at a particular facility.
“Relatives want care for the injured, up-to-date information on their loved ones, and contact with staff,” said Shaw. “When deaths occur, they want compassionate, unhurried notification of a relative's death.”
It is also crucial that hospital staff respect the legal, cultural, and religious issues that accompany death and offer practical assistance to survivors.
“Traumatic bereavement is different than a death after a long illness,” he said. “Because there has been no anticipatory bereavement, grief reactions can be more acute, and survivors need more immediate psychosocial support.”
Hospital personnel need help too, said Shaw. Some may leave the hospital to look after their own families, as happened in New Orleans after Hurricane Katrina and Toronto during the SARS outbreak. Others get too involved, feeling indispensable and becoming sleep deprived.
“So it's important to manage the workload of health care workers,” he said. “Bring their families to the hospital if necessary, offer places to go for respites, and help them remain aware of their own stress levels.”
Training and preparation are the best defenses against “contagious PTSD” on the health care team, but everyone is vulnerable on some level, in his or her own way, Shaw emphasized. 
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Published online: 18 December 2009
Published in print: December 18, 2009
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