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M O D U L E 9
INTRODUCTION
SECTION I / EMOTIONAL
VULNERABILITY
EMOTIONAL VULNERABILITY IN
CHILDREN AND ADOLESCENTS IN
DISASTER SITUATIONS
and cognitive ability to understand and antic- trauma, loss, family distress, or emotional/
ipate the immediate or longer-term con- behavioral problems increases the likelihood
sequences of the disaster. On the other of a more intense and persistent emotional
In spite of their
vulnerability, many hand, adolescents may be more self-suf- disturbance after disasters. Children who
girls and boys have ficient and react in a manner somewhat have been receiving medication for mood
inner resources that
enable them to be independent from their care givers. The or behavior may be additionally at risk after
more resilient than adaptive capacity of nearly all chil dren is a disaster if the supply of medication is
many adults in
disaster situations. influenced by the physical and emotion- disrupted or if they experience side effects
al availability of their caregivers, but this from sudden discontinuation.
is especially true for younger children. They
may experience intense feelings of abandon- Factors that Influence the
ment when separated from adults in the Emotional Impact on Children
family who have been injured, dislocated,
in Disaster Situations
killed, or who are doing community work Events that cause a great deal of damage
work and thus not available in ways they or long-lasting disruptions, or occur with
would normally be. little warning, tend to cause a greater
degree of distress. Factors that influence
Gender the type and intensity of the emotional
Cultural and biological differences between impact experienced by affected children
girls and boys make it more likely for boys are shown in Box 1.
to have more disruptive or externalizing
behavioral symptoms and longer recovery
periods than girls. Boys tend to react with BOX 1. Factors that influence the
aggressive behavior, violence, substance emotional impact on children in
disaster situations
abuse and antisocial attitudes. Girls, on the
other hand, are more at risk for internalizing l Characteristics, extent and duration of the
disorders such as depression and anxiety. In disaster
l Direct exposure to disaster
some cultures, girls may be more willing l Earlier exposure to disaster and chronic
Both girls and boys are at risk for interper- l Effects on parents or caregivers
tors per se, but their dynamic relationship Effects on Parents or Caregivers
that predict good or bad outcomes. Children are sensitive to how a d isaster
has affected families and community.
Disasters may
generate situations of Type, Extent, and Duration Adults, who normally provide support,
chaos and disruption of Disaster protection, and stability, may be unable to
that undermine the
normal rule of law Acute situations of short duration that gen- provide shelter, food, or safety. They may
and lead to desperate erate few changes in everyday life cause less fail to respond appropriately to their
and criminal
behavior. psychological damage than those that are child’s emotional distress because they
prolonged and cause extensive damage to are incapacitated by their own emo-
the social environment. tional response. Children are affected by
their caregiver’s response to an event.
Direct Exposure to Disaster An over-whelmed caregiver frequently
When children are direct witnesses to leads to a distressed child. Emotional or
the impact of a disaster, the emotional behavioral disorders manifested by care-
consequences are more severe. givers increase a child’s feelings of insecu-
rity and fear; making long-term emotional
Perception of Life-threat to Self or and behavioral disorders more likely.
Significant Other
Children’s subjective perceptions of the Family Inner Resources: Relationships
disaster and its effects are an important and Communication among Family
influence. A perceived threat to an indi- Members
vidual’s life is as important to assess as any Families characterized by tense and conflict-
objective risk, since the perception of a life- ing relationships prior to the disaster are
threat is a strong risk factor for developing more likely to react in nonadaptive and dis-
an emotional disorder. In children, their organized manners. This reinforces feelings
belief that their parent might die is also a of helplessness and insecurity in children.
significant risk factor for developing emo-
tional problems, more than the event itself. Exposure of Children to Mass Media
Repetitive exposure of children to
Separation From Caregivers ter ri
fying images on television has an
Children who suffer potentially traumatic emotional impact on them. Children
events are more likely to develop last- may mis understand these images and
ing emotional probems if they are not believe that the event is ongoing or
with their parents — or are separated more severe or closer to them
from their parents — immediately after than in reality. Graphic images can
the event. overwhelm and frighten younger chil-
dren, and impact older children and
Physical Injury adolescents as well. Indirect exposure to
Physical injury and related pain is associ- disaster through TV images is associated
ated with chronic PTSD symptoms. with anxiety and other emotional distur-
SECTION I / EMOTIONAL VULNERABILITY 9
CHILDREN’S EMOTIONAL
RESPONSE TO DISASTER
distinguish between reactions that do not
OBJECTIVES require clinical management, and those
who need clinical management. Transient
l Know the stages of the emotional reactions for which people do not seek
response to a disaster. help and that do not impair day-to-day
l Know the most common emotional functioning (beyond what is culturally
disorders in children exposed to disaster expected in case of bereavement) do not
situations. need clinical management. In these cases,
l Recognize the cases that require referral health providers need to be supporti-
for mental health professional assistance. ve, help address the person’s need and
concerns, and monitor whether expec-
ted natural recovery occurs. People with
acute stress or grief may present with a
Normal Emotional Response
wide range of non-specific psychological
When a child is exposed to a disaster,
the emotional responses can range from and medically unexplained physical com-
minimal distress to inattention, fear, plaints. Recognize that help seeking may
lack of enjoyment (anhedonia), anxiety, be a poor indicator of need — various
and depressed mood, to symptoms of factors including shame, fear of conse-
re-experiencing, avoidance, hypervigi-
quences, actual physical barriers may lead
lance, and disruptive behavior. people in need to not seek services or
In many instances these symptomatic resist being identified as in need of help.
reactions are considered normal respon-
ses to a traumatic experience and are Stages of Normal Emotional
time-limited. Children, however, may also Response of Children to
have significant impairment and chronic Disaster
symptomatology. As emphasized in the There is a range of emotional responses
mhGAP Humanitarian Intervention Guide, or reactions that can be seen, some of
children in humanitarian emergencies are which are more likely to occur during
often exposed to major losses and/or or immediately after the disaster and
potentially traumatic events. Such events some which are more likely to be seen
trigger a wide range of emotional, cog- at a later time. The emotional response
nitive, behavioral and somatic reactions. to disaster are often conceptualized as
People with severe reactions are particu- a linear model with different phases.
larly likely to present to clinical services While this may be valid for many chil-
for help. Clinicians need to be able to dren, it is important that many others
SECTION II / EMOTIONAL RESPONSE 11
follow different pathways and that this cies often focused on the effects of ‘trau-
is not necessarily problematic. ma’ and particular on post-traumatic stress
The first stage, occurring immediately disorder (PTSD). However, more recently,
after the traumatic experience, often specialists and practitioners increasingly The most frequent
childhood disorders
include reactions of fear, denial, confu- agree that it is essential not to assume following a disaster
sion, and sorrow as well as feelings of that all children in an emergency are trau- are in the areas of
anxiety, mood, and
relief if loved ones are unharmed. It may matized. In the short term most children behavior.
also include dissociative symptoms: feel- show some changes in emotions, thoughts,
ings of emotional numbing, being in a behavior and social relations. The majority
daze, a sense of what has occurred is not of children will regain normal functioning
real or that one doesn’t feel like oneself, with access to basic services, security and
or lack of memory for some aspects of family and community-based support. Only
the experience (amnesia). a smaller number of children showing per-
The second stage occurs days or sistent and more severe signs of distress
weeks after the disaster. In many chil- are likely to be suffering from more severe
dren it may be characterized by regres- mental disorders, including post-traumatic
sive behavior (in younger children) and stress, and require focused clinical atten-
signs of emotional stress such as anguish, tion. In general, it is recommended not
fear, sadness, and depressive symptoms; to use trauma terminology outside of a
Most of the
hostility and aggressiveness against oth- clinical context in order to avoid a focus on emotional responses
ers; apathy, withdrawal, sleep distur- traumatic stress disorders at the expense of children in the
wake of disaster
bance, somatization, pessimistic thoughts of other mental health and psychosocial are not pathological
about the future, and repetitive play problems. See Table 1. by themselves
and do not
enactment of the trauma. Repetitive play Although grief is not a mental disorder, require psychiatric
may take the form of reenacting the it may require or benefit from profession- interventions but
trauma or of distancing the child from basic supportive
al attention, especially if it is prolonged interventions by
thinking about it. longer than 6 months, unusually severe trusted others in
As long as these symptoms do not with an inability to return to normal their environment
impair normal childhood activities, they function or complicated by an emotional
are considered part of the normal recov- disorder such as depression or PTSD.
ery process and they can be expected to The proposed ICD-11 contains a separate
lessen or disappear after some weeks. diagnosis for prolonged grief disorder,
Emotional responses that are persistent characterized by persistent and severe
and impair a return to normal functioning yearning for the deceased, and associated
should be considered pathologic. with difficulty accepting the death, feelings
of loss of a part of oneself, anger about
Psychological trauma the loss, guilt or blame regarding the
Historically, humanitarian organizations death, or difficulty in engaging with new
working on mental health of children in social or other activities due to the loss.
disasters and other humanitarian emergen- To meet diagnostic criteria, the symp-
12 SECTION II / EMOTIONAL RESPONSE
toms need to persist beyond 6 months ety, mood, and behavior (Box 2). These
after the death and lead to function- disorders are reviewed below.
al disturbance. Traumatic deaths are of
particular concern for precipitating Severe Stress Reaction and
severe grief reactions in disasters. Adaptive Disorders (F43),
Five factors that increase the risk of Acute Stress Reaction, and
“traumatic grief” are: Post-traumatic Stress Disorder
l Sudden, unanticipated deaths.
(F43.1)
Post-traumatic stress disorder (PTSD) is a
l Deaths involving violence, mutilation,
clinical entity that commonly occurs after
and destruction. exposure to a traumatic event. A traumatic
l Deaths that are perceived as random or
event threatens the physical or psychologi-
preventable, or both. cal integrity of the affected person, and is
l Multiple deaths.
associated with feelings of confusion, inse-
l Deaths witnessed by the survivor that curity, terror, and bewilderment.
are associated with a significant threat to Data on the prevalence of PTSD in
personal survival or a massive or con- childhood vary widely, reflecting the indi-
frontation with death and mutilation. vidual experience of the children and fam
The most frequent childhood disorders ilies as well as the amount of personal and
following a disaster are in the areas of anxi- communal loss. However, most children,
SECTION II / EMOTIONAL RESPONSE 13
ing minor details that may seem obses- of activities that were usually pleasant
sional. They may also re-enact troubling l Loss of interest in playing
l Loss of friends
(Note: With small children star charts and enjoyable activities with a parent work well as rewards)
SECTION III / SPECIFIC INTERVENTIONS
SPECIFIC INTERVENTIONS
MHPSS Intervention Pyramid
OBJECTIVES The intervention pyramid represents
l Describe the different types of the interagency consensus around men-
interventions for emotional responses tal health and psychosocial support in
seen in children at differing humanitarian emergencies as enshrined in
developmental stages.
l Be aware of recommendations to
the IASC Guidelines for Mental Health
restore routines and child and family and Psychosocial Support in Emergency
functioning. Settings (2007), and has been endorsed
l Be acquainted with the possible by the major organizations involved in
interventions aimed at lessening the humanitarian response including
the emotional impact of disasters
childhood. United Nations Agencies such as the
World Health Organization, UNICEF and
UNHCR, and international organization
such as the International Federation of
CASE 1. Red Cross and Red Crescent Societies,
An important part of the population in
The International Committee of the Red
your city has been affected by a flood,
prompting an evacuation plan that Cross, the International Organization for
involves displacement of most people to Migration, and major non nongovernmen-
shelters. You have been summoned as tal organization such as Save the Children,
part of the multidisciplinary rescue teams. CARE, War Child etc.
It outlines the importance of differ-
l As a pediatrician, what do you
entiating specific layers of interventions
consider to be your role in hel-
ping families during the first and supports adapted to different groups.
days? Preventive interventions as well as initiatives
that restore safety and a sense of normalcy
are complementary to clinical support.
CASE 2. This multi-layered framework highlights
After an earthquake the population of the need for services to be integrated and
your town is progressively returning to holistic. It is not possible for one agency to
normal. Children are gradually returning implement all levels of the pyramid and all
to school. levels might not be required at all stages of
the displacement cycle or emergency. The
l What do you think should be
your role in this phase layers are not mutually exclusive, so a child
regarding school and school that receives support on layer 4 will also
teachers? need the supports of layer 3, 2 and 1. The
conceptual model fosters collaboration
and encourages participatory approaches
SECTION III / SPECIFIC INTERVENTIONS 19
LAYER 4. CLINICAL SERVICES and professional mental health support for children under significant distress that
disrupts their ability to function on a day-to-day basis. Interventions at this level should be undertaken by specialized
mental health professionals and the treatment (e.g. counselling or psychotherapy) is often more long-term and should
not be disrupted. It is done via individual case management it is preferable to keep the child on site as long as
LAYER 3. FOCUSED PSYCHOSOCIAL SUPPORT is specific assistance provided to children at risk of developing
mental disorders. Interventions are not specialized, but should be undertaken by staff with significant training and
supervision. Examples could be support groups, peer-to-peer support programs, and structured sessions aimed at
strengthening resilience.
LAYER 2. STRENGTHENING FAMILIES’ AND COMMUNITIES’ ABILITY TO SUPPORT children’s learning and devel-
opment. It is important to promote everyday activities such as attending play and social activities, going to school and
options of participation in traditional and community events. Interventions could include child friendly spaces, support
for family tracing and reunification, and other family, peer and community support initiatives.
LAYER 1. SOCIAL CONSIDERATIONS IN BASIC SERVICES AND SECURITY implies ensuring or advocating for
basic services to be functional and accessible to children and their caregivers. Important activities are re-establishing
a sense of safety, ensuring basic services such as water, food and shelter, and access to health services for the whole
community, including child-friendly information on where to go for help. This should take into account ‘hard to reach’
categories of children such as adolescent girls, younger children and children with disabilities. This work represents a
general approach carried out by all humanitarian workers.
20 SECTION III / SPECIFIC INTERVENTIONS
l Encourage children to return to his/her l Encourage activities that help them express
silence, even though it may seem awk- process, try to assess if the survivors
ward. Listen more than you speak. have any physical (e.g., severe heart
Silence is often better than anything you disease) or psychological (e.g., major
can say. Stay with the family members as depression) risk factors, and assess
they are reacting to the news, even if their status after notification has been
they are not talking. completed.
l If possible, write down your name and
l Use clear and simple language. Avoid
son how to feel) or “Both my parents driven to the notification, they may
died when I was your age” (don’t not feel able to drive back safely), and
compete with the survivor for sym- inquire if they have someone they can
pathy). Provide whatever reassuring be with when they return home.
information you may be able to, such as l Help survivors identify potential
“It appears your husband died immedi- sources of support within the com-
ately after the explosion. It is unlikely munity (e.g., member of the clergy,
he was even aware of what hap- their pediatrician, family members, or
pened and did not suffer before he close friends).
died.” However, do not use such infor l In mass disasters it may be challenging
Death is seen as a permanent Child expects the deceased to Failure to comprehend this
phenomenon from which return, as if from a trip. concept prevents child from
there is no recovery or taking the first step in the
return. mourning process, that of
appreciating the permanence
of the loss and the need to
adjust ties to the deceased.
Finality (Nonfunctionality)
Death is seen as a state in Child worries about a buried Can lead to preoccupation
which all life functions cease relative being in pain or trying with physical suffering of the
completely. to dig himself or herself out deceased and may impair
of the grave; child wishes to readjustment; serves as the
bury food with the deceased. basis for many horror stories
and films directed at children
and youth (e.g., zombies,
vampires, and other “living
dead”).
Inevitability (Universality)
Death is seen as a natural Child views significant If child does not view death as
phenomenon that no living individuals (i.e., self, parents) inevitable, he or she is likely
being can escape indefinitely. as immortal. to view death as a punishment
(either for actions or thoughts
of the child or the deceased),
leading to excessive guilt and
shame.
Causality
It is also helpful for children to find their ing for a tree, praying, lighting a candle, or
own unique way of saying goodbye to any other suitable expression. The perma-
someone they have lost; this can be nence of the situation can be supported
achieved through painting, planting and car over time.
26 SECTION III / SPECIFIC INTERVENTIONS
and developmental stimulation (e.g., singing, bed-wetting, and baby-talk) are common
cuddling, playing) is desirable. Resume daily responses to stress. They provide some
routines to the extent possible. sort of comfort to the child, are not inten-
tional, and usually are transitory. The best
manner for parents to respond is to
Preschool-age Children accept this as a measure of how distressed
The best way to reduce the emotional the child is by the situation and to gently
impact of disaster is to try to keep the encourage her/him to return to their
family together and the parents function- developmental achievements. Parents
ing well. In this way, children can get the should avoid criticism, mockery, or annoy-
support and care they need. ance, and should reward developmentally
The most important thing for the emo- appropriate behavior through praise.
l Give them all the information they
tional health of children who experience
need, without unnecessarily alarming
disaster situations is to feel loved, cared for,
them. Answer questions in a truthful
and protected by their parents or caregivers. but plain and simple way. Do not share
The intervention for preschool-age chil- descriptions of specifics of loss and
dren depends on their symptoms: trauma with them at this age as it may
l If they become passive and listless, pro- lead to further traumatization. If they
vide them with a routine safe place, do not understand what is going on and
where they can feel emotionally con- cannot discern their own feelings, help
nected and have suitable materials for them understand what they feel
drawing, playing, or other activities. through playing or drawing, especially if
Encourage them to draw people they it is shared with parents or caregivers.
would like to be with, put names to Caregivers should also share some of
those people, create a story about the their similar feelings and explain how
drawing, and make a poster where new they feel safer now. This helps the child
elements can be added. to understand that their feelings are
l If they feel scared, provide supportive
common responses and that they are
not alone in having them.
opportunities for them to express their
l Children may attribute magical quali-
fears and emotions.
l If the child is having sleep disturbance
ties to certain objects or situations
(magical thinking) through their ego-
(nightmares and or fear of being alone
centric cognitive capacity. They may
at night), try routine calming activities
believe that seeing an object related to
before bedtime, such as reading a com-
the emergency may cause the event to
forting book or telling a hopeful story.
be repeated. Avoid exposing the chil-
dren to the news media, especially TV.
SECTION III / SPECIFIC INTERVENTIONS 27
Images can be retraumatizing, and the adults) may worry that something they
children may not understand that the did or failed to do, or even just thought or
images shown are from a past discrete wished about, may have caused or con-
event rather than new disasters. tributed to the disaster or the death of
l Children separated from close rela-
loved ones, even if there is no logical rea-
tives, even for a short period of time,
son for such feelings. Children are natu-
may feel distressed, anxious, and irrita
ble. It is important for parents to rally reluctant to disclose such feelings of
understand that this is also likely to be guilt, which may significantly impair their
transient, and that they should try to adjustment to the disaster.
spend more time together as a family, When traumatic reminders trigger spe-
providing the children a safe space to cific fears, it is important to help them
express themselves. identify and verbalize the setting and/or
emotion that elicited those feelings.
School-age Children Although they may be able to understand
The emotional impact of disaster on chil- what occurred, repeated graphic images
dren of school age is also strongly related of the disaster can trigger and exacerbate
to the adaptation of their caregivers. They feelings of fear and anxiety. One way to
comprehend the notion of good and bad, minimize the impact of media exposure is
and as they develop, they can verbally to watch TV together and mutually share
express their feelings and emotions. their emotions about the images and the
However, disasters typically surpass the event. Some children will repeatedly re-
ability of many people to cope and it is enact a traumatic situation with obsessive
common for children to feel confused and detail, cognitive distortions, and occasion
worried about their own reactions. ally with an absence of specific informa
An appropriate response for school- tion. Frequently the intensity of the emo-
age children is to provide them a safe tions is so extreme that children may
space where they can share their experi- become overwhelmed. It is important to
ence and fears. A dialogue with caregivers allow them to cry and express anger and
can be very helpful, especially if the care- sadness. If this occurs in the presence of
giver is adapting well. supportive parents or caregivers, it can be
School-age children frequently worry quite therapeutic. If they are unable to
about their behavior during the disaster. verbally express themselves, art and play
They may feel responsible for not having material can assist them.
done enough and may blame themselves. Encourage continued socialization of
It is important to create conditions where children, but without making it burden-
they can express their feelings and emo- some. Plan structured activities for the
tions, and to reassure them that what differing developmental stages and inter-
happened was nobody’s fault (particularly ests. These activities are beneficial for chil
in natural disasters), and especially not dren and for the community. For example,
their fault. Children of all ages (and even children can help with cleaning the school
28 SECTION III / SPECIFIC INTERVENTIONS
if it was affected or gathering food for situation for feelings of revenge to arise. It
those who had been displaced to shelters. is important for adults to acknowledge
Provide additional supports, both at home these emotions discourage this kind of
and at school, to assist children in learning retaliatory behavior. Discuss the real con-
and meeting other academic demands. sequences of following these emotions to
discourage impulsive revenge.
Adolescents Adolescents may also need a space to
Provide adolescents with a space to dis- talk about the events, with freedom to ask
cuss the event and their initial and ongo- all the questions they have. Adolescents
ing response to it. It can also be helpful should be invited to talk about their feel-
for a reliable adult to share valid informa- ings, but should not be forced by parents
tion with them. to engage in discussions when they are
Adolescents are frequently self-con- not yet ready. They can also participate
scious about their emotions, especially in family decisions and help in reconstruc-
fears generated by the traumatic event. tion tasks; being provided opportunities
Fears can sometimes create a sense of where they can help others may assist
vulnerability and shame. It may be benefi- adolescents in coping with their own
cial for them to share these feelings with- distress.
in a group of peers.
Adolescents may “act-out” what they School-based Interventions
cannot verbally express. Substance abuse, Pediatricians should work with schools
criminal behaviors, and sexual promiscuity (and sites that provide daycare) in d
isaster
are some possible behaviors. These pose a planning as well as during the post d
isaster
challenge for the parents and should be response, because schools are often the
addressed by the family, school, and the best (and sometimes only) setting to deliv-
community. er mental health services to children after
In addition, abrupt shifts in interperson- a disaster. Getting children back to school
al relationships can occur during times of as soon as possible encourages a more
crisis. Changes in familial, peer, and other normal routine and provides access to
(teacher) relationships may occur. Provide emotional support from both teachers and
a safe place for parents and adolescents peers. Abnormal grief reactions and mental
to talk about these changes and how they health disorders such as PTSD are likely to
affect them. Reflecting on abrupt losses or emerge in the school setting. For example,
changes in relationships and how to adapt intrusive thoughts and difficulty concen-
to these changes may result in a plan on trating may interfere with academic per-
how to redesign the family structure. formance and social adaptation. Therefore,
Typically adolescents place a high value school programs that deal with the conse
on the sense of justice. This may lead quences of trauma and the recovery
certain individuals to a strong desire for process may be helpful. These programs
revenge. Man-made disasters are the ideal should integrate efforts to identify and
SECTION III / SPECIFIC INTERVENTIONS 29
refer children in need of more intensive when necessary. Inherent in this early
individual evaluation and treatment. intervention is the recognition that inter-
pretation or directive interventions are
Early Intervention and Crisis not to be provided. After assuring that
Response for Children and Families basic necessities are available and are not
http://www.nctsn.org/ a pressing concern, the basic principles of
Unfortunately, there is no clear e mpirical intervention should be followed. These
evidence for the effectiveness of any crisis principles should ensure that no harm is
response intervention. In fact, the fre- being done in the intervention process
quently used and previously heralded and hopefully prevent or reduce symp-
Critical Incident Stress Debriefing or tomatology and impairment.
Management (CISD or CISM) strategies An international expert panel proposes
have not demonstrated effectiveness, and five broad intervention principles for mass
in some studies they have proved detri- trauma: promote a sense of safety, pro-
mental. It is strongly advised to stop all mote calming, promote a sense of self- and
forms of compulsory debriefing of disas- collective efficacy, promote connected-
ness, and promote hope (Hobfoll, 2007).
ter. While it is possible that an alternative
l Interventions should be grounded in
method of early crisis intervention may
the basic principles of child develop-
be helpful for assisting recently trauma-
ment, and providers should be experi-
tized people, there is at this stage no enced in working with children of dif-
clear evidence based intervention, apart ferent ages and levels of development.
from Psychological First Aid. There is l Mental health providers should have
PREVENTION AND
DETECTION OF MENTAL
HEALTH PROBLEMS
cian. The pediatrician is also an impor-
OBJECTIVES tant link in the child-family-school-com-
munity chain. Part of the pediatrician’s
l Understand how pediatricians can
role is to encourage communica tion
provide a perspective on children and
adolescents in relation to their families,
between families, schools, and leaders
schools, and communities. in the community, and to develop a joint
l Be acquainted with the activities that plan that aims to reduce or avoid long-
may be effective before, during, and after term emotional consequences, and return
a disaster, in the direct care of children children to a sense of routine and secu-
and their families. rity. The first aspect pediatricians should
address is a plan for their own security
and the security of their family. Lack of
planning and intense worry about one’s
own and family’s security will undermine
the ability to assist others.
How can Pediatricians Detect
Conditions, Intervene and Help Pre-disaster Intervention
Reduce the Emotional Impact Ensure that the emotional needs of chil- Pediatricians have a
of Disaster on Children and dren are adequately considered and fundamental role in
Adolescents? addressed as part of the anticipatory plan- the assessment of
Pediatricians can have a significant role in the emotional
ning of disasters. impact of disasters
the assessment of the emotional impact Understanding the physical and emo- on children and
of disasters on children and adolescents. adolescents.
tional needs of children throughout their
Pediatricians can advise families, teachers, different developmental stages is impor-
and the community on ways to minimize tant and pediatricians can assist in all
the emotional consequences of the disas- phases of planning to create a plan that
ter, help families cope and assist humani- addresses the psychosocial aspects of
tarian workers to do their work in ways children and families.
that it conducive to child mental health With this knowledge, one can advise
and wellbeing. parents, teachers, police officers, fire-
The pediatrician is a very significant fighters, and others on some of the basic
elements needed to prevent or reduce
fig
ure for parents who have entrusted
the expected emotional impact on chil-
the care of their child to this physi-
dren, and to identify children at high risk
32 SECTION IV / PREVENTION AND DETECTION
for an intense and immediate emotional National Center for PTSD have made a
disturbance and chronic mental health comprehensive set of training materials
problems. for Psychological First Aid.
If teachers and school Pediatricians can give advice on the
personnel are trained
to identify the most emotional needs of children at each During the Disaster
frequent emotional developmental stage, and can assist in Pediatricians should help community lea-
manifestations of
students and how to
community collaboration. One way to ders identify the existing resources to
deal with them, the prepare the community is by giving talks, deal with the disaster and make sure that
school can provide an distributing leaflets or other informa- those resources are distributed equitably.
adequate place for
children and tional material, and educating the local It is important to participate in disaster-
adolescents to feel media. related call centers and educate the mass
safe and confident. A pediatrician can also assist in the media in order to educate broader seg-
planning for the placement of available ments of the population. It is also crucial
resources and structure of the rescue to become integrated into an organized
teams in pediatric hospitals, shelters, and relief and recovery program. It should be
emergency rooms. kept in mind that children spend many
Pediatricians should also work t ogether hours at school, and disasters often occur
with school personnel in the preparation while they are there. Hence, if teachers
of programs aimed at helping teachers and school personnel are trained to iden-
deal with distressed children. It is impor- tify the most frequent emotional manifes
tant to train teachers and personnel tations of students and know how to deal
in charge about the specific emotional with them, the school can provide an ade
needs and typical reactions to a disaster. quate place for children and adolescents
The pediatrician should talk with par- to feel safe and confident enough to
ents about the reactions they might express their concerns and carry on acti-
expect from their children according to vities appropriate for their age. This will
their developmental stage (see Section likely reduce the emotional impact and its
III). Implementation of this kind of antici- consequences.
patory planning is especially crucial in
those communities considered to be at After the Disaster
high risk for being exposed to earth- It is important for pediatricians to be
quakes, hurricanes, floods, and other nat available for consultation to families,
ural disasters. A good and feasible way schools, and the community in recogni-
of to help communities and professionals zing the different long-term emotional
prepare for helping others is to organize reactions that appear among the child-
workshops in Psychological First Aid. hood/adolescent population.
There are various training materials and
Once the event is over and the threat
manuals. The World Health Organization
has abated, they should give emotional
has made generic materials, and Save the
support and guidance to families, especially
Children have made specific materials
for child focused Psychological First Aid. the parents. Consider referring parents
In the United States the The National for support when needed, since the par-
Child Traumatic Stress Network and the ents are the main vehicle by which chil-
SECTION IV / PREVENTION AND DETECTION 33
dren recover. They should listen and The pediatrician should also be aware of
advise parents on how to respond to the criteria for a child or adolescent referral
their child’s emotional distress. Clarifying to a mental health professional, a specialist,
Once the event is
normal reactions and those reactions that or community-based treatment. Many pedia- over and the threat
are more concerning can be very h elpful tricians believe it is their responsibility to has abated,
to parents. If intact, the pediatrician’s screen for emotional distress and make pediatricians should
give emotional
office should remain a safe place for chil- referrals after trauma and disaster. Formal support and guidance
dren and families to feel comfortable, and screening of all individual can be very to families, especially
helpful and is more suitable than informal the parents.
free to ask for guidance and support. It is
ideal to have an adequate place where screening or routine surveillance
meetings with the whole family can be (http:/massgeneral.org/schoolpsychiatry/
held. Encourage dialogue between parents checklists_table.asp).
and their children that can be modeled by The identification of mental health dis
the pediatrician. turbance can be complicated by an indi-
The pediatrician should continue to vidual’s reluctance to discuss symptoms,
provide emotional support and facilitate and ongoing fears for safety, and by
communication among family members. shame and guilt associated with the
He/she should help rebuild a normal trauma. It may be difficult for medical
routine so children can regain a sense of providers to inquire about symptoms
security. He/she should be alert to those since they may be affected by the disas-
children with special needs, e.g. those ter and are uncomfortable with the sub-
who have been direct witnesses of the ject. Those who believe it is not their
disaster, children with previous diseases, responsibility or lack suitable training or
or orphans. It is imperative to follow up confidence can still provide suitable
on children in order to establish the need anticipatory guidance and counseling, and
for specialist referral. can identify those vulnerable individuals
The role of the pediatrician also most at risk for persistent or severe
includes being an advisor to school per emotional impact. In this regard, special
sonnel, helping to screen children for attention should be paid to children who
impairing symptoms, and being available have been direct witnesses of terrorist
for further assessment with treatment or attacks or slaughter or who have suf
referral of children who have more severe fered significant losses.
or chronic symptoms.
In addition to providing information When should Professional
that the observed emotional disturbance Help be Sought?
is transitory, the pediatrician should also In most cases, expressions of emotional
counsel families, educators, and the media, impact are transient and children go
that a certain percentage of children will progressively back to normal activities.
develop long-term symptoma tology and However there are cases that require
impairment benefiting from treatment. referral to a mental health professional.
34 SECTION IV / PREVENTION AND DETECTION
needed measures to and emotions with respect to the situa- which should be taken into special con-
lessen the potential sideration, since traumatic situations
impact of the tion he/she is undergoing.
experienced disaster can reactivate previous conflicts with
To prevent the symptoms from beco-
l
situations on the over-whelming effects.
developing ming chronic and interfering with
personality of
Some communities lack a formal mental
everyday performance.
the child. health system or are overwhelmed by the
To implement the needed measures to
l
needs of the populace. In these instances,
lessen the potential impact on the deve- innovative community-based treatments
loping personality of the child. can be effective.
The pediatrician can also help mental
Refer if the child presents:
health professionals by describing local
l Suicidal thoughts or suicidal ideation.
idioms for emotional symptoms, and cul-
l Symptoms that persist for more than
tural patterns of distress as well as local
1 to 3 months and interfere with every
day life. stigma associated with mental disorder
l Aggressive behavior, threatening his/her
treatment. The pediatrician should inform
own or other people’s life. parents that many individuals have chronic
l Behavioral school problems that inter- emotional disturbance after disaster, but
fere with acceptable functioning. that treatment is helpful. The p ediatrician
l Persistent (longer than 1 month) can also be helpful to mental health
with drawal behavior that interferes professionals by identifying suitable volun
with social life. teers in the community. Mature individuals
l Frequent nightmares that persist over who are motivated, adapting well, and
time. trusted within the community can be
l Frequent outbursts of anger, annoyan-
trained by mental health professionals
ce, explosive behavior. to help implement community-based
l Persistent (longer than 1 month) soma-
programs.
tic complaints.
SUMMARY / SUGGESTED READING 35
SUMMARY
Disasters place affected populations in great danger. Only in recent years have we
recognized the importance of emotional impact and its short, median, and long-
term consequences.
Children and adolescents are an especially vulnerable group, since the reaction to
disaster in these age groups depends on their psychosocial developmental stage,
individual characteristics, degree of emotional and affective dependency on adults,
and previous experiences.
In the aftermath of a disaster, an emotional response is expected in the pediatric
population that can be considered a “normal reaction to an abnormal situation.”
However, if the response becomes very intense or persistent, or the child has an
increased vulnerability, more immediate specific support is necessary.
The role of the pediatrician as part of the child-family-school-community chain is
crucial, for he/she knows the physical and emotional needs of children in each deve
lopmental stage and represents an important source of information, support and
help for the community, school, families, and children.
Acknowledging and addressing emotional disturbances in the childhood
population at an early stage is, to a great extent, the most effective way to prevent
persistent and long-term disorders.
SUGGESTED READING
Action for the Rights of Children (ARC) (2009): Foundation Cavallera V, Jones, L., Weisbecker, I., Ventevogel, P. Mental health
module 7, Psychosocial Support, available at: http://goo.gl/ in complex emergencies. In: Kravitz A, ed. Oxford Handbook of
OgHpkA Humanitarian Medicine. Oxford: Oxford University Press; 2017, in press.
American Academy of Pediatrics. Committee on Psychosocial Crane PA, Clements PT. Psychological response to disasters: focus in
Aspects of Child and Family Health. How Pediatricians can adolescents. J Psychosoc Nurs Ment Health Serv 2005; 43(8):31-38.
Respond to The Psychosocial Implications of Disasters. Pediatrics Ferguson SL. Preparing for disasters: Enhancing the rol of
1999;103:521-523. pediatric nurses in wartime. J Pediatr Nurs 2002;17(4):307-38.
American Psychiatry Association. Diagnostic and Statistical Groome D, Soureti A. Posttraumatic Stress Disorder and anxiety
Manual of Mental Disorders, 4a ed. Washington DC: American symptoms in children exposed to the 1999 Greek earthquake. Br
Psychiatry Association 1994;424-429. J Psychol 2004;95(pt 3):387-397.
American Academy of Pediatrics. Pediatric Education for Prehospital Gurwitch RH, Kees M, Becker SM, Schreiber M, Pfefferbaum B,
Professionals. 2nd ed. Children in Disasters. 2006;173-189. Diamond D. When disasters strikes: responding to the needs of
ACEP and American Academy of Pediatrics. APLS: The Pediatric children. Prehospital Disaster Med 2004;19(1):21-28.
Emergency Medicine Resource. 4th ed. 2004;542-563. Hagan JF Jr. American Academy of Pediatrics Committee on Psychosocial
Breslau N, Davis GC, Andreski P, Peterson E. Traumatic Events Aspects of Child and Family Health. Task Force on Terrorism. Psychosocial
and Posttraumatic Stress Disorder in an urban population of implications of disaster or terrorism on children: a guide for the
young adults. Arch Gen Psychiatry 1991;48:216-222. pediatrician. Pediatrics 2005;116(3):787-795.
Caffo E, Belaise C. Psychological aspects of traumatic injury in children Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer,
and adolescents. Child Adolesc Psychiatr Clin Am 2003;12(3):493-535. M. J., Friedman, M. J., ... & Maguen, S. (2007). Five essential
Carr A. Interventions for Posttraumatic Stress Disorder in children elements of immediate and mid-term mass trauma intervention:
and adolescents. Pediatr Rehab 2004;7(4):231-24. empirical evidence. Psychiatry, 70(4), 283-315.
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Hohenhaus SM. Practical considerations for providing pediatric Tol, W. A., Song, S., & Jordans, M. J. (2013). Annual
care in mass casuality incident. Nurs Clin North Am 2005;40(3): research review: Resilience and mental health in children and
523-533. adolescents living in areas of armed conflict–a systematic
Hagan JF Jr and the Committee of Psychosocial Aspects of Child and review of findings in low‐and middle‐income countries. Journal
Family Health and The Task Force on Terrorism. Implications of of Child Psychology and Psychiatry, 54(4), 445-460.
disaster or terrorism on children: a guide for the pediatrician. Work Group on Disasters. Psychosocial Issues for Children and
Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines Families in Disasters: A guide for The Primary Care Physician.
on Mental Health and Psychosocial Support in Emergency American Academy of Pediatrics.
Settings, available at: http://goo.gl/vYJtl4 World Health Organization. Practical guide of mental health in
Jones, L. (2008). Responding to the needs of children in crisis. disaster situations, Washington D.C, 2006.
International review of psychiatry, 20(3), 291-303. World Health Organization and United Nations High Commissioner
Jordans, M. J., Pigott, H., & Tol, W. A. (2016). Interventions for Refugees (2015). mhGAP Humanitarian Intervention Guide:
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Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., Reed, G. M.,
van Ommeren, M., & Rousseau, C. (2013). Proposals for mental World Health Organization, War Trauma Foundation, & World
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Bryant, R. A. (2014). Prolonged grief: where to after Diagnostic World Health Organization, War Trauma Foundation, & World
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http://goo.gl/oNfyOP
Markenson D, Reynolds S. American Academy of Pediatrics
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SUGGESTED BIBLIOGRAPHY
CASE RESOLUTION 37
Case resolution
Case 1.
It is important to convey the message that emotional manifestations following situations of
disaster are the expected adaptive reactions to a chaotic unexpected situation.
The emotional impact on children is related to a great extent to parent’s or caregiver’s
reactions, so it is essential to first listen to them and give them support to minimize the
adults’ distress.
It is important for parents to know the potential emotional reactions of their children,
according to their developmental stage. In the same way, it is important to identify the dif-
ference between an expected reaction and one that requires attention.
Case 2.
Children spend a great part of the day at school in contact with their teachers. Therefore,
it is essential for teachers to be familiar with the different emotional needs of their
students according to their specific developmental stage. Also, teachers need to know the
different reactions and symptoms that may develop among their students.
It is important that the pediatrician work together with the school to implement pro-
grams aimed at early detection of emotional disturbances.
The role of the pediatrician as an advisor for school personnel is crucial, and he or she
should be available whenever required for the assessment of certain students.
38 MODULE REVIEW
MODULE REVIEW
SECTION I - EMOTIONAL VULNERABILITY IN CHILDREN AND
ADOLESCENTS IN DISASTER SITUATIONS
1. What are the most frequent emotional disturbances in the childhood population
exposed to disaster?
2. What are the characteristics of post-traumatic stress disorder?
3. What are the major symptoms in depressive disorders?
1. What is the role of the pediatrician in helping reduce the emotional impact in
the childhood population?
2. How should the pediatrician intervene before a disaster takes place?
3. What is the role of the pediatrician during the disaster?
4. What contributions can the pediatrician make after the disaster?
5. What is Psychologcial First Aid and who should provide it?
APPENDIX 39
3 - 5 years • Behavioral changes, passivity, • Regressive behavior: bed-wetting, • School or day care center refusal
irritability, restlessness baby talk, thumb-sucking • Headaches and bodily pain
• Excessive fear of any stimuli, • They cannot bear being alone • Food refusal or excessive eating
especially of those reminiscent • Appetite loss or increase • Repetitive play enactment of the
of the event • Sleep disorders traumatic event
• Spatial disorientation (cannot tell • Loss of powers of speech or
where they are) stammering
• Sleep disturbances: insomnia, waking • Specific fears: of real people or
up in a state of anxiety, etc. situations (animals or darkness) or
of imaginary ones (witches, etc).
From: PAHO, Practical guide of mental health in disaster situations. Washington D.C., 2006
Anxiety • Reassure them • Bear in mind that anxiety interferes with attention
• Do not transmit them adults’ anxiety and concentration and causes restlessness
• Give clear and honest explanations about the past and • Reward positive behaviors: staying seated, following
current situation (avoid making assumptions about an instructions, etc
uncertain future) • Make periodic evaluations of achievements with them
• Explore management strategies with them (breathing (acknowledgment and reinforcement of positive
techniques, physical activity, etc.) behaviors) and ignore negative behaviors
Aggressiveness • Help them face fears gradually; be with them • Do not allow aggressive behaviors.
• Set an example as regards self-control • Declare a truce
• Do not use either corporal or verbal punishment; the
best punishment is indifference or a neutral attitude • Explain what the desirable and expected behavior is
(still lovingly) • Reward achievements
• Make it clear that aggression to others shall not be • Punish through indifference
allowed
• Declare a truce: ignore the aggression while demanding
isolation in a supervised place for a short time
–“until you are able to control yourself”
• Let them know what the desirable and expected
behavior is
• Encourage channeling of excessive energy, anxiety and
anger through non-harmful strategies
• Reward self-control achievements (hugs, picture cards,
stickers, etc.)
From: PAHO, Practical guide of mental health in disaster situations. Washington D.C., 2006