P-FLASH with Kids: PRACTICAL FRONT LINE ASSISTANCE & SUPPORT FOR HEALING Betty Pfefferbaum, MD, JD 1 Carol S. North, MD 2 Robin H. Gurwitch, PhD 1 Barry Hong, PhD 2 University of Oklahoma Health Sciences Center 1 Washington University School of Medicine 2

I

NTRODUCING...

Y

OUR

P

RESENTERS

P

URPOSE

To provide a tool kit for practical, front line postdisaster mental health interventions with children following the 9/11 terrorist attacks

G

OALS OF THE

T

RAINING

1) Differentiate normative and pathological responses 2) Review disaster responses, assessment, and treatment 3) Provide disaster mental health education and skill-building

I NTRODUCTIONS

Please introduce yourself to the group What issues do you face?

T

OPICS

Part 1:

Reactions to disaster

Part 2:

Assessment

Part 3:

Intervention

P ART 1

Reactions

R

EACTIONS

 Posttraumatic stress disorder  Other disorders  Reactions  Factors affecting response

D

ISASTERS

  Overwhelming events Affect many individuals and entire communities  Result in:  Property damage  Disruption of daily life  Human suffering, injury, and/or loss of life

T

ERRORISM AS

U

NIQUE

T

RAUMA

 Intentional human design - to undermine sense of safety and trust in government and social institutions   Innocent people targeted Unpredictable

T

IMING:

P

HASES OF

D

ISASTER Disaster phases:

    Pre-disaster Acute impact Early post-disaster Long-term post-disaster

R

EACTIONS TO

D

ISASTER



Normal reactions

 Most children significantly exposed to a disaster will manifest some distress, but most do not develop psychiatric illness 

Pathological reactions

 Some children will develop a diagnosable mental disorder after a disaster

D

IAGNOSIS VS.

D

ISTRESS Psychiatric diagnosis: not just a label -

Need for professional evaluation and treatment

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Has implications for prognosis

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Used to select appropriate interventions

Subdiagnostic distress: -

Deserves recognition and intervention (just because it is not PTSD does not mean it is not significant)

PTSD D

OESN'T

C

APTURE

I

T

A

LL

Comorbidity with PTSD in adolescents

 Population adolescents: 6% PTSD (lifetime)

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80% of those with PTSD had another disorder  Adolescents in cruise ship sinking: 52% PTSD

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Few or no delayed-onset cases

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1/3 of those with PTSD recovered within 1 year and another 1/3 recovered by 5-8 years

C

OMMON

N

ORMAL

R

EACTIONS PTSD FEATURES:

 Group B Intrusive re-experience  Re-enactment in play  Group C Emotional constriction  Group D Heightened arousal  Increased sensitivity to sounds  Increased activity    Irritability Concentration problems Sleep disturbance

C OMMON N ORMAL R EACTIONS Fear and anxiety

 Disaster-specific fears  Fear of recurrence  Concerns about safety  Separation anxiety

C OMMON N ORMAL R EACTIONS

Depressive symptoms are common. They may:  Pre-date the trauma exposure  Occur in the context of:    PTSD and other disorders Intervening stressors Bereavement

I

NFANTS

 Sleeping problems  Feeding problems  Irritability  Failure to meet developmental milestones

P

RESCHOOL

C

HILDREN

      Behavioral regression Separation anxiety, clinging, and dependence Irritability, temper tantrums, and behavior problems Sleep disturbance; nightmares Repetitive play re-enactment Withdrawal: subdued or even mute

S

CHOOL

C

HILDREN

 Excessive questions or discussion about the incident  Irritability  Increased negative behaviors  Somatic complaints  Changes in school performance

A

DOLESCENTS

         Irritability Isolation and withdrawal Guilt and self-blame Anger and hate Anxiety about the world and their future Fascination with death and dying Absenteeism Risk for substance abuse/alcohol use Poor impulse control and high-risk behaviors

B EREAVEMENT AND T RAUMATIC G RIEF

 Bereavement is a normal process that may be a focus of clinical attention; traumatic grief is complicated  Bereavement may complicate recovery from traumatic events, and traumatic circumstances may complicate the grief process  Bereavement and traumatic grief are distinct from, but share common features with, psychiatric disorders, most notably major depression and PTSD

F

ACTORS

A

FFECTING

R

ESPONSE

 Disaster characteristics  Exposure  Child factors  Family factors  Community factors

C HARACTERISTICS OF THE D ISASTER

Man-made disasters may be more traumatizing than natural disasters because:  they are intentional  their purpose is to create fear, mistrust, and societal disruption

T

YPE OF

E

XPOSURE

 Physical presence and witnessing  Proximity  Subjective experience  Interpersonal relationship with those directly exposed

E

LEMENTS OF

E

XPOSURE

    Separation Property damage Secondary adversities Traumatic reminders

M

EDIA

C

OVERAGE

 Exposure to media coverage absent other means of exposure does not meet the PTSD stressor criterion  Research connecting media exposure and PTSD symptoms does not imply causality  Cognitive processing of media coverage depends on the child's developmental level

C

HILD

F

ACTORS

    Age and development Gender Ethnicity Pre-existing conditions and prior trauma

F

AMILY

F

ACTORS

  Association between child and parent reactions Risk:  Disruption of routine  Parent symptoms  Family stressors  Impaired family functioning  Strained parent-child relationship  Interpersonal awareness

C

OMMUNITY

F

ACTORS

 Pre-disaster characteristics of communities  Post-disaster changes  Property damage  Community disruption  Competition for resources  Community response