Transcript www.nwcphp.org

CHILD AND FAMILY
DISASTER RESEARCH
TRAINING AND EDUCATION
Northwest Center for
Public Health Practice
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Research on Children’s
Disaster Mental Health
Gaps and Challenges
Randal Beaton, PhD, EMT
University of Washington
Adopted/adapted from
Gilbert Reyes, PhD
Terrorism and Disaster Center
University of Oklahoma Health Sciences Center
Northwest Center for
Public Health Practice
Federal Sponsors
• NIMH National Institute of Mental Health
• NINR National Institute of Nursing
Research
• SAMHSA Substance Abuse and Mental
Health Services Administration
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Public Health Practice
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Principal Investigators
• Betty Pfefferbaum, MD, JD
University of Oklahoma Health Sciences Center
• Alan M. Steinberg, PhD
University of California, Los Angeles
• Robert S. Pynoos, MD, MPH
University of California, Los Angeles
• John Fairbank, PhD
Duke University
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Learning Objectives
Participants will learn to:
• Identify significant gaps in knowledge about
harmful effects of disasters on children’s
psychosocial functioning.
• Identify significant gaps in knowledge about
variables that influence the differential effects of
disasters on children’s psychosocial functioning.
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Learning Objectives
(Continued)
Participants will learn to:
• Identify significant gaps in knowledge about the
effectiveness of psychosocial services and
interventions for children affected by disasters.
• Identify significant challenges to extending and
elaborating knowledge about the effects of
disasters on children’s psychosocial functioning
and the effectiveness of disaster mental health
interventions.
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General Research Questions
• What are the psychosocial effects of disasters?
• What factors influence those effects?
• What can be done to alter those effects?
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What are the psychosocial effects of
disasters?
• Where are the effects found (location)?
• Who is affected (populations)?
• How much are they affected (caseness)?
• When are they affected (time course)?
• Do the effects unfold in phases as conditions
change?
• How do the effects differ as a function of
children’s development?
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What are the psychosocial effects of
disasters?
• Pathogenesis:
• What are the pathogens?
• Exposure to what?
• Under what conditions?
• At what levels?
• Severity
• Frequency
• Chronicity
• Duration
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What are the psychosocial effects of
disasters?
• What pathologies are generated or exacerbated?
• Trauma symptoms? PTSD?
• Depression?
• Anxiety?
• Substance Abuse?
• Social Disadvantages; e.g. stigma
• At what levels?
• Among whom?
• By what mechanisms?
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What are the psychosocial effects of
disasters?
Categories of studies found in the (adult) literature:
 Empirical Epidemiological
• Study entire population
• Define and describe psychopathology
• Prevalence and incidence rates
• Clinical Descriptive
• Selected samples
• Case study methods
• Assess symptom levels
• More descriptive than inferential
Rubonis & Bickman, 1991
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What are the psychosocial effects of
disasters?
Findings from a meta-analysis of the empirical literature
Psychopathology
Prevalence
Depression
26 %
Anxiety
40 %
Stress
7%
Phobia
31 %
Somatic
36 %
Alcohol
35 %
Drug
23 %
Other
36 %
Global
35 %
Rubonis & Bickman, 1991, p.391:
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What are the psychosocial effects of
disasters?
Findings from an empirical review of the empirical literature
(a) specific psychological problems (disorders in the DSM-IV)
(b) nonspecific distress (i.e., subclinical elevation of symptoms
associated with reactions to extreme stress),
(c) health problems and concerns (e.g., somatic complaints,
substance abuse)
Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002
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What are the psychosocial effects of
disasters?
Findings from an empirical review of the empirical literature
(continued)
(d) chronic problems in living (e.g., increased daily hassles
secondary to the disaster)
(e) psychosocial resource loss (e.g., deterioration of personal
hardiness and social support)
(f) problems specific to youth (e.g., separation anxiety,
developmental regression, and externalizing behavior
problems)
Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002
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What are the psychosocial effects of
disasters?
• Findings from Norris, Friedman, Watson, Byrne, Diaz, &
Kaniasty, 2002:
• Levels of Impairment in studied samples:
• 51% (of 160) empirical studies reported moderate
impairment among disaster survivors
• 39% reported severe to very severe impairment
• Suggests that a very substantial proportion of disaster
survivors could benefit from psychosocial interventions
Comparable specification of effects on children is not evident in the literature
Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002
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What are the significant gaps in
knowledge about the harmful effects
of disasters on children’s
psychosocial functioning?
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Gap 1: Descriptive Epidemiology
How are the psychosocial effects of disasters
distributed among the exposed children?
• Populations at risk (i.e., exposed) are inadequately
defined.
• Children are particularly overlooked.
• Minority groups are underrepresented.
• Exposure is inconsistently defined.
• Case definitions are inconsistently defined.
• Reporting (data) sources are inconsistently selected.
• Biased sampling methods (representativeness)
distort incidence and prevalence estimates
(validity/reliability).
• The instruments of measurement are not
standardized.
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Gap 1: Descriptive Epidemiology
How are the psychosocial effects of disasters
distributed among the exposed children?
• Change over time is seldom studied:
• Lack of longitudinal investigations
• Delayed onset latency is poorly studied.
• Periodicity (e.g., phases, anniversaries) is poorly
studied.
• “Natural” attenuation (i.e., tincture of time) goes
unmeasured.
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Challenges To Accurately Assessing
Of The Psychosocial Effects Of
Disasters On Children
• Defining the populations at risk with sufficient
breadth and specificity to ensure that children at all
levels and types of exposure are properly screened.
• Employing unbiased sampling methods that yield
results representative of the populations at risk.
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Challenges To Accurately Assessing
Of The Psychosocial Effects Of
Disasters On Children
• Adopting a standardized:
• set of instruments and protocols to be employed
with consistency across studies.
• set of adequately differentiated (not just trauma)
and specified case definitions to be employed
with consistency across studies.
• protocol of data sources to be employed with
consistency across studies.
• Overcoming the lack of baseline information.
• Difficulty distinguishing disaster effects from
preexisting pathology.
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Challenges To Accurately Assessing
Of The Psychosocial Effects Of
Disasters On Children
• Decreasing the time-lag between precipitating
events and the initial point of measurement (time 1).
• Advanced preparation.
• Funding.
• Permissions and access.
• Persuading and training researchers to adopt
epidemiological standards.
• Replacing static snapshot studies with longitudinal
designs that account for change over time.
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Which Factors Influence Those Effects?
• Factors that increase risk (risk factors).
• Factors that reduce risk (protective factors).
• Factors that amplify or attenuate the translation of
exposure into pathology (moderators)?
• Affects the strength of the relationship.
• Factors that are necessary for the translation of
exposure into pathology (mediators)?
• Explains a mechanism of the relationship.
• These are the keys to resilience.
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Which Factors Influence Those Effects?
•
Vulnerability (Mediators and Moderators):
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•
What are the risk factors?
• Female gender
• Early or advanced age
• Low SES
• Pre-existing conditions
• Degree of exposure
• Unique event characteristics; e.g. terrorism & media
What are the protective factors?
• Opposites of risk factors?
• Training and experience?
• Hardiness?
• Self-efficacy?
• Social support?
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Which Factors Influence Those Effects?
Risk factors for more severe psychosocial impairment
• Conditions of mass violence or massive casualties
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Severity and level of exposure
Severity and pervasiveness of the financial & social effects
Threat of or actual loss of life
Physical injuries
Pre-disaster psychosocial functioning
Post-disaster (secondary) stressors
Low Socioeconomic Status (SES)
Fewer social and economic resources (e.g., social support)
Higher risk among women, youth, disadvantaged “minority”
groups, and residents of less developed countries
Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002
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What are the significant gaps in
knowledge about variables that
influence the psychosocial effects of
disasters on children?
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Gap 2: Differential Impact Factors
Which variables influence the psychosocial effects
of disasters children?
• Risk and protective factors are poorly specified
and inconsistently operationalized.
• Personal attributes
• Social/Cultural attributes
• Environmental conditions and operators
• Stressors & buffers
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Gap 2: Differential Impact Factors
Which variables influence the psychosocial effects
of disasters in children?
• Utility of risk and protective factors for
screening is insufficiently examined
• sensitivity
• specificity
• Mediating and moderating relationships are
insufficiently examined.
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Challenges To Assessing Variables That
Influence The Psychosocial Effects Of
Disasters On Children
• Hastily prepared research designs lead to:
• Over reliance on small samples and convenience
samples.
• No power to examine complexity between
variables (e.g., mediation and moderation)
• Over reliance on categorical variables.
• Inability to examine complexity within variables
(e.g., threshold effects).
• Over reliance on immutable variables; e.g. gender
• Poor utility for interventions.
• Settling for descriptive results with poor
explanatory power.
• Inability to study change over time.
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Challenges To Assessing Variables That
Influence The Psychosocial Effects Of
Disasters On Children
• Risk and protective factors need to be
conceptualized in ways that better inform
prevention, intervention, and public policy.
• Examine relationships among risk and protective
factors to distinguish between direct effects,
mediators, and moderators.
• Increase reliance on theory-driven models that move
from mere description to explanatory mechanisms.
• Examine the evolving influence of risk and protective
factors over time.
• Employ more sophisticated modeling techniques to
clarify complex interactions of predictors and
outcomes.
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What can be done to alter those effects?
• Which interventions will proactively reduce risk
(prevention)?
• Which interventions will reduce manifest
pathology?
• Which factors amplify or attenuate the
translation of exposure into pathology
(moderators)?
• Affect the strength of the relationship.
• Which factors are necessary for the translation
of exposure into pathology (mediators)?
• Explain a mechanism of relationship.
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What can be done to alter those effects?
• Conceptual and Design Issues
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Targets of Intervention?
Scope of Intervention?
Modes of Intervention?
Timing of Intervention?
Levels of Intervention?
Method of Evaluation?
Timing of Evaluation?
Indices of Response to Intervention
(outcomes)?
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What can be done to alter those effects?
•
Needs Assessment
• What is needed?
• When is it needed?
• Where is it needed?
• Needed by whom?
• What works?
• What works with whom?
• Individuals
• Adults
• Children
• Families
• Institutions (e.g., schools)
• Communities
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What can be done to alter those effects?
•
Modes of Service Delivery
• Provided by whom?
• In what amounts?
• When?
• For how long?
• At what locations?
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What can be done to alter those effects?
•
Barriers to Care: What facilitates or discourages
the seeking of treatment?
• Accessibility?
• Financial concerns?
• Logistical Concerns?
• Competing priorities?
• Acceptability?
• Stigma?
• Credibility?
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What can be done to alter those effects?
Direct Psychosocial Interventions
• Debriefing (prophylactic crisis intervention).
• EMDR (Chemtob, Nakashima, & Carlson,
2002).
• Stress Management (coping skills).
• Crisis Intervention (arousal reduction, problem
solving).
• Grief Counseling (loss and bereavement).
• Psychotherapy (clinical disorders).
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What can be done to alter those effects?
Indirect Interventions with Psychosocial Targets
• Psychological First Aid
• Reduction of unnecessary stressors
• Respite care for caregivers
• Advocacy to reduce “bureaucratic” frustration
• Psycho-education to inform effective coping
• Parenting education
• Teacher education
• Leadership training in the fire service
• Community mobilization
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What are the significant gaps in
knowledge about the effectiveness
of psychosocial interventions for
children exposed to disasters?
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Gap 3: Characteristics of Effective
Interventions
Which characteristics influence the effectiveness
of psychosocial interventions for children exposed
to disasters?
• Inadequate scientific evidence to support use of
•
•
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popularized interventions in the early postdisaster environment.
Treatment samples don’t represent the
population.
Therapists in studies differ from counterparts in
field settings.
Tested interventions not employed in field
settings
Commonly used disaster interventions with
children go untested under field conditions.
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Gap 3: Characteristics of Effective
Interventions
Which characteristics influence the effectiveness
of psychosocial interventions for children exposed
to disasters?
• Tested interventions are poorly
disseminated and seldom adopted for field
use, and field interventions are seldom
tested.
• Modes of service delivery differ
substantially between clinical settings and
field settings.
• Barriers to care go unexamined
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Challenges In Assessing the
Effectiveness Of
Psychosocial Interventions for
Disaster Exposed Children
• Competing priorities during the early phases of
disasters.
• Political and social concerns about unintended
consequences and implications.
• Community resistance.
• Limitations on access.
• Ethical concerns.
• IRB approval barriers.
• Funding barriers.
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Conclusion
The existing research literature on disaster mental
health, while rich and useful in many ways, is
inadequate in the following ways:
1.
2.
3.
4.
5.
Inadequate basic epidemiology.
Unrepresentative samples.
Delay between precipitant and measurement (decay)
Neglect of time as a variable.
Unsubstantiated extrapolation and generalization of
weak findings.
6. Inadequately systematic and precise examination of
variables and relationships.
7. Untested effectiveness of interventions.
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Impediments
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•
•
Lack of Prediction and Preparation
Lack of Funding and Human Resources
• Slow funding process
Lack of Access to Affected Populations
• Proximity
• Competing Agendas & Priorities
• Stigma and negative bias towards research
• Ethical Objections
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Proposed Solutions
Prepare for predictable events and aspects.
Alter funding mechanisms to promote rapid
response protocols.
Integrate research designs into governmental
and non-governmental relief efforts.
Form geographically distributed research
networks to facilitate access and cut response
times.
Integrate research with other agendas &
priorities.
Target stigma, ignorance and negative biases
towards research with public education
campaigns.
Promote policy reforms that raise the priority of
children’s disaster mental health research.
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Proposed Solutions
•
•
•
•
•
•
Adopt a public health approach to studying the
psychosocial effects of disasters on children.
Adopt a developmental psychopathology
approach that examines the the risk and
protective factors related to the psychosocial
effects of disasters
Promote the use of longitudinal designs that
assess change over time.
Adhere to scientific standards of evidence.
Develop and test approaches to interventions
that are congruent with local cultural values and
expectations; e.g. community action research
Confront pseudo-ethical objections: “We
already know it works so…”
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Sustainability of Pacific NW
LMRT: Next Steps
• Listserv- notify of future projects
• Access to Regional Mentoring
Consultants
• All the DRT Newsletter
• Invitation to describe and chronicle this
technological training effort in an article
• Specific Research Projects-brainstorm
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