P-FLASH with Kids: PRACTICAL FRONT LINE

ASSISTANCE & SUPPORT FOR HEALING

P-FLASH with Kids: PRACTICAL FRONT LINE

ASSISTANCE & SUPPORT FOR HEALING

Betty Pfefferbaum, MD, JD1

Carol S. North, MD2

Robin H. Gurwitch, PhD1

Barry Hong, PhD2

University of Oklahoma Health Sciences Center1

Washington University School of Medicine2

INTRODUCING...

YOUR PRESENTERS

INTRODUCING...

YOUR PRESENTERS

PPURPOSEURPOSE

To provide a tool kit for practical,

front line postdisaster mental

health interventions with children

following the 9/11 terrorist attacks

GGOALS OF THE OALS OF THE TTRAININGRAINING

1) Differentiate normative and pathological responses

2) Review disaster responses, assessment, and treatment

3) Provide disaster mental health education and skill-building

PleasePlease introduceintroduce yourself yourself to the groupto the group

What issues do you face?What issues do you face?

IINTRODUCTIONSNTRODUCTIONS

TOPICS Part 1:Part 1: Reactions to disaster Reactions to disaster

Part 2:Part 2: Assessment Assessment

Part 3:Part 3: Intervention Intervention

ReactionsReactions

PPART ART 11

REACTIONS

Posttraumatic stress disorder

Other disorders

Reactions

Factors affecting response

DDISASTERSISASTERS

Overwhelming events

Affect many individuals and entire communities

Result in:

Property damageDisruption of daily lifeHuman suffering, injury, and/or loss of life

Innocent people targeted

Unpredictable

TTERRORISM AS ERRORISM AS UUNIQUE NIQUE TTRAUMA RAUMA

Intentional human design

- to undermine sense of safety and trust in government and social institutions

TIMING: PHASES OF DISASTER

Disaster phases:

Pre-disaster

Acute impact

Early post-disaster

Long-term post-disaster

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

REACTIONS TO DISASTER

DDIAGNOSIS VS. IAGNOSIS VS. DDISTRESSISTRESS

Subdiagnostic distress: Subdiagnostic distress: -- Deserves recognition and interventionDeserves recognition and intervention

(just because it is not PTSD does (just because it is not PTSD does not mean it is not significant)not mean it is not significant)

Psychiatric diagnosis: not just a labelPsychiatric diagnosis: not just a label -- Need for professional evaluation and treatmentNeed for professional evaluation and treatment -- Has implications for prognosisHas implications for prognosis -- Used to select appropriate interventionsUsed to select appropriate interventions

PTSD DOESN'T CAPTURE IT ALL

Comorbidity with PTSD in adolescents Population adolescents: 6% PTSD (lifetime)

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

- Few or no delayed-onset cases- 1/3 of those with PTSD recovered within 1 year

and another 1/3 recovered by 5-8 years

COMMON NORMAL REACTIONSPTSD FEATURES:

Intrusive re-experience Re-enactment in play

Group B

Group C Emotional constriction

Group D Heightened arousal Increased sensitivity to sounds Increased activity Irritability Concentration problems Sleep disturbance

COMMON NORMAL REACTIONS

Fear and anxietyFear and anxiety Disaster-specific fears

Fear of recurrence

Concerns about safety

Separation anxiety

COMMON NORMAL REACTIONS

Depressive symptoms are common. They may:Pre-date the trauma exposure

Occur in the context of: PTSD and other disorders Intervening stressors Bereavement

INFANTS

Sleeping problems

Feeding problems

Irritability

Failure to meet developmental milestones

PRESCHOOL CHILDREN

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

SCHOOL CHILDREN

Excessive questions or discussion about the incident

Irritability

Increased negative behaviors

Somatic complaints

Changes in school performance

ADOLESCENTS 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

BEREAVEMENT AND TRAUMATIC GRIEF

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

FACTORS AFFECTING RESPONSE

Disaster characteristics

Exposure

Child factors

Family factors

Community factors

CHARACTERISTICS OF THE DISASTER

Man-made disasters may be more traumatizing than natural disasters because:

they are intentional

their purpose is to create fear, mistrust, and societal disruption

TYPE OF EXPOSURE

Physical presence and witnessing

Proximity

Subjective experience

Interpersonal relationship with those directly exposed

ELEMENTS OF EXPOSURE

Separation

Property damage

Secondary adversities

Traumatic reminders

MEDIA COVERAGE

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

CHILD FACTORS

Age and development

Gender

Ethnicity

Pre-existing conditions and prior trauma

FAMILY FACTORS Association between child and parent reactions

Risk:Disruption of routine

Parent symptoms

Family stressors

Impaired family functioning

Strained parent-child relationship

Interpersonal awareness

COMMUNITY FACTORS

Pre-disaster characteristics of communities

Post-disaster changesProperty damageCommunity disruptionCompetition for resourcesCommunity response