Treating traumatized children

When Hurricane Katrina struck New Orleans, psychologist Joy D. Osofsky, PhD, lost her office and had to provide her services aboard a cruise ship that had been pressed into duty to house first responders. Despite Osofsky’s own losses, what haunts her are the children she encountered aboard the boat.

One family was more upset about the closing of the daughter’s school than the loss of their home and a job. A set of grandparents was alarmed by the sudden hyperactivity of their grandson, a boy who had been separated from his family and landed in three homes in as many weeks. A teenager revealed he had spent weeks convinced his parents were dead.

“It gives me chills every time I think about that story,” says Osofsky, a professor of pediatrics and psychiatry at Louisiana State University Health Sciences Center.

But in addition to these memories, the experience gave Osofsky a new understanding of how to meet the needs of children and adolescents after a disaster. Now she and other psychologists are using lessons learned during Katrina’s aftermath to inform the response to future disasters. They’re collecting data on Katrina’s youngest victims that suggest how children in disasters elsewhere will fare. And they’re exploring how lessons learned after Katrina may contribute to the global understanding of disaster response.

A growing sophistication

Psychologists’ understanding of disasters’ impact on children has become more sophisticated in recent years, says Annette M. La Greca, PhD, a University of Miami psychology and pediatrics professor and co-editor of “Helping Children Cope with Disasters and Terrorism” (APA, 2002). Until relatively recently, she says, psychologists in the United States assumed children’s post-disaster distress was fleeting.

“When we started work after Hurricane Andrew in 1992, it wasn’t clear whether children had any significant reaction,” says La Greca, who chaired APA’s 2008 Presidential Task Force on PTSD and Trauma in Children and Adolescents. Because of storm-related disruptions, it took three months before La Greca and her colleagues could conduct their first assessment. “Even we thought that was probably too late, that children would already be settling back into their routines and be fine.”

That assumption turned out to be false. La Greca’s research after Hurricanes Andrew and Charley and more recent findings by psychologists tracking children post-Katrina have shown that while most children are resilient, many do have significant reactions. And it can take a long time to recover.

In a study of 7,258 Katrina-affected children published in 2009 in the American Journal of Orthopsychiatry (Vol. 79, No. 2), for example, Osofsky found that half the children surveyed in the 2005–06 school year had symptoms of post-traumatic stress and depression severe enough to meet the cut-off for referral to mental health services. The following year, the number was still high, with 41 percent meeting the criteria.

Four years out, says Osofsky, the number is still a little high but dropping.

“According to the disaster literature, after three years, the percentage should be pretty much back at the normal level,” she says. “We’re still a little above normal.”

That’s to be expected, she says, given the magnitude of disaster Katrina brought. And Osofsky attributes the drop in part to the lack of subsequent serious hurricanes. Children in earthquake-wracked Chile, Haiti and China may not be so lucky because aftershocks can stir up feelings of trauma again, warns Osofsky, who is working with Chilean psychologists and other members of the country’s disaster response field.

Certain factors put children at greater risk. In a study published in 2009 in the Journal of the American Academy of Child and Adolescent Psychiatry (Vol. 48, No. 11), researchers found that death of a loved one had the strongest association with serious emotional disturbances in children who had lived in New Orleans before Katrina. For the rest of the sample, exposure to physical adversity, such as the destruction of homes and schools or the loss of possessions or pets, was the biggest predictor of problems. Poverty and parents with mental health problems also increased children’s risk.

Those findings may have implications for children in low-income countries, says co-author John A. Fairbank, PhD, co-director of the U.S. Substance Abuse and Mental Health Services Administration-sponsored National Center for Child Traumatic Stress at Duke University Medical Center.

“If you think about children who have a high level of exposure to a disaster, live in an economically challenged situation and have parents who are struggling with the ability to provide and function, it’s logical these children would be at high risk of developing serious emotional disturbances,” he says. “We should be paying very close attention to how they’re doing and mobilizing resources to provide assistance.”

Lessons learned

When asked what advice they would give to psychologists and other responders in other recent disaster sites, disaster-response researchers offer several suggestions:

• Acknowledge children’s distress. Even today, says La Greca, “parents underestimate children’s levels of distress.” Since parental support can mitigate that distress, she says, lack of awareness can have serious consequences. To help parents understand what their children are going through and help them work through issues together, La Greca has created free guides, including After the Storm: A Guide to Help Children Cope with the Psychological Effects of a Hurricane. The manual has been translated into Spanish. Another widely disseminated, school-based manual is an earthquake-oriented version that has been translated into Japanese and Taiwanese. La Greca is working with the Australian government to create a version about bush fires.

• Keep developmental stages in mind. While all children need support, consistency and routine to get back on track, says Osofsky, different age groups have different reactions and needs. Adolescents’ needs are often neglected, she says, adding that Chile’s disaster response community is worried about substance abuse and other forms of risk-taking among teens. To forestall problems, Osofsky recommends focusing on strengths and putting adolescents to work helping others and rebuilding their communities.

• Use schools as resources. “Post-disaster, schools can be a means of helping children reclaim normalcy, routine and structure,” says Ryan P. Kilmer, PhD, a psychology professor at the University of North Carolina at Charlotte and co-editor of “Helping Families and Communities Recover from Disaster: Lessons Learned from Hurricane Katrina and its Aftermath” (APA, 2010). Kilmer offers the example of an East Baton Rouge Parish elementary school that reopened in Katrina’s immediate aftermath and focused on meeting students’ emotional needs and families’ practical needs. The principal also sought to develop a sense of community with parents and have the school serve as a central source of information and resources. To that end, the school hired a full-time parent liaison, for example, who helped communicate with parents, held events for them and worked to increase their awareness of supports and services in the area. The school also capitalized on partnerships in the community to host informational and resource fairs to help families learn about academic and social services, as well as help available from federal agencies and others. The approach worked, says Kilmer. Although many students entered the school a grade or two behind, he says, they demonstrated significant gains. Many reached grade level academic functioning or better. “We have to make sure we don’t just attend to the three Rs,” he says. “Even in this time of high-stakes tests, the principal recognized the need to focus on kids’ psychological needs first.”

• Be aware of ancillary consequences. Disasters can often set into motion a cascade of problems for children. One area that La Greca is exploring is how disasters affect children’s physical health. “We’re finding that children have much more sedentary behavior if they’ve been affected by a hurricane,” she says. “Neighborhoods may be unsafe because they’re full of debris, and children may have lost possessions like bikes and rollerskates that keep them active.” Stress related to a disaster and recovery can also cause conflict or tensions in parents’ relationships that can eventually lead to separation or divorce and interfere with children’s support systems, adds La Greca.

• Be sensitive to cultural differences. Adapting interventions to specific cultural contexts is crucial, emphasizes Melissa J. Brymer, PhD, PsyD, director of terrorism and disaster programs at the National Center for Child Traumatic Stress at UCLA. Take American Samoa, where Brymer has been helping communities cope after the 2009 tsunami.

“Kids are struggling. Some of them lost a parent, some lost siblings, some lost homes,” says Brymer. Normally, psychologists and other mental health professionals would talk directly with the children, but that approach doesn’t work in American Samoa, where children aren’t supposed to speak in the presence of elders. Because of that cultural prohibition, says Brymer, counselors hoping to help kids must first introduce themselves to the village high chief, explain why their program is important and ask permission to meet with children separately. “That’s the only way the kids have the opportunity to talk,” says Brymer.

Rebecca A. Clay is a writer in Washington, D.C.