Children Exposed to Disaster: The Role of the Mental Health Professional

Nathaniel Laor

Leo Wolmer

Introduction

Mass disasters, whether natural, technological or human made, take an enormous toll in human life and impose untold physical, psychological, and economic hardships on survivors. Indeed, disasters affect individuals, families, and entire communities. In recent years, we have been witness to significant growth in the mortality associated with nearly all types of disasters, apparently as a result of increased population density, urbanization and climatic changes (1). From 1980 to 2000, about 75% of the world’s population lived in areas that had been affected at least once by an earthquake, a tropical cyclone, flooding, or drought (2). Less developed countries account for a considerable proportion (about 40%) of the worst natural disasters, and an even higher proportion of disaster-related deaths. For example, in 2004 the tsunami in the Indian Ocean took an estimated 250,000–300,000 lives (2).

This chapter focuses on the psychological impact of disasters on children. Unlike physical damage, which is usually easy to identify, the internal suffering of children can remain hidden even from the most sensitive observers. Therefore, clinicians and researchers have begun attempting to elucidate the type, extent, and risks of children’s maladaptive responses to mass disaster.

Modern empirical methodologies and clinical observations have proven erroneous the statement by Garmezy and Rutter (3) that children show only a mild response to traumatic conditions. Indeed, the adverse psychological effects of such conditions can be severe and long lasting (4,5,6,7,8), and they may persist even in the face of apparently normal social functioning (9). Nevertheless, according to the Task Force Report of the American Psychological Association, “few psychologists have had specific training for working with children after disasters, and discussions of children’s responses to disasters have been rare in texts on psychopathology or issues in normal development (7)”.

The aims of this chapter are: a) to present a theoretical perspective of disaster as a systemic social phenomenon; b) to clarify the role of child mental health professionals in large-scale preparedness and community reactivation under conditions of disaster; c) to review the major findings on children’s responses to disaster from the developmental perspective; and d) to propose models of assessment and intervention for children, families, and communities exposed to mass disaster.

Definitions

The literature distinguishes between “trauma” and “disaster.” Traumas are experiences that threaten individual health and well-being, render one helpless in the face of intolerable internal or external danger, overwhelm coping mechanisms, violate basic assumptions about survival, and stress the uncontrollability and unpredictability in the world (10). Traumas may be caused by an isolated, unanticipated event or they may be long lasting, the result of repeated exposure to several extreme external events (11).

Disasters are relatively sudden events that are more or less time delimited. They are public events that cause extensive damage to property and lives and that have a total and ongoing disruptive impact on the social network and on the basic daily routines of children and families (7,12,13). During a disaster, the community as a whole is compromised in its capacity to negotiate the recovery of its individual members. Matters are often made worse when resources are overwhelmed (1) and the community’s infrastructure is affected, often resulting in unemployment, housing and food shortages, poor health, deficient school and mental health services, job absenteeism, and family dysfunction.

Unlike traumas, disasters are characterized by the immediate, long-lasting and repeated exposure of victims to reminders of the event. Disasters usually involve three interconnected types of experiences: terror due to threats to one’s life or exposure to grotesque sights; grief following loss (e.g., human lives, basic trust, self-esteem); and disruption of normal living (14). On the social level, disasters are accompanied by shock, depression and mourning, confusion and social disarray, rage and blame, the collapse of formal leadership, and social disintegration. Children sense that their family,
neighborhood, and school have been disrupted (12). The recovery processes continues long after the disastrous event itself is over, even if it was limited to a single point in time. Hence, theoretical, research, and intervention studies should be both all encompassing and long term.

Disasters and the Mental Health System

Mass disaster poses a multifaceted challenge to the mental health system (15): a) Environmental challenge: Massive needs, routinely defined as pathological, emerge and must be confronted; b) Systemic challenge: Multidisciplinary orientation and multisystemic collaboration are required to counter the impact; c) Practical challenge: Problems to be faced involve resource allocation, extended deployment, organization, dissemination of information and communications; d) Theoretical challenge: The mental health system lacks a comprehensive and integrative “mass disaster theory” with a general social perspective in addition to the public health perspective; (16) and e) Professional challenge: Most teaching programs are not committed to disaster intervention training. Hence, professionals have insufficient knowledge and little stamina due to continuous stress.

Mental health professionals operate within multiple social systems: psychiatric, medical, welfare, urban, and national. Each of these systems may be characterized by its degree of adaptability and flexibility under stress. Static systems are rigid, indifferent to the environment, and show no adaptive change in structure or function over time. Chaotic systems show an anarchic response to the environment (disintegrated, disorganized, and dysfunctional). Learning systems respond in a flexible-reactive manner, show sensitivity to the environment and openness to some change in structure or function; however, their range of change is restricted to routine operations, based on past experience. Meta-adaptive systems are both flexible and proactive, containing units specializing in forecasting and preparing alternative scenarios for coping with change.

Stages of Disasters

Different models have been proposed to describe the disaster response, most from the event perspective (warning, threat, impact, inventory, rescue, and recovery) (17). The systemic model allows a formulation of disaster that integrates the event, the individual, and the sociocultural reaction, including the mental health response (18). From this perspective, a disaster consists of three stages, though it may loom long before the expected event actually takes place (e.g., the months of anticipation preceding the outbreak of a war). This pre-disaster stage includes warning, alert and alarm signs, and a sense of massive threat to communal and personal security.

The first stage consists of the damaging event itself, the primary disaster, and the attempts to alleviate its effects, i.e., rescuing as many victims as possible and providing basic needs (food, water, and shelter) to the affected population. The second stage consists of massive changes in societal structure and function (establishment of evacuation centers and tent-cities, movement of refugees), which may lead to a breakdown of norms, structures, and functions. This breakdown, reflected in societal regression, may be viewed as the secondary disaster. Life usually stabilizes in due course, generally after 18 to 36 months. At this point, there may be a third stage of disaster wherein the sociocultural losses, the tertiary disaster, threaten the existing collective ideology and identity (the religious identity of generations of Holocaust survivors) (19,20).

When the severity of the damage evolves gradually and over an extended period of time (AIDS epidemic in Africa), primary, secondary, and tertiary types of disaster coexist. This gradual pattern allows for preparation and short-term adaptation to minor increments of destruction. Yet it may also engender habituation (21), within both the affected and the international communities, hence damaging the capacity for long-term forecasting and proper coping.

Children’s Reactions to Disaster: The Disaster Syndrome

A child’s protective matrix consists of various dimensions in his or her reality that can be disrupted and rehabilitated, among them political, cultural, social, physical, familial, maternal, and personal dimensions (22). Since disasters affect all these components, the disaster syndrome, unlike posttraumatic syndrome, involves all aspects of a child’s developing cognitive structures and capacities and poses a more intricate pathological threat. Children must cope with many different kinds of losses: of people, of support systems, of normal routines, and of basic assumptions of safety and normalcy. Children may become withdrawn and alienated from the reality they perceive as having betrayed them: nature, parents, society, and its technology (23,24).

Disasters may affect children’s ability to regulate the intensity of their impulses and unconscious fantasies, thereby jeopardizing their sense of self-efficacy, security, and autonomy, and the normal maturation of their defensive functioning, object relations, reality testing, and attachment. Structural developments, such as superego consolidation and its behavioral consequences, ego ideal structure formation with its relevance to affiliation and ideology development, and ego functions with their significance in areas of cognition and attention, may also be hampered. Traumatization has a potentially damaging effect on the development of a lasting sense of identity and of the historical continuity of the self that integrates thoughts, images, feelings, and sensations (25).

Preschoolers may exhibit behavioral changes and regressive behaviors, mostly within the normal range. These may include irritability, sleep difficulties, separation problems, fears, nervousness, posttraumatic play, demanding or dependent behavior, whining or temper tantrums (26,27,28). Older children may report disturbances in conscience functioning, although their moral functioning may seem advanced (29).

Studies suggest that parents and teachers tend to report fewer posttraumatic symptoms in children than the children themselves report (30,31). Adults may be preoccupied with their own stress and not be attuned to their child’s inner emotional states. Children may also be more reliable reporters of internalizing or dissociative symptoms. Thus, clinicians must be careful to assess children’s functioning directly and not rely exclusively on external reports. They must bear in mind that while the initial response tends to predict later adjustment, initial symptomatic ratings may not correlate with later assessments (32), and posttraumatic responses may have a delayed onset (33). If a disaster is limited and well controlled, most of the pathological reactions in children will abate within the first year (32). If community functioning is substantially disrupted, however, symptoms may persist for years (4,9,33).

Types of Post-Disaster Symptoms

In response to disasters, children may exhibit a combination of some or many of the following behaviors: posttraumatic stress
symptoms, fears, depression and grief, and dissociation (34). Anthony et al. (35) found that anhedonia, inattention and learning problems are the most common symptoms after disasters. But rather than being markers of a pathological reaction, such symptoms reflect the normal disruptive consequences of disasters.

Symptoms of posttraumatic stress disorder (PTSD) are grouped under three domains: intrusion, avoidance/numbing, and arousal. Empirical studies have identified certain symptoms that are specific to children, such as persistent posttraumatic play, omens, and somatic complaints (36). Scheeringa et al. (37) proposed the following diagnostic criteria for this disorder in young children: intrusive reexperiencing of the event, avoidance of reminders, general psychic numbing, and increased arousal.

Intrusive reexperiencing of the event may be observed in thoughts, feelings, or sensations. Children may retell their experiences over and over, report nightmares and exhibit repetitive trauma-related play. They may also describe vivid traumatic images: visual (mutilated bodies), auditory (the sound of the earthquake or screams for help), olfactory (odors of burned or decaying bodies) or kinesthetic (feeling as if they were buried under the rubble).

Avoidance of reminders is manifested in the evasion of places, people, thoughts or activities associated with the disaster. Such avoidance can be both a symptom and a defensive maneuver to reduce internal stress. Nevertheless, persistent avoidance coping is associated with negative mental health outcomes (38). The avoidance may be active (purposeful engagement in thoughts unrelated to the trauma to avoid traumatic reminders) or passive (not engaging in social interactions) (35).

General psychic numbing may be considered a mild dissociation response, and is more difficult to detect in children than in adults (31). Children exposed to disasters may lose interest in activities that were significant in the past, feel estranged from others, exhibit constricted affect, lose recently acquired developmental skills, and express a sense of foreshortened future.

Increased arousal symptoms include irritability, angry outbursts, exaggerated startle response, hypervigilance, difficulty in concentrating, and sleep disturbances such as difficulties in falling asleep or in sleeping alone (39). In a study of Armenian children exposed to the 1988 earthquake, 18 months after the event about 90% of those living adjacent to the epicenter met the diagnosis of PTSD, compared to only 30% of children from the periphery of the earthquake zone (40).

Mass disasters typically induce specific fears and dependent behavior in children (28,41). Old fears may be reactivated, current ones may intensify, and new fears with a more or less clear relationship to the event may emerge. Fears may lead to dependent and clingy behavior, difficulty separating from caretakers, or refusal to attend school, thereby interrupting the separation-individuation process. Vogel and Vernberg (7) claimed that disasters challenge children’s basic assumption that the world is a secure place, leaving them helplessly vulnerable. Empirical support for this hypothesis was provided by the finding that 5 years after a disaster, young children’s symptoms still correlated with the reactions of their mothers (42).

Children exposed to disasters may show symptoms of depression and grief, but these are usually of lesser severity than are PTSD symptoms (7). Since grief and posttraumatic stress symptoms may appear independently of one another, separate diagnostic interviews are required for each domain (43). The mood symptoms, which have been suggested to be at least partially secondary to the posttraumatic reactions (44), are the result of different types of loss (of home, family members, personal belongings, basic assumptions). The traumatic grief reaction, recently defined for adults (45), still awaits validation in children.

After the 1999 earthquakes in Turkey, Laor et al. (46) found that children who had seen severely injured or dead people, experienced hunger or lack of sleep after the event, or had undergone more traumatic experiences in the past reported more depressive/grief symptoms.

Disasters may be perceived as an overwhelming interruption of human experience, thereby distorting an individual’s basic assumptions, both cognitive (“What is real and what is imaginary?”) and existential (“Is it happening to me?”). To reestablish well being, some people define a different “spatial” arrangement of their position relative to the world: “I am not affected because I am elsewhere.” This type of distancing is adaptive. Pathological dissociation goes one step further, with manipulation of adverse stimuli through the reconstruction of perception and the splitting up of consciousness: “What is happening to me is not real” or “I, who is experiencing, am not real (22)”.

Dissociative reactions may be manifested by symptoms that reflect a discontinuation of personal experience. Children may have out-of-body experiences, perceive life as a dream or a movie, and “see” or “hear voices” of people who died. Amnesia is apparently less frequent in children than in adolescents. Dissociative mechanisms may provide temporary relief from the overwhelming trauma. If they persist, however, they may engender a long-term alteration in normally integrative functions of identity, memory, and/or consciousness (47).

Factors Affecting Children’s Responses to Disasters

Several factors have an impact on the scope of children’s symptomatic response to disaster.

Factors Related to the Disaster

Children whose traumatic exposure is more severe tend to react more extremely. This “dose of exposure” effect is apparent, for example, in the child’s proximity to the epicenter of an earthquake (40), the impact zone of a hurricane (48), or the site of missile attacks (27). More severe responses have been noted in children who were exposed to the harshest experiences, such as witnessing severely injured people and mutilated bodies, being faced with a direct threat to their own life, or suffering human loss, especially of family members (49,50), as well as in children who sustained personal injuries (44,51,52). Continuous displacement predicts the degree of psychological response (9,53), with children exposed to several traumatic experiences more likely to exhibit a greater number of posttraumatic symptoms (54,55).

In cases of severe disaster, children need to cope with a massive range of problems: lack of food, water and shelter; property damage; inadequate housing; violence; lack of medical care; traumatic reminders; bereavement; relocation; separation from parents; and economic crisis. Under such circumstances, their posttraumatic reactions may intensify and interfere with symptomatic recovery, at least during the first year, as well as with their long-term development (25,40,49,56).

Factors Related to the Child

Age

The variations in both subject age and symptom domains that have been examined by different studies make generalizations
difficult, even though young children are considered more vulnerable (21,57). Nevertheless, behavioral problems, specific fears, regressive symptoms and separation problems appear to be more characteristic among young children, whereas depression and anxiety are more characteristic of older children and adolescents (58). Three months after Hurricane Hugo, preadolescent children reported more posttraumatic symptoms than those in early and late adolescence who had similar responses (59).

Gender

Results regarding gender differences are conflicting. Some studies reported no gender differences (9,27,48). Others found that girls tend to report more internalizing symptoms (anxiety, depression, fears) and posttraumatic symptoms, while boys exhibit more externalizing behavior (acting out, aggression) (40,52,58,59). Girls tend to be described as more resilient than boys in childhood, but more vulnerable in adolescence (60). The greater readiness among girls to share their concerns may explain some of these gender differences.

Vulnerabilities and Resiliency

Children with prior pathology, particularly anxiety and learning difficulties (38,52,53), and children who have suffered more traumatic events in the past (55,61) are more prone to severe symptoms months after a disaster. By contrast, resilient children are those who have the support of caring adults during and after major stressors, as well as those who are also good learners, good problemsolvers, and engaging to other people. These children have areas of competence and are perceived by themselves or by society to have high efficacy (60,62). Kassam-Adams et al. (63) found an association between early physiological arousal and the development or persistence of PTSD symptoms in children with traffic-related injuries. Asarnow et al. (38) found that children’s reactions to the Northridge earthquake, a mild to moderate stressor, showed that the role of heritable biology was minor compared to the role of the children’s subjective appraisals of stress and past psychopathology.

Coping Skills

A child’s coping skills also mediate between exposure severity and response. More immature coping/defensive strategies for dealing with stress (blaming others, anger) are associated with greater symptomatic persistence over time (39,64).

Factors Related to the Family

Reaction of the Parents

The presence of adults caring for a child during and after a major stressor is considered the most important and consistent protective factor (60,61). Indeed, the reaction of the parents, especially the mother, to the disaster is generally correlated with the severity of the child’s responses (65). Researchers found that the reaction of preschool children to the missile attacks during the Gulf War was highly correlated with the reaction of their mothers (9,27,42). This was true for 3–4-year olds, but not for 5-year-olds, probably owing to the older children’s increasing autonomy and the control of psychological buffering systems for development (60). Five years after the war, poor psychological functioning among mothers was associated with heightened symptoms in their children (66).

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