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While research and clinical experience have dramatically increased our knowledge about the emotional and behavioral effects of disasters, the focus has been primarily on individuals. In this paper, we summarize the literature on child and family adaptation to disasters, the influence of family members on one another’s disaster reactions, the effects of disasters on parenting, and the ability of parents to identify disaster reactions in their children. We include policy implications and present recommendations for preparedness and intervention and for empirical study. We conclude with general thoughts about the status of the field and the need for future research.
Families are defined by relationships—parent to parent, parent to child, and sibling to sibling in immediate families and through even more combinations in extended families. Families are characterized by their structure, roles, and boundaries; emotional bonds and responsiveness; cohesiveness; flexibility, adaptability, and coping; communication; and decision making and problem solving (Moos & Moos, 1976). Families support, nurture, and protect children. This is at no time more essential than in the context of disasters.
While there are many definitions of “disaster,” common to most is an emphasis on the destruction they cause and their abrupt onset (World Health Organization [WHO], 1992). McFarlane and Norris (2006, page 4) define a disaster as “a potentially traumatic event that is collectively experienced, has an acute onset, and is time-delimited.” Others emphasize the consequences of these events and the ability of the affected community to cope with the consequences (WHO, 1992). For example, the World Health Organization (1992) defines a disaster as “a severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the affected community” (WHO, 1992, page 2). This means that the usual community support structures available to families may be overwhelmed following a disaster. A key aspect of disaster response involves reestablishing the pre-existing structures and creating new structures to address individual, family, and community needs.
Numerous studies have documented the emotional and behavioral effects of disasters at the individual level, but little empirical research has addressed family adaptation to disasters.
In their review of the disaster literature, Norris and colleagues (2002) identified the psychosocial effects of disasters including specific psychological problems such as posttraumatic stress disorder (PTSD), other anxiety disorders, and depression; non-specific distress such as stress reactions and psychosomatic symptoms; and health concerns and problems including increased smoking and drinking. Individual reactions are influenced by severity of exposure and personal characteristics, socioeconomic status, pre-disaster functioning, family factors, secondary stresses, and psychosocial resources (Norris et al., 2002).
Children may be especially vulnerable to the effects of disasters (Norris et al., 2002). They may be frightened by what they do not understand, and their misperceptions may lead to inaccurate interpretations and attributions. Like adults, children’s reactions are influenced by their exposure, individual characteristics inherent in the child including developmental level and cognitive capacity to understand the event and its consequences, and family and social characteristics. Not only does development shape a child’s reactions to trauma, but trauma has the potential to adversely affect the child’s development with life-long implications.
While not extensively examined, studies suggest that marital stress (Norris & Uhl, 1993) and even domestic violence (Adams & Adams, 1984) may follow disasters. Other studies evidence family solidarity following disasters. For example, studies of the 1995 Oklahoma City bombing revealed a decrease in divorce rates (Nakonezny et al., 2004) and an increase in births (Rodgers et al., 2005) after the disaster. Another study revealed higher marriage and birth rates, but also higher divorce rates, in counties affected by Hurricane Hugo compared to unaffected counties (Cohan & Cole, 2002) and suggested that after disasters, people may take actions in their close relationships that alter their subsequent life course. More research is needed to confirm the results in these studies, to identify the factors that motivate changes in relationships, and to explore alterations in family dynamics post-disaster.
The quality of interactions within a family and the family’s reactions are determinants of the child’s adjustment in the disaster setting (Laor et al., 1996, 1997, 2001; McFarlane, 1987), yet few studies have examined adaptation to disasters on a family level. Parental symptoms and parental dysfunction create risk for distress and trauma symptoms in children (Green et al., 1991; Laor et al., 1997; McFarlane, 1987). Specifically, emotional and behavioral problems (McFarlane, 1987) and posttraumatic stress symptoms (Green et al., 1991) in children appear to be associated with irritable, depressed, and overprotective families. In one study, consistency in reaction and mood between mother and father was also associated with the intensity of the child’s reaction (Handford et al., 1986).
Laor and colleagues (1996, 1997, 2001) conducted a five-year longitudinal study of displaced and non-displaced families during SCUD missile attacks. Among the factors they studied were the mother’s response to the event and the family’s cohesion (emotional bonds among family members) and adaptability (family’s capacity to adjust the power structure, roles, and norms) (1996 (2001). Family cohesion rather than adaptability was the primary determinant of the child’s ability to withstand the stressful events (Laor et al., 1996). Child adjustment problems were associated with both extremes of cohesion—suggesting that disengaged or enmeshed families may put children at risk (Laor et al., 2001). Disengaged families may not help the child process the traumatic experience while enmeshed families may transmit unmodified adverse emotions from one family member to another (Laor et al., 1996, 2001).
The findings regarding family interactions and adaptation suggest that certain families may be at risk for maladjustment post-disaster, but the studies are too few in number and too diverse in methods and measurement to draw definitive conclusions about when and how to intervene. Until the research advances further, providers should assume that family dynamics may change in the face of disasters and that already troubled and newly troubled families are those most likely to be at risk for difficulties functioning in the post-disaster setting.
Family members influence one another in various ways in the aftermath of a disaster. While several family members may be exposed to an event, details of their individual exposure may vary considerably. Family members may experience distress in association with one another’s experiences.
Children’s disaster reactions reflect their developmental status and thus may differ from those of adults, but it is well documented that children’s reactions generally parallel in degree those of their parents (Breton et al., 1993; Earls et al., 1988; Green et al., 1991). Although children’s and their parents’ exposure to a disaster may be similar, children take cues from their parents about danger and safety, and children may respond to parental distress. The relationship between child and parent reactions may be especially important with respect to maternal reactions (Winje & Ulvik, 1998; Green et al., 1991) and the reactions of younger children (Laor et al., 1997; Laor et al., 2001; Wolmer et al., 2000). Stronger relationships between children’s reactions and those of their mothers, compared to those of their fathers, may reflect the traditionally prominent role of mothers in child-rearing and the relatively greater time mothers usually spend with children. Age-related associations, with a decreasing strength in the relationship between parent and child reactions as children age, may reflect the greater autonomy of children as they develop and mature (Wolmer et al., 2000).
Not only do parents influence their children’s reactions, children also influence parents. Koplewicz and colleagues (2002) compared children who were in the World Trade Center at the time of the 1993 bombing and their parents to a control sample of children and parents who were affected only through their relationships with people who were directly exposed and through the media. Parents, especially those of the exposed children, reported posttraumatic stress symptoms and fears, which decreased over time. Parental distress at three months did not predict their own distress at nine months, but parental perceptions of their children’s distress at three months predicted parental distress at nine months, suggesting that longer-term distress in parents of child disaster victims is driven, in part at least, by their children’s early reactions or by their perceptions of their children’s distress (Koplewicz et al., 2002).
Being the parent of a disaster survivor carries risk for a variety of conditions. Mirzamani and Bolton (2002, 2003) studied mothers of adolescent survivors of a shipping disaster six years after the incident. These mothers waited anxiously to learn of their children’s fate and to be reunited with their children. The mothers of survivors were compared with a sample of widows and a sample of women with no history of major negative life events. The three groups did not differ on demographic variables or post-event stressful events. The mothers of survivors had a significantly higher post-event prevalence of major depression, anxiety disorder, and any psychopathology than the mothers with no history of major negative life events but a lower post-event prevalence of these disorders than widows (Mirzamani & Bolton, 2002). Mothers of survivors with PTSD were more likely to develop PTSD themselves than mothers of survivors without PTSD (Mirzamani & Bolton, 2002, 2003).
In major natural disasters, siblings are likely to be exposed to similar experiences though this is not the case with respect to all disasters, especially human-caused and terrorist events. Children who themselves are not exposed to a disaster must nonetheless process the experiences of a traumatized sibling or peer. Terr (1979) described posttraumatic play and frightening dreams in the non-exposed siblings and other family members of kidnapped children. Applebaum and Burns (1991) found posttraumatic stress reactions in the siblings of victims of unexpected traumatic death even though the siblings had not directly witnessed the deaths. Further empirical study is needed to determine the extent and nature of these sibling behaviors, to understand the mechanisms by which these behaviors arise, and to guide intervention efforts focused on siblings in the post-disaster environment.
The status of parenthood itself may confer risk in disaster settings, and the effects of disasters likely complicate the tasks of parenting.
Simply being a parent appears to be associated with the level of disaster stress endorsed by people involved in traumatic events (Gleser et al., 1981; Solomon et al., 1993). Parents, as opposed to adults without children, have the physical, economic, and emotional burden of caring for their children and they may experience distress associated with concern for their children. Therefore, it is not surprising that a survey of Manhattan residents after the 2001 World Trade Center attacks revealed greater distress in parents than in adults without children (Stuber et al., 2002). Thus, it is essential that disaster response efforts address the needs of parents and families. This includes engaging parents in family disaster planning and in preparedness activities that focus on children’s reactions to disasters, prioritizing the reunification of families in the aftermath of an event, educating parents about children’s disaster-related psychosocial needs, and including parents in the care of children needing disaster mental health services post-event.
Disasters impose increased demands on parents who may be less available to their children as their attention shifts to the crisis and issues that arise in the disaster environment. In a longitudinal study of the relationship between children’s psychological problems and patterns of parental care, McFarlane (1987) found a consistent association of parenting characterized by overprotection (increased parental worry about harm coming to their children and increased need to know their children’s whereabouts) and irritable distress (family interaction characterized by irritability, fighting, emotional withdrawal, and loss of pleasure from shared activities) with emotional and behavioral problems in children at 8- and 26-month follow-up.
Noting feelings of frustration and powerlessness that accompany disasters, Curtis and colleagues (2000) studied child abuse rates in disaster-affected communities following several events. They found increased rates following some disasters but, due to a number of limitations, their study failed to establish a definitive connection between child abuse and disasters. For example, social service agencies and child protection staff may lose records and may be unable to adequately investigate cases, reporting laws may vary across time and place, and mobility and evacuation of the disaster-affected population after an event may alter rates.
Future research is needed to validate the results of these studies but even in the absence of more research, family preparedness, response, and recovery efforts should address the potential for post-disaster family conflict and maladaptive and abusive behaviors. Professionals who serve children and families in schools, social service programs, primary care, faith-based institutions, and community-based organizations should be trained in identification of abuse and factors predisposing to it and in intervention at the individual and family level. As part of preparedness, social service agencies must establish policies and procedures to report incidents of abuse, investigate cases, secure records, and coordinate services across jurisdictional lines in accordance with local and state regulations. Where they do not currently permit service coordination across jurisdictional boundaries, local and state regulations should be adopted to provide for such coordination.
Parents have an important role in disaster preparedness through individual and family disaster planning and by addressing the concerns their children experience in anticipation of disasters. Parents are also an important source of support for children in post-disaster environments. Parents may assist their children in a number of ways. They may decrease children’s exposure to secondary adversities, help children process the traumatic experience, restore routine activities, redirect children from troubling thoughts and emotions toward more productive endeavors, and limit children’s exposure to media coverage and facilitate their processing of this material (Pfefferbaum R. et al., 2003; Prinstein et al., 1996). Professionals are needed to help parents identify and complete these tasks.
Compared to their children’s self-reports, parents appear to underestimate children’s disaster reactions (Earls et al., 1988; Handford et al., 1986; Koplewicz et al., 2002). For example, Koplewicz and colleagues (2002) found that parents of children in the World Trade Center during the 1993 bombing reported a decrease in their children’s posttraumatic stress and incident-related fears at nine months, but their children reported no decrease. Applebaum and Burns (1991) found similar results with respect to parental assessment of siblings of victims of unexpected traumatic death. It is unclear the extent to which these discrepancies between child and parent report may relate to the distress parents experience themselves in traumatic situations, to parental preoccupation with other issues, and/or to parental difficulty acknowledging the suffering of their children. Furthermore, children may be unusually compliant at these times and not fully display their distress (McFarlane et al., 1987; Shaw et al., 1995), perhaps to avoid burdening their parents (Mollica et al., 1997).
The differences between child self-report and parent-report of psychosocial issues of children after disasters raise questions about how to assess children’s adjustment. Given that parents are better at identifying externalizing symptoms and children are better at reporting internalizing symptoms, a comprehensive approach would obtain reports from both parents and children. Reports of school personnel would add a third dimension to understanding the reactions and needs of children. Ideally, information about pre-disaster emotional status and functioning would further help to interpret findings in relation to baseline measures.
Concern that parents underestimate their children’s reactions underscores the need for parent and professional education about children’s disaster reactions and for outreach efforts post-event. The issue is complicated by the importance of normalizing disaster reactions among those whose experiences are not of pathological proportions. Thus, risk communication strategies must describe the anticipated effects of disasters on children, identify reactions that suggest the need for professional attention, and inform the public about the availability of services. Locating services in venues that are accessible, such as schools, is crucial.
We know a great deal about the reactions of individuals to disasters and we recognize the importance of families in child post-disaster adjustment, but few empirical studies have sufficiently examined the range of family issues that are necessary to inform clinical and social policy. Nonetheless, it is clear that disaster preparedness, response, and recovery should respect the essential role of families by generating services specifically designed to address their needs and their capacities to recover in the post-disaster environment.
Disaster preparedness and intervention programs should capitalize on the support that parents and families provide while acknowledging and educating families about the potential for differences in reactions of family members. Post-disaster problems in functioning among children and families should be identified and interventions provided to those in need of services. Finally, a policy agenda for family disaster mental health must address the lack of relevant findings from empirical research in the area. Family effects and the challenges of parenting are particularly difficult to study empirically in the aftermath of disasters when chaos and disruption create many pressing problems for families and may hinder research endeavors. Thus, thoughtful consideration to access to children and families in post-disaster settings, appropriate measurement tools, and methods that allow baseline and longitudinal assessment and comparison are essential to the conduct of this research.
This work was supported in part by National Institute of Mental Health (NIMH) grant MH068853 to Carol S. North. Points of view expressed in this article are those of the authors and do not necessarily represent the official position of NIMH.
Betty Pfefferbaum, Paul and Ruth Jonas Chair; Professor and Chairman; Director, Terrorism and Disaster Center; Department of Psychiatry and Behavioral Sciences; College of Medicine; University of Oklahoma Health Sciences Center; Oklahoma City, Oklahoma.
Carol S. North, Nancy and Ray L. Hunt Chair in Crisis Psychiatry; Professor of Psychiatry and Emergency Medicine; Director, Program in Trauma and Disaster at the Dallas Veterans Affairs Medical Center; Department of Psychiatry; University of Texas Southwestern Medical Center; Dallas, TX.