Introduction. On May 22, 2011 the deadliest tornado in the United States since 1947 struck Joplin, Missouri killing 161 people, injuring approximately 1,150 individuals, and causing approximately $2.8 billion in economic losses.
Methods. This study examined the mental health effects of this event through a random digit dialing sample (N = 380) of Joplin adults at approximately 6 months post-disaster (Survey 1) and a purposive convenience sample (N = 438) of Joplin adults at approximately 2.5 years post-disaster (Survey 2). For both surveys we assessed tornado experience, posttraumatic stress, depression, mental health service utilization, and sociodemographics. For Survey 2 we also assessed social support and parent report of child strengths and difficulties.
Results. Probable PTSD relevance was 12.63% at Survey 1 and 26.74% at Survey 2, while current depression prevalence was 20.82% at Survey 1 and 13.33% at Survey 2. Less education and more tornado experience was generally related to greater likelihood of experiencing probable PTSD and current depression for both surveys. Men and younger participants were more likely to report current depression at Survey 1. Low levels of social support (assessed only at Survey 2) were related to more probable PTSD and current depression. For both surveys, we observed low rates of mental health service utilization, and these rates were also low for participants reporting probable PTSD and current depression. At Survey 2 we assessed parent report of child (ages 4 to 17) strengths and difficulties and found that child difficulties were more frequent for younger children (ages 4 to 10) than older children (ages 11 to 17), and that parents reporting probable PTSD reported a greater frequency of children with borderline or abnormal difficulties.
Discussion. Overall our results indicate that long-term (multi-year) community disaster mental health monitoring, assessment, referral, outreach, and services are needed following a major disaster like the 2011 Joplin tornado.
This review of the literature on disaster media coverage describes the events, samples, and media formats studied and examines the association between media consumption and psychological outcomes. A total of 36 studies representing both natural and man-made events met criteria for review in this analysis. Most studies examined disaster television viewing in the context of terrorism and explored a range of outcomes including posttraumatic stress disorder (PTSD) caseness and posttraumatic stress (PTS), depression, anxiety, stress reactions, and substance use. There is good evidence establishing a relationship between disaster television viewing and various psychological outcomes, especially PTSD caseness and PTS, but studies are too few to draw definitive conclusions about the other media formats—newspapers, radio, and internet (including social media)—that have been examined. As media technology continues to advance, future research is needed to investigate these additional formats especially newer formats such as social media.
disaster; disaster media coverage; internet; mass media; media; media coverage; news; newspaper; posttraumatic stress; posttraumatic stress disorder; radio; social media; television; terrorism; traditional media
This review summarizes current knowledge on the timing of child disaster mental health intervention delivery, the settings for intervention delivery, the expertise of providers, and therapeutic approaches. Studies have been conducted on interventions delivered during all phases of disaster management from pre event through many months post event. Many interventions were administered in schools which offer access to large numbers of children. Providers included mental health professionals and school personnel. Studies described individual and group interventions, some with parent involvement. The next generation of interventions and studies should be based on an empirical analysis of a number of key areas.
children; disaster; intervention; parent; posttraumatic stress; posttraumatic stress disorder; recovery; terrorism; therapy; treatment
Children; disasters; physiological reactivity; posttraumatic stress disorder; secondary trauma; trauma; terrorism
This review of child disaster mental health intervention studies describes the techniques used in the interventions and the outcomes addressed, and it provides a preliminary evaluation of the field. The interventions reviewed here used a variety of strategies such as cognitive behavioral approaches, exposure and narrative techniques, relaxation, coping skill development, social support, psychoeducation, eye movement desensitization and reprocessing, and debriefing. A diagnosis of posttraumatic stress disorder (PTSD) and/or posttraumatic stress reactions were the most commonly addressed outcomes although other reactions such as depression, anxiety, behavior problems, fear, and/or traumatic grief also were examined. Recommendations for future research are outlined.
children; disaster; intervention; outcomes; posttraumatic stress; posttraumatic stress disorder; research; terrorism; therapy; treatment
Children face innumerable challenges following exposure to disasters. To address trauma sequelae, researchers and clinicians have developed a variety of mental health interventions. While the overall effectiveness of multiple interventions has been examined, few studies have focused on the individual components of these interventions. As a preliminary step to advancing intervention development and research, this literature review identifies and describes nine common components that comprise child disaster mental health interventions. This review concluded that future research should clearly define the constituent components included in available interventions. This will require that future studies dismantle interventions to examine the effectiveness of specific components and identify common therapeutic elements. Issues related to populations studied (eg, disaster exposure, demographic and cultural influences) and to intervention delivery (eg, timing and optimal sequencing of components) also warrant attention.
children and adolescents; cognitive behavioral therapy; disaster; disaster mental health interventions; intervention components; mental health interventions; terrorism; trauma
Although many post-disaster interventions for children and adolescent survivors of disaster and terrorism have been created, little is known about the effectiveness of such interventions. Therefore, this meta-analysis assessed PTSD outcomes among children and adolescent survivors of natural and man-made disasters receiving psychological interventions. Aggregating results from 24 studies (total N=2630) indicates that children and adolescents receiving psychological intervention fared significantly better than those in control or waitlist groups with respect to PTSD symptoms. Moderator effects were also observed for intervention package, treatment modality (group vs. individual), providers’ level of training, intervention setting, parental involvement, participant age, length of treatment, intervention delivery timing, and methodological rigor. Findings are discussed in detail with suggestions for practice and future research.
Child disaster; Interventions; Meta-analysis; Terrorism; Posttraumatic stress disorder; Acute stress disorder; Natural disaster; Treatment efficacy; Psychosocial treatment
This review addresses universal disaster and terrorism services and preventive interventions delivered to children pre and post event. The paper describes the organization and structure of services used to meet the needs of children in the general population (practice applications), examines screening and intervention approaches (tools for practice), and suggests future directions for the field. A literature search identified 17 empirical studies which were analyzed to examine timing and setting of intervention delivery, providers, conditions addressed and outcomes, and intervention approaches and components.
Children and adolescents; disaster; disaster interventions; disaster mental health services; preparedness; screening; terrorism; universal interventions
The terrorist attacks of 11 September 2001 (9/11) left workplaces in pressing need of a mental health response capability. Unaddressed emotional sequelae may be devastating to the productivity and economic stability of a company’s workforce. In the second year after the attacks, 85 employees of five highly affected agencies participated in 12 focus groups to discuss workplace mental health issues. Managers felt ill prepared to manage the magnitude and the intensity of employees’ emotional responses. Rapid return to work, provision of workplace mental health services, and peer support were viewed as contributory to emotional recovery. Formal mental health services provided were perceived as insufficient. Drawing on their post-9/11 workplace experience, members of these groups identified practical measures that they found helpful in promoting healing outside of professional mental health services. These measures, consistent with many principles of psychological first aid, may be applied by workplace leaders who are not mental health professionals.
disaster; employees; focus group; terrorism; workplace; 9/11; 11 September attacks
To estimate the prevalence of serious emotional disturbance (SED) among children and adolescents exposed to Hurricane Katrina along with the associations of SED with hurricane-related stressors, socio-demographics, and family factors 18–27 months following the hurricane.
A probability sample of pre-hurricane residents of areas affected by Hurricane Katrina was administered a telephone survey. Respondents provided information on up to two of their children (n=797) aged 4–17. The survey assessed hurricane-related stressors and lifetime history of psychopathology in respondents, screened for 12-month SED in respondents’ children using the Strengths and Difficulties Questionnaire (SDQ), and determined whether children’s emotional and behavioral problems were attributable to Hurricane Katrina.
The estimated prevalence of SED was 14.9%, and 9.3% of youth were estimated to have SED that is directly attributable to Hurricane Katrina. Stress exposure was associated strongly with SED, and 20.3% of youth with high stress exposure had hurricane-attributable SED. Death of a loved one had the strongest association with SED among pre-hurricane residents of New Orleans, whereas exposure to physical adversity had the strongest association in the remainder of the sample. Among children with stress exposure, parental psychopathology and poverty were associated with SED.
The prevalence of SED among youth exposed to Hurricane Katrina remains high 18–27 months after the storm, suggesting a substantial need for mental health treatment resources in the hurricane-affected areas. Youth who were exposed to hurricane-related stressors, have a family history of psychopathology, and have lower family incomes are at greatest risk for long-term psychiatric impairment.
Hurricane Katrina; SED; natural disaster; child mental health
Disasters and terrorism present significant and often overwhelming challenges for children and families worldwide. Individual, family, and social factors influence disaster reactions and the diverse ways in which children cope. This article links conceptualizations of stress and coping to empirical knowledge of children’s disaster reactions, identifies limitations in our current understanding, and suggests areas for future study of disaster coping. Coping strategies, developmental trajectories influencing coping, and the interplay between parent and child coping represent critical areas for advancing the field and for informing programs and services that benefit children’s preparedness and foster resilience in the face of mass trauma.
child development; coping; disasters; resilience; stress; terrorism
This second of two articles describes the application of disaster mental health interventions within the context of the child’s social ecology consisting of (he Micro-, Meso-, Exo-, and Macrosystems. Microsystem interventions involving parents, siblings, and close friends include family preparedness planning and practice, psychoeducation, role modeling, emotional support, and redirection. Mesosystem interventions provided by schools and faith-based organizations include safety and support, assessment, referral, and counseling. Exosystem interventions include those provided through community-based mental health programs, healthcare organizations, the workplace, the media, local volunteer disaster organizations, and other local organizations. Efforts to build community resilience to disasters are likely to have influence through the Exosystem. The Macrosystem – including the laws, history, cultural and subcultural characteristics, and economic and social conditions that underlie the other systems – affects the child indirectly through public policies and disaster programs and services that become available in the child’s Exosystem in the aftermath of a disaster. The social ecology paradigm, described more fully in a companion article (Noffsinger, Pfefferbaum, Pfefferbaum, Sherrieb, & Norris,2012), emphasizes relationships among systems and can guide the development and delivery of services embedded in naturally-occurring structures in the child’s environment.
children; disasters; disaster interventions; mental health; social ecology; terrorism; trauma
A comprehensive review of the design principles and methodological approaches that have been used to make inferences from the research on disasters in children is needed.
To identify the methodological approaches used to study children’s reactions to three recent major disasters—the September 11, 2001, attacks; the 2004 Indian Ocean Tsunami; and Hurricane Katrina.
This review was guided by a systematic literature search.
A total of 165 unduplicated empirical reports were generated by the search and examined for this review. This included 83 references on September 11, 29 on the 2004 Tsunami, and 53 on Hurricane Katrina.
A diversity of methods has been brought to bear in understanding children’s reactions to disasters. While cross-sectional studies predominate, pre-event data for some investigations emerged from archival data and data from studies examining non-disaster topics. The nature and extent of the influence of risk and protective variables beyond disaster exposure are not fully understood due, in part, to limitations in the study designs used in the extant research. Advancing an understanding of the roles of exposure and various individual, family, and social factors depends upon the extent to which measures and assessment techniques are valid and reliable, as well as on data sources and data collection designs. Comprehensive assessments that extend beyond questionnaires and checklists to include interviews and cognitive and biological measures to elucidate the negative and positive effects of disasters on children also may improve the knowledge base.
Disaster; Research design; Research methods; Research samples; Terrorism; Trauma
Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD.
Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11–related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision.
The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate’s direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness.
Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.
September 11 attacks; posttraumatic stress disorder; trauma exposure; disaster; disaster mental health services
Child development and adaptation are best understood as biological and psychological individual processes occurring within the context of interconnecting groups, systems, and communities which, along with family, constitute the child’s social ecology. This first of two articles describes the challenges and opportunities within a child’s social ecology, consisting of Micro-, Meso-, Exo-, and Macrosystems. The parent-child relationship, the most salient Microsystem influence in children’s lives, plays an influential role in children’s reactions to and recovery from disasters. Children, parents, and other adults participate in Mesosystem activities at schools and faith-based organizations. The Exosystem—including workplaces, spcial agencies, neighborhood, and mass media—directly affects important adults in children’s lives. The Macrosystem affects disaster response and recovery indirectly through intangible cultural, social, economic, and political structures and processes. Children’s responses to adversity occur in the context of these dynamically interconnected and interdependent nested environments, all of which endure the burden of disaster. Increased understanding of the influences of and the relationships between key components contributes to recovery and rebuilding efforts, limiting disruption to the child and his or her social ecology. A companion article (R. L. Pfefferbaum et al., in press) describes interventions across the child’s social ecology.
child development; children; disasters; mental health; social ecology; terrorism; trauma
This case study describes the process and outcomes of the Northwest Center for Public Health Practice Child and Family Disaster Research Training (UWDRT) Program housed at the University of Washington, which used web-based distance learning technology. The purposes of this program were to provide training and to establish a regional cadre of researchers and clinicians; to increase disaster mental health research capacity and collaboration; and to improve the scientific rigor of research investigations of disaster mental health in children and families. Despite a number of obstacles encountered in development and implementation, outcomes of this program included increased team member awareness and knowledge of child and family disaster mental health issues; improved disaster and public health instruction and training independent of the UWDRT program; informed local and state disaster response preparedness and response; and contributions to the child and family disaster mental health research literature.
disaster mental health; research training; team building
Exposure to mass trauma has contributed to increasing concern about the well-being of children, families, and communities. In spite of global awareness of the dramatic impact of mass trauma on youth, little is known about how children and adolescents cope with and adapt to disasters and terrorism. While coping has yet to be fully conceptualized as a unified construct, the process of responding to stress includes recognized cognitive, emotional, and behavioral components. Unfortunately, research on the complex process of adaptation in the aftermath of mass trauma is a relatively recent focus. Further study is needed to build consensus in terminology, theory, methods, and assessment techniques to assist researchers and clinicians in measuring children's coping, both generally and within the context of mass trauma. Advancements are needed in the area of coping assessment to identify internal and external factors affecting children's stress responses. Additionally, enhanced understanding of children's disaster coping can inform the development of prevention and intervention programs to promote resilience in the aftermath of traumatic events. This article examines the theoretical and practical issues in assessing coping in children exposed to mass trauma, and includes recommendations to guide assessment and research of children's coping within this specialized context.
child coping; coping appraisal; coping assessment; coping effectiveness; coping self-efficacy; disasters; mass trauma; social support; terrorism; trauma
The objective of this exploratory pilot study was to examine autonomic reactivity and hypothalamic pituitary adrenal axis dysregulation in spouses of highly exposed survivors of the 1995 Oklahoma City bombing.
This study compared psychiatric diagnoses and biological stress markers (physiological reactivity and cortisol measures) in spouses of bombing survivors and matched community participants. Spouses were recruited through bombing survivors who participated in prior studies. Individuals with medical illnesses and those taking psychotropic medications that would confound biological stress measures were excluded. The final sample included 15 spouses and 15 community participants. The primary outcome measures were psychiatric diagnoses assessed with the Diagnostic Interview Schedule for DSM-IV (DIS-IV). Biological stress markers were physiological reactivity and recovery in heart rate and blood pressure responses to a trauma interview and cortisol (morning, afternoon, and diurnal variation).
Compared to the community participants, spouses evidenced greater reactivity in heart rate, systolic blood pressure, and diastolic blood pressure; delayed recovery in systolic blood pressure; and higher afternoon salivary cortisol.
The results support the need for further research in this area to clarify post-disaster effects on biological stress measures in the spouses of survivors and the potential significance of these effects and to address the needs of this important population which may be overlooked in recovery efforts.
Clinical work and research relative to child mental health during and following disaster are especially challenging due to the complex child maturational processes and family and social contexts of children’s lives. The effects of disasters and terrorist events on children and adolescents necessitate diligent and responsible preparation and implementation of research endeavors. Disasters present numerous practical and methodological barriers that may influence the selection of participants, timing of assessments, and constructs being investigated. This article describes an efficient approach to guide both novice and experienced researchers as they prepare to conduct disaster research involving children. The approach is based on five fundamental research questions: “Why?, Who?, When?, What?, and How?” Addressing each of the “four Ws” will assist researchers in determining “How” to construct and implement a study from start to finish. A simple diagram of the five questions guides the reader through the components involved in studying children’s reactions to disasters. The use of this approach is illustrated with examples from disaster mental health studies in children, thus simultaneously providing a review of the literature.
assessment; child trauma research; conducting research; disaster; disaster mental health; investigation; measurement; posttraumatic stress; research; research assessment; research variables; study design; terrorism; trauma
To prospectively examine the long-term course of psychiatric disorders, symptoms, and functioning among 113 directly exposed survivors of the Oklahoma City bombing systematically assessed at six months and again nearly seven years post-bombing.
The Diagnostic Interview Schedule/Disaster Supplement was used to assess predisaster and postdisaster psychiatric disorders and symptoms and other variables of relevance to disaster exposure and outcomes.
Total prevalence of PTSD was 41%. Seven years post-bombing, 26% of the sample still had active PTSD. Delayed-onset PTSD and new postdisaster alcohol use disorders were not observed. PTSD non-remission was predicted by the occurrence of negative life events after the bombing. Posttraumatic symptoms among survivors without PTSD decayed more rapidly than for those with PTSD, and symptoms remained at seven years even for many who did not develop PTSD. Those with PTSD reported more functioning problems at index than those without PTSD, but functioning improved dramatically over seven years, regardless of remission from PTSD. No survivors had long-term employment disability based on psychiatric problems alone.
These findings have potentially important implications for anticipation of long-term emotional and functional recovery from disaster trauma.
To examine patterns and predictors of trends in DSM-IV serious emotional disturbance (SED) among youths exposed to Hurricane Katrina.
A probability sample of adult pre-hurricane residents of the areas affected by Katrina completed baseline and follow-up telephone surveys 18-27 months post-hurricane and 12-18 months later. Baseline adult respondents residing with children (ages 4-17) provided informant reports about the emotional functioning of these youths (n = 576) with the Strengths and Difficulties Questionnaire (SDQ). The surveys also assessed hurricane-related stressors and ongoing stressors experienced by respondent families.
SED prevalence decreased significantly across survey waves from 15.1% to 11.5%, although even the latter prevalence was considerably higher than the pre-hurricane prevalence of 4.2% estimated in the US National Health Interview Survey. Trends in hurricane-related SED were predicted by both stressors experienced in the hurricane and ongoing stressors, with SED prevalence decreasing significantly only among youths with moderate stress exposure (16.8% vs. 6.5%). SED prevalence did not change significantly between waves among youths with either high stress exposure (30.0% vs. 41.9%) or low stress exposure (3.5% vs. 3.4%). Pre-hurricane functioning did not predict SED persistence among youths with high stress exposure, but did predict SED persistence among youth with low-moderate stress exposure.
The prevalence of SED among youths exposed to Hurricane Katrina remains significantly elevated several years after the storm despite meaningful decrease since baseline. Youths with high stress exposure have the highest risk of long-term hurricane-related SED and consequently represent an important target for mental health intervention.
Hurricane Katrina; SED; natural disaster; child mental health; stress
Disaster mental health is a burgeoning field with numerous opportunities for professional involvement in preparedness, response, and recovery efforts. Research is essential to advance professional understanding of risk and protective factors associated with disaster outcomes; to develop an evidence base for acute, intermediate, and long-term mental health approaches to address child, adult, family, and community disaster-related needs; and to inform policy and guide national and local disaster preparedness, response, and recovery programs. To address the continued need for research in this field, we created the Child & Family Disaster Research Training & Education (DRT) program, which is focused specifically on enhancing national capacity to conduct disaster mental health research related to children, a population particularly vulnerable to disaster trauma. This paper describes the structure and organization of the DRT program, reviews the training curriculum, discusses implementation and evaluation of the program, and reviews obstacles encountered in establishing the program. Finally, key lessons learned are reviewed for the purpose of guiding replication of the DRT model to address other areas of community mental health.
children; disaster; mental health; research; training
The October 2001 anthrax attacks heralded a new era of bioterrorism threat in the U.S. At the time, little systematic data on mental health effects were available to guide authorities' response. For this study, which was conducted 7 months after the anthrax attacks, structured diagnostic interviews were conducted with 137 Capitol Hill staff workers, including 56 who had been directly exposed to areas independently determined to have been contaminated. Postdisaster psychopathology was associated with exposure; of those with positive nasal swab tests, PTSD was diagnosed in 27% and any post-anthrax psychiatric disorder in 55%. Fewer than half of those who were prescribed antibiotics completed the entire course, and only one-fourth had flawless antibiotic adherence. Thirty percent of those not exposed believed they had been exposed; 18% of all study participants had symptoms they suspected were symptoms of anthrax infection, and most of them sought medical care. Extrapolation of raw numbers to large future disasters from proportions with incorrect belief in exposure in this limited study indicates a potential for important public health consequences, to the degree that people alter their healthcare behavior based on incorrect exposure beliefs. Incorrect belief in exposure was associated with being very upset, losing trust in health authorities, having concerns about mortality, taking antibiotics, and being male. Those who incorrectly believe they were exposed may warrant concern and potential interventions as well as those exposed. Treatment adherence and maintenance of trust for public health authorities may be areas of special concern, warranting further study to inform authorities in future disasters involving biological, chemical, and radiological agents.
Youth’s reactions to disasters include stress reactions, posttraumatic stress disorder (PTSD), and comorbid conditions. A number of factors contribute to outcome including characteristics of the event; the nature of the youth’s exposure; and individual, family, and social predictors. Demographic features may be less important than exposure and other individual variables like preexisting conditions and exposure to other trauma. While youth’s disaster reactions reflect their developmental status and thus may differ from those of adults, their reactions generally parallel those of their parents in degree. Family factors that appear to influence youth’s reactions include parental reactions and the quality of interactions within the family. Social factors have not been well examined. We describe these outcomes and predictors to prepare professionals who may work with youth in post-disaster situations.