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.
Studies have demonstrated a positive relationship between exposure and posttraumatic stress, but one's subjective appraisal of danger and threat at the time of exposure may be a better predictor of posttraumatic stress than more objective measures of exposure. We examined the role of peritraumatic response in posttraumatic stress reactions in over 2,000 middle school children 7 weeks after the 1995 Oklahoma City, Oklahoma, bombing. While many children reported hearing and feeling the blast and knowing direct victims, most were in school at the time of the explosion and therefore were not in direct physical proximity to the incident. Physical, interpersonal, and television exposure accounted for 12% of the total variance in our measure of posttraumatic stress when peritraumatic response was ignored. Peritraumatic response and television exposure accounted for 25% of the total variance, and physical and interpersonal exposure were not significant in this context. These findings suggest the importance of peritraumatic response in children's reactions to terrorism. These carly responses can be used to help determine which children may experience difficulty over time.
Children; Disaster; Posttraumatic Stress; Terrorism; Trauma
This study explored the impact of the 1995 Oklahoma City, Oklahoma, bombing on the spouses and significant others of a volunteer sample of Oklahoma City firefighters who participated in the bombing rescue effort. Twenty-seven partners of Oklahoma City firefighters participated in this study, conducted 42 to 44 months after the bombing. These partners were assessed using a structured diagnostic interview and a companion interview to examine exposure, rates of psychiatric disorders and symptoms, functioning, health, and relationships. Coping and perception of the firefighter partner's response were also examined. Some of the women were exposed directly; most knew someone who had been involved in the disaster, and all reported exposure through the media. The rate of psychiatric disorders in the women following the disaster was 22%, essentially unchanged from before the incident. One developed bomb-related posttraumatic stress disorder (PTSD). Most were satisfied with their work performance; 15% reported that their health had worsened since the bombing, and more than one third reported permanent changes in relationships as a result of the bombing. Most coped by turning to friends or relatives, with less than 10% seeking professional help. Many described symptoms in their firefighter mate; all reported that their mate had been affected by the experience, and one half said their mate had fully recovered. The mates of these firefighters fared relatively well in terms of psychiatric disorders, symptoms, and ability to function. The prevalence of bomb-related post-traumatic stress disorder was considerably lower in this sample than in samples of individuals more directly exposed to the bombing, although some reported changes in relationships and health. The results suggest the need for further study of the impact of interpersonal exposure in those who provide support for rescue-and-recovery workers in major terrorist incidents.