"After the Hurricanes, the Inner Storm for Children," New York Times 9/27/05
New "Pediatrics" journal study finds children are "exceptionally vulnerable," and need "to have hope."
Once the water recedes, mud is hauled away and families are reunited with those who survived Hurricanes Katrina and Rita, most of the displaced residents will be focused on finding new places to live and work. But it will be equally important to pay attention to the effects of these vast disruptions on the mental health of children whose lives were torn apart.
In an almost prophetic coincidence, in the September issue of the journal Pediatrics, experts from the American Academy of Pediatrics published a 10-page report to help pediatricians deal with the psychosocial effects of traumatic events - natural disasters and acts of terrorism - on children of all ages.
The report, by the academy's Committee on Psychosocial Aspects of Child and Family Health, and its Task Force on Terrorism, was compiled in response to the terrorist attacks on Sept. 11, 2001. But it could not have come out at a more appropriate time.
Dr. Joseph F. Hagan Jr., a pediatrician in Burlington, Vt., headed both the committee and the task force. In his view, the job ahead is similar to that faced by those trying to address the needs of children after Sept. 11, even though the catastrophes resulted from an act of nature, not a deliberate act of terrorism, and there are many child survivors to care for.
'Profound Sadness'
"The children will have post-traumatic stress disorder, anxiety and depression, and some will have bereavement issues," Dr. Hagan said in an interview. "They've lost their homes, neighbors, pets, friends and some have lost parents and grandparents - all factors that can lead to profound sadness."
At the same time, parents whose lives were affected may themselves experience emotional problems that can make it difficult for them to recognize and cope with the mental health needs of their children.
"If a parent has a sense of hopelessness, that parent's ability to attend to a child's needs is compromised," Dr. Hagan noted. And parents who will have to find a new life for themselves and their families "are not as likely to be available to their children and sensitive to their needs," he said.
The report states: "Any effect of trauma on key or trusted adults can result in magnified psychological effect on the children they care for. An adult's emotional problems can add to a child's fear. Distressed adults may fail to recognize a child's distress."
Under these circumstances, he said, "We wouldn't want parents to have to figure it out. It's the role of communities, family doctors, pediatricians and schools to anticipate the mental health needs of children," he explained. And they must prepare to deal with these needs, he said.
"We lack a cohesive health care system in this country, particularly with regard to mental health," Dr. Hagan said. "We have inadequate mental health services for children, and it's much harder for children to access these services than it is for adults."
Dr. Hagan said the first task was to get shelter for families and the second was to get parents jobs so they could have some sense of autonomy and control over their lives.
"This is important to a child's sense of safety," he said. "If parents are frantic because of their own losses and needs, it's pretty hard for children to be protected."
Equally important is to get children in school as quickly as possible.
"School is what's supposed to happen in September," Dr. Hagan noted, and returning to school restores a sense of normalcy for children.
Even in the best of circumstances, children who have been the victims of devastating natural disasters like the back-to-back hurricanes are likely to experience emotional distress that can affect their behavior and mood for months to come.
"Parents and caregivers can expect children to respond to disaster in distinct stages," the report states. "The first stage, immediately after the disaster, includes reactions of fright, disbelief, denial, grief, and feelings of relief if loved ones have not been harmed."
The second stage comes a few days to several weeks after the disaster. It might include regression to an earlier stage of development, anxiety, fear, sadness and depression, hostility and aggression toward others, apathy, withdrawal, sleep disturbances, psychosomatic symptoms like stomachaches, a pessimistic view of the future and play acting that recreates aspects of the event.
Children with marked distress are in urgent need of counseling, the report notes. Professional help is also needed for children with stress reactions that persist for longer than a month, or who are at risk for developing a persistent post-traumatic reaction or "violent or delinquent behaviors later in life," the report notes.
Even infants and toddlers can be adversely affected by disasters. For infants, the reaction can be an increase in crying and irritability, separation anxiety and an exaggerated startle response. For toddlers and preschoolers, signs of trouble may include sleep terrors and nightmares, helplessness, clinging behavior and temper tantrums.
School-age children may re-enact the trauma in play, behave aggressively, become withdrawn or apathetic, develop psychosomatic symptoms or behavior problems, and experience sleep disturbances and regressive behaviors like separation anxiety.
Traumatized children may become hypervigilant, always on the alert for possible danger, Dr. Hagan said. They may be afraid to go to go to sleep or to school lest they get washed away while their mothers are somewhere else.
Even young children distant from the trauma can be adversely affected, thinking a hurricane will next hit where they live, Dr. Hagan said. "They need to be reassured that Katrina was far, far away."
Exceptionally Vulnerable
Adolescents, who are already going through a difficult period of development, are particularly vulnerable to the effects of a disaster, the report states. They may become withdrawn, apathetic and depressed. They may also engage in risk-taking behaviors like drug abuse and sexual behaviors as a means of coping with trauma-induced distress.
On the other hand, some adolescents may try to mask or withhold symptoms of distress and even try to protect other family members who are upset. As a result, parents may underestimate the effects of the disaster on adolescents and fail to get them the help they need.
The report also points out that boys and girls tend to react differently to a disaster. Girls commonly develop symptoms like anxiety and mood disturbances, while boys are more likely to show behavioral symptoms and take longer to recover than girls.
Most important, the report concludes, is to "allow our children to have hope."
"Even children living in unsafe communities or those affected by prejudice, racism, or violence depend on trusted adults to feel safe or protected so that they might anticipate a less stress-laden future," it says.
Achieving this goal will depend on the actions taken in the coming weeks by federal, state and community governments, schools and health care professionals, not just by parents who themselves have been traumatized.
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