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Pediatric Disaster © Life Support (PDLS ) A Course in Caring for Children During Disaster Continuing Medical Education University of Massachusetts Medical School © PDLS : Psychosocial Issues: Children in Disasters Disasters have Significant Psychological Impact on Children PDLS - Psychosocial Issues A “Bio-Psycho-Social” approach to victim management is best Recognizes that effective preparedness and response requires integration of three realms Biological Psychological Social PDLS - Psychosocial Issues - Anatomy and Physiology unique to children - Focus on vulnerabilities of children, not on resuscitation - Discuss relationship to: Environmental exposure (heat, cold, entrapment) Decontamination Susceptibility to Chemicals, Toxins Behaviors that increase risk Immature immune systems Biological Lack of verbal skills Lack of self-preservation skills PSYCHOLOGICAL - A child's emotional Response to Disaster - How to anticipate and recognize problems - How long do these disorders last? - Integrating these concepts into disaster preparedness and response plans SOCIAL - Kids are irreversibly integrated into our society • If children are not accounted for, parents will not comply with officials - Adapting to the concept that children may be intentional targets of terrorism - Role of parents in disaster - Role of media in disaster, a double edged sword - Role of schools, where children spend the bulk of their time away from home - Children routinely cause increased stress in emergency providers Interplay of Medical and Mental Health Triage Separate mental health triage and treatment area may be established - Once medically cleared Separate child from adult mental health area Photo Credit: FEMA Interplay of Medical and Mental Health Triage Primary triage: Physical health must take first priority - Walking, crying patients that have good airways are triage category ambulatory Secondary triage: Identify patients with signs of acute distress - Panic/fear Confusion Disorientation Anger Withdrawn or apathetic Photo Credit: FEMA Infants and severely cognitively disabled don’t understand disaster Provide: Feeding Comfort Familiar caretakers Photo Credit: FEMA Toddlers, preschoolers and moderately cognitively disabled Concerned about consequences of disaster Reactions often are behavioral disturbances, mood changes and anxiety Can comprehend absence of parents but not the permanence of death Photo Credit: FEMA Specific Responses of Toddlers to Disasters Reaction reflects that of parents Regressive behaviors Decreased appetite Vomiting, constipation, diarrhea Sleep disorders (insomnia, nightmares) Tics, stuttering, muteness Specific Responses of Preschoolers to Disasters Clinging Reenactment via play Exaggerated startle response Irritability Posttraumatic stress disorder Specific Responses of School Age Children to Disasters (5-12) Most marked reaction Fear, anxiety Increased hostility with siblings Somatic complaints Sleep disorders School problems School Age Children to Disasters (continued) Social withdrawal Reenactment via play Apathy Posttraumatic stress disorder Decreased interest in peers, hobbies, school Adolescents (13–19) Have full understanding of disaster’s causes and consequences Tend to retain sense of omnipotence, boys > girls May suffer depression and anxiety May be aggressive to self or others, risk of suicide May become sullen and withdrawn Photo Credit: FEMA Specific Responses of Adolescents to Disasters Decreased interest in social activities, peers, hobbies, school Anhedonia (inability to experience pleasure) Decline in responsible behaviors Rebellion, behavior problems Somatic complaints Sleep disorders QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Adolescents Response to Disasters (continued) Eating disorders Change in physical activity Confusion Lack of concentration Risk-taking behaviors QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Stress response in children “Fight or flight” Adrenaline/epinephrine mediated Arousal state Increased startle, response, agitation Increased heart rate, respiratory rate, blood pressure Alternate stress response “Freeze and hide” Vagal nerve stimulus Opposite of “fight or flight” Blunted reactions, affect, responses Lowered heart rate, respiratory rate, blood pressure Syncope may result Short term reactions Disbelief Denial Anxiety Grief Altruism Relief Short-term reactions Grief, loss, anger, guilt Coping strategies - Regression – loss of developmental milestones - Clinging and increased dependency - Helpfulness – more useful in older children - Acting out – competing for attention Second Stage: Immediate PostEvent Period Time A few days to several weeks after disaster Reaction Clinging, appetite changes, regressive symptoms, somatic complaints, sleep disturbances, apathy, depression, anger, and hostile delinquent acts Aggressive/Defiant Behavior Toddlers and preschoolers may exhibit hostile behaviors such as hitting and biting. School age children may get involved in peer fights. Adolescence may become delinquent or rebellious. Aggressive/Defiant Behavior (continued) Recommendations For the younger child, limit setting may be of help. With adolescents, involving them in the rebuilding of the community or helping with younger children or elderly may aid recovery. Repetitious Behavior Most commonly seen in toddlers and preschoolers after disaster. These children will reenact crucial details of the disaster. Other repetitive behaviors are recurrent nightmares and frequent flashbacks. The Healthcare worker should allow the child or preschooler to reenact the events as these are therapeutic and can help in recovery. Somatic Symptoms These include headaches, abdominal pain, and chest pain and are commonly observed in children and adolescents. Reassurance by the healthcare worker can be of help after evaluation. Counseling and mental health intervention may be necessary for the victims as well as the Healthcare workers. Delayed Post-event Period (months) Depression - More likely to manifest sleep, somatic and behavioral symptoms than adults Family and personal history of depression increase risk Exacerbated by re-exposure to venue of or media Delayed Post-event Period Post-Traumatic Stress Disorder (PTSD) - An anxiety disorder with psychological and physical symptoms including: Intrusive thoughts, memories and nightmares Exacerbation by anniversaries and reminders of the event Aggression, anger and fear Apathy, numbness QuickTime™ and a decompressor are needed to see this picture. Delayed Post-event Period Children have special susceptibility to certain risk factors - Witnessing terror in parents and loved ones - Repeated exposure to media of the disaster Little data about Photo Credit: FEMA preventing and treating PTSD in children People with Special Healthcare Needs (PSHCN) Cognitive and/or Emotional Disabilities Reaction to disaster similar to typical children with important differences May be and feel particularly vulnerable due to technology dependence and impaired mobility - Cognitively impaired children may respond similarly to chronologically younger children Emotionally disabled children are at increased risk for acute and chronic negative disaster responses Photo Credit: FEMA Caring for Disaster Mental Health Adapted mental health first aid: Strategy for identifying children in need of help Introduce yourself in a developmentally appropriate way Explain that you are trying to help Remain non-threatening but be honest and direct - Preserve credibility Avoid unrealistic promises or false statements Photo Credit: FEMA Caring for Disaster Mental Health Listen for anxiety, fear about location of care-takers and immediate needs - Acknowledge the child’s emotions Give reassurance and information If available, guide child to mental health triage/treatment facility Encourage self-help strategies - Guided imagery Exercise Preservation of routine Caring For Disaster Mental Health Play Home Drawings Nightmares Guided play/imagery to take control of scenario and make a happy ending. Caring For Disaster Mental Health Treatment/Recommendations Parents, teachers, and Healthcare workers should create and maintain a predictable schedule for children. Night lights, stuffed animals, and reassurance are helpful. Compassion is helpful but punishment is not. Consultation with psychiatrist or psychiatric social worker may be a benefit. Responding to children’s needs Parents should know age appropriate responses Monitor and limit media exposure to disaster coverage Early counseling may reduce long term negative effects Responding to children’s needs Rehearsal of plan reduces anxiety and gives a sense of control - Rehearsal of plan with a live drill that has children acting out roles Step #1 exercise – school bus accident Step #2 exercise – school evacuation Normal Recovery Talking with others Coping mechanisms - Learning healthy mechanisms Counseling