Download here - Australian Psychological Society

Childhood Trauma in the
Aftermath of a Natural Disaster
Wednesday 28th May 2014
12:30pm - 2:00pm AEST
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PRESENTERS:
Dr Susie Burke
Psychologist
Australian Psychological Society
Dr Rowena Conroy
Clinical psychologist
Royal Children’s Hospital
Facilitator: Jan-Louise Godfrey, APS
Childhood trauma in the aftermath
of a natural disaster
Susie Burke
APS
Agenda
• Introduction
Recent disasters in Australia
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Perth Fires 2014
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Blue Mountain Fires Oct 2013
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35 died,
70 towns
200,000 people affected
Victorian floods 2010
83 towns
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1 died,
150 homes, + 650 uninhabitable, 2000 + damaged
QLD Floods
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100 properties destroyed
Cyclone Yasi
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248 homes destroyed
2 died
Dunalley (TAS) Fires Jan 2012
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50 homes destroyed
Black Saturday Fires 2009
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173 died
2000 homes destroyed
Current and future threats
• Climate change is
expected to underpin
a steady increase in
climate related
disasters
• Worldwide, children
have the greatest risk
of harm from climate
change impacts
• Our health system is
under-prepared for
increased weatherrelated disaster
service demand
Children in disasters
• “whilst it is
extremely common
for children to
experience some
symptoms of
traumatic stress
after a natural
disaster, most do not
experience a serious
mental health
syndrome”
•
•
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•
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Children’s responses are different to adult responses
Reactions will be different for each individual
There is no ‘one way’ to respond
Responses range from mild stress reactions to more
serious responses
Resilience is the norm
Most recover well with the support of family and friends
The path of recovery is not smooth
Setbacks are part of normal recovery
Children’s needs often go up over time
A minority (10-20%) of survivors are at risk of
developing significant mental health problems
Children’s
reactions by age
Behavioural signs
0 to 5 years
Clinginess and separation
difficulties
Easily frightened
Changes to eating & sleeping
patterns
Regressions
Crying easily
Searching for the person or
thing that has been lost as a
result of the traumatic event
Need for routine, consistency
and familiarity
Struggling to communicate in
words
0 to 5 years
Common feelings
Confusion and uncertainty
Challenges to ‘basic trust’
Being confused or
frightened by intense
feelings and reactions
Sensitive to trigger
reminders and changes in
mood of primary caregivers
Long-lasting perceptual
memories
5-12 years
Behavioural signs
Difficulty concentrating, vagueness or acting
‘hyper’
Poor relationships at home or school, or poor
performance at school
Preoccupation with other traumatic events or
disasters
Lack of interest in new activities
Persistent sleep disturbances or nightmares
Reenactments
Personality changes
Regressions
5 to 12 years
Common thoughts and
feelings:
Fear of recurrence
Distress at reminders
Concern about personal
responsibility
Mood or personality changes
Increased self focusing or
withdrawal
Lowered self esteem
Wish for revenge
How to help
children?
3 tiered framework
• Level 1 - Simple
practical, emotional
& informational
support
• Level 2 – Simple
psychological
strategies
• Level 3 – Formal
mental health
interventions
3 - Formal mental
health interventions
2 - Simple
psychological
strategies
1 - Simple practical,
emotional &
informational
support
Stepped care for children
Evidence-based
Must include families
Starting with least intrusive, population
level
Ending with clinical consultation if needed
Level 1 type
Continuity of schooling
Activities for recovery
Creativity (play, art)
Books, workbooks
Psycho-education – (e.g., information for
parents re helping children feel safe)
Classroom programs
Resilience building
Level 2 type
Skills for Psychological recovery
Level 3
Psychological therapies
Five Empirically-Supported
Early Intervention Principles
Australian Centre for Post Traumatic Mental Health (ACPMH)
Hope
SelfEfficacy
Safety
Calming
Connectedness
What is psychological first aid
• Human, caring, compassionate
response
• Basic common sense principles of
support
• DO NO HARM
• Evidence informed
• Focus on:
– Practical needs
– Basic comfort
– Connection to necessary supports
PFA for children
•
•
‘PFA is probably the most
immediate and useful method
of assisting children and
young people whether it is
directly or via caregiver’.
(Ursano et al., 2007)
LISTEN
with your ears and eyes
don’t force talking
ask questions like:
• what do you think has
happened?
• what are you most worried
about?
PROTECT – keep the child safe,
be patient, try and keep
routines, monitor media
exposure
CONNECT – reach out to family,
friends, community resources
etc.
(UCLA Centre for Public Health & Disasters)
Supporting children aged 0 to 5
Maintain routines
Reassure them that they are safe
Keep a calm atmosphere in
children’s presence
Avoid unnecessarily separating
children from their important
caregivers
Tolerate children’s clinginess and
lack of independence
Listen to children’s retelling of
events
Respect children’s fears and give
them time to cope
Protect children from reexposure
Accept and help children to
name strong feelings during brief
conversations
Expect uncharacteristic
behaviour but maintain basic
rules
Ruth Wraith
Supporting children aged 5 to 12
Listen to what children say, think and feel
Correct any misperceptions about the disaster, help them to understand
what has happened
Keep to normal routines
Protect children from re-exposure, monitor amount of media exposure
Ask you child what you could do to help them
Watch how they play, monitor how they are coping at school and in
community activities
Expect uncharacteristic behaviour but maintain basic rules
Remain aware of your own reactions to children’s distress
Provide opportunities for children to experience control
Encourage children to explore ways of helping others
Discuss your feelings openly and honestly and explain how you feel
Use creative outlets
Treating moderate distress
• Some children will experience ongoing
reactions that will cause enough distress to
interfere with adaptive coping.
• These children do NOT have severe mental
health problems
• These children do NOT have long-term
difficulties in recovery
• Research suggests that a skills building
approach is more effective than supportive
counseling
Skills for Psychological Recovery
Developed in US post Hurricane Katrina
Adapted for Australian use in 2009
Model for facilitating recovery following
disasters
For anyone effected by disaster
Designed to reduce distress, regain control,
increase self-efficacy, accelerate recovery
In weeks and months, after PFA
Practical, skills-building approach
Does not assume pathology
Components of SPR
• gathering information & prioritising
assistance
• building problem-solving skills
• promoting positive activities
• managing reactions
• promoting helpful thinking
• rebuilding healthy social connections
Problem-Solving
Disasters often result in many practical problems
Problem-solving helps the child to manage the
problem actively and move on; improves feelings of
control and self efficacy
(Considered most useful of all SPR skills)
Steps
what is the problem? (how often, who is
involved, how do you feel, rank, decide ownership)
What do you need, want?
Brainstorm (go for at least 10!)
Choose best options (rate each option)
Managing Emotional Reactions
“when something bad has happened there are lots of ways that you might be
reminded of it afterwards. Eg…
Your reactions to these reminders can get in the way of what you are doing at
home, at school, or when you are with your friends.
It is really good to learn some skills that can help you deal with these
reactions so that they don’t get in your way.
Each time you practice them you will find that you get a little better at it.
Also, you learn that you have more control than you think”.
Toolkit:
Identifying body reactions
Calming skills
Breathing exercise
Self talk
Social support
Naming feelings and concerns to better understand
and to communicate with others
Helpful Thinking
Disasters can change the
way we think about
ourselves and our world
Distressing disasterrelated thoughts can
maintain negative
emotions (fear, anger)
Focus on helpful thoughts
improves mood and paves
way for more effective
coping
Children rely heavily on
caregivers/adults in their
environment when forming
thoughts
Work with caregivers to
identify their unhelpful
thoughts as well
• Games and activities to
discuss thoughts:
• Go fish
• Good coach, bad coach
Social connections
• Children maintain social
connection through play
• Often after a disaster children
may slow down, disengage
from play, mimic the ‘energy
and posture’ of their
caregivers (slowed down,
slumped, depressed)
• Adults need to remember how
helpful play is
• Caregivers can practice giving
permission for children to play
• Caregivers can help to
organise plays for children
Positive activities
“Since the disaster you
may have felt like you
were filled up with a lot
of icky feelings. Now, I
can’t just make those
feelings go away! I
wish it were that easy!
What we can do is work
on filling up some of
your time with activities
that will fill you with
positive, happy
feelings”
(From ACPMH 2009, SPR manual,
2009)
Psychological assessment and intervention
with children and adolescents after natural
disasters
APS Webinar, May 28th 2014
Rowena Conroy
M.Psychol(Clin.), PhD, MAPS (CCLlN)
The Royal Children’s Hospital, Melbourne
The University of Melbourne
Murdoch Children’s Research Institute
Recovery Trajectories
• Initial distress for most
• Most recover without formal mental health
intervention
• A significant minority have ongoing
difficulties; course can be chronic if
untreated
Common psychological
difficulties
Affective: fear; worry; irritability; sadness; anger; guilt
Cognitive: concentration; intrusions; nightmares;
thoughts (about event/symptoms/self/world/future)
Behavioural: avoidance; school refusal; substance use;
self-harm; suicidal behaviours; vigilance; safety-seeking;
regression; tantrums; aggression; non-compliance
Physical: stomach aches; headaches; sleep;
“jumpiness”
Functional Impairments: academic; social; physical
Developmental considerations
Where there is a history of
Type II Trauma (“Complex
Trauma”)
• Dysregulation (affective, behavioural,
cognitive)
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Emotional reactivity
Numbing
Dissociation
Self-harm
• Attachment difficulties
– Other relationship difficulties
– Prominent shame
– (Sexual behaviour)
Mental Health Disorders
• Post-traumatic Stress Disorder (PTSD)
• Other Anxiety Disorders
• Depression
• Oppositional Defiant Disorder (ODD)
• Attention Deficit Hyperactivity Disorder
(ADHD)
• Substance Abuse (Adolescents)
Risk Factors: Event-related
• Proximity/Exposure
• Subjective fear/Perceived life threat
• Pain
• Separation from parents
• Interpersonal
• Repeated
• Subsequent stressors
Risk Factors: Individual
• Prior trauma exposure
• Prior emotional/behavioural difficulties
• Female gender (for “internalising”
presentations)
• Post-event avoidance, rumination
Risk Factors: Family/Other
Systems
• Parent mental health
• Parental trauma history
• Family functioning difficulties
• Low social support
Assessment Considerations
• Always assess for trauma exposure
• Consider multiple outcomes
• Multiple informants
• Developmental considerations
• Hallmark avoidance
Assessment Considerations, cont.
• Assessment of current coping strategies
• Consider standardised measures
• Assess functioning of family system (&
other systems)
• Risk assessment
• Assessment is ongoing
Australian Centre for
Posttraumatic Mental
Health (ACPMH; 2013)
www.acpmh.unimelb.edu.au/resources
American Academy of Child & Adolescent Psychiatry (AACAP; 2010)
www.aacap.org
National Institute for
Clinical Excellence (NICE;
2005) (UK)
www.nice.org.uk
Intervention for PTSD
• Trauma-Focussed Cognitive Behaviour
Therapy
(TF-CBT):
– Strongest empirical support
– Endorsed by national “best-practice” guidelines
• Substantial reductions in severity of PTSD
symptoms after:
– Natural disasters
– Terrorist attacks
– Motor vehicle accidents
– Witnessed violence
– Sexual & nonsexual assaults
– Sexual abuse
Trauma-Focussed CBT:
Components
Psychoeducation
Parenting
Relaxation
Affective expression & modulation
Cognitive coping
Trauma narrative (imaginal
exposure)
• In vivo exposure
• Conjoint parent-child sessions
• Enhancing safety and future
development
•
•
•
•
•
•
Cohen, J. A., Mannarino, A. P. & Deblinger, E. (2006). Treating trauma and traumatic
grief in children & adolescents. New York: Guilford Press.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2012). Trauma-focused CBT for children and
adolescents: Treatment applications. New York: Guilford Press.
Psychoeducation
• Enhancing understanding of
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Reactions
Triggers
Role of coping strategies
Role of family
• Normalises reactions
• Opportunity to correct misconceptions
• Engendering hope
Affect Labelling/Modulation
• Immediate symptom relief
• Replacing less adaptive coping strategies
• Groundwork for other therapy components
• May need plenty of attention if history of
repeated trauma
Cognitive Therapy
• Addressing cognitions that are causing
distress/impairment
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“Our house will burn down again”
“Nowhere is safe anymore”
“I’m never going to be happy again”
“If I hadn’t gone back to get my bag, our
house would have been ok”
Exposure (Graded, Prolonged)
• May be indicated when intrusive trauma-related
symptomatology is prominent
• Exposure to memories (trauma narrative)
(imaginal)
• Exposure related to situations (in vivo)
• Going outside when it’s
hot(/stormy/windy/raining/….)
• Going to barbeques
• Sleeping in own bed
• With care, consent, and appropriate clinician
training
Caregiver Involvement
• Consider barriers and strengths
• Parenting behaviour as the target
• Parents as “coaches”
• Referrals for caregivers
“Process” considerations
• Formulation-driven intervention
• Hallmark avoidance (can be subtle)
• Consider longer sessions (habituation/arousal
reduction)
• Developmentally-appropriate adaptations
“Process”, cont.
• Home-based tasks
• Rewards
• Impact of heightened arousal on therapy
• Control
TF-CBT & Complex PTSD
• Modifications may be needed when Type II
trauma history present
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Attachment and the therapeutic relationship
Initial engagement & stabilisation
Affect regulation/distress tolerance
Pace
Length
Crisis management “derailing” TF-CBT
Resources
• National Child Traumatic Stress Network (USA)
www.nctsnet.org
• Australian Child & Adolescent Trauma, Loss & Grief
Network (ACATLGN)
www.earlytraumagrief.anu.edu.au
• Australian Centre for Posttraumatic Mental Health
www.acpmh.unimelb.edu.au
• National Center for PTSD (USA)
www.ncptsd.va.gov
• Australian Psychological Society
www.psychology.org.au/topics/disasters/bushfires
• International Society for Traumatic Stress Studies
www.istss.org
Resources, cont.
• Tulane Institute of Infant and Early Childhood
Mental Health
www.infantinstitute.org
• Australian Centre for Grief and Bereavement
www.grief.org.au
• Psychosocial Support in Disasters
www.psid.org.au
• Children and War Foundation
www.childrenandwar.org
• Online TF-CBT training
http://tfcbt.musc.edu
QUESTIONS &
ANSWERS
REMINDERS
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details.
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