Microsoft word - chapter laor wolmer lewis 2006.doc

Children Exposed to Disaster:
The Role of the Mental Health Professional
Nathaniel Laor, MD, PhD1,2 and Leo Wolmer, MA1 1 Tel Aviv Community Mental Health Center and Sackler School of Medicine, Tel Aviv 2 Yale Child Study Center, New Haven, CT In: M Lewis (ed),
Child and Adolescent Psychiatry: A Comprehensive Textbook.
Third edition. Baltimore: Williams & Wilkins
Introduction
Mass disasters, whether natural, technical or human-made, take an enormous toll in human life and exert untold physical, psychological and economic hardships on survivors. They affect individuals, families, and whole communities. Recent years have witnessed a significant growth in mortality associated with nearly all types of disasters, apparently as a result of the increase in population density, urbanization and climatic changes (1 Ursano et al., 1994). Between 1980 and 2000, about 75% of the world's population live in areas that have been affected at least once by either an earthquake, a tropical cyclone, flooding or drought (2 Integrated Regional Information Networks, 2005). Less developed countries account for a considerable proportion (about 40%) of the worst natural disasters, and an even higher proportion of disaster-related deaths. For example, in 2003 the earthquake that destroyed Bam (Iran) killed more than 40,000 people, and in 2004 the tsunami in the Indian Ocean killed an estimated 250,00-300,000 lives (2 Integrated Regional Information Networks, 2005). Modern technology and mass communication have increased the worldwide awareness of the devastating effects of earthquakes, tornadoes, floods, fires, epidemics, nuclear accidents and wars. In December 1987, the United Nations General Assembly designated the 1990s the Decade of Natural Disaster Reduction. As part of this effort, research has been conducted on the short- and long-term physical and psychological effects of disaster on individuals at high risk, such as the very old and the very young. The present chapter focuses on the psychological impact of disasters on children. Unlike physical damage, which is usually easy to identify, internal suffering of children can remain hidden even from sensitive observers. Therefore, clinicians and researchers are attempting to elucidate the type, extent, and risks of maladaptive responses of Garmezy and Rutter's (3) statement that children show only a mild response to traumatic conditions have been shown erroneous by the application of modern empirical methodologies and direct observations. Indeed, the adverse psychological effects can be severe and long-lasting, also in preschoolers (4-8 Goenjian et al., 2005; Pfefferbaum, 1997; Udwin, 1993; Vogel and Vernberg, 1993; Yule et al., 1999), and they may persist even in the face of apparently normal social functioning (9 Laor et al., 1997). Nevertheless, according to the Task Force Report of the American Psychological Association, “Few psychologists have had specific training for working with children after disasters, and discussions of children’s responses to disasters have been rare in texts on psychopathology or issues in normal development” (7 Vogel and Vernberg, 1993). The aims of this chapter are fourfold: (a) to present a theoretical perspective of disaster as a systemic social phenomenon; (b) to clarify the role of child mental health professionals in large scale preparedness and community reactivation under conditions of disaster; (c) to review the major findings on children’s responses to disaster from the developmental aspect; and (d) to propose models of assessment and intervention for children, families and communities exposed Definitions
The literature distinguishes between “trauma” and “disaster”. Traumas are experiences that threaten individual health and well being, render one helpless in the face of intolerable internal or external danger, overwhelm coping mechanisms, violate basic assumptions about survival, and stress the uncontrollability and unpredictability in the world (10 Eisen and Goodman, 1998). Traumas may be caused by an isolated, unanticipated event or long-lasting, due to repeated exposure to several extreme external events (11 Terr, 1991). Disasters are relatively sudden, more or less time-limited, and public events that extensively damage properties and lives, engendering a systemic continuously disruptive impact on the social network and basic daily routines of children and families (7,12-13 Laor and Wolmer, 1999; López -Ibor, 2005; Vogel and Vernberg, 1993). The community as a whole is compromised in its capacity to negotiate the recovery of its individual members (e.g., massive displacement and relocation). Matters are often made worse when resources are overwhelmed (1 Ursano et al., 1994) and the community’s infrastructure is affected. This can result in unemployment, lack of housing and food, poor health and mental health services, school closures, school and job absenteeism, family dysfunction, and displacement of large populations. Disasters differ in scope and schedule. Some result mainly in loss-disruption (loss of possessions and housing), whereas others involve also a threat to life. Some last a few seconds (e.g., earthquake), whereas others continue for years (e.g., war). Unlike traumas, disasters are characterized by the immediate, long-lasting and repeated exposure of victims to reminders of the disastrous event. Usually, three types of experience are combined: terror due to a danger to one’s life or exposure to grotesque sights; grief following loss (e.g., human lives, basic trust, self-esteem); and the disruption of normal living (14 Austin and Godleski, 1999). On the social level, there are shock, depression and mourning, confusion and social disarray, rage and blaming, norm breaking and delinquent behavior, emergence of mythic ideologies, collapse of formal leadership, ascension of informal popular leadership, and social disintegration into primary affiliations. Children feel the disruption in their family, neighborhood and school (12 Laor and Wolmer, 1999). Since the pathological and recovery processes continue long after the disastrous event itself is over, even if it was restricted to a single point in time, theoretical, research and intervention studies should follow both a systemic and a long-term design. Systemic theory of disaster
Disasters and the mental health system
Mass disaster poses a multifaceted challenge to the mental health system (15 Laor, 2001): (a) Environmental. There is an emergence of massive needs, routinely defined as pathological. (b) Systemic. A multidisciplinary orientation and a multisystemic societal collaboration are needed to counter the adverse impact; (c) Practical. There are problems of resource allocation, extended deployment, organization, dissemination of information and communications. (d) Theoretical. Like in other relevant fields (e.g., medicine), the mental health system lacks a comprehensive and integrative “mass disaster theory”, mainly because of the lack of a general social perspective in addition to the public health perspective (16 Pynoos et al., 1998); and (e) Professional. Most mental health teaching programs are not committed to disaster intervention training. Hence, professionals have insufficient knowledge of diagnosis (of risk factors, clinical picture, and assessment) and of therapeutic technology (protocol-driven, short-term, group- and community-based, and disaster-related), and little endurance due to continuous stress (changing needs and priorities, traumatization, and burnout). Mental health professionals operate within multiple social systems: psychiatric, medical, welfare, urban, and national. Each may be characterized by degree of adaptability and flexibility under stress. Static systems are rigid, indifferent to the environment, and show no adaptive
change in structure or function over time. Under extreme stress, static systems may prove brittle and disintegrate. Chaotic systems show an anarchic response to the environment (disintegrated,
disorganized and dysfunctional). Learning systems respond in a flexible-reactive manner, show
sensitivity to the environment and openness to some change in structure or function; however, their range of change is restricted to routine operations, based on past experience. Meta-adaptive
systems are the most advanced, being both flexible and proactive. They are learning systems that contain units specializing in forecasting and preparing alternative scenarios for coping with Stages of disasters
Different models have been proposed to describe the disaster response, most from the event perspective (e.g., warning, threat, impact, inventory, rescue, and recovery; 17 Raphael, 1986). The systemic model allows a formulation of disaster that integrates the event, the individual, and the socio-cultural reaction, including the mental health response (18 Laor et al, 2004). From this perspective, disaster consists of three stages but it may loom long before the expected event actually takes place (e.g., the months of expectation and rising anxiety preceding the outbreak of a war). This pre-disaster stage includes warning, alert and alarm signs and a sense of massive threat to communal and personal security. The first stage consists of the damaging event itself, the primary disaster, and the attempts to alleviate its effects, that is, rescuing as many victims as possible and providing basic needs (food, water, shelter) to the affected population. The second stage consists of massive changes in societal structure and function (e.g., establishment of evacuation centers and tent- cities, movement of refugees) which may lead to loss of norms, structures and functions. This loss, reflected in societal regression, may be viewed as the secondary disaster and may appear early, even as part of the first stage. Usually, the early optimism of survivors, encouraged by waves of incoming resources and VIP visits, diminishes after a few weeks and turns into disillusionment, fears of abandonment and anger. For children, this stage may represent the loss of all social coordinates, causing confusion and disruption of meaning. Brittle social systems may collapse and turn chaotic, aggravating the damage. Life usually stabilizes in due course, generally after 18 to 36 months. At this point, there may be a third stage of disaster wherein the sociocultural losses, the tertiary disaster, threaten the existing collective ideology and identity (e.g., religious identity of generations of Holocaust survivors). Often, even when the first and second stages are well managed, the third stage is neglected, with effects surfacing even years later. [Note the reports on transgenerational transmission of the culture and the trauma of disaster (19-20 Danieli, 1998; Laor, 1998)]. Sometimes, the transition between stages and/or the increase in damage severity evolve gradually and over an extended period of time (e.g., AIDS epidemic in Africa, the armed conflict in the Balkans and the Israeli-Palestinian conflict). Primary, secondary, and tertiary types of disaster coexist. The gradual pattern allows for preparation and short-term adaptation to minor increments of destruction. However, it may also engender habituation (21 Solomon, 1995), both within the affected and the international community, damaging the capacity for long-term Children’s reactions to disaster: The disaster syndrome
The child’s protective matrix consists of various dimensions in the child’s reality that could be disrupted and rehabilitated differentially: the political, the cultural, the social, the physical, the familial, the maternal and the personal (22 Laor, 1996). Since disasters affect all these components, the disaster syndrome, unlike posttraumatic syndrome, involves all aspects of the child’s developing cognitive structures and capacities and poses a more intricate pathological threat. Children must cope with many different kinds of losses: of people, support systems, normal routines, and basic assumptions of safety and regularity. To help them, the mental health professional must recognize and help to restore the various dimensions of the destroyed reality. Children may become withdrawn and alienated from the reality they perceive as having betrayed them: nature, parents, society and its technology. The withdrawal may take the form of psychic shock that may lead to a serious catastrophic reaction or it may partially resolve by the mobilization of coping mechanisms (23-24 Krystal, 1968; Valent, 2000). Specifically, disasters may affect children’s ability to regulate the intensity of impulses and unconscious fantasies, thereby jeopardizing their sense of self-efficacy, security and autonomy, normal maturation of defensive functioning, object relations, reality testing, and attachment with caretakers. Structural developments, such as superego consolidation and its behavioral consequences (e.g., empathy, prosocial behavior), ego ideal structurization, with its relevance to affiliation and ideology formation, and ego functions, with their significance in areas of cognition and attention, may also be hampered during the primary, secondary and tertiary disasters. Traumatization has a potentially damaging effect on the development of a lasting sense of identity that integrates thoughts, images, feelings and sensations. The sense of historical continuity of the self (past, present, and future) may therefore be disrupted (25 Pynoos The clinical picture observed in children immediately after disaster is characteristic of acute stress and/or acute grief reaction, depending on the type of trauma and loss they have suffered. The severity of the response depends on many factors, such as level of exposure, developmental level, culture, parental support, and pre-disaster personality. Hours or days immediately after a disaster, children may be in a state of shock and numbness. Dissociative symptoms such as depersonalization and derealization -- a sense of unreality of the world or of oneself -- may be the first line of defense against the overwhelming experience, before the prolonged process of reconstructing the internal world and the external environment begins. Preschoolers may show behavioral changes and regressive behaviors, mostly within the normal range. These may include irritability, sleep difficulties, separation problems, fears, nervousness, posttraumatic play, demanding or dependent behavior, whining or temper tantrums (26-28 Bingham and Harmon, 1996; Laor et al., 1996; Sullivan et al., 1991). Older children may report disturbances in conscience functioning, although their moral functioning may seem Studies suggest that parents and teachers tend to report fewer posttraumatic symptoms in children than the children themselves (30-31 Vernberg et al., 1996; Yule and Williams, 1990). Adults may be preoccupied with their own stress and not be attuned to their child’s inner emotional states. Children may also be more reliable reporters of internalizing or dissociative symptoms. Thus, clinicians must be careful to assess children’s functioning directly and not rely exclusively on external reports. They must bear in mind that while the initial response tends to predict later adjustment, initial symptomatic ratings may not correlate with later assessments (32 Green et al., 1994), and posttraumatic responses may show a delayed onset (33 Sack et al., 1999). If the disaster is limited and well controlled, most of the pathological reactions in children will abate within the first year. In a 17-year follow-up of children exposed to a dam collapse, Green et al. (32 1994) found that survivors recovered from the initial symptomatic reaction and functioned similarly to non-exposed children. However, if community functioning is substantially disrupted, symptoms may persist for years (4,9,33 Goenjian et al., 2005; Laor et al., 1997; Sack et al., 1999). These data underscore the need for effective persistent disaster management on all levels – primary, secondary, and tertiary. Types of post-disaster symptoms
In reaction to disasters, children may show a combination of some or many of the following: posttraumatic stress symptoms, fears, depression and grief, and dissociation (34 Gordon and Wraith, 1993). Anthony et al. (35 1999) found that anhedonia, inattention and learning problems are the most common symptoms after disasters. However, rather than being markers of a pathological reaction, they reflect the normal disruptive consequences of disasters. The symptoms of posttraumatic stress disorder (PTSD) are grouped under three major domains: intrusion, avoidance/numbing, and arousal. Empirical studies have recognized certain symptoms that are specific to children, such as persistent posttraumatic play, omens, and somatic complaints (e.g., 36 Terr, 1983). Scheeringa et al. (37 1995) proposed diagnostic criteria for the Intrusive reexperiencing of the event may be observed in thoughts (about the traumatic experience), feelings (as if the event were happening again), or sensations (being acutely distressed by stimuli related to the trauma). Children may retell their experiences over and over, report nightmares and show repetitive trauma-related play. They may also describe vivid traumatic images: visual (e.g., mutilated bodies), auditory (e.g., the sound of the earthquake or screams for help), olfactory (e.g., odors of burned or decaying bodies) or kinesthetic (e.g., feeling as if they were buried under the rubble). Avoidance of reminders is evidenced in the evasion of places, people, thoughts or activities associated with the disaster. This can be both a symptom and a defensive maneuver to reduce internal stress. However, persistent avoidance coping is associated with negative mental health outcomes (38 Asarnow et al., 1999). The avoidance may be active (e.g., purposeful engagement in trauma unrelated thoughts to avoid traumatic reminders) or passive (e.g., not engaging in social interactions) (35 Anthony et al., 1999). General psychic numbing may be considered a mild dissociation response, and it is more difficult to detect in children than in adults (31 Yule and Williams, 1990). Children exposed to disasters may lose interest in activities that were significant in the past, feel estrangement from others, show constricted affect, lose recently acquired developmental skills (e.g., toilet training or talking) and express a sense of foreshortened future. Increased arousal symptoms are the most easily recognized by external observers, and include irritability, angry outbursts, exaggerated startle response, hypervigilance, difficulty in concentrating, and sleep disturbances such as difficulties getting to sleep or in sleeping alone (39 In a study of Armenian children exposed to the 1988 earthquake, about 90% of those living adjacent to the epicenter met the diagnosis of PTSD 18 months later compared to only 30% of children from the periphery of the earthquake zone (40 Pynoos et al., 1993). Mass disasters typically induce specific fears and dependent behavior in children (28,41 Goenjian, 1993; Sullivan et al., 1991). Old fears may be reactivated, current ones may intensify, and new fears may emerge with a more or less clear relationship to the event. Particularly in young children, fears may lead to dependent and clingy behavior, difficulty separating from caretakers, or refusal to attend school, thereby interrupting the separation-individuation process. Vogel and Vernberg (7 1993) explained the separation anxiety of children after disasters in terms of the child-parent attachment relationship. They claimed that disasters challenge the basic assumption that the world is a secure place, leaving the child helplessly vulnerable. Empirical support for this hypothesis was provided by the finding that five years after a disaster, young children’s symptoms still correlated with their mother’s reaction (42 Wolmer et al., 2000). Children exposed to disasters may show symptoms of depression and grief, but these are usually of lesser severity than the specific PTSD symptoms (7 Vogel and Vernberg, 1993). Since grief and posttraumatic stress symptoms may appear independently of one another, Pynoos et al. (43 1987) stressed the need for separate diagnostic interviews for each domain. The mood symptoms, which have been suggested to be at least partially secondary to the posttraumatic reactions (44 Goenjian et al., 1995), are the result of different types of loss (e.g., of home, family members, personal belongings, basic assumptions). The traumatic grief reaction, recently defined for adults, may include persistent preoccupation with thoughts of or searching for the deceased, feelings of disbelief about the death, or anger and detachment from others (45 Noaghiul and Prigerson, 2000). This construct still awaits validation in children. After the 1999 earthquakes in Turkey, Laor et al. (46 2002) found that children who had seen severely injured or dead people, experienced hunger or lack of sleep after the event, or had had more traumatic experiences in the past reported more depressive/grief symptoms. Goenjian et al. (44 1995) reported high levels of depressive symptoms in the most affected Armenian children 18 months after the 1988 earthquake, apparently due to the extent of family losses and the persistence of posttraumatic symptoms. Disasters may be perceived as an overwhelming interruption of human experience, thereby distorting the individual’s basic assumptions, both cognitive (e,g, “What is real and what is imaginary?”) as well as existential (e.g., “Is it happening to me?”). To reestablish well-being, some people define a different “spatial” arrangement of their position relative to the world: “I am not affected by the circumstances because I am focused on my own task” or “I am not affected, because I am elsewhere”. This type of distancing is adaptive. Pathological dissociation goes one step further, with manipulation of adverse stimuli through the reconstruction of perception and the re-division of consciousness: “What is happening to me is not real” or “I, who is experiencing, is not real” (22 Laor, 1996). Under conditions of mass disaster, this maladaptive response may encompass extensive spheres of experience (moral, familial, social, cultural, and political) and affect a wide range of self systems. Dissociative reactions may be manifested by symptoms that reflect a discontinuation of personal experience (e.g., affective detachment, perceptual distortions or body- and self- distortions). Children may have out-of-body experiences, perceive life like a dream or a movie, and “hear voices” of or “see” people who died. Amnesia is apparently less frequent in children than in adolescents. Under certain conditions, dissociative mechanisms provide temporary relief from the overwhelming trauma. If persistent, however, they may engender a long-term alteration in normally integrative functions of identity, memory and/or consciousness (47 Putnam, 1995). Factors affecting children’s responses to disasters
Several factors influence the extent of the children’s symptomatic response to disaster. Some relate to the disaster itself, others to individual, familial and social characteristics. (a) Factors related to the disaster
Children whose traumatic exposure is more severe tend to react in a more extreme way. This “dose of exposure” effect is apparent, for example in proximity to the epicenter of an earthquake (40 Pynoos et al., 1993), to the impact zone of a hurricane (48 Shaw et al., 1995), or to the site of missile attacks (27 Laor et al., 1996). More severe responses have been noted in children who were exposed to the cruelest experiences, such as witnessing severely injured people and mutilated bodies, faced a direct threat to their own life, or suffered human loss, especially of family members (49-50 Husain et al., 1998; Pfefferbaum et al., 1999), and in children who sustained personal injuries (44,51-52 Goenjian et al., 1995; Green et al., 1991; Udwin et al., 2000). Continuous displacement is also predictive of a worse psychological response (9,53 Laor et al., 1997; Lonigan et al., 1994). Children exposed to several traumatic experiences are more likely to exhibit more posttraumatic symptoms (54-55 Thabet and When the disaster is severe, children need to cope with a massive range of problems: lack of food, water and shelter, property damage, inadequate housing, violence, lack of medical care, traumatic reminders, bereavement, relocation, separation from parents and economic crisis. Their posttraumatic reactions may intensify and interfere with symptomatic recovery, at least during the first year, as well as with long-term development (25,40,49,56 Husain et al., 1998; McFarlane, 1987a; Pynoos et al., 1993, 1995). (b) Factors related to the child
Age. The variations in both subject age and symptom domains examined among the various studies make generalizations difficult, although young children are considered more vulnerable (21,57 Garbarino and Kostelny, 1996; Solomon, 1995). Nevertheless, behavioral problems, specific fears, regressive symptoms, and separation problems appear to be more characteristic of young children, whereas depression and anxiety are more characteristic of older children and adolescents (58 Gleser et al., 1981). Three months after Hurricane Hugo, preadolescent children reported more posttraumatic symptoms than early and late adolescents, who had similar responses (59 Shannon et al., 1994). Green et al. (51 1991) reported a similar level of some specific posttraumatic symptoms (intrusion and arousal) in preschoolers and in school age children and adolescents, although the latter reported more avoidant symptoms. This pattern may reflect different ways of expressing the same basic symptomatic domain in groups with different levels of cognitive and affective maturity, resulting in dissimilar coping styles and Gender. Regarding gender differences, results are conflicting. Some studies report no gender differences (9,27,48 Laor et al., 1996, 1997; Shaw et al., 1995). Others found that girls tend to report more internalizing symptoms (anxiety, depression, fears) and posttraumatic symptoms, and boys, more externalizing behavior (acting out, aggression) (40,52,58,59). Girls tend to be described as more resilient than boys in childhood, but more vulnerable in adolescence (60 Masten et al., 1990). Girls’ greater readiness to share their concerns may explain some of Vulnerabilities and resiliency. Children with prior pathology, particularly anxiety symptoms and learning difficulties (38,52,53 Asarnow et al., 1999; Lonigan et al., 1994; Udwin et al., 2000), and children who have suffered more traumatic events in the past, e.g., divorce, surgery, car accidents, losses (55,61 Earls et al., 1988; Wolmer et al., 2003), are more prone to severe symptoms months after a disaster. By contrast, resilient children are those with caring adults during and after major stressors, who are also good learners, good problem-solvers, and engaging to other people. In addition, they have areas of competence and a high perceived efficacy by self or society (60,62 Cohler et al., 1995; Masten et al., 1990). Kassam-Adams et al (63 2005) found an association between early physiological arousal and the development or persistence of PTSD symptoms in traffic-related injured children. In a study of children exposed to the Northridge earthquake, a mild to moderate stressor, Asarnow et al. (38 1999) found that the role of heritable biology in the children’s reaction was minor compared to the role of the children’s subjective appraisals of stress and past psychopathology. Coping skills. The child’s coping skills may also mediate between the severity of the exposure and the response. More negative coping strategies (or a more immature defensive style) to deal with stress (e.g., blaming others, anger) are associated with greater symptomatic persistence over time (39,64 La Greca, 2000; Wolmer et al., 2001b). (c) Factors related to the family
Reaction of the parents. The presence of adults caring for the child during and after a major stressor is considered the most important and consistent protective factor (60,61 Earls et al., 1988; Masten et al., 1990). Indeed, the reaction of the parents, especially the mother, to the disaster is generally correlated with severity of the child’s responses (65 Winje and Ulvik, 1998). Researchers found that the reaction of preschool children to the missile attacks during the Gulf War was highly correlated with the reaction of their mothers (9,27,42 Laor et al., 1996, 1997; Wolmer et al., 2000). This was true for 3-4-year olds, but not for 5-year-olds, probably owing to the latter’s increasing autonomy and control of the psychological buffering systems for development (60 Masten et al., 1990). Five years after the war, the mothers’ poor psychological functioning (increased symptoms, immature object relations and defense style) was associated with increased symptoms in their children (66 Laor et al., 2001a). McFarlane (56 1987a) stressed that the ability of parents to contain the anxiety generated by the extreme threats of disasters was the most important factor influencing their children’s responses. Consistent love and encouragement to grieve and to discuss emotions openly within the family seem to have protected even unborn children and infants of parents evacuated after the 1986 Chernobyl disaster (67 Bromet et al., 2000). Parents are critical mediators of stress mainly owing to their roles in social referencing (pooling information and processing of meaning), responding emotionally, and caring for and supporting the child (60 Masten et al., 1990). Functioning of the family system. The family is an important mediatory factor, particularly in young children (9,27,68 Laor et al., 1996, 1997; McFarlane, 1987b). Families with extreme levels of cohesion – boundaries that are either too loose or too rigid -- may not provide the appropriate support or allow the child to withdraw at times in order to process the traumatic experiences and reach a constructive resolution of concerns. Caring support, open communication patterns, and sensitivity to the child’s needs enable parents and children to regulate dyadic processes and discuss disaster-related issues when necessary. Alternatively, parental stress may lead to a pattern of preoccupation with their own suffering and overprotection of the child which interferes with the healthy process of resolution (56 (d) Factors related to the society and the culture
Friendships. Friendships are valuable sources of reciprocal affection and attachment, mutual assistance, emotional security and self-esteem, and nonfamilial contexts for intimacy, thereby contributing to the child’s ability to cope with stress (69 Parker et al., 1995). The natural sources of friendships, the family (the sibship), the neighborhood, and the school, may be shattered in times of disaster. Friendships may also include supportive relationships with teachers or other adults (30,52 Udwin et al., 2000; Vernberg et al., 1996). Even the presence of a single concerned and caring adult may do much to offset the impact of misfortune in the lives of Community. Communities mobilize under disaster relying on their inner strength and external backup support. The inner strength of a community under disaster is a result of the operation of various factors and processes: (1) effective leadership; (2) social cohesiveness; (3) institutional empowerment; (4) available emergency services; (5) appropriate infrastructure; (6) disaster preparedness plans; (7) communal hardiness which depends on cultural factors (e.g., Culture. Cultural factors may also affect the clinical picture after a disaster. Cultures define the terms under which symptoms are expressed and set the parameters for the expression of personal distress. Some cultures encourage children to express their distressing feelings (anger, sadness, or longing), and others do not. For example, in some cultures, adults may admonish children who were victims of disaster to be prim and proper or to refrain from crying (41,70 Goenjian, 1993; Laor et al., 2001b). Thus, cultural background, including strengths and weaknesses, needs to be taken into account by clinicians when planning treatment interventions. In addition, culture also mediates ideology and identity. As the purveyor of the meaning ascribed to disastrous events and consequences, the culture regulates the capacity of the individual to maintain an active and resilient stance. At the same time, it can lead some children to take as well as to be exposed to risks that transcend their age (e.g., child soldiers, sexual exploitation). Assessment of children under conditions of disaster
It is extremely important that children at risk of psychopathology after exposure to disaster be identified and treated as early as possible. This is a difficult challenge for clinicians. Child mental health professionals need to be well informed about the valid assessment tools available. In the first and second stages of the disaster, they must remain sensitive to the setting in which they operate: an evacuation center, or destroyed neighborhood beset by fighting, flooding or an infectious epidemic, or an existing natural setting, such as a school. Under both, the clinical evaluation must remain subordinate to the social one. That is, efforts must be directed not only to the treatment of the children themselves, but also to the reactivation of the society’s child care systems via its existing child care workers. In a natural setting, the assessment may be integrated into the normal institutional activity (see “School-based interventions” below). Furthermore, to identify the children’s strengths and needs, professionals should also evaluate the group to which children belong (e.g., perceived support or hardiness of families, schools and displaced communities). This mandates close collaboration among an interdisciplinary team of teachers, school counselors, social workers, psychologists and community leaders. The preferred clinical screening tools are those that directly assess the child rather than rely on external reporters. They should also be simple and quick to administer, accurate, repeatable, sensitive, and specific (71-72 Cochrane and Holland, 1969; Stallard et al., 1999). The criteria for identifying pathological cases should be tempered by consideration of the psychological and economic costs of possible false-positives and false-negatives. Furthermore, the use of cutoff scores may facilitate the decision-making process, but they can obscure minor but “real” differences between children with scores slightly above or slightly below threshold. Green (73 1982) suggested that clinicians think in terms of degree of impairment in a given sample rather than case identification. Also, the assessment of a single domain rather than the complex of posttraumatic, dissociative and grief symptoms may decrease the sensitivity of the battery (71 Stallard et al., 1999). (For a review of screening tools to assess trauma and its effects see 74-75Ohan et al., 2002 and Strand et al., 2005). The assessment of risk factors deserves special attention. Information should be gathered concerning the child’s past functioning (traumatic/stressful experiences such as divorce, hospitalization, birth of a sibling, mental and general health problems) as well as disaster-related events (personal injury, loss of family members or friends, witnessing severely injured or dead people, separation from parents, experiencing hunger or lack of sleep). A Risk Index may prove a useful guide to identify symptomatic children as well as those requiring special attention (55 Principles of child mental health intervention
Systemic perspective
Mass disasters impact not only on the exposed children, but also on their families, school system, and whole socio-cultural milieu. Derivative effects also appear in peripheral communities (41,48 Goenjian, 1993; Shaw et al., 1995). To cope with this complex challenge, interventions must be formulated from an integrative perspective and focus on maximizing well- being and self-efficacy and minimizing stress and disorganization; they must help victims find meaning and institute a sense of control. In their approach to public mental health, Pynoos et al. (16 1998) provided guidelines for the effective utilization of government and social institutions, school communities and interventional teams. They emphasized the need, among others, to resolve institutional conflicts over authority and resource allocation, to address the teachers’ own disaster experiences, and to properly select and train intervention teams to work with severely traumatized victims. Population screening is useful to pinpoint areas that require specific resources and government support. Treatment interventions should be directed at the following factors: traumatic experiences and reminders, interplay of trauma and grief, and post-disaster adversities and their The effect of mass disasters is so devastating because of the concomitant loss of socio- cultural regulators, leading to the destruction of basic schemes, values, roles and structures (family and individual) and leaving the community open to pain, grief, trauma and anger. In this process, individual regression and dissociation reflect, complement and reinforce the collective ones. Working in such a milieu, professionals may find themselves embroiled in confusion and red tape among the various social/government systems (e.g., medicine, education, welfare, NGOs) and intervention teams that are trying to help. Therefore, a systemic perspective is needed to clarify the picture and help the psychiatrist (a) formulate the newly established needs of child-oriented institutions, (b) transfer knowledge and empower professionals in related fields to resume their role, and (c) define their own role and carry out specific interventions Mental health interventions for children and families exposed to mass disaster should follow the five AREST principles, as follows (18 Laor et al., 2004): Anticipate. First, they must provide an integrated vision, foresee different scenarios, and
include contingency plans. Professionals and paraprofessionals need to be trained, human and economic resources appropriately allocated, and relevant treatment protocols created. To accomplish these goals, efficient local, national and international networks need to be developed, with collaboration among agencies (education, police, health), and sponsorship and legitimacy established (76 Vernberg and Vogel, 1993). Redifferentiate. The child psychiatrist must identify the extent of social loss in terms
of institutional and role dysfunction and plan the process of context-related re-development of professional roles within and between systems (health, welfare, education) with the help of multidisciplinary teams. Attention should be addressed particularly to reconstitute the roles of Empower. The child psychiatrist needs to debrief (if necessary), educate, and
empower social agents (e.g., teachers) who are in direct contact with children to serve as mental health mediators. They must help these agents adapt and restore their original roles, and delegate some therapeutic responsibilities to them. The child psychiatrist must take a leadership position and supply the team with a professional vision and positive expectations. Supervise and Assess. The psychiatrist must define boundaries, provide knowledge,
expertise and support to therapeutic agents, assess program development and identify needs by feedback mechanisms. As a leader, the professional needs to encourage creative initiatives in team members and provide them with individualized consideration. Treat and Follow-up. Treatment focuses on the rehabilitation of individuals and
families. Delayed responses should also be considered.
Systems and stages of disaster
The application of the AREST principles is far from straightforward. Routine and disaster operations differ not only in intensity, speed, and expediency, but also – and primarily – in the planned systemic change. The response of the mental health professionals is determined, at each stage of the disaster, by the type of the reacting system. Preparedness and flexibility are key factors ensuring response effectiveness. During the first stage of disaster – coping with the event itself -- rigid systems tend to remain encapsulated in their normal routine, whereas learning systems may undergo structural modifications and create information centers and outreach programs. Meta-adaptive systems, owing to their forecasting capacity, may already be in state of partial readiness and will be able to initiate professional interdisciplinary teaming-up with social agencies early in the process of In the second stage of societal regression, rigid systems treat acute referrals in existing clinics; learning systems establish field stations and initiate self-training toward the formation of larger trauma centers. Meta-adaptive systems concentrate on the rehabilitation of roles and institutions and draw on resources prepared by national and international collaborations. In the third stage, rigid systems revert to their original constricted outlook and ignore the larger scope of the tertiary disaster -- the loss of ideology and identity. They deal with suffering individuals as they are referred to their clinics, this time as chronic victims. Learning systems maintain operative trauma centers, although their perspective is narrow. They may, however, internalize some of the lessons learned from coping with the first two stages into the institutional response pattern. The main focus of meta-adaptive systems is the establishment of community- based disaster intervention centers. These address the tertiary disaster by operating on both the sociocultural and the communal clinical levels to enhance resilience, regeneration and growth. Such centers may be planned in advance and developed out of the existing community mental health system, in conjunction with the general public agencies responsible for disaster Professional role containment and enhancement in conditions of disaster
At times of disaster, first priority is given to basic survival. Safety, shelter, and food are the most immediate and conspicuous, and these are usually within the domain of professional relief teams. However, the members of these teams themselves may suffer from role-related problems because of the disaster-induced collapse of the socio-cultural matrix of which they were a part. Therefore, to initiate an effective intervention, mental health professionals in positions of authority must respond to these needs, in their own team and in teams in which they act as mediators (e.g., teachers, school counselors). They must make team members feel cared for and help them to develop a sense of belonging and purpose. Professionals may take a leadership position by formulating a vision (e.g., “developing the best intervention program”, “revitalizing our school and preventing suffering”), providing individualized consideration (being sensitive to individual needs of professionals), fostering an atmosphere of creative intellectual coping (supporting initiatives, delegating authority) and transmitting positive expectations (concerning the professionals’ capacities and end results) (77 Bass and Avolio, Program implementation
Studies of mental health interventions after disasters clearly support their effectiveness (78-80 Galante and Foa, 1986; Goenjian et al., 1997; Wolmer et al., 2001a). However, their ongoing operation requires the continuous commitment of professionals, leaders and local agencies. By endorsing a systemic perspective, mental health professionals may overcome the repeated adversities and challenges, inadequate professional training, limited resources and organizational conflicts that tend to characterize the process. Parents and teachers are known to underestimate the extent of children’s suffering (31 Yule and Williams, 1990), perhaps due to their capacity to maintain routine functioning in the face of internal strife. Given that disaster survivors are also often reluctant to seek professional help (81 Schwarz and Kowalski, 1992), outreach efforts should be made to systematically screen victims at risk, optimally one to three months after the disaster (82 Lindy et al., 1981). Thereafter, clinical triage protocols could be utilized to match risk groups with intervention programs (14,50,82 Austin and Godleski, 1999; Lindy et al., 1981; Pfefferbaum et al., 1999). Studies have demonstrated the applicability of Western therapeutic programs also in non- Western cultures (79,83 Goenjian et al., 1997; Wolmer et al., 2005). The first step in implementing these programs is to train members of the affected community. The local staff may need continuous support and supervision. If handled correctly, this process may help traumatized survivors reduce their ambivalent resistance to what might be perceived as a foreign “intrusion” that threatens the “trauma membrane” protecting from an overload of psychic tension (14,82 Austin and Godleski, 1999; Lindy et al., 1981). Intervention models
Effective treatments for traumatized children should include the psychoeducation of children and parents about the nature of the disorder, some form of exposure work, and dysfunctional cognitive restructuring (84 Perrin et al., 2000). Furthermore, the commonly accepted treatments specific to posttraumatic conditions need to be implemented within the broader social reality of the disaster (e.g., whole community, neighborhood, peer group) in order to alleviate the sequelae of the secondary and the tertiary disasters. To this effect, the child psychiatry system must collaborate with three additional systems that will provide the psychiatrist with the authority to intervene on all institutional levels: the community leadership, Commonly used structured treatment and rehabilitation community programs (e.g., psychotherapy, programs for the disadvantaged, adolescents, and women, as well as school empowerment and class activation), stressing participant’s enhancement of initiative, activity, empowerment, hardiness and responsibility may be adapted for disaster conditions. The adaptation rests on the formulation of disaster as destructive to both external (concrete) reality and internal functional representations -- of stability (i.e. predictability and controllability) as well as of effective engagement with the environment (i.e. the physical and the communal world). Therefore, child intervention programs should aim to restitute the damage to both communal institutions and norms, and communal functioning (i.e. recovering communal roles: parent, teacher, worker, leader). Drawing on our understanding of the disaster syndrome, engendering massive grief, dissociation and trauma, intervention programs will be enriched by emphasizing the following transitions: from a freeze on past experience to a creative future orientation; from a fixation on death and loss to an involvement with life and revitalization; from being passively locked into grief, shame and anger to owning up to one’s potency; from withdrawal and alienation into reconciliatory involvement with nature, family and society and its technology; and from recourse to mythological world view into critical transformation of socio- In circumscribed mass disasters, effective programs may take 12 to 18 months. The first phase is dedicated to the assessment and reactivation of the community and its institutions, as well as to the introduction of clinical intervention programs. This phase may take up to a year and lead toward the first commemoration ceremony of the disaster. The second phase is characterized by the community and the individual taking responsibility for their future: development of physical and social infrastructure and job opportunities. Immediate interventions
During the acute stage, the role of the mental health professional needs to be modified because of the unique conditions, namely, the limited number of professionals and the masses of individuals, often dispersed over a large area, that require help. Large populations need to be screened to identify children at risk. Other important tasks include initiating telephone crisis hotlines, supplying psychological first-aid for children and families in evacuation centers and hospitals, consulting authorities to assess immediate needs, and planning large scale public health education programs. To prioritize needs and promote efficacy, professionals need to use medical criteria for classifying and assessing both levels of psychological damage and available individual (coping) and familial (support) resources. At this stage, professionals become aware of the need to quickly acquire new disaster- related skills. They may come upon technically formulated protocol-based interventions, but soon discover that mastering new therapeutic techniques and implementing them under disaster conditions requires thorough training and ongoing supervision, which can be secured before proceeding with the intervention program. The mass media (e.g., television, newspapers) can be helpful for confused parents. They can learn about typical reactions to stress and ways of coping with them and of restoring the parental role. They should be advised to tolerate regression, encourage children to ask questions and express feelings, assure children that there are no bad thoughts or feelings, assign children appropriate activities, re-establish stability and family rituals, and convey positive expectations for the future (85 Flynn and Nelson, 1998). Television programs directly addressing children Delegating age-appropriate functions to children, allowing them to take responsibility and provide active help, serves as an important mechanism for preventing the sense of helplessness and the passivity that leads to more severe responses. The appropriate preparedness of a city/country can lessen significantly the consequences of a disaster. For example, as part of its general Disaster Preparedness Program, the Tel-Aviv Municipality has developed an Emergency Treatment System (ETS; 86 Spirman et al., 2001a) that focuses on social and psychological welfare in times of emergency. The ETS is composed of eight multi-disciplinary units dealing with: (1) on-site crisis (triage and evacuation), (2) family notification (of losses), (3) hospital liaison, (4) population behavior (information center), (5) brief psychological support over the phone, (6) emergency shelters (for evacuees), (7) community resources (volunteers and donations), and (8) delivery of basic needs. The ETS headquarters coordinates the units and their cooperation with relevant institutions (e.g., police, army) as well as with the clinical trauma and disaster community center, out of which the child Interventions during the second and third stages
The disaster syndrome may be viewed as an expected reaction akin to the fear response to danger or the mourning process following loss. In the long run, most affected individuals recover their functioning. It is assumed that the recovery of traumatized survivors may be facilitated by a debriefing process that allows them to review their experience. In mass disasters debriefing is The aims of group debriefing are to allow the expression of traumatic experiences and flooding reactions; facilitate relaxation; promote cognitive organization and self-control; identify and mobilize internal and external resources; set realistic expectations; restore self-worth and hope; and prepare participants for future experiences (87 Stallard and Law, 1993). The implementation of this structured technique with children may last one or more meetings and must be done by an educated professional. The technique may include play activities, such as individual or group drawing, writing, or imagery games. Participants are given time for expression and questions. The tasks of the leader are to protect limits, set rules, provide information, facilitate verbal and physical peer support, and manage containment. The leader may also identify symptomatic children and refer them for further help when the meeting ends, and distribute psychoeducational handouts on symptoms or positive coping strategies for follow- After reporting their trauma-related experiences, participants are encouraged to focus on thoughts, emotions, images and sensations related to the event. Special attention should be given to feelings of guilt and anger, since clinical experience shows that these may interfere with the process of working-through the trauma. Thereafter, participants explore personal and communal coping resources and use creative imagery to return to the “here and now”, fantasize about a positive future and construct plans of action. Parallel sessions may be held with the parents. Debriefing may be an efficient tool to help children and adults (87-88 Chemtob et al., 1997; Stallard and Law, 1993). However, one should be aware that very early exposure to the memory of the traumatic event may interfere in some individuals with the normal affective- cognitive processes that lead to recovery, resulting in neutral effects or even an exacerbation of symptoms (89-90 Mayou et al., 2000; Wessely et al., 1998). The specific therapeutic factors of the debriefing intervention, and who may benefit from it, remain open questions. To assist as many children as possible, professionals may need to work with groups rather than individuals. Since teachers have trustful relations with children and parents, and most are ready to be educated and serve a therapeutic role, intact school environments are appropriate sites for societal recovery centers for early interventions (76,91-92 Klingman, 1993; Pynoos and Several researchers have found that support from classmates and teachers is a significant predictor of fewer posttraumatic symptoms after a major disaster and prevents withdrawal and isolation (30,92 Pynoos and Nader, 1988; Vernberg et al., 1996). Furthermore, the class setting provides a predictable routine, clear expectations, consistent rules, and immediate feedback. It is recognized as the place to apply learning skills for exploring causes and consequences of disasters, and to emphasize that survivors may experience “normal reactions to abnormal Teachers should allocate time to deal with traumatic experiences, model the children’s responses, reinforce emerging coping skills, provide factual information and correct rumors, facilitate mutual support, identify suffering children and prepare the class for future experiences. They may also encourage students to become active contributors to their family, school and For the program to be effective, mental health professionals should ensure that the teachers (a) are not traumatized themselves; (b) are capable of mastering disaster-related educational techniques, and (c) have adapted their view of their role as teachers/educators to the new and harsh reality. To help regenerate the normal school setting after a disaster, the child psychiatrist needs to meet with the teachers, debrief them about their own experiences of the disaster, and clearly lay out the educational task at hand. Based on these principles, Wolmer et al. (55 2003) implemented a three-stage supervision of one school’s principal and teachers after the 1999 earthquake in Turkey. First, a group debriefing session was conducted to normalize responses and enable the expression of trauma- related affects (anger, guilt, helplessness, hopelessness). Thereafter, an experiential activity was introduced to help the teachers redefine their role vis-a-vis the students as “educators” and “leaders”. The authors stressed that in times of disaster, rather than merely covering the regular curricula, teachers were expected to maintain and enhance their role by providing individualized consideration, transmitting values, and conveying positive expectations. As part of this role, they were taught to implement a disaster-related classroom activation program (see below). Finally, a continuous supervision process was begun, led by local professionals, wherein teachers were not only educated but also provided support for each other (see also 79 Goenjian et al., 1997). School-based interventions include single-session debriefings, small-group programs, and Targeted small group programs within the school setting may benefit high-risk children or children who are more agitated and need closer attention than can be provided in the classroom (91,93 Gillis, 1993; Klingman, 1993). Smith et al. (94 1999) formulated a three- session program to teach recovery techniques to small groups of children affected by disaster. The techniques used are psychoeducation, imagery and cognitive techniques and exposure practice. Each session is dedicated to one domain of the posttraumatic syndrome: intrusion, avoidance and arousal. The professional may also offer a fourth session for bereaved children and a session with parents, to provide them with information and suggest ways for them to help Programs implemented in the classroom itself may vary in focus, scope and depth, but all are intended to minimize stigma, encourage normalcy, and reinforce the expectation that the children will soon resume their roles as students (5,76,91 Klingman, 1993; Pfefferbaum, 1997; Vernberg and Vogel, 1993). It is important to stress, however, that the teachers themselves may be struggling with severe posttraumatic symptoms and personal losses, and consequently, feel unable to help their students. Some teachers may try to avoid dealing with reminders of the event by stressing that children have no need to talk about their traumatic experiences (see 16 Pynoos Galante and Foa (78 1986) provided children who survived an earthquake in Italy seven monthly sessions for discussing and dealing with related feelings, and noted a significant reduction in symptoms. Other models also utilize expert mental health professionals in school settings with or without the presence of the teacher (91,95 Eth, 1992; Klingman, 1993). Direct teacher involvement is, however, encouraged for disasters of large proportions, when expert The class activation of Wolmer et al (55 2003) was led by the teachers, and it consisted of an introductory meeting with the parents to provide information about the program and the children’s expected reactions to the disaster, and to engage them in the process. The remaining eight 2-hour meetings of the whole class focused on various aspects of the recovery process (e.g., debriefing, establishing a safe place, learning about the earthquake, loss and death, dealing with anger and lessons of life, planning the future). The program combined psycho-educational modules, cognitive-behavioral techniques, play activities and an ongoing documentation in personal diaries. The program resulted in significant immediate reduction in symptoms of posttrauma and dissociation. In addition, a controlled follow up showed that children who participated in the class intervention showed a better adaptation than non-participants in terms of academic, social and behavioral functioning, three years later (83 Wolmer et al., 2005). Clinical interventions
Although efficient and cost-effective, group interventions may not be enough for the most affected children. Controlled and uncontrolled studies have confirmed the effectiveness of brief cognitive behavioral treatment in traumatized children (84 Perrin et al., 2000). Other modes of individual psychotherapy have been employed, such as play therapy, psychodynamic psychotherapy, or eye movement desensitization and reprocessing (EMDR; 96 Lovett, 1999). Particular attention should be directed to prior and current comorbid pathology as well as to a thorough differential diagnosis (e.g., mania, ADHD). After the 1988 earthquake in Armenia, Goenjian and colleagues (79 1997) implemented a brief treatment program combining classroom group psychotherapy and individual sessions focusing on trauma and grief. The sessions, led by therapists, allowed for open discussion of the traumatic experiences and associated feelings, assisted the children in solving intra- and inter- personal problems, and offered effective cognitive-behavioral techniques to manage thought distortions, disturbing images and stress-related sensations. Five years after the event, the posttraumatic symptoms of treated adolescents decreased more significantly that those of untreated adolescents (4Goenjian et al., 2005). Families have the potential to either protect children and mitigate their post-disaster suffering or to jeopardize their adjustment to and processing of the event, thereby exacerbating their symptoms. After disasters, children and parents tend to avoid discussing their distress, probably to avoid further disturbing each other (6 Udwin, 1993). However, studies consistently show a significant association between the symptomatic response of parents (particularly of mothers) and their children (9,27,65 Laor et al., 1996, 1997; Winje and Ulvik, 1998), which may have a traumatic impact on the whole parent-child dyad (42 Wolmer et al., 2000). Based on the previous successful application of parent-child group psychotherapy in the treatment of child anxiety disorders (97 Toren et al., 2000), and as a second stage of school- based intervention, Laor et al. (70 2001b) formulated an eight-session therapeutic protocol for mothers and children (4-5 dyads) with chronic posttraumatic symptoms. Led by two therapists, the group addressed dynamic, cognitive and behavioral aspects of the disaster syndrome, and offered techniques to manage anxiety, relieve, control and transform distressing affects, correct thought distortions, and plan for the future. Special attention was paid to identifying and correcting maladaptive family dynamics and helping mothers and children recover their attachment and roles. Preliminary clinical and empirical results showed significant symptomatic alleviation as well as a dramatic improvement in familial communication and mutual support. Group interventions with mothers allow for the indirect focus on preschool children, a population that may not be reached in formal settings yet may show maladaptive behavioral reactions. These reactions are known to correlate highly with the mothers’ psychological response (42 Wolmer et al., 2000). Providing structured therapeutic interventions, psychoeducation and practical suggestions in regard to the children as well as strengthening the participants’ confidence in their maternal role are important objectives for these groups (98 Post disaster community-based interventions
Disasters affect whole communities, threatening social structures and functions. To be effective, interventions require collaborative efforts among non-governmental organizations and formal and informal agencies. The development of a local leadership of committed individuals and its empowerment to actively meet the short- and long-term needs of the community provides a valuable source of support (99 Rappaport, 1987). In this regard, child psychiatry relief programs need to respond to disasters on three levels: (a) The family. Families may suffer from injured, lost, or dead members; relocation and unemployment; loss of boundaries, routine and values (sometimes internalizing the societal anarchy); and loss of esteem and hope. (b) The neighborhood. During disasters, neighborhoods are subject to physical and economic destruction, loss of routines, boundaries and safety, disintegration of informal networks, and restriction of leisure time activities; these apply also to temporary neighborhoods established by relocated families. (c) The community: Communities suffer from an insufficiency of proper leadership and resources, frozen initiative, dependence on external resources, destruction of social and cultural institutions (schools, community centers, religious centers) and as a result, a foreshortened sense of communal future. Drawing on auxiliary social functions and structures introduced from the outside, as well as on professional clinical and social teams, it is possible to help temporary communities of displaced population gradually to develop coping and functioning. In a nutshell, the goal of the community-based intervention is to transform evacuated fragments of families and singletones -- first stage -- into self-governing communities with autonomous individuals and families -- third stage (15 Laor, 2001) (see Table 1). Since children cannot be fully rehabilitated until their parents resume work and regain income, professionals may also help facilitate the creation of Using the intervention principles described above, child mental health together with child community workers and the local leadership can help set up community-center programs for young mothers, children and adolescents. Empowering- and hardiness-enhancing programs may include arts, sports, gardening and decorating, continuous education, job clubs, and volunteer recruitment and training in different areas (100 Kobasa, 1979). By empowerment we mean a process of involvement by which individuals and communities replace their helpless stance by recovering their dignity and self-esteem, enhancing their critical self-awareness, control over resources and objectives, sense of personal and collective responsibility and self-efficacy (99 Rappaport, 1987). Individuals are able to identify specific needs and discover hidden leadership qualities, while communities gain a greater sense of interdependence, cohesion and cooperation. In the case of dislocated population, communal empowerment is the process by which communities are formed and achieve greater control over their environment. Interventions at the level of the whole community facilitate the integration of community members with the natural and the social environment. For example, as part of the Community Reactivation Program after the 1999 earthquake in Turkey, Spirman et al. (98 2001b) developed a two-week summer program for a whole village of displaced individuals to transform the community and its habitat as culturally internalizing death and alienation (e.g., withdrawn fathers, unemployment, uncultivated neighborhood). The method rested on five principles: (1) On-site teaming-up and training of international and local youth leaders to serve as instructors. (2) Identifying a natural habitat adjacent to the village, representing “life” for the community, where the program’s activities (e.g., arts, sport) take place. (3) Enlisting the revitalization and initiative achieved, to construct recreation areas and cultivated gardens, within the original village habitat. As a result, the artificial prefab neighborhood representing “death and displacement” turns into a lively community. (4) Designating an area within the village to serve for the erection of an artistic commemoration monument, for which individuals were invited to contribute dear personal remains. The event culminated in an anniversary ceremony. This process of collective mourning allows for an honorable and lively representation of dear loss and the dynamic reconnection with historical identity. (5) Involvement of social and political leaders, local and international, to facilitate the social integration of the community. These interventions allow child mental health professionals entry into the sphere of the long-term effects of the tertiary disaster, the socio-cultural losses that threaten the collective ideology and identity. Professionals may take part in the modification of the school curricula to address group mourning and hardiness, collective memorials as well as celebrations of rebirth. The juxtaposition of commemoration and rebirth ceremonies help individuals to gain a new meaning of life in the face of deep mourning and leads to an integration on both the personal and communal levels, which offers children an uninterrupted supportive matrix. For example, in Israel, the Independence Day celebrations follow on the heels of the Memorial Day ceremonies, and in Turkey, communities celebrated group circumcision of children about one month before Building a child-centered model of urban resilience
The mobilization of community resources to confront the vast devastation and needs following a disaster is a complex and demanding operation. Experience shows that when plans and processes are operational during routine times, the chances increase they will be implemented after the event. To that end, communities need to (1) foresee which emergency interventions can be developed and practiced routinely by central institutions as part of their regular goal; (2) empower these institutions as mediators of operations in the areas of mental health and rehabilitation; and (3) create a network of collaborations between these institutions. Table 2 summarizes the institutions, routine goals and emergency functions of the Tel Aviv Network, initiated and coordinated by the Donald J. Cohen & Irving B. Harris Center for Trauma and Disaster Intervention, to function synergistically once a disaster breaks out (18 Laor Pharmacological interventions
It is widely accepted that psychotherapy, rather than medication, is the first-choice modality for posttraumatic states (101 Shiloh et al., 1999). Nonetheless, one should keep in mind that reduction in even one disabling symptom (e.g., insomnia, hyperarousal) may have a positive ripple effect on a child's functioning (102 Donnelly, 2005). The systematic assessment of pharmacological treatments for traumatized children and adolescents has so far been limited (76,84 Perrin et al., 2000; Vernberg and Vogel, 1993). Therefore, most proposals for pharmacotherapy with children are based on studies with adult PTSD. These studies, too, invite improved controlled design (103 Marshall et al., 1998). Medications can be given even in the early stages of intervention to children with a known history of psychopathology prior to the disaster; to individuals who do not respond to short-term specific interventions; and to members of families at risk that are flooded by severe symptoms. These medications must be directed at specific symptoms, such as intrusion, hyperarousal and impulsivity (e.g., carbamazepine, lithium, clonidine), anxiety (e.g., buspirone, alprazolam), depression (e.g., tricyclic medication or SSRI’s), psychotic symptoms or severe aggression (e.g., antipsychotic drugs) (101Shiloh et al., 1999). A recent comprehensive review proposes that broad-spectrum agents such as SSRIs are a good first choice, because these agents have efficacy in treating the core symptoms of PTSD and comorbid symptoms (depression, anxiety) (102 Donnelly, 2003). In addition, Donnelly suggests that adrenergic agents may be useful to alleviate symptoms of hyperarousal and impulsivity, mood stabilizers may be necessary in severe affective dyscontrol, and atypical neuroleptics may be necessary in cases of severe self-injurious behavior, dissociation and aggression. Professionals should beware that well-intentioned donations of medications by drug companies and the urge to reach as many individuals as fast as possible my lead to anarchic management and nonprofessional medication of children. A detailed description of pharmacological interventions is presented in the relevant chapters. Taking care of the caretaker
Professionals engaged in disaster intervention programs (psychologists, teachers, social workers and nurses) are more analogous to marathon runners than to short-distance sprinters. Project coordinators need to be aware of each worker’s strengths and weaknesses, personal losses and vulnerabilities in order to regulate their exposure and prevent burnout. Program leaders need to help relief workers enhance their own coping mechanisms, tolerate the shock inherent in their work, and maintain high levels of commitment and motivation (14,104 Austin and Godleski, 1999; Cohen, 1987). Therefore, leaders should facilitate adequate training and peer supervision, encourage mutual support, lead debriefing sessions, teach stress management skills and introduce appropriate work breaks (limiting shift durations or breaks in schedules). Disaster research
Disaster research is of utmost importance yet extremely hard to perform. Most disasters occur unexpectedly, and even those that are predictable have such an overwhelming impact, they exhaust all professional and economic resources. Furthermore, even when professional curiosity is maintained, assessment measures are enlisted, and questions are defined, the implementation of the research is met by resistance on the part of both the victims and the clinicians. They tend to perceive research under these conditions as hostile, foreign, exploitative and abusive, intended to satisfy an alien agenda that is irrelevant to their priorities. There is a kernel of truth to this: the hands that give out questionnaires could have offered bread. Furthermore, from the standpoint of the clinician, many of the responses of disaster victims reflect a normal and time-limited reaction to stress and should not be structured as pathology. The perspective offered in this chapter enables the mental health professional to deal seriously with these issues and not simply explain them away. Research initiatives need to be integrated within the systemic interventional program and to rely on the direct assessment of the affected population at every stage. That way, real risks and needs can serve a basis for rational planning (e.g., resource allocation, assignment to different therapies) as well as for improvement of existing programs. It is the responsibility of the professional to educate community leaders to take practical advantage of assessment data. The disaster scene, a large-scale natural experiment, offers access to communities that constitute different types of research groups and controls. Furthermore, in each community, one may encounter a large number of whole families whose members were simultaneously exposed and affected in different manners (direct/indirect) and degrees and for different lengths of time, as well as individuals suffering from losses of varying severity. An important issue in studies of children is the phenomenology and biological susceptibility to the disaster syndrome, that is, the interplay of traumatic grief, posttraumatic symptoms and dissociation with psycho-neuro- endocrinological and psychophysiological parameters. This particular setting provides a unique opportunity for genetic studies. Special attention ought to be given also to partial and delayed onset types of disorder as well as concurrent psychiatric and medical morbidity. Another area of interest is the control study and the comparative effectiveness of the various interventions (social interventions vs. pharmaco- and psychotherapies), and the assessment of parameters of community hardiness and vulnerability. Other important avenues of research are the long-term sequelae of disaster in terms of developmental psychopathology of high-risk populations, the transgenerational transmission of trauma and grief, and the development of sociopolitical attitudes and preferences. However, the search for answers to these intellectual questions, pressing though they may be, cannot at any time violate the privacy of the children being studied, and clinicians must be careful to comply with the accepted ethical guidelines. Institutional Review Boards can facilitate the process by offering a fast track for Conclusion
Disasters irrevocably destroy the space within which children and families thrive, thereby disrupting normal development. The overwhelming quality of the event combined with the massive extent of the loss gives rise to a complex clinical and social picture that may be termed the disaster syndrome. Children, families, neighborhoods, and whole communities are affected. Immediate damages can be only partially remedied and, therefore, the physical, psychological For effective intervention, the child mental health professional needs a comprehensive systemic, social and mental health perspective in order to develop the proper program, team-up with the proper authorities, accurately assess needs, and implement treatment. Best results are effected when the community is prepared. Some interventions are clinical and specific. Others can be mediated by educated professionals who work with children in schools and community centers. No single community can cope on its own. This requires networking in advance on the local, national and the international levels. The challenge of disasters, thus, is offered to our vision of the siblinghood of humanity. A global community committed to the cause of children References
1. Ursano RJ, Fullerton CS, McCaughey BG: Trauma and disaster. In: Ursano RJ, McCaughey BG, Fullerton CS (eds): Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Cambridge: Cambridge University Press, 2. Integrated Regional Information Networks: Disaster reduction and the human cost of disaster. http://www.irinnews.org/webspecials/DR (Retrieved Dec. 18, 2005). 3. Garmezy N, Rutter M: Acute reactions to stress. In: Rutter M, Hersov L (eds): Child and Adolescent Psychiatry: Modern Approaches (2nd Edition). Oxford: Blackwell, 1985, pp. 4. Goenjian AK, Walling D, Steinberg AM, et al: A prospective study of posttraumatic stress and depressive reactions among treated and untreated adolescents 5 years after a catastrophic disaster. Am J Psychiatry 162:2302-2308, 2005. 5. Pfefferbaum B: Posttraumatic stress disorder in children: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 36:1503-1511, 1997. 6. Udwin O: Annotation: Children’s reactions to traumatic events. J Child Psychol 7. Vogel JM, Vernberg EM: Children’s psychological responses to disasters. J Clin Child 8. Yule W, Perrin S, Smith P: Post-traumatic stress reactions in children and adolescents. In: Yule W (ed): Post-Traumatic Stress Disorders: Concepts and Therapy. Chichester: John 9. Laor N, Wolmer L, Mayes LC, et al: Israeli preschoolers under Scuds: A thirty-month follow-up. J Am Acad Child Adolesc Psychiatry 36:349-356, 1997. 10. Eisen ML, Goodman GS: Trauma, memory, and suggestibility in children. Dev 11. Terr LC: Childhood traumas: An outline and overview. Am J Psychiatry 148:10-20, 12. Laor N, Wolmer L: Trauma and emergency in child psychiatry: Clinical theory and innovative, multidisciplinary and multi-modal interventions. Presented at the 11th International Congress of the European Society for Child and Adolescent Psychiatry, 13. López-Ibor, JJ: What is a disaster. In: López-Ibor JJ, Christodoulou G, Maj M, et al (eds): Disasters and Mental Health. Chichester: John Wiley & Sons, 2005, pp 1-11. 14. Austin LS, Godleski LS: Therapeutic approaches for survivors of disaster. Psychiatr Clin 15. Laor N: The role of mental health professionals after mass disasters. Presented at the Congress on The Promised Childhood, Tel Aviv, 2001. 16. Pynoos RS, Goenjian AK, Steinberg AM: A public mental health approach to the postdisaster treatment of children and adolescents. Child Adol Psychiat Clin North Am 17. Raphael B: When Disaster Strikes: How Individuals and Communities Cope with Catastrophe. New York: Basic Books, 1986. 18. Laor N, Wiener Z, Spirman S, et al Community Mental Health Procedures for Emergencies and Mass Disasters: The Tel-Aviv Model. In: Danieli Y, Brom D, Sills J (eds): The Trauma of Terrorism: Sharing Knowledge and Shared Care, An International Handbook. NY: The Hawarth Press, 2004, pp. 681-684. 19. Danieli Y (ed): International Handbook of Multigenerational Legacies of Trauma. New 20. Laor N: Saving the Holocaust witness. In: Ariel Y, Biderman S, Rotem O (eds): Relativism and Beyond. Leiden: Brill, 1998, pp. 265-298. 21. Solomon Z: Coping with War-Induced Stress: The Gulf War and the Israeli Response. 22. Laor N: The protective matrix as risk-modifying function of traumatic effects in preschool children: A development perspective. Presented at the 6th International Psychoanalytic Association Conference on Psychoanalytic Research, London, 1996. 23. Krystal H: Massive Psychic Trauma. New York: International University Press, 1968. 24. Valent P: Disaster syndrome. In: Fink G (ed): Encyclopedia of Stress (Vol 1). San Diego, 25. Pynoos RS, Steinberg AM, Wraith R: A developmental model of childhood traumatic stress. In: Cicchetti D, Cohen DJ (eds): Developmental Psychopathology. Vol 2: Risk, Disorder, and Adaptation. New York: John Wiley & Sons, Inc, 1995, pp. 72-95. 26. Bingham RD, Harmon RJ: Traumatic stress in infancy and early childhood: Expression of distress and developmental issues. In Pfeffer C (ed): Severe Stress and Mental Disturbance in Children. Washington, DC: American Psychiatric Association Press, 27. Laor N, Wolmer L, Mayes LC, et al: Israeli preschoolers under Scud missile attacks: A developmental perspective on risk-modifying factors. Arch Gen Psychiatry 53:416-423, 28. Sullivan MA, Saylor CF, Foster KY: Post-hurricane adjustment of preschoolers and their families. Adv Behav Res Ther 13:163-171, 1991. 29. Goenjian A, Stillwell BM, Steinberg AM, et al: Moral development and psychopathological interference in conscience functioning among adolescents after trauma. J Am Acad Child Adolesc Psychiatry 38:376-384, 1999. 30. Vernberg EM, La Greca AM, Silverman WK, et al: Prediction of posttraumatic stress symptoms in children after Hurricane Andrew. J Abnorm Psychol 195:237-248, 1996. 31. Yule W, Williams RM: Post-traumatic stress reactions in children. J Trauma Stress 32. Green BL, Grace MC, Vary MG, et al: Children of disaster in the second decade: A 17- year follow-up of Buffalo Creek survivors. J Am Acad Child Adolesc Psychiatry 33:71- 33. Sack WH, Him C, Dickason D: Twelve-year follow-up study of Khmer youths who suffered massive war trauma as children. J Am Acad Child Adolesc Psychiatry 38:1173- 34. Gordon R, Wraith R: Responses of children and adolescents to disaster. In: Wilson JP, Raphael B (eds): International Handbook of Traumatic Stress Syndromes. New York: 35. Anthony JL, Lonigan CJ, Hecht SA: Dimensionality of posttraumatic stress disorder symptoms in children exposed to disaster: Results from confirmatory factor analyses. J Abnorm Psychol 108:326-336, 1999. 36. Terr LC: Chowchilla revisited: The effects of psychic trauma four years after a school- bus kidnapping. Am J Psychiatry 140:1543-1550, 1983. 37. Scheeringa MS, Zeanah CH, Drell MJ, et al: Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. J Am Acad Child Adolesc 38. Asarnow J, Glynn S, Pynoos RS, et al: When the earth stops shaking: Earthquake sequelae among children diagnosed for pre-earthquake psychopathology. J Am Acad Child Adolesc Psychiatry 38:1016-1023, 1999. 39. La Greca AM: Posttraumatic stress disorder in children. In: Fink G (ed): Encyclopedia of Stress (Vol 3). San Diego, CA: Academic Press, 2000, pp. 181-186. 40. Pynoos RS, Goenjian A, Tashjian M, et al: Post-traumatic stress reactions in children after the 1988 Armenian earthquake. Br J Psychiatry 163:239-247, 1993. 41. Goenjian A: A mental health relief programme in Armenia after the 1988 earthquake: Implementation and clinical observations. Br J Psychiatry 163:230-239, 1993. 42. Wolmer L, Laor N, Gershon A, et al: The mother-child facing trauma: A developmental outlook. J Nerv Ment Dis 188:409-415, 2000. 43. Pynoos RS, Nader K, Frederick C, et al: Grief reactions in school age children following a sniper attack at school. Isr J Psychiatry Relat Sci 24:53-63, 1987. 44. Goenjian AK, Pynoos RS, Steinberg AM, et al: Psychiatric comorbidity in children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry 34:1174-1184, 45. Noaghiul S, Prigerson H: Grieving. In: Fink G (ed): Encyclopedia of Stress (Vol 3). San Diego, CA: Academic Press, 2000, pp. 289-296. 46. Laor N, Wolmer L, Kora M, et al: Posttraumatic, dissociative and grief symptoms in Turkish children exposed to the 1999 earthquakes. J Nerv Ment Dis 190:824-32, 2002. 47. Putnam FW: Development of dissociative disorders. In: Cicchetti D, Cohen DJ (eds): Developmental Psychopathology. Vol 2: Risk, Disorder, and Adaptation. New York: John Wiley & Sons, Inc, 1995, pp. 581-608. 48. Shaw JA, Applegate B, Tanner S, et al: Psychological effects of Hurricane Andrew on an elementary school population. J Am Acad Child Adolesc Psychiatry 34:1185-1192, 1995. 49. Husain SA, Nair J, Holcomb W, et al: Stress reactions of children and adolescents in war and siege conditions. Am J Psychiatry 155:1718-1719, 1998. 50. Pfefferbaum B, Nixon SJ, Tucker PM, et al: Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. J Am Acad Child Adolesc Psychiatry 51. Green BL, Korol M, Grace MC, et al: Children and disaster: Age, gender, and parental effects on PTSD symptoms. J Am Acad Child Adolesc Psychiatry 30:945-951, 1991. 52. Udwin O, Boyle S, Yule W, et al: Risk factors for long-term psychological effects of a disaster experienced in adolescence: Predictors of posttraumatic stress disorder. J Child Psychol Psychiatry 41:969-979, 2000. 53. Lonigan CJ, Shannon MP, Taylor CM, et al: Children exposed to disaster: II. Risk factors for the development of post-traumatic symptomatology. J Am Acad Child Adolesc 54. Thabet AA, Vostanis P: Post-traumatic stress disorder in children of war. J Child Psychol 55. Wolmer L, Laor N, Yazgan Y: School reactivation programs after disaster: could teachers serve as clinical mediators? Child Adolesc Psychiatr Clin N Am 12:363-381, 2003. 56. McFarlane AC: Posttraumatic phenomena in a longitudinal study of children following a natural disaster. J Am Acad Child Adolesc Psychiatry 26:764-769, 1987a. 57. Garbarino J, Kostelny K: The effects of political violence on Palestinian children’s behavior problems: A risk accumulation model. Child Dev 67:33-45, 1996. 58. Gleser G, Green BL, Winget C: Prolonged Psychosocial Effects of Disaster: A Study of Buffalo Creek. New York: Academic Press, 1981. 59. Shannon MP, Lonigan CJ, Finch JR AJ, et al: Children exposed to disaster: I. Epidemiology of post-traumatic symptoms and symptom profiles. J Am Acad Child Adolesc Psychiatry 33:80-93, 1994. 60. Masten AS, Best KM, Garmezy N: Resilience and development: Contributions from the study of children who overcome adversity. Dev Psychopathol 2:425-444, 1990. 61. Earls F, Smith E, Reich W, et al: Investigating psychopathological consequences of a disaster in children: A pilot study incorporating a structured diagnostic interview. J Am Acad Child Adolesc Psychiatry 27:90-95, 1988. 62. Cohler BM, Stott FM, Musick JS: Adversity, vulnerability, and resilience: Cultural and developmental perspectives. In: Cicchetti D, Cohen DJ (eds): Developmental Psychopathology. Vol 2: Risk, Disorder, and Adaptation. New York: John Wiley & Sons, 63. Kassam-Adams N, Garcia-España, JF, Fein, JA, et al: Heart rate and posttraumatic stress in injured children. Arch Gen Psychiatry 62:335-340, 2005. 64. Wolmer L, Laor N, Cicchetti DV: Validation of the Comprehensive Assessment of Defense Style (CADS): Mothers’ and children’s responses to the stresses of missile attacks. J Nerv Ment Dis 189:369-376, 2001. 65. Winje D, Ulvik A: Long-term outcome of trauma in children: The psychological consequences of a bus accident. J Child Psychol Psychiatry 39:635-642, 1998. 66. Laor N, Wolmer L, Cohen DJ: Mothers’ functioning and children’s symptoms five years after a Scud missile attack. Am J Psychiatry 158:1020-1026, 2001. 67. Bromet EJ, Goldgaber D, Carlson G, et al: Children’s well-being 11 years after the Chernobyl catastrophe. Arch Gen Psychiatry 57:563-571, 2000. 68. McFarlane AC: Family functioning and overprotection following a natural disaster: The longitudinal effects of posttraumatic morbidity. Aust N Z J Psychiatry 21:210-218, 69. Parker JG, Rubin KH, Price JM, et al: Peer relationships, child development, and adjustment: A developmental psychopathology perspective. In: Cicchetti D, Cohen DJ (eds): Developmental Psychopathology. Vol 2: Risk, Disorder, and Adaptation. New York: John Wiley & Sons, 1995, pp. 96-161. 70. Laor N, Wolmer L, Sunar S, et al: Mother-child short-term group psychotherapy for posttraumatic stress disorder. Presented at the Congress on The Promised Childhood, Tel 71. Cochrane A, Holland W: Validation of screening procedures. Br Med J 27:3-8, 1969. 72. Stallard P, Velleman R, Baldwin S: Psychological screening of children for post- traumatic stress disorder. J Child Psychol Psychiatry 40:1075-1082, 1999. 73. Green BL: Assessing levels of psychological impairment following disaster: Consideration of actual and methodological dimensions. J Nerv Ment Dis 170:544-552, 74. Ohan JL, Myers K, Collet BR: Ten-year review of rating scales. IV: scales assessing trauma and its effects. J Am Acad Child Adolesc Psychiatry 41:1401-1422, 2002. 75. Strand VC, Sarmiento TL, Pasquale LE: Assessment and screening tools for trauma in children and adolescents. Trauma, Violence & Abuse 6:55-78, 2005. 76. Vernberg EM, Vogel JM: Interventions with children after disasters. J Clin Child Psychol 77. Bass BM, Avolio BJ: Improving organizational effectiveness through transformational leadership. Thousand Oaks, CA: Sage Publications, 1994. 78. Galante R, Foa E: An epidemiological study of psychic trauma and treatment effectiveness after a natural disaster. J Am Acad Child Adolesc Psychiatry 25:357-363, 79. Goenjian AK, Karayan I, Pynoos RS, et al: Outcome of psychotherapy among early adolescents after trauma. Am J Psychiatry 154:536-542, 1997. 80. Wolmer L, Laor N, Kora M: School reactivation after disaster: The case of the Israeli Village. Presented at the Congress on The Promised Childhood, Tel Aviv, 2001. 81. Schwarz ED, Kowalski JM: Malignant memories: Reluctance to utilize mental health services after a disaster. J Nerv Ment Dis 180:767-772, 1992. 82. Lindy JD, Grace MC, Green BL: Survivors: Outreach to a reluctant population. Am J Orthopsychiatry 51:468-478, 1981. 83. Wolmer L, Laor N, Dedeoglu C, et al: Teacher-mediated intervention after disaster: a controlled three-year follow-up of children's functioning. J Child Psychol Psychiatry 84. Perrin S, Smith P, Yule W: Practitioner review: The assessment and treatment of post- traumatic stress disorder in children and adolescents. J Child Psychol Psychiatry 41:277- 85. Flynn BW, Nelson ME: Understanding the needs of children following large-scale disasters and the role of government. Child Adolesc Psychiatr Clin North Am 7:211-227, 86. Spirman S, Friedman Z, Buchner N: Mass Emergency Treatment System. Tel Aviv-Jaffa 87. Stallard P, Law F: Screening and psychological debriefing of adolescent survivors of life- threatening events. Br J Psychiatry 163:660-665, 1993. 88. Chemtob CM, Tomas S, Law W, et al: Postdisaster psychosocial intervention: A field study of the impact of debriefing on psychological stress. Am J Psychiatry 154:415-417, 89. Mayou RA, Ehlers A, Hobbs M: Psychological debriefing for road traffic accident victims. Br J Psychiatry 176:589-593, 2000. 90. Wessely S, Rose S, Bisson J: A systematic review of brief psychological interventions (“debriefing”) before the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. Cochrane Library (Vol 4). Oxford: Update 91. Klingman A: School-based interventions following a disaster. In: Saylor CF (ed): Children and Disaster. New York: Plenum Press, 1993, pp. 187-210. 92. Pynoos RS, Nader K: Psychological first aid and treatment approach to children exposed to community violence: Research implications. J Trauma Stress 1:445-473, 1988. 93. Gillis HM: Individual and small group psychotherapy for children involved in trauma and disaster. In: Saylor CF (ed): Children and Disasters. New York: Plenum Press, 1993, pp. 94. Smith P, Dyregrov A, Yule W et al: Children and disasters: Teaching recovery techniques. Bergen, Norway: Children and War Foundation, 1999. 95. Eth S: Clinical response to traumatized children. In: Austin LS (ed): Responding to Disaster. A Guide for Mental Health Professionals. Washington, DC: American 96. Lovett J: Small Wonders. Healing Childhood Trauma with EMDR. New York: The Free 97. Toren P, Wolmer L, Rozental B, et al: Case series: Brief parent-child group therapy for childhood anxiety disorders using a manual-based cognitive-behavioral technique. J Am Acad Child Adolesc Psychiatry 39:1309-1312, 2000. 98. Spirman S, Mizrahi C, Refetov, et al: Development and implementation of a community reactivation program after disasters. Presented at the Congress on The Promised 99. Rappaport J: Terms of empowerment/exemplars of prevention. Toward a theory for community psychology. Am J Community Psychol 15:121-145, 1987. 100. Kobasa SC: Stressful life events, personality, and health: An inquiry into hardiness. J 101. Shiloh R, Nutt D, Weizman A: Atlas of Psychiatric Pharmacotherapy. London: Martin 102. Donnelly CL: Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder. Child Adolesc Psychiatr Clin N Am 12:251-269, 2003. 103. Marshall RD, Davidson JRT, Yehuda R: Pharmacotherapy in the treatment of posttraumatic stress disorder and other trauma-related syndromes. In: Yehuda R (ed): Psychological Trauma. Washington, DC: American Psychiatric Press, Inc., 1998. 104. Cohen RE: The Armero tragedy: Lessons for mental health professionals. Hosp Community Psychiatry 38:1316-1321, 1987. Table 1: The recovery process from a mass disaster in evacuated communities. Disaster
Stage
Social
structures in
the affected
community
Auxiliary
social
structures and
functions
(introduced
from the
outside)
Professional
child mental
health
interventions
Rehabilitated
roles
Existential
orientation
Table 2: The Tel Aviv Network of Urban Resilience. counseling to schools team of counselors as

Source: http://www.childrenatrisk.co.il/src//Children-Exposed%20to%20disaster.pdf