Sunday, May 23, 2010



       Working in Sarajevo in 1993 during the Bosnian-Serb war Dr. Arshad Husain, a child psychiatrist from the University of Missouri-Columbia was impressed with how many children were suffering from post-traumatic-stress disorder and how few specialists were available to provide treatment. He according developed a program to train teachers in group treatment techniques that could be integrated into their regular school work with the children.
       He made 26 trips to Bosnia to work with physicians and teachers and early on discovered that some teachers who were especially skilled at using the techniques themselves could be trained to train other teachers. This program he called “Training the Trainer,” and for a number of years these teachers were brought to the U.S. for a summer program giving them the additional training they needed in order to pass their skills on to others.
         I joined the team in 1995 and made six trips with Dr. Husain to Bosnia and later joined the team on trips to Kosovo, Palestine, and Pakistan working with teachers and mental health workers in war zones. In 2001 we worked the earthquake in India and found that the children there had suffered similar traumas what we had seen in war zones and had similar symptoms that responded to the same therapeutic techniques.
       As a member of the trauma team from the University of Missouri-Columbia’s International Center for Psychosocial Trauma, I have worked closely with many teachers, physicians and mental health professionals treating victims in war zones, earthquake and tsunami sites in Indonesia and Sri Lanka and more recently with victims of Hurricane Katrina.
       In these natural disasters thousands of children lost their homes and experienced the destruction and death similar to what happens in a war zone. In fact in recent natural disasters there has been a greater loss of life and more destruction of property than in our ongoing wars. In this book I will explore the nature of natural disasters, how individuals react to them and what techniques we train our participants to use in treating victims.
       After Hurricane Floyd in 1999 and Hurricane Andrew in 1992, short- and long-term studies examined children’s reactions. The information collected in the studies, combined with studies of reactions after the Oklahoma City bombing and many earthquakes, has given us a picture of how children react to life-threatening disasters.

Victims of the India earthquake are attended to in a tent hospital in the city of Anjar. The highest estimate reported 80,000 dead and many more wounded.

How many will suffer post-traumatic symptoms?
       The smallest number I have found in formal studies of post-traumatic stress disorder was 16.5 percent of preschool children 12 months after Hurricane Andrew. A year after Hurricane Floyd, a study of a group of North Carolina schoolchildren found that 44 percent of the girls and 21 percent of the boys had severe to very severe symptoms. A study immediately after Andrew found 95 percent of the children showing initial symptoms.
        Because so many children have symptoms initially, they are not labeled as having a disorder until the symptoms have lasted for more than a month. Most children are highly resilient, and although they have symptoms immediately after a disaster, these fade rather quickly. That still leaves helpers with an overwhelming number of children who could benefit from some kind of therapeutic interventions.
        Girls have more symptoms than boys, and children who have lost their homes have more serious symptoms than children who had to leave the area but could return to their homes.
        Given that Katrina did more damage than previous hurricanes that have been studied, I would predict that a larger number of children exposed to this disaster will have post-traumatic stress symptoms.

Children in a refugee camp in Sri Lanka after the tsumani

What are the most frequent symptoms?
       To be diagnosed with PTSD, a child must first of all been exposed to a life threatening experience or one where there was a great deal of destruction. The person exposed to this out of the ordinary experience must then show symptoms in three categories: (1) re-experiencing the trauma, (2) avoidance/numbing and (3) increased arousal. Nightmares are the most frequent re-experiencing symptoms reported by children who have undergone a life-threatening trauma. In young children, we often can see the re-experiencing in their play, in which they repeat over and over again some aspect of the disaster.
       Avoidance/numbing is shown by avoidance of any reminders of the traumatic event, and for some children, this might include amnesia regarding the trauma. Some children become withdrawn and won’t even participate in their usual activities. Occasionally, this will show itself by the child talking as if he or she does not have long to live; the child sees life as shortened.
       Increased arousal includes sleep difficulties, irritability and angry outbursts. Some children are hyper-vigilant, constantly searching their surroundings for signs of danger. They also have a strong startle response, overreacting sometimes with panic to sounds and sudden movements. In Sri Lanka, we found children running from a room upon hearing the sound of a flushing toilet.
       Although not listed as PTSD symptoms, other common reactions are clinging, crying, not eating and whining. Some children become more aggressive and, because of difficulty concentrating on a task, can be mistaken for individuals with attention-deficit disorders.
       Because so many children have symptoms after a disaster, it is unrealistic to expect them to receive individual therapy. Therefore, we have found that teachers, social workers, psychologists and physicians can be taught to use a variety of group techniques. Many of these techniques, such as relaxation can also be used with individuals.

What are some ways traumatized children are helped?
● The helpers and parents need to be educated about what symptoms to expect and to understand that these symptoms are normal reactions to a life-threatening event.
● Stress-reduction techniques need to be taught. We typically demonstrate and teach helpers to use four techniques, including progressive muscle relaxation, and usually find that a group can come up with four or more others, such as prayer, that are useful.
● Children might feel guilt because they believe they are responsible for what happened because of some perceived bad behavior, or they might think the world is no longer safe. These distortions can often be confronted directly with logic.
● A group of children can become a support base to help its members improve their internal self-talk: “I’m a good person, and others like me.”
● For children who are withdrawn or nonverbal, art and play therapy are often helpful.
● Traumatized children should be given opportunities to tell their stories about what happened.
• Opportunities need to be provided for the children to physically work off tensions caused by the stress.

Although it has been rare for us to be able to work directly with parents, we have found that parents’ reactions are important. If parents can be helped with their distress, the children will have easier times dealing with their reactions.

       In summary, earthquakes, hurricanes, typhoons, tornados, floods and tsunamis have subjected thousands of children to a life-threatening events in which they may have lost family members, been injured and lost parts of their support system, such as their homes and their schools.
       Most of these children will show signs of strong emotional reactions, and in some cases such a Katrina perhaps as many as 40 percent will continue to have problems in the future if they do not receive some therapeutic interventions. It must be recognized that this is an ongoing problem that needs attention. There are group treatment activities that can alleviate some of the psychological damage done by disasters.

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