Nursing Spectrum
August 28, 2006
Karen Patterson
These days, wide young eyes are watching.
They’re seeing urban landmarks crumble, rural vistas consumed by flames, maybe their own homes engulfed by water.
Consider the young Americans who will turn 18 today. In just five years they’ve experienced the profound tragedies of 9/11 and Hurricane Katrina.
Over the years there was the Oklahoma City bombing — and Columbine, among a spree of school slayings. Major earthquakes have rocked California: first north, then south. Much of Florida has been upended by hurricanes, with southern Florida ravaged twice in just over a dozen years.
Flash flooding. Wildfires. Mudslides.
Sometimes our children experience disaster personally. Other times, it’s on TV. But too often, it’s no longer just a bad dream.
Mental health practitioners say that children are often an afterthought amid catastrophe — even though they’re at real risk for a host of psychosocial ills. Moreover, the crush of recent calamities has raised this nagging concern: Is America facing a generation of youth who will be permanently psychologically scarred?
“That’s the million-dollar question,” says Air Force Col. John S. Murray, RN, PhD, CPNP, CS, FAAN. “Natural disaster, human-caused disaster, violence with weapons, terrorist acts — all have directly touched the lives of children in ways we’ve never seen before.”
feeling the aftershocks
As the dust of a disaster settles, responders are ready for psychological fallout. But discerning such fallout over the long term, when time separates trauma from subsequent tears, is often difficult.
Mental distress can be subtle, says Bernadette Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP, manifesting itself with symptoms such as recurrent headaches or abdominal pain. Yet, months or more from a disaster, providers often don’t look more deeply into such somatic symptoms. “We have a lot of kids who are suffering from depression, from anxiety, and they live like this for years before they are ever diagnosed,” says Melnyk, dean of the Arizona State University College of Nursing & Healthcare Innovation.
Traumatized kids may develop other psychological ills, including posttraumatic stress disorder (PTSD). The condition, notes Murray, arises by means of neurobiological changes that happen in response to stress.
PTSD can cause a variety of changes in the brain stem, says Murray, an experienced disaster responder and a consultant to the surgeon general for research and for pediatric nursing. “It’s possible that this altered development includes a disregulated brain stem, which leads to all the signs and symptoms of altered brain stem function: cardiovascular function, mood lability, behavioral impulsivity, increased anxiety, increased startle response, sleep abnormalities.”
Psychological trauma can also lead children to long-term behavioral or relationship problems. Kids may falter in school, develop low self-esteem, or erupt with aggression or violence.
“Any number of problems can surface,” says Claude Chemtob, PhD, professor of psychiatry and pediatrics at Mount Sinai School of Medicine in New York. “And the big challenge is that people will not recognize them after a year or two as being tied to the disaster.”
relevant research
The medical literature gives just a glimpse of what might happen years later to children who have survived communal tragedies. Long-term research is scant in part because it takes time and money. And there really is no “textbook case,” but rather a multitude of disasters, circumstances within a disaster, child and family factors, and investigative limitations that can affect outcomes.
Still, a handful of studies have aimed to shed light on the question. Among them:
- A comparison of children ages 4 to 12, and adolescents 13 to 18, who were exposed to a fireworks depot explosion six years ago in the Netherlands. Up to two years later, in both groups of kids, researchers found increased rates of problems including psychological and musculoskeletal ills and stress reactions. Among the younger group, gastrointestinal and sleep problems were more troublesome; in the older group, skin problems and anxiety issues. The study appeared this year in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP).
- An examination of young adults who as teenagers survived a 1988 ship sinking in Greek waters. More than half had PTSD at follow-up as many as eight years later, with most of the cases documented in the first six months. PTSD lasted more than five years in 26% of the survivors. Parallel research found elevated rates of anxiety and mood disorders — some on the heels of the sinking, some arising years later, mainly in the subjects who also had suffered PTSD. Both studies were published in 2000 in the Journal of Child Psychology and Psychiatry.
- A follow-up, 17 years after the 1972 collapse of the Buffalo Creek dam in Appalachia, focusing on children who were ages 2 to 15 at the time. At follow-up, little difference was found between the survivors included in the study and the unaffected peers, suggesting that over the long term, the outlook may be good for many child victims. The research appeared in 1994 in JAACAP.
- A study six decades later of the effects of evacuation on British youngsters during World War II. Researchers found that those who were living in areas threatened by bombing who were removed from their parents’ care fared worse psychologically than those who stayed put. The research was published in 2003 in Aging & Mental Health.
Separations like those during World War II — and maybe even some in the aftermath of Katrina — can have profound effects on a developing personality, showing up in the form of attachment disorders, a psychological result of neglect or lengthy negative experiences with caregivers. “Genuine attachment experiences are so critical to sound development of children,” Murray says.
Attachment disorders may later surface as aggression or violence, low self-esteem, lack of self-control, breakdown in the face of adversity, or difficulty establishing intimacy.
“A lot of these kids are very negative; their outlook on life is very hopeless,” Murray says. “Society didn’t help them when they needed it most.”
Another influence on children’s health after disaster is how well parents hold themselves together, researchers have found.
About a year after 9/11, Chemtob and colleagues began studying preschool children and their mothers who lived near the World Trade Center. The children seemed seriously affected only by the most extreme exposures to the tragedy — for instance, if a child saw someone leap out of the towers, or someone who’d been killed or severely hurt. “Most of the children, however, were affected indirectly,” Chemtob says, “by the impact of 9/11 on their mothers. So mothers who had 9/11-related psychological symptoms tended to have children who had significantly more symptoms,” including sleep disruption, separation problems, and emotional volatility.
Even children who aren’t yet born at the time of loss or disaster might suffer harm, apparently through the psychological ills a tragedy can stir in a parent. The phenomenon, known as the intergenerational transmission of trauma, has been documented, for instance, in children of Holocaust survivors.
Murray says he always tells parents: “Before you can take care of the child, you have to take care of yourself.”
It’s important, says Elizabeth C. Poster, RN, PhD, FAAN, that parents help their children understand “that they are now safe, that they are protected, and that they are not alone.”
across the timeline
In part, predicting the future health of children in disasters requires looking at their past and present.
In a study following the ship sinking off Greece, researchers distinguished factors from before, during, and after the accident affecting whether survivors developed PTSD. Factors included sex of the survivor (females fared worse), predisaster mental or domestic trouble, severity of exposure to the event, how the survivors judged the experience, how they adjusted shortly after, and life events and social support that followed. Among those who developed PTSD, key factors predicting duration and severity of the illness included social, physical, and psychological woes that preceded the disaster.
“What coping skills were they bringing to the table when this happened?” Melnyk asks, speaking generally about children who survive catastrophe. “What social support? The kids who are going to have more long-lasting effects from this are the kids who are more predisposed to developmental issues and don’t have developmental assets.”
A strong support system can absolutely be protective against disaster trauma, writes Poster, president of the American Psychiatric Nurses Association, in an e-mail interview. So can a child’s emotional foundation before a disaster.
“Having confidence in oneself, the world around us, and the future is nurtured over time,” she says, “and takes a complex mix of daily positive experiences [and] caring people who allow us to grow and be ourselves, and allow us to experiment with making decisions and interacting with others.”
psychiatric infrastructure
Melnyk has no doubt that children affected by disaster will suffer psychological consequences. But she believes the underlying problem is the fractured U.S. mental health care system. She cites an estimated 70% of children with psychological problems who don’t receive treatment. “It’s staggering to think about these kids growing into adults with chronic mental health problems,” she says. “Whether the disasters are there or not, we are going to have these continuing, gathering problems unless we mount a bigger effort.”
While a disaster may overburden an already stressed mental health system, Poster says such a one-time event may not be as harmful to a child as the types of ongoing trauma that daily tap the system of care. “For example, long-term sexual abuse as a childhood trauma, and a single devastating event such as Katrina, may have very different long-term consequences,” says Poster, who is dean of the University of Texas at Arlington School of Nursing. “While both are traumatic, we would expect that without other ongoing stress in a child’s life, children experiencing a single trauma such as a natural disaster would have less long-term effect.”
Just before 9/11, the National Association of Pediatric Nurse Practitioners (NAPNAP) launched a program called KySS: Keep Your Children/Yourself Safe and Secure. Its goal is to promote treatment of, and to prevent, psychosocial ills in kids. NAPNAP surveyed youngsters and parents and found major worries about anxiety, depression, self-esteem, the parent-child relationship, and most of all, coping with stress.
Yet these families weren’t raising the concerns with primary care providers, either before or after September 11th, the survey found.
challenges from 9/11
A major challenge in connecting young disaster victims with mental health care is finding the kids who need it most.
After 9/11, the nation tallied how many people died at the World Trade Center, the Pentagon, and on Flight 93, but no single group — including major relief agencies — had a full list of children who had lost parents, says Mount Sinai’s Chemtob.
He and his colleagues began an exhaustive effort to compile such a list. They identified 1,363 victims of 9/11 who were parents with minor children; these parents left behind 2,752 children under age 18, including more than 100 conceived but not born by the time of the tragedy.
“You really can’t start to do any long-term follow-up without [such a] registry,” Chemtob says. “A major issue in terms of national preparedness is to develop methods that would allow us … to intervene from a public health perspective.”
He says the federal government should require development of such registries after any disaster of national proportions. In the team’s work since 9/11, “We’ve learned that a lot of children, despite having a lot of resources thrown at them, are continuing to have substantial problems.”
The nation, Chemtob argues, must invest more in preparing for disaster’s psycho-social fallout. “Our country is primarily invested in hard assets, things like more drugs and more gas masks, but not very much in preparing people.”
