JSPN Vol. 11, No. 2, April, 2006 133

Blackwell Publishing LtdOxford, UKJSPNJournal for Specialists in Pediatric Nursing1088-145X© 2006 Blackwell Publishing, Inc.April 2006112

ORIGINAL ARTICLE

Collaborative Practice

Collaborative Practice

Addressing the Psychosocial Needs of Children Following Disasters

Colonel John S. Murray Column Editor: Kathleen Ryan Kuntz

Collaborative Practice

provides a forum for healthcare professionals to share expertise and enhance communication.

The effects of Hurricanes Katrina and Rita, some of theworst natural disasters in our nation’s history, haveonce again caused the people of the United States toexamine how we respond to large-scale disasters.Images of incomprehensible destruction and heart-break throughout the Gulf Coast Region showed usemotionally distraught evacuees; people desperately inneed of water, food, medical care, and shelter; andtowns and communities that were totally decimated.These are just some of the long-lasting impressions thatwill be fixed in the minds of people around the worldfor years to come. The numerous lives lost and hun-dreds of thousands of Americans suffering great hard-ships include children who may be the most affectedvictims. The aftermath of such catastrophic eventsplaces great strain on entire communities, includingthose of pediatric healthcare professionals who aresources of support and assistance for children and fam-ilies but may also be victims and survivors themselves.

As the former pediatric consultant to the SurgeonGeneral for 7 years, I was asked to help develop a dis-aster response plan for the pediatric victims of the tsu-nami disaster in South and Southeast Asia last year. Atthat time, I never imagined that in the span of less thana year we would be experiencing events of comparablemagnitude here in the United States. Like the tragedyin Asia, Hurricanes Katrina and Rita were enormouslyfrightening to children and adults alike. It is importantfor pediatric healthcare professionals to understandnormal responses to trauma, acknowledge the impactof disasters on children, and understand the factorsthat affect their response to such events (AmericanPsychological Association, 2005). Past disasters in theUnited States, whether from terrorism such as theOklahoma City bombing and the September 11 attacks,or natural disasters such as the Northridge earthquake,Hurricane Ivan, and now Hurricanes Katrina andRita, critically highlight the importance of the need for

pediatric healthcare professionals to understand thestress reactions of children to disasters and the inter-ventions necessary to address their psychosocial needsfollowing such events. Hurricane Katrina, in particular,has demonstrated that we have much more to doacross the country to be prepared for such large-scalecatastrophes in addition to understanding the possiblelong-term psychosocial morbidity among children as aresult of all types of disasters.

Children’s Reactions to Disaster

A child’s reaction to disaster largely depends onhow much destruction and loss he or she has seen as aresult of the disaster. If a family member, friend,teacher, and/or pet has been lost, seriously injured, orkilled, or if the child’s home, school, or neighborhoodwas severely damaged, there is a significantly greaterchance that the child will experience adjustment diffi-culties. A child’s age will also affect how the child willrespond to disaster. For example, a 5-year-old mayshow his or her worries by regressing to behaviors pre-viously outgrown, whereas adolescents may protectthemselves emotionally by distancing themselves fromparents, family, and friends (American Academy ofChild and Adolescent Psychiatry, 2005). The mostcommon reactions to disaster seen in children closelymirror those found in other circumstances where stressand separation are paramount concerns. Helping chil-dren during these extremely difficult times requiresattentiveness to a vast array of psychosocial responsesthat children might exhibit.

Infants will show signs of anxiety reflective of theadults who provide their care. When parents and care-takers are stressed as a result of disaster, infants maybe affected as well, demonstrating changes in sleep,eating patterns, and levels of responsiveness, includingepisodes of irritability, exaggerated startle response, orapathy (Murray, 2002; Plum, 2003). Infants may also showsigns of regression and even detachment, especially ifseparated from the primary caretaker as a result of thedisaster (e.g., being evacuated or parental loss).

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Collaborative Practice

Toddlers will be affected by the stress of disastermuch more than infants, especially if separated fromtheir primary caretaker, as we have seen all too oftenin the media in the wake of Hurricane Katrina. Chil-dren in this age group will respond by being with-drawn and even depressed, looking to adults forcomfort and attention at a level greater than previ-ously needed. Like infants, toddlers may also experi-ence changes in eating and sleeping behaviors(Murray, 2002). Of particular concern in this age groupare signs such as sleep terrors, recurring nightmares,behavioral regression manifesting as helplessness,clinging behavior, and increased temper tantrums.

Children of preschool age may respond to the stressof disaster by regressing, and/or by exhibiting extremehelplessness, passivity, lack of awareness of theirphysical surroundings, and/or fear and guilt. Persist-ent fears related to the catastrophe (such as fears aboutbeing permanently separated from parents), as well asloss and feelings of guilt that somehow they wereresponsible for the disaster, are common. Preschoolerswill typically also display a greater number of usuallyself-limited somatic complaints such as dizziness,headaches, and stomachaches (American Academy ofChild and Adolescent Psychiatry, 2005; Murray, 2002;Plum, 2003).

School-age children are better able to comprehendthe nature of events occurring during a disaster. How-ever, despite their greater emotional and cognitivedevelopment, they are still quite vulnerable to stressreactions. Children in this age group fear for their ownsafety as well as for the safety of family members. Thisresults in difficulty with sleeping, such as nightmaresand screaming during sleep, which in turn leads toproblems with school performance and fluctuations inmood. Withdrawal from family and friends, sadness,listlessness, decreased activity, and preoccupation withthe events of the disaster may also occur (AmericanAcademy of Child and Adolescent Psychiatry, 2005).

Adolescents are better able to understand the cir-cumstances of disasters on a level that more closelyresembles adults. However, they are a particularly

vulnerable group because they are already goingthrough a period of complex changes. Teens mayengage in risk-taking behaviors as a mechanism forcoping with inconceivable stress. Although stressreactions such as acting out, delinquency, poorschool performance, and resentment may be exhibitedas possible emotional grief reactions, positive behaviorssuch as contributing to recovery efforts, assumingadditional responsibilities, and providing support andencouragement to other victims may also be seen(Murray, 2002; Plum, 2003).

How Nurses Can Help Meet the Psychosocial Needs of Children

When responding to disasters, it is critically impor-tant for pediatric healthcare professionals to rememberthat despite the pandemonium, many of the stressreactions of children and families witnessed are nor-mal reactions to a very unusual circumstance. Manag-ing the psychosocial consequences resulting fromdisaster requires a very thoughtful and comprehensiveplan of care to lessen the adverse impact of disaster onchildren from an emotional, cognitive, and behavioralperspective. This is especially true for children if theywere separated from their families as a result of thecalamity. Nurses and all healthcare professionalsresponding to disasters must be familiar with the spe-cial needs of children under such adverse conditions,including the necessary assessment strategies andinterventions based on age, developmental level, andcognitive development (Plum & Veenema, 2003). Pedi-atric healthcare professionals should actively seek outchildren and families involved in disasters to let themknow of available services.

The principal effect of a disaster on children is theinterruption of their lives through injury and loss, ordestruction of home, school, and/or neighborhood.This leads to a loss of consistency, structure, and pre-dictability, which affects children regardless of ageand developmental level. There are specific interven-tions that pediatric healthcare professionals can

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employ to help children of all ages. Of utmost impor-tance is being available for parents to provide theemotional support needed to help them to be betterable to care for their children. Providing educationalsupport, such as teaching parents and other caretakersabout common behaviors children or adolescentsmight exhibit, will help parents to mobilize theresources needed to provide the care needed. For fam-ilies with children requiring mental health support,referrals to qualified mental health clinical nurse spe-cialists, nurse practitioners, psychologists, child-lifeexperts, etc. are needed. Oftentimes the American RedCross provides these services when they are deployedto disaster areas. An experienced mental health profes-sional can help children and parents understand andcope with thoughts, feelings, and behaviors that resultfrom such adversity by providing constructive meansof dealing with the inconceivable emotional impact.

Families and healthcare professionals should makesure that adults spend more time with children, allow-ing them to be more dependent on adults for as longas needed in the aftermath of the disaster. The impor-tance of social support networks cannot be empha-sized enough when children are under stress (Murray,2000). These networks, including family, friends,members of the clergy, healthcare professionals, andrescue volunteers, can be one of the most influentialinterventions in the aftermath of a disaster (Plum &Veenema, 2003).

Providing for basic needs, such as physical comfort,and ensuring that routines are maintained and consist-ent, and that familiar caretakers are available for thechild are the most important of interventions forinfants. Ensuring that the parents’ needs are addressedwill also make certain that the infant has a parentavailable who is emotionally and physically able toprovide appropriate care. For toddlers, nothing ismore important than re-establishing and maintaining apredictable routine for activities, such as eating, play-ing, and sleeping. All these interventions serve to helprestore a sense of safekeeping and normalcy, even forfamilies who have been relocated to a shelter, the

home of friends and family, or other temporaryaccommodations. On occasion, especially when thechild demonstrates difficulty with sleeping, parentsshould be accommodating, but also need to establish aroutine as much as possible. Use of night lights if pos-sible, favorite stuffed animals if available, comfort,and relaxing interventions such as music, singing, orstorytelling are helpful.

With preschoolers, ensuring that parents are readilyavailable will help to alleviate unnecessary fears ofseparation. Younger children do not understand whathas occurred, nor will they understand the conse-quences. These children should receive plenty of reas-surance that they will be safe and protected. Allowingregression to previously outgrown behaviors on atemporary basis will assist with coping. Nonverbalactivities, such as play, will also help to minimizestress and provide a vehicle for sharing thoughts andfeelings. Because of their cognitive stage of develop-ment, school-age children may feel that in some waythey are responsible for the disaster and ensuing chal-lenges faced by their family. Reassurance and oppor-tunities to express feelings and emotions are criticalfor this age group. Many children may not be ready totalk about what has happened. Use of expressive ther-apy, such as play, drawing, puppets, etc., will help tofacilitate expression of feelings. Finding another childof the same age with whom the child can share his orher anger, concerns, and fears would be invaluable. Ifresiding in a shelter, groups of children might gettogether to talk about how they are feeling. If childrenunderstand disaster, and are able to see they are notalone, they can better cope with the suffering of adisaster.

Adolescents should also be given opportunities toshare their stories. It is vitally important to keep allavenues of communication open and available. Pro-viding age-appropriate social activities, roles in com-munity rebuilding, and additional responsibilities willprovide opportunities for teens to share their feelingsand make them feel like they have an important partin the recovery and healing process.

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Assessment Tools for Pediatric Healthcare Professionals

A number of assessment tools exist for pediatrichealthcare professionals to evaluate the degree towhich children have been affected by disaster. Initialclinical assessments should include an evaluation forany of the psychosocial reactions noted previously,such as changes in eating, sleeping, behavior, andrelationships with family members and/or friends.Additionally, there are a number of screening toolsavailable to determine if a child is experiencing adjust-ment difficulties following a disaster.

The newest version of the Child Behavior Checklistcan be used for children and adolescents from 6 to 18years of age (Achenbach & Rescorla, 2001). A ChildBehavior Checklist exists for younger children (18months to 5 years) as well (Achenbach & Rescorla,2000). Both instruments evaluate emotional andbehavioral adjustment over the previous six months.

The Trauma Symptom Checklist for Children (TSCC)is a self-report measure of posttraumatic distress as itrelates to a number of sources of trauma, includingdisasters. The TSCC is helpful as an intervention forchildren ages 8–16 years (Briere, 1996). Other assess-ments for trauma in the pediatric population includeTraumatic Events Screening Inventory–Child version(TESI–C) (Ribbe, 1996) and the When Bad ThingsHappen Scale (WBTH) (Fletcher, 1996a). A number ofself-report scales also exist to screen for posttraumaticstress disorder (PTSD) in children, such as the Child-hood PTSD Interview (CPTSDI) (Fletcher, 1996b),PTSD Reaction Index (Nader, 1996), and the Clinician-Administered PTSD Scale for Children and Adolescentsfor DSM-IV (CAPS-CA) (Newman & Ribbe, 1996).

The Importance of Community Collaboration

The importance of collaboration between pediatricnurses and professionals in communities impacted bydisaster cannot be overemphasized. In the aftermathof disasters, schools are an ideal place to assess

children, especially when this setting is being used as atemporary shelter for families. Collaboration betweenthe pediatric healthcare professionals and school per-sonnel is extremely important. Pediatric nurses shouldbe encouraged to work with school staff to developinformation about what to expect from children after adisaster, provide suggestions on age-appropriateinterventions, assist in developing a list of referralservices, and offer to provide assessments for adjust-ment difficulties and high-risk behaviors. Also usingthe school as a point of intervention, mental healthproviders can offer counseling programs for childrenand/or families to discuss anger, fear, grief, and lossas a result of the disaster. A poignant example of howthis can work is the story of an American Red Crossvolunteer in Baton Rouge, Louisiana, who recognizedthat there were hundreds of school-age children in aschool shelter who needed something to do to taketheir minds off of the massive devastation imposed byHurricane Katrina. The volunteer had the children makesurvivor bracelets that represented hope—hope thatthey would be OK. This intervention helped many ofthe children on their journey toward emotional healing.

Pediatric healthcare professionals also have an import-ant role as a source of information. Pediatric nursesand other professionals are frequently asked to speakwith various community organizations, such as disas-ter response groups or at places of worship, about thepsychosocial effects of a disaster on children and fam-ilies. Collaborative efforts should be undertaken to usethe media to inform the public of how they can obtainservices for children and families. Individuals special-izing in pediatric health care should contribute articlesor sessions on the psychosocial impact of disasters onchildren by using media formats, such as newspapers,news bulletins, radio, and television where possible.The same professional might also assist with disasterhotlines, such as those set up by organizations like theAmerican Red Cross, Federal Emergency ManagementAgency, Direct Relief International, and NationalCenter for Missing and Exploited Children, to provideguidance for children displaced in natural disasters.

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The collaboration of professional organizations suchas the National Association of Pediatric Nurse Practi-tioners, Society of Pediatric Nurses, National Associa-tion of School Nurses, National Association of SchoolPsychologists, American Psychological Association, Ameri-can Nurses Association, and the American Academyof Pediatrics are also vitally important. Many of theseorganizations have created Web site links that containresources and networks needed to provide informa-tion to disaster response teams who provide care tochildren and families. In addition, some organizationslike the American Psychological Association havepartnered with the American Red Cross to providepediatric healthcare professionals who are trained andavailable to respond to disasters for emergency crisisintervention and/or longer term referral.

The recent events in the United States have demon-strated the importance of having healthcare profes-sionals able to respond to large-scale disasters thatcould quite possibly affect all of us around the worldat any given time. An alarming question still remains,are we ready to respond? In the aftermath of Hurri-cane Katrina, healthcare professionals learned thateven though one of the largest responses ever to anational disaster was launched, we were still notready to support the needs of all the victims of thatterrible tragedy. It is critically important that pediatrichealthcare professionals continue their collaborativeefforts to ensure that we are ready to respond to thenext disaster that we face.

Colonel John S. Murray, PhD, RN, CPNP, CS, FAAN

Consultant to the SurgeonGeneral for Research

Malcolm Grow Medical CenterAndrews Air Force Base, MD

The views expressed in this article are those of the authorand do not reflect the official policy or position of theUnited States Air Force, Department of Defense, or the U.S.Government.

Author contact: john.murray3@andrews.af.mil with a copyto the Editor: roxie.foster@uchsc.edu

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