draft storyboard: psychosocial impacts of disasters on...

Draft Storyboard: Psychosocial Impacts of Disasters on Children July 24, 2013

These are the storyboards for the NCDMPH lesson titled ”Psychosocial Impacts of Disasters on Children.”

This lesson includes a title screen and the following topics:

Title/Faculty Disclosures Objectives Introduction Children’s Post-Disaster Reactions Adjustment Risk Factors Reactivation of Stressors Fostering Wellness & Recovery Professional Self-Care Summary References & Resources Author & Reviewers Special Thanks CME/CE Credit

General Lesson Navigation

If users just keep clicking “Next,” they should be able to progress through the lesson and all 10 topics, from beginning to end. However, users will also be able to jump from one topic to another with the left-hand side navigation, in which links to the 10 topics will be presented on the left side of the screen.

Left Side Navigation Information

The left side navigation should be visible at all times.

The Topic Titles (links) in the navigation may be shorter versions of the Page Titles, because of available screen space.

Each Topic in the navigation will be preceded by a line to mark off a new section. Once the learner clicks into a Topic, the subsections for the topic should be displayed.

The subsections should be displayed as long as the learner remains in a specific topic.

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Navigation Branching

Following are the initial screens for each topic of the lesson. (The page numbers shown reference the starting point of each topic in the storyboard document.)

Title/Faculty = NC_PI_T00_010...............................................................................................................2

Disclosures = NC_PI_T00_020................................................................................................................4

Objectives = NC_PI_T00_030..................................................................................................................5

Introduction = NC_PI_T01_010................................................................................................................6

Children’s Post-Disaster Reactions = NC_PI_T02_010.........................................................................13

Adjustment Risk Factors = NC_PI_T03_010.........................................................................................34

Reactivation of Stressors = NC_PI_T04_010........................................................................................40

Fostering Wellness & Recovery = NC_PI_T05_010..............................................................................45

Professional Self-Care = NC_PI_T06_010............................................................................................70

Summary = NC_PI_T07_010.................................................................................................................75

References & Resources = NC_PI_T08_010........................................................................................77

Author & Reviewers = NC_PI_T09_010.................................................................................................84

Special Thanks = NC_PI_T10_010........................................................................................................86

CME/CE Credit = NC_PI_T11_010........................................................................................................88

Each screen of the lesson will contain the following buttons: [Back] Moves learners back one screen (should be inactive on first screen). [Next] Moves learners forward one screen (should be inactive on last screen). Text Size: [ + ] [ - ] allows learners to change the font size to enhance readability [Share/Email] expands to allow learner to choose from Email or Facebook icons (TBD)

Email option: OnClick open a screen that lets user add their name/email, a title, recipient’s email, and comment. Comment is autopopulated with link to the specific page.

Facebook option: OnClick open a screen that lets user share on a Facebook page.

Optional Buttons (appear as indicated in the storyboards): [Resource] appears whenever a resource of note is mentioned in the text – this button is present and

shows INACTIVE state when it is not applicable.

Section 508 Considerations

Following are some guidelines that should be followed to ensure improved access for learners using screen readers or similar assistive devices:

Each graphic or photo should have an ALT tag associated with it. Code should be included in each page that directs screen reading devices to “skip” reading the

navigation to a learner using the device.

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Lesson Name: Psychosocial Impacts of Disasters on Children

Topic Name: Lesson Home

Storyboard: NC_PI_T00_010 Template: [TextGraphic]

Screen Title: Title/Faculty

On–Screen Text:

Psychosocial Impacts of Disasters on ChildrenDavid J. Schonfeld, MD, FAAP

Footnotes: n/a

Graphic: Graphic = NC_PI_T00_010photo (FPO Only)ALT tag: alt="Photo collage of a stormy sky, young boy holding a candle with tears in his eyes, and evacuation route sign with stormy sky"Photo caption: n/aPhoto credit: n/a

Screen Prompt: Click Next to continue.

Programmer Notes / Interactions & Feedback:This screen contains text and a photo. The photo should be centered on this title screen. The links should open in the same window.

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Screen Title: DisclosuresOn–Screen Text:

This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity.

Commercial Support was not received for this activity.

Neither the author nor any of the reviewers involved in this educational activity have any relevant financial relationships with commercial interests to disclose. (A complete listing of the author and reviewers is available at the end of this activity)

CME Staff DisclosuresProfessional Educational Services Group staff have no financial interest or relationships to disclose.

Graphic: Graphic = NC_PI_T00_020ALT tag: alt="logo for Professional Education Services Group, A CME Company"


Programmer Notes / Interactions & Feedback:

This screen contains text and an inline graphic (logo) -- This logo will likely be smaller than the standard right-size photo.

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Storyboard: NC_PI_T00_030 Template: [TextOnly]

Screen Title: ObjectivesOn–Screen Text:

After completing this lesson, you should be able to

describe common adjustment reactions in children exposed to disasters, including the unique ways that bereavement and specific risk factors make adjustment more difficult.

take steps to create a healthcare delivery environment that anticipates and reduces contributions to child and family distress after a disaster.

advise parents and other caregivers about supporting children’s recovery after a disaster.

Footnotes:

n/a



This screen contains text.

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Introduction = NC_PI_T01_010



Topic Name: Introduction


Screen Title: Long-Term Psychological and Social Impacts

On–Screen Text:

When disaster strikes — whether natural or manmade — lives and communities are permanently altered. Visible damage provides clues to the devastation and loss of life, while news reports progress from grim to hopeful to stories of recovery. Less frequently reported are the lingering psychological and social impacts of disasters on a population.

The psychosocial impacts of disasters have potentially long-term consequences for the psychological functioning, emotional adjustment, and developmental trajectory of children. In fact, an Institute of Medicine report has shown that children are among those at highest risk of psychological trauma and behavioral difficulties after a disaster.[1] Adults who care for – and about – children play a vital role in mitigating the negative effects of these events and promoting children’s ultimate coping and adjustment.

This lesson addresses the common adjustment reactions of children to community-wide disasters and crisis events, identifies risk factors associated with their adjustment difficulties, and describes strategies to promote successful coping and resiliency for children. Because it is important for any successful helping strategy, we also address self-care for healthcare professionals.

Footnotes:1 Institute of Medicine. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. Washington, DC: National Academics Press; 2003.

Graphic = NC_PI_T01_010Photo collage of a stormy sky, family at I AM JOPLIN event, and evacuation route sign with stormy sky”Photo caption: n/a Photo credit: n/a


Programmer Notes / Interactions & Feedback:This screen contains text and a graphic aligned to the right of the text.

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MollieMcCormick, 09/27/13,

Updated 9/2013 to create a distinct head for this screen


[Objectives moved to Home topic]




Screen Title: Competencies

On–Screen Text:

If you are using a competency-based approach for your professional development, or participating in this lesson as part of a competency-based education or training program, the following information is provided to assist you in relating this lesson to competency development.

This lesson supports learning related to the following competencies, with regard to psychosocial impacts of disasters on children:*

Core Competencies and Subcompetencies for Disaster Medicine and Public Health by Walsh et al.[2]

Subcompetency 1.4 “Describe methods for enhancing personal resilience, including physical and mental health and well-being, as part of disaster preparation and planning”

Subcompetency 5.2 “Describe risk reduction measures that can be implemented to mitigate or prevent hazardous exposures in a disaster or public health emergency”

Subcompetency 7.1 “Discuss common physical and mental health consequences for all ages and populations affected by a disaster or public health emergency”

Core Competency 8.0 “Demonstrate knowledge of public health principles and practices for the management of all ages and populations affected by disasters and public health emergencies”

Subcompetency 8.1 “Discuss public health consequences frequently seen in disasters and public health emergencies”

Subcompetency 8.2 “Identify all ages and populations with functional and access needs who may be more vulnerable to adverse health effects in a disaster or public health emergency”

Subcompetency 8.3 “Identify strategies to address functional and access needs to mitigate adverse health effects of disasters and public health emergencies”

Subcompetency 8.4 “Describe common public health interventions to protect the health of all ages and populations affected by a disaster or public health emergency”

Subcompetency 11.4 “Discuss the importance of monitoring the mental and physical health

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impacts of disasters and public health emergencies on responders and their families”[2]

* There are many published competency sets within the field of disaster health. For additional information, see Disaster-related competencies for healthcare providers. Disaster Information Management Research Center, National Library of Medicine [http://disaster.nlm.nih.gov/dimrc/professionalcompetencies.html]

Footnotes:

2 Walsh L, Subbarao I, Gebbie K, et al. Core competencies for disaster medicine and public health. Disaster Med Public Health Prep. 2012;6(1):44-52.



This screen contains text.

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http://disaster.nlm.nih.gov/dimrc/professionalcompetencies.html




Storyboard: NC_PI_T01_030 Template: [ClickGraphic]

Screen Title: Addressing a Preparedness Void

On–Screen Text:

Pediatric healthcare providers are increasingly recognizing the benefit of further training in behavioral health, particularly as it relates to helping children cope with crisis.

Click each photo in turn below to discover the value of pediatric behavioral health training for providers, whether during disaster response or every day.

[ClickGraphicText1]

Boosting Disaster PreparednessSurveys show that nearly 3 out of 4 pediatric healthcare providers feel unprepared to respond to a bioterrorist event and its overall aftermath, including mental health concerns.[3] Most pediatric healthcare providers after Hurricane Katrina reported wanting more help identifying and meeting the mental health needs of their patients,[4] and more recent disaster responders have indicated that this need persists unabated.

[ClickGraphicText2]

Increasing Everyday AwarenessBecause stress is intrinsic to many major life events, including significant illness and its treatment, pediatric healthcare providers regularly interact with children and families who are in distress. Through the process known as somatization [NC_PI_T08_040/#soma], psychological distress may present as symptoms that mimic physical conditions, exacerbate or complicate physical symptoms, interfere with accurate reporting of medical concerns, or complicate medical management.[5] Healthcare providers who develop skills to identify emotional and psychological difficulties and can offer effective adjustment and coping strategies will use these skills every

day—even outside of a major crisis event—to the benefit of their patients and practices.

Footnotes:

3 Hu Y, Adams RE, Boscarino JA, et al. Training needs of pediatricians facing the environmental health and

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bioterrorism consequences of September 11th. Mt. Sinai J Med. 2006;73:1156-64.

4 Madrid PA, Grant R, Reilly MJ, et al. Challenges in meeting immediate emotional needs: short-term impact of a major disaster on children’s mental health: building resiliency in the aftermath of Hurricane Katrina. Pediatrics. 2006;117:S448-53.

5 Schonfeld D. Providing psychological first aid and identifying mental health needs in the aftermath of a disaster or community crisis. In: Foltin G, Tunik M, Treiber M, Cooper A. Pediatric Disaster Preparedness: A Resource for Planning, Management, and Provision of Out-of-Hospital Emergency Care. New York, NY: Center for Pediatric Emergency Medicine; 2008. Available at: http://cpem.med.nyu.edu/teaching-materials/pediatric-disaster-preparedness. Accessibility verified January 25, 2013.

Graphic = NC_PI_T01_030a

ALT tag: alt="young African American man in scrubs leaning head on window in exhaustion "

Photo caption: n/a Photo credit: n/a

Graphic = NC_PI_T01_030b

ALT tag: alt="older female physician in lab coat comforting a crying young girl in her office"


Screen Prompt: Click each photo to learn more. Click Next to continue.


This screen contains introductory text and 2 photos. All images should have an ALT text tag. All footnotes should be displayed at the bottom of the screen at all times.

When the learner clicks a graphic, associated text (noted as [ClickGraphicText#]) displays under both graphics.

This screen contains a glossary term; link to the full text of the glossary term with an anchor tag so that the term is displayed at the top when the page loads. Provide a Back button that returns learner to the screen they were on from the glossary.

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http://cpem.med.nyu.edu/teaching-materials/pediatric-disaster-preparedness




Storyboard: NC_PI_T01_040 Template: [MultiChoice]

Screen Title: Are You Prepared?

On–Screen Text:

How prepared do you feel to deal with the psychosocial issues that children and their families face immediately after a disaster or in the long-term? (Check all of the statements that apply to you.)

□ I am aware of acute stress reactions that pediatric patients may display following a disaster.□ I am familiar with typical post-traumatic stress disorder symptoms that children may exhibit.□ I am familiar with how a crisis event may re-activate or compound existing stressors for children and

families.□ I feel confident about helping parents and children establish supportive communications after a

disaster, including how to address bereavement.□ The healthcare environment where I work is sensitive to the needs of younger patients and families in

distress.

□ I have a plan in place for professional self-care, including a personal disaster plan.

Feedback: [CORRECT] Good for you! You are well on your way to understanding how to best support children who have experienced a disaster or crisis event. This lesson will help you discover additional means for helping children and their families. Let’s get started!

[INCORRECT]There’s definitely room for improvement. This lesson will describe how to best support children who have experienced a disaster or crisis event. Let’s get started!

Resource: Include Resource button at top of screen, link to NC_PI_T01_040.pdf

Screen Prompt: Check all statements that apply, then click Submit. Click Next to continue.

Programmer Notes / Interactions & Feedback:This screen contains text statements (in checkboxes) that the learner must check to indicate their agreement with. OnSubmit feedback is displayed below the Question and their responses.

If 4 or more statements are checked (any 4), show CORRECT feedback. If 3 or less are checked, show the INCORRECT feedback.

Please code so that users can click next without completing (this is true for any knowledge checks, since you are not actually tracking completion).

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Submit


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Topic Name: Children’s Post-Disaster Reactions


Screen Title: Common Reactions to Disasters

On–Screen Text:

Acute reactions and individual post-traumatic symptoms are very common among children directly affected by a crisis event. The following may be seen in children after a disaster:

Anxiety, worries, and fears Separation anxiety or avoiding school Bereavement and grief Sadness or depression, pessimism or decreased future perspective Avoiding previously enjoyed activities, withdrawal and decrease in peer social interactions Difficulties with concentration and academic work Sleep problems Irritability Regression – developmental or social Substance abuse – onset or increase Somatization

Whenever possible, practitioners should compare these symptoms to a child’s pre-existing functioning and behavior and consider family and cultural modes of expressing emotions.

Graphic = NC_PI_T02_010

ALT tag: alt="photo collage of teen boy sitting alone in a park, a pre-teen girl looking confused in a classroom, and a young girl avoiding eye contact"

Photo caption: n/a Photo credit: n/a (all dreamstime.com)


Programmer Notes / Interactions & Feedback: This screen contains text and a photo, centered over the text.

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Children’s Post-Disaster Reactions = NC_PI_T02_010




Storyboard: NC_PI_T02_020 Template: [ClickExpand]

Screen Title: Symptoms of Adjustment Reactions in Children

On–Screen Text:

Let’s take a closer look at children’s symptoms of acute stress after a disaster.[6] Any adult in a child healthcare or caregiving capacity may observe these reactions, particularly if they have prior knowledge of a child’s behavior or family situation.

Click each symptom to reveal additional information.

[+ Anxiety, worries, and fears]Children have limited knowledge and experience and tend to misunderstand and misattribute. Keep in mind that their fears and worries may be very different from those of adults.

[+ Separation anxiety or school avoidance]Look for any extreme or prolonged distress when separated from caregivers or avoidance of school.

[+ Bereavement and grief]This is a special concern if deaths occurred as a result of the disaster, and even more relevant if close family members or friends of a child died. Children may also experience traumatic reactions if they witnessed a death.

[+ Sadness or depression]In addition to sadness or depression, children may develop a sense of pessimism about the future or decreased perspective on what the future may hold.

[+ Avoidance of previously enjoyed activities]Ask about or look for withdrawal from activities and decreased social interactions, especially with peers.

[+ Difficulties with concentration and academic work]Explore (or observe) how children and adolescents are able to attend to their work or focus on an activity, comparing their performance to pre-disaster levels.

[+ Problems with sleep]Does the child have difficulty falling or staying asleep, have nightmares or frequent waking, resist sleeping alone, or have trouble waking in the morning?

[+ Irritability]Consider observed irritability with surroundings or others or reported reactions by parents or caregivers.

[+ Regression – developmental or social]Has the child taken a step back in developmental milestones (e.g., bedwetting)? Is he or she regressing socially – becoming more clingy, less cooperative, more demanding, more self-centered, or less tolerant of others?

[+ Substance abuse]Look for the onset of tobacco, alcohol or other substance abuse or an increase in these behaviors.

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[+ Somatization]Children may unconsciously present psychological distress as physical symptoms.

Footnotes:

6 Schonfeld D, Gurwitch R. Children in disasters. In: Elzouki AY, Stapleton FB, Whitley RJ, Oh W, Harfi HA, Nazer H, eds. Textbook of Clinical Pediatrics, 2nd ed. New York, NY: Springer-Verlag; 2011: 687-698, modified from Table 489.1.




This screen contains text statements that, onClick, will reveal additional text below each statement. Once revealed, the text will remain revealed (until the learner leaves and returns to the page). The statements will be brief and coded as “buttons” so that they are easy to open on a mobile device. Each statement will be preceded by a + sign.

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Screen Title: Post-Traumatic Stress Disorder

On–Screen Text:

Although less common, post-traumatic stress disorder (PTSD) [NC_PI_T08_030#ptsd] may occur in children who have survived a disaster.

PTSD is characterized by symptoms of re-experiencing, avoidance, and increased arousal that persists for at least one month’s time and results in significant impairment in social, academic or other areas of functioning.


ALT tag: alt=" pre-teen boy looking sad and confused"

Photo caption: n/a

Photo credit: n/a



This screen contains text and a photo, right-aligned with the text.

Reminder: All photos should be padded by 5px all around.

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Screen Title: PTSD Characteristics in Children

On–Screen Text:

Take a moment to more closely explore the core symptoms of PTSD. Click each symptom for details about how PTSD may present in children.

[+ Re-experiencing]Re-experiencing may take various forms:

Dreams or nightmares (in young children, nightmares may not include content from the event) Hallucinations or intrusive images (i.e., flashbacks) Intense reactions to cues that remind children of the event

Children may demonstrate re-experiencing through repetitive play involving reenactment.

[+ Avoidance] Children may avoid activities, places, or people associated with an event or may make efforts to avoid associated thoughts or feelings. As a result, they may withdraw from previously enjoyed activities or friends and family.

[+ Increased Arousal]Children may display sleep problems, difficulty with concentration, increased irritability, or angry outbursts. They may appear hyper-alert or exhibit an increased startle response.

Footnotes: n/a


Screen Prompt: Click each statement to reveal details. Click Next to continue.


This screen contains text statements that, onClick, will reveal additional text below each statement. Once revealed, the text will remain revealed (until the learner leaves and returns to the page). The statements will be brief and coded as “buttons” so that they are easy to open on a mobile device. Each statement will be preceded by a + sign.

When the learner clicks a statement, associated text with display under the statement.

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Screen Title: PTSD Evaluation of Children

On–Screen Text:

When evaluating children for PTSD, keep the following in mind:

The potential for PTSD is especially strong among children who perceived during an event that their life was in jeopardy or who experienced intense fear, helplessness, or horror.

Individuals with PTSD actively attempt to avoid thinking, talking about, or even remembering the event, so symptoms may not become evident to others for months (or longer) without active screening or outreach.[7]

Footnotes:

7 Schonfeld D, Gurwitch R. Children in disasters. In: Elzouki AY, Stapleton FB, Whitley RJ, Oh W, Harfi HA, Nazer H, eds. Textbook of Clinical Pediatrics, 2nd ed. New York, NY: Springer-Verlag; 2011: 687-698.


ALT tag: alt="a girl walking through her elementary school parking lot in Henryville, IN after the town was devastated by a large tornado in March 2012"

Photo caption: n/a

Photo credit: U.S. Army photo by Sgt. John Crosby/Released


Programmer Notes / Interactions & Feedback: This screen contains text and a photo right-aligned with the text.

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Screen Title: Guidelines for Immediate Referral

On–Screen Text:

If children display any of the following behaviors immediately after a disaster, providers should consider promptly administering a more urgent mental health evaluation:

Demonstration of intense fear, anxiety, panic, helplessness or horror or uncontrollable and intense grief Presence of dissociative symptoms such as detachment [NC_PI_T08_030#detach], derealization

[NC_PI_T08_030#dereal], or depersonalization [NC_PI_T08_030#deperson], which may manifest in children who appear confused, distant, daydreaming, or aloof

Extreme confusion or inability to concentrate or make even simple decisions Evidence of extreme cognitive impairment or intrusive thoughts Marked physical complaints suggesting somatization[NC_PI_T08_030#soma] Suicidal ideation or intent [8]

Children whose caregivers are having significant difficulty coping are also candidates for referral.

Footnotes:

8 Schonfeld D. Providing psychological first aid and identifying mental health needs in the aftermath of a disaster or community crisis. In: Foltin G, Tunik M, Treiber M, Cooper A. Pediatric Disaster Preparedness: A Resource for Planning, Management, and Provision of Out-of-Hospital Emergency Care. New York, NY: Center for Pediatric Emergency Medicine; 2008. Available at: http://cpem.med.nyu.edu/teaching-materials/pediatric-disaster-preparedness. Accessibility verified January 25, 2013.



This screen contains text and links to glossary terms.

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http://cpem.med.nyu.edu/teaching-materials/pediatric-disaster-preparedness





Screen Title: Considerations

On–Screen Text:

Man-Made vs. Natural Disasters

Children’s reactions to and recovery from a disaster event may vary depending on if the disaster was caused randomly by nature or intentionally by man.

Because the major aim of terrorism is to instill a state of intense fear or anxiety in victims — rather than to physically harm — the predominant effects are psychological and emotional. Most people of age during the September 11 attacks can tell you where they were at the time, what they were doing, and how it changed their lives.

Man-made disasters, especially when there is such intent to cause harm, therefore result in more psychological distress than do natural disasters, and may have longer-term effects.

As we’ll see below, disasters also tend to compound any existing stress already present in the community or family.


ALT tag: alt="a young African-American boy sitting alone at the 9/11 Pentagon Memorial"

Photo caption: n/a

Photo credit: DoD photo by Glenn Fawcett/Released



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On–Screen Text:

Overestimating Children’s Resilience

Parents and other adults tend to significantly underestimate children’s adjustment difficulties after a disaster, for several reasons:

Professionals may miss changes or signs of distress that are more apparent to family members and teachers or child care providers familiar with the child’s personality and characteristic style of interacting and behavior.

Symptoms (e.g., nightmares) may occur only outside the context of a healthcare encounter.

Children old enough to verbalize symptoms and worries may withhold complaints and concerns to avoid appearing “abnormal” or further burdening adults struggling to cope.

Although a return to school and home routines as soon as practical is recommended and can be therapeutic, expectations should be modified until children have adjusted; a quick return to previous level of functioning should not be expected.


ALT tag: alt="a typical child’s crayon drawing of sunny skies and a happy family"

Photo caption: n/a

Photo credit: n/a



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On–Screen Text:

Pre-Existing Stressors & Secondary Losses

Take a moment to review the post-disaster adjustment reactions [NC_PI_T02_020.pdf] that children and adults may experience. In evaluating actual reactions, consider that many are not post-traumatic and may not result directly from the disaster event.

A major disaster often worsens pre-existing problems and initiates a cascade of secondary losses and stressors, any of which may be the primary source of difficulty for children or families.


ALT tag: alt="evacuation route sign on a stormy highway"

Photo caption: n/a

Photo credit: n/a




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On–Screen Text:

Disasters Compound Existing Problems Disasters may cause economic and other hardships for the community in many ways, including

loss of jobs or income for parents. loss of homes and need for families to relocate, resulting in changes in schools or peer groups for

children. depression, substance use, or discord among parents. loss of neighborhood supports to mitigate the stress.

After Hurricane Katrina, marital stress, domestic violence, and parental mental health problems were found to increase in the Gulf Coast Region.[9, 10] Any of these types of stressors may be the primary cause of children’s current distress.

Footnotes:

9 Larrance R, Anastario M, Lawry L. Health status among internally displaced persons in Louisiana and Mississippi travel trailer parks. Ann Emerg Med. 2007;49:590-601.

10 Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak. Part II: summary and implications of the disaster mental health research. Psychiatry. 2005;65:240-60.


Programmer Notes / Interactions & Feedback: This screen contains text.

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On–Screen Text:

Knowledge Check

Pause for a moment to reflect on what you’ve learned so far. Which of the following should you consider when evaluating children’s post-disaster reactions? (Select all that apply.)

□ Adults may be overestimating children’s resilience. [CORRECT]□ If children perceived during an event that their life was in jeopardy or experienced intense fear,

helplessness, or horror. [CORRECT]□ Whether the disaster was man-made or a result of natural forces. [CORRECT]□ Pre-existing stressors may be an issue. [CORRECT]

□ Children may present psychological distress as physical symptoms. [CORRECT]

Feedback:

[CORRECT]You’re right! Each of these should be a consideration when evaluating children’s post-disaster reactions.

[INCORRECT]Actually, each of these should be a consideration when evaluating children’s post-disaster reactions.

Screen Prompt: Select all statements that apply, then click Submit. Click Next to continue.


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Submit





Screen Title: Assessment

On–Screen Text:Extending the Focus

Comprehensive assessment of children’s post-disaster reactions requires a shift in focus, from solely assessing how children reacted on the day of an event to determining how they are adjusting to what followed.

Click each photo for guidelines about how to adjust your assessments.

[ClickGraphicText1]Extend Assessments to Determine Current CopingGo beyond asking how children are adjusting to the initial event and evaluate how well they’re currently coping. Reported sleep problems or anxiety may be due to worries about financial problems and parental stress, resulting from parent job loss after a disaster, and may not result from nightmares or anxiety related to the disaster itself.

[ClickGraphicText2]Anticipate Long-Term RecoveryAs long as these secondary losses and stressors persist within the community, adjustment difficulties for children should be anticipated to continue. Home, school, and community environments and supports for children may not return to being fully functional for many years, explaining in part the often lengthy process for community recovery seen after major disasters.

Graphics = NC_PI_T02_100aALT tag: alt="destroyed overturned truck on front lawn of tornado damaged home"Photo caption: n/a Photo credit: n/a

Graphics = NC_PI_T02_100bALT tag: alt="angry young boy with parents arguing in background"Photo caption: n/a Photo credit: n/a


Programmer Notes / Interactions & Feedback:This screen contains text and 2 photos. When the learner clicks a graphic, associated text (noted as [ClickGraphicText#]) displays under both graphics.

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On–Screen Text:

In the FieldConsider this report from the field experience of healthcare practitioners:

Pediatricians in a community on the United States’ Gulf Coast noted that, many months after Hurricane Katrina, they had learned to modify the format of their typical visit. In addition to the usual components of the visit (e.g., chief complaint, history, review of symptoms, physical exam, etc.) they had added the “Katrina History.” They reported that this was the part of the visit that had the most “pathology,” took the longest time to cover adequately, and, unfortunately, was the least compensated by most health insurance.


ALT tag: alt="Louisiana Gulf Coast residents gathering outside the Houston Astrodome after Hurricane Katrina evacuation"




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On–Screen Text:

Online Resource

Feelings Need Check Ups Too. Addressing the Mental Health Needs of Children in Response to September 11th and Other Catastrophic Events: An Educational Resource for Pediatricians is a training tool for pediatric healthcare providers that includes video vignettes of children and families related to bereavement, anxiety, depression and post-traumatic stress disorder, as well as a tool-kit with screening instruments and background information.[11]

The materials, including the video vignettes, can be accessed at no charge through the American Academy of Pediatrics’ website.Access symptom-specific vignettes … [http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Medical-Home-for-Children-and-Adolescents-Exposed-to-Violence/Pages/Vignettes.aspx]Access the toolkit… [http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Feelings-Need-Checkups-Too-CD-Page-4.aspx] (requires Flash Player)

Footnotes: 11 Laraque D, Jensen P, Schonfeld D. Feelings Need Check Ups Too. Addressing the Mental Health Needs of Children in Response to September 11th and Other Catastrophic Events: An Educational Resource for Pediatricians. American Academy of Pediatrics; September 2004. [interactive CD-ROM]

Resource: Include Resource button and link to the vignette page in a new window (most accessible to learners):http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Medical-Home-for-Children-and-Adolescents-Exposed-to-Violence/Pages/Vignettes.aspx

Graphic = NC_PI_T02_130ALT tag: alt="capture of American Academy of Pediatrics Website “Feelings Need Checkups Too" web-based tool”Photo caption: n/a Photo credit: n/a



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Screen Title: When Bereavement is Involved

On–Screen Text:

When children have experienced the deaths of family members or friends as a result of a disaster, bereavement may be a predominant concern.

Children may experience post-traumatic grief when bereavement is further complicated by posttraumatic reactions, such as after witnessing the violent death of a loved one. However, bereavement resulting from disaster is not typically that different from bereavement experienced at most other times. In any context, children struggle with understanding the loss and its implications and adjusting to a life devoid of the person who died.[12]

Footnotes: 12 Schonfeld D, Quackenbush M. The Grieving Student: A Teacher's Guide. Baltimore, MD: Brookes Publishing; 2010.

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Screen Title: Bereavement

On–Screen Text:

The Importance of Guidance

Adults are often reluctant to talk with children (or even other adults) who are grieving their loss, fearing they will cause further distress by raising the topic or “saying the wrong thing.” In fact, children are upset about the death itself, rather than the questions or comments. It is not in their best interest to be left alone to adjust.

Click Play to watch this video clip of comments from children and parents about their experiences after a parent’s death and consider how healthcare providers and schools can be better prepared to offer support.

[Play > ] [[http://www.youtube.com/watch?v=BBHm_L2Fb9k&feature=youtu.be]

Graphic = NC_PI_T02_150ALT tag: alt="screen capture from video showing a pre-teen girl talking to the interviewer”Photo caption: n/a Photo credit: n/a

Play button = Play.pngALT tag: alt="play”TITLE tag: title=”watch the video to hear from children who have experienced loss”

Screen Prompt: Click Play to watch the video in a new window. Click Next to continue.


This screen contains text and a Play button linked to a youtube video. OnClick, open a new full-sized window showing the link; the learner will need to click Play in the new window to start the video.

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http://www.youtube.com/watch?v=BBHm_L2Fb9k&feature=youtu.be






On–Screen Text:

A Perspective on Grief

How well do you understand how grief may affect a child, particularly if the child lost someone to disaster or through violence? Take a few minutes to review bereavement resources related to Doug — a young boy who lost his father in the September 11th terrorist attacks — on the American Academy of Pediatrics website.

Doug’s Case Summary [http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Medical-Home-for-Children-and-Adolescents-Exposed-to-Violence/Pages/Bereavement-Case-Summary.aspx]

Bereavement Fact Sheet [http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Medical-Home-for-Children-and-Adolescents-Exposed-to-Violence/Pages/Bereavement.aspx]

Explore Doug’s Case in the Feelings Toolkit [http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Feelings-Need-Checkups-Too-CD-Page-4.aspx] (Note: Choose “Doug” from the waiting room; requires Flash Player.)

Footnotes: n/a


Programmer Notes / Interactions & Feedback: This screen contains text. All links should be designated to open in new windows.

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On–Screen Text:

Resources for Grieving & Death Notification We’ve heard how healthcare practitioners and adults working with children can support grieving children and families by listening and offering support. Take a few minutes to review the following two resources that offer practical tips and guidelines.

After a Loved One Dies—How Children Grieve and How Parents and Other Adults Can Support Them [http://www.achildingriefcom]This booklet for parents and other caring adults provides information on explaining death to young children, strategies to help them with personal loss, guidance on funeral attendance, and advice about supporting children as they adjust to significant loss. The booklet may be downloaded in English or Spanish; hard copies can be requested at no charge.

Practical Guidelines Regarding Death Notification [http://archive.ahrq.gov/research/pedprep/pedchap8.htm#Death]Practitioners should consider how to best approach notifying children regarding the death of a family member or friend. This list of guidelines offers an excellent overview. Additional guidelines for those tasked with death notification in the context of a disaster may be found elsewhere.[13,14]

Footnotes: 13 Foltin GL, Schonfeld DJ, Shannon, MW, eds. Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians. AHRQ Publication No. 06-0056-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2006.

14 Schonfeld D. Providing support for families experiencing the death of a child. In: Kreitler S, Ben-Arush MW, Martin A, eds. Pediatric Psycho-oncology: Psychosocial Aspects and Clinical Interventions, 2nd ed. West Sussex, UK: John Wiley & Sons, Ltd.; 2012: 223-230.

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Storyboard: NC_PI_T02_175 Template: [SingleChoice]


On–Screen Text:

Knowledge CheckTrue or False? Adults should avoid asking questions or commenting when a child has lost a loved one; it’s better to leave them alone and let them try to get back to normal.

o Trueo False [CORRECT]

Feedback:

[CORRECT]Yes, this statement is false. Adults are often reluctant to talk with children (or even other adults) who are grieving their loss, fearing they will cause further distress by raising the topic or “saying the wrong thing.” In fact, children are upset about the death itself, rather than the questions or comments. It is not in their best interest to be left alone to adjust.

[INCORRECT]No, this statement is false. Adults are often reluctant to talk with children (or even other adults) who are grieving their loss, fearing they will cause further distress by raising the topic or “saying the wrong thing.” In fact, children are upset about the death itself, rather than the questions or comments. It is not in their best interest to be left alone to adjust.

Screen Prompt: Select your answer, then click Submit. Click Next to continue.

Programmer Notes / Interactions & Feedback:This screen contains a true/false statement that the learner must respond to. OnSubmit feedback is displayed below the Question and their response.

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Submit


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Adjustment Risk Factors = NC_PI_T03_010



Topic Name: Adjustment Risk Factors


Screen Title: Interrelated Factors Affect Risk

On–Screen Text:

The impact of a disaster on individual children depends on a number of interrelated factors, including the nature of the disaster itself (e.g., man-made versus natural, extent of damage and death caused). what children or those closest to them experienced or saw. the level of exposure to graphic media or online coverage. the extent and nature of secondary losses and stressors. if there was associated physical injury. the emotional impact experienced by children and their family and disruption to children’s extended

support system. children’s pre-existing skills in coping with distress. the ability of adults in the family and community to provide support and promote adjustment and

recovery. [15]

Footnotes: 15 Schonfeld D, Gurwitch R. Children in disasters. In: Elzouki AY, Stapleton FB, Whitley RJ, Oh W, Harfi HA, Nazer H, eds. Textbook of Clinical Pediatrics, 2nd ed. New York, NY: Springer-Verlag; 2011: 687-698.

Graphic = NC_PI_T03_010 ALT tag: alt="photo collage of Hurricane Sandy aftermath, young sad girl against a graffiti covered wall, and a line of adults waiting with gas cans"Photo caption: n/a Photo credit: n/a



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MollieMcCormick, 09/27/13,

Changed 9/2013 to create unique subtitle for screen





Screen Title: Factors Associated with Increased Risk

On–Screen Text:

These particular factors are associated with an increased risk of adjustment problems after a disaster:[16]

Injury of the child, or death or injury of those close to the child Child’s perception (at the time of the event) that his or her life was in jeopardy Extent of exposure to horrific scenes (including indirectly through the media) Separation of a child from parents or other important caregivers as result of event Loss of property or belongings; disruption in daily routine or environment Prior psychopathology, significant losses, or traumatic events Parental difficulty in coping Lack of supportive family communication style Lack of community resources and support

The presence of one or more of these risk factors indicates the need for closer monitoring for adjustment difficulties and/or the provision of supportive services.

Footnotes: 16 Schonfeld D, Gurwitch R. Children in disasters. In: Elzouki AY, Stapleton FB, Whitley RJ, Oh W, Harfi HA, Nazer H, eds. Textbook of Clinical Pediatrics, 2nd ed. New York, NY: Springer-Verlag; 2011: 687-698. Adapted from Table 489.2.

Resource: display Resource button and link to NC_PI_T03_020.pdf


Programmer Notes / Interactions & Feedback: This screen contains text and displays the active Resource button

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Screen Title: Make Family Reunification a Priority

On–Screen Text:Because separation from parents or other important caregivers is associated with increased difficulty adjusting to a disaster, efforts to reunite children separated from families by the event should be a high priority. The NCDMPH online lesson “Tracking and Reunification of Children in Disasters: A Lesson and Reference for Health Professionals” [http://ncdmph.usuhs.edu/Learn/PedsTR/TRCD_0a.htm] focuses on achieving family reunification as a first step in disaster recovery.

Click each photo for general guidance to minimize the effects of family separation.

[ClickGraphicText1]Give Children Consistent Alternative SupportIn those situations where children require medical treatment before reunification is possible, assign individual volunteers who can provide consistent and ongoing support to individual children until reunification is achieved.

[ClickGraphicText2]Guide Parents in Recovery RolesWhen parents, guardians or other family members are available, guide them to serve an active and appropriate role in the evaluation and treatment process, so they can help reduce children’s distress.

Resource: link Resource button to http://ncdmph.usuhs.edu/Learn/PedsTR/TRCD_0a.htm; the links should open in a New Window

Graphics = NC_PI_T03_030aALT tag: alt=" nurse with young patient "Photo caption: n/a Photo credit: n/a

Graphics = NC_PI_T03_030bALT tag: alt=" dad hugging young son, wearing a backpack"Photo caption: n/a Photo credit: n/a


Programmer Notes / Interactions & Feedback:This screen contains text and 2 photos. When the learner clicks a graphic, associated text (noted as [ClickGraphicText#]) displays under both graphics.

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http://ncdmph.usuhs.edu/Learn/PedsTR/TRCD_0a.htm





Screen Title: Perform Mental Health Triage

On–Screen Text:

Immediate disaster response requires that pediatric healthcare providers assess both the physical and mental health of young patients. To identify children most likely to benefit from mental health referral, providers should conduct a secondary mental health triage as soon as possible after initial medical stabilization and evaluation.

The identified risk factors for increased adjustment difficulties [NC_PI_T03_020.pdf] can be an important part of this evaluation for children of all ages.

Resource: display Resource button and link to NC_PI_T03_020.pdf in a new window.


ALT tag: alt="close up teenaged girl, looking worried"




This screen contains text and a photo, right-aligned with the text + display active Resource button and link to NC_PI_T03_020.pdf

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Screen Title: Adjustment Risk Factors

On–Screen Text:

Knowledge Check

Which of the following may indicate an increased risk of adjustment problems for children after a disaster? (Select all that apply.)

□ A. The child’s parents are having great difficulty coping after a disaster. [CORRECT]

□ B. Children were separated from their parents or other caregivers during an event. [CORRECT]□ C. A child is exposed to horrific scenes after the event, on TV and social media. [CORRECT]□ D. This is the first time a child has experienced an overwhelming traumatic event.□ E. If a child was injured or someone close to them was injured or killed. [CORRECT]□ F. A family must move away from their community support system into temporary housing.

[CORRECT]

Feedback:

[CORRECT]That’s right. All of the statements except D are indicators of an increased risk of adjustment problems for children after a disaster.

[INCORRECT]Actually, all of the statements except D are indicators of an increased risk of adjustment problems for children after a disaster.

Screen Prompt: Select all statements that apply, then click Submit. Click Next to continue.


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Submit


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Reactivation of Stressors = NC_PI_T04_010



Topic Name: Reactivation of Stressors


Screen Title: Reactivation of Pre-Existing or Past Stressors

On–Screen Text:

Disasters often uncover prior or concurrent psychopathology or adjustment difficulties caused by stressors that individuals have not fully resolved.

These pre-existing stressors may become the primary focus for children or adults. Reactivation of pre-existing stressors may occur even if prior and current events do not seem to be

related.

Footnotes: n/a

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Screen Title: Reactivation of Existing Stressors

On–Screen Text:

In the FieldConsider this report from the field, in which pre-existing stressors played a role:

Students on a field trip were inadvertently exposed to N-butyl mercaptan (an odorant with a skunk-like odor used in natural gas) when a student opened a personal protective device on a bus. Students who did not require medical treatment underwent controlled decontamination at a local children’s hospital in a very supportive context. They were greeted by a nurse and child life specialist who explained the decontamination process, and they showered one at a time and changed into donated, new clothing. Children then waited with child life specialists and watched movies, played games, and had cookies and punch until being promptly reunited with their caregivers.

Despite nearly ideal conditions for decontamination, two adolescents experienced panic attacks for several weeks after the incident and could not return to school. The school attributed the panic attacks to trauma from the decontamination event and wondered what could have been done differently. Professionals advised looking into the personal lives of the two children. One student was a new transfer to the school, and the reason for the transfer was the recent murder of a parent. Further inquiry with the other student identified previously undisclosed assault by a family member as the cause of her distress.

Footnotes: n/a

Graphic = NC_PI_T04_020 ALT tag: alt="neighborhood damage surrounded by emergency tape"Photo caption: n/a Photo credit: n/a


Programmer Notes / Interactions & Feedback: This screen contains text and a photo, right-aligned with text.

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Screen Title: Unrelated Events & Experiences

On–Screen Text:When working with children, families, and professional staff that have been affected by a disaster, it is important to anticipate that unrelated events and experiences may be the cause for what appear to be reactions to the disaster itself. As the following story illustrates, such reactions may be experienced by professionals as well.

In the FieldA primary school student is accidentally shot when another child discovers a loaded gun and discharges it during play. During a meeting to train teaching staff about how to support grieving children, one teacher begins to cry, resulting in the need to pause the training session. When asked about her reaction, the teacher disclosed for the first time to her colleagues that she had miscarried – over 10 years before.

Footnotes: n/a


Programmer Notes / Interactions & Feedback: This screen contains text.

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Screen Title: Future Triggers

On–Screen Text:

Future events and references that remind children of losses or disturbing images, sensations, and emotions associated with a disaster event may trigger grief or trauma symptoms.

Click Play to hear children in this video explain how everyday occurrences of studying in school and interacting with friends can trigger thoughts and strong feelings associated with their loss.

[Play > ] [[http://www.youtube.com/watch?v=taJi-4I4Yuw&feature=youtu.be]

Graphic = NC_PI_T04_040ALT tag: alt="screen capture from video showing a young boy talking to the interviewer”Photo caption: n/a Photo credit: n/a

Play button = Play.pngALT tag: alt="play”TITLE tag: title=”watch the video to hear from a child who has experienced loss”

Screen Prompt: Click Play to watch the video in a new window. Click Next to continue.


This screen contains text and a Play button linked to a youtube video. OnClick, open a new window showing the link; the learner will need to click Play in the new window to start the video.

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Fostering Wellness & Recovery = NC_PI_T05_010



Topic Name: Fostering Wellness & Recovery


Screen Title: Community Wellness & Recovery

On–Screen Text:

Healthcare providers and other professionals that work with children and families are well positioned to lead the way toward recovery for children and their families in the wake of a disaster or crisis event. By creating supportive environments, coordinating services, providing information about resources, and fostering skills, adults in positions of trust can provide a strong foundation for rebuilding community health. Basic steps for fostering recovery include:

Creating a safe, child-friendly healthcare environment Providing basic psychological first aid and supportive services Facilitating supportive parent-child communications Identifying short- and long-term interventions Planning useful school-based crisis response

Continue on for details about these interventions or navigate to the areas that reflect your potential contributions to community healing.

Footnotes: n/a

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Screen Title: A Child-Friendly Healthcare Environment

On–Screen Text:

Pediatric healthcare providers can work to ensure that sites delivering medical care after a disaster are adapted to minimize conditions that may increase post-traumatic distress for children and families.

Click each of the steps below to discover recommendations for creating safe, child-friendly environments.

[+ Reduce exposure to frightening images and sounds] Close doors/curtains to reduce exposure to others who are injured or in pain. Turn off televisions in waiting and exam rooms after a disaster. Be aware that children can overhear conversations with staff and take action to shield them from too much

information.

[+ Minimize painful or invasive procedures or treatments]Provide appropriate analgesia and sedation as needed.

[+ Facilitate connections with loved ones]Encourage parents or other family members to remain with children throughout the evaluation and treatment process to the extent possible.

[+ Encourage children to use coping strategies] If children are familiar to you, suggest strategies they have found effective in the past, or suggest additional strategies (e.g., distraction, guided imagery).

[+ Provide explanations in positive terms, underscoring what you are doing to keep them safe or healthy]Avoid emphasizing potential risks and reframe information in a positive light. For example, state “We are going to put this belt around your waist so you stay safely in the stretcher while we bring you to the hospital,” rather than “This belt will make sure you don’t go flying out of the ambulance if we have to stop quickly.”

Footnotes: n/a

Screen Prompt: Click each statement to reveal details. Click Next to continue.


This screen contains text statements that, onClick, will reveal additional text below each statement. Once revealed, the text will remain revealed (until the learner leaves and returns to the page).

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Screen Title: Psychological First Aid & Basic Supportive Services

On–Screen Text:

In the immediate aftermath of a disaster, all individuals who are affected (whether or not they appear to have adjustment difficulties) should be provided psychological first aid (PFA)[ NC_PI_T08_030#pfa] and offered basic supportive services.

The goals of PFA are to

promote effective coping strategies and accelerate the natural healing process by providing timely and accurate information, appropriate (but not false) reassurance and psychoeducation, including guidance regarding likely reactions to the event and strategies to promote adjustment.

help people identify supports in their family and community. offer compassionate support.[17]

Pediatric healthcare providers and all those who support children (e.g., educators, youth leaders, spiritual leaders) should aim to develop PFA skills and offer such support after a disaster.

Footnotes: 17 American Red Cross. Foundations of Disaster Mental Health. Washington, DC: American Red Cross; 2006.


Programmer Notes / Interactions & Feedback: This screen contains text and a link to the glossary.

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Screen Title: Supportive Parent-Child Communications

On–Screen Text:

By fostering parent-child communications during disaster recovery, practitioners help establish a vital source of long-term support for children and help families move toward a brighter future. Effective communications can be achieved by following a few basic guidelines:

Seek first to inform. Start the conversation. Encourage open dialogue. Monitor media coverage. Model healthy coping skills. Reassure and encourage action.

Let’s take a closer look at each of these recommendations.

Footnotes: n/a

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Programmer Notes / Interactions & Feedback: This screen contains text and a photo, right-aligned with the text.

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On–Screen Text:

Seek First to Inform

It’s best to inform children as soon as information is known about a disaster, rather than attempting to hide or shield them from the reality. Even very young children readily pick up on the distress of trusted adults and will overhear or otherwise learn information about events.

A brief recording by one parent of conversations with his 2 year-old daughter after the 9/11 terrorist attack on the World Trade Center illustrates that even very young children are aware of such events. Furthermore, with assistance, they can come to their own understanding (at least at a basic level).[Play > ]

[View Transcript ]

Footnotes: n/a

Audio = NC_PI_T05_050 Mp3 format

Graphic = NC_PI_T05_050 ALT tag: alt="young Indian girl looking scared"Photo caption: n/a Photo credit: n/a

Play button = Play.pngALT tag: alt="play”TITLE tag: title=”listen to the audio recording of a young child’s perspective after the 9/11 terrorist attacks”

“View Transcript” button = view_transcript.pngAlt tag: alt="view transcript”Title tag: title=”read the transcript of a discussion between and young child and parent after the 9/11 terrorist attacks”


Programmer Notes / Interactions & Feedback: This screen contains text and a photo, right-aligned with the text. Place a Play > button below the text that opens an audio player and play the provided MP3 file from this page. Original audio link = [http://soundcloud.com/michaelsradio/talking-2-sophia]

OnClick of View Transcript button, branch to NC_PI_T05_055 to display a page showing the audio transcript. The Next button for this screen advances to NC_PI_T05_060; learner only sees the transcript if they clicked View Transcript.

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http://soundcloud.com/michaelsradio/talking-2-sophia






On–Screen Text:

Audio Transcript

Sophia: [Inaudible]

[Music begins to play]

Sophia: sings to music [inaudible]

Father (narration): I was talking to Sophia my two year old daughter. We talk a lot, she and I. One day not too long ago I woke up to the sound of crying; not Sophia’s but her mother’s.

“A plane crashed.”

“They crash all the time,” I said sleepily.

“Into a building- the World Trade Center, New York.”

We decided to make it a normal day; Sophia would go to our friend’s house for the day as usual. I would go to work and pick her up at the end of the day.

When I came to pick her up, our friend was watching TV, so was my daughter; watching the plane go into the building again, and again, and again. Our friend said that Sophia was building block towers earlier and knocking them down again, and again, and again.

Sophia: Crash!

Father (narration): What would I tell her about what happened? Well, the next night my wife and I talked about this. She had told Sophia that it was an accident; that they didn’t mean to fly the airplane into the towers, but, I don’t want to lie to my daughter. Even those little parental white lies: “there’s no more ice cream,” “if you eat your spinach you can jump higher, right away,” “monsters aren’t real.” I decided to see how much of the situation she had absorbed from TV, from our little talks, from her parents anxiety. I asked her what happened on September 11 in New York.

Sophia: The airplane, it crashed! It went in the building and then the smoke came. Then I saw it. Then it crashed!

Father (narration): It seems that she had taken in a lot, had thought about it. She asked me more questions and I tried to relate September 11 to other things that were in her life, to help her and me to understand why.

Sophia: The airplane flew in the building. What if somebody was angry so decided to hurt all the people.

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Father: All which people?

Sophia: All the New York people.

Father (narration): in the beginning she called them ‘the New York people,’ but after a while they became ‘the die people.’ Were the like plants? Do they dry up? Were they broken like the raccoon that’s lying out in the street?

Sophia: What happens when you die?

Father (narration): A tough question for the best of them. I told her I didn’t know. What I did know was that here in San Francisco the terrorist attack seemed blessedly far away and I just couldn’t imagine New York and what it must be like these days; the physical and mental scars still fresh. I asked Sophia if the story made her sad.

Sophia: No. I wasn’t in there. I wasn’t in..I wasn’t in New York. I wasn’t in the building that crashed. Our building is okay.

Father: Yeah?

Sophia: Yeah.

Father (narration): Was I reading a nervous assurance in her voice? Or was she trying like many of us to tell herself a story to make the world a safer place, at least in her mind?

Sophia: I don’t like the story of New York.

Father: Is it sad?

Sophia: Yeah.

Father (narration): I don’t like the story of New York either, but, its one I’m afraid I may have to tell again, and again, and again, as I talk to Sophia.

[Music begins to play]

Sophia: sings to music [inaudible]

Footnotes: n/a

Graphic = NC_PI_T05_050 ALT tag: alt="young girl looking scared"Photo caption: n/a Photo credit: n/a REUSE photo here from NC_PI_T05_050


Programmer Notes / Interactions & Feedback: This screen contains text and a photo, right-aligned with the text. This screen displays only if the learner clicks the View Transcript button on NC_PI_T05_050. The Back button returns to screen NC_PI_T05_050 and the Next button advances to NC_PI_T05_060.

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draft storyboard: psychosocial impacts of disasters on...

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