Section 14 - The Psychosocial Needs of Children during a Disaster
Purpose: To properly care for children in hospitals it is necessary to consider both their physical and mental health needs and to treat them in the context of the family unit. Children's responses to disaster and hospitalization may share some aspects of adult responses, but are distinguished by the developmental contexts in which children of varying ages experience the impact of associated events and procedures. An unfamiliar environment such as a medical setting can be made to feel safer for pediatric visitors and patients by including familiar people, familiar things and routines. Hospital staff need to consider the cultural differences that may cause a group of children exposed to the same trauma to react differently. Lastly, there are legal concerns regarding the treatment and release of children, which each hospital should consider when creating the pediatric response portion of its disaster plan.
- General Guidelines
- How Children Can React to a Disaster
- Table - Children's Characteristics, Reactions and Interactions
- Development-specific Guidelines for Treating Children in the Hospital
- Supporting Families following a Disaster
- Understanding Death - Developmental and Cultural Considerations
- When to Consult a Mental Health Professional
- Legal Considerations
- Obtaining Mental Health Services in the Community
- After a Disaster-A Guide for Parents and Caregivers
- Helping Children Cope with Fear and Anxiety
- Online Resources for Pediatric Psychosocial Issues
- When describing the hospital experience to children of any age, it is important to be honest in your description and in answering any questions they may have. However, it is important not to give preconceived notions about what a child may feel. Caregivers should avoid the use of the words 'pain' and 'scary' in describing experiences the child may have since everyone feels pain and emotions differently.
- Since young children (preschool through school-aged) learn best by experience, provide as much information as you can to help the child learn about their upcoming experience. Describe what the child may smell, hear, touch and feel, using as many tangible items as possible, such as dolls and books.
- Children's reactions and symptoms can be expressed through behavior, thoughts, emotions, and physical reactions. Children's fears about their own safety can contribute to symptoms of anxiety and depression and may lead to oppositional and aggressive behavior. This may be an attempt to reassert some sense of control and should be recognized as such.
- Answer questions reassuringly but honestly. Take the child's age and development level into consideration. Use pacing, for example, "There was a big explosion and many people were badly hurt. What else would you like to know?"
- Children and teens need to be reassured that the staff at the hospital and professionals in the field are working to keep them safe, help protect everyone, assist those who are hurt, and look for people who cannot be found (in general) and their family and friends (specifically).
- Give children and teens opportunities to tell their story and exercise acceptance and patience if they are unable to do so at the time. Provide a variety of mediums to facilitate this: tape or video recorder, art materials or journals. On the other hand, restrict the amount of "storytelling" by others that the children or teens are exposed to in the initial aftermath.
- Gather unit staff and develop language for describing events of the disaster. Ensure that all staff is educated accordingly and then communicate this information consistently to avoid adding to the children's confusion.
- Opportunities for play are important for learning, expression of feelings, normalcy, escape and mastery. Age-appropriate toys and diversionary activities are helpful to have on hand. This may include puzzles, books, simple art supplies, videos/DVDs and audiotapes/CDs. If possible, allow children to interact in groups and monitor for misconceptions.
- Try not to separate children from their primary caregivers for extended periods. Allow a parent/caregiver to accompany the child to procedures as much as possible. To encourage feelings of safety and familiarity try to limit the number of staff caregivers (i.e., assign the same nurse to care for specific children).
- Parents will be most helpful when they are/feel informed. If they are upset from not knowing what is going on, that tension is going to affect the child.
- Assess for any underlying mental health disorder that may require immediate psychiatric consultation such as trouble sleeping, lack of appetite and physical complaints with no medical basis.
- It may be helpful to gather information ahead of time about varying cultural responses to trauma and death. This can be very helpful in assisting caregivers in understanding family and child reactions.
- Have available a list of community resources (mental health and counseling services, etc.) for distribution to parents/caregivers upon discharge. This can be very helpful in dealing with responses that arise after the immediate emergency is over.
- Identify staff within the hospital that can assist with addressing the emotional and psychological issues (i.e., social workers, psychologists, psychiatrists, chaplains and psychiatric nurses) and have an on-call list available for unit staff.
- Dedicate a 'safe area' where no procedures take place.
- Identify resources for staff support to cope with their impact upon seeing injured and/or dying children.
- Identify community resources that may be able to donate services, supplies, etc., specifically for the children.
How Children Can React to a Disaster
Children react differently to stressful events than adults. Their response may be delayed and hard to detect. They may find it difficult to express their feelings.
- Staff needs to be aware of changes in children's behavior such as extra clinging or a change in appetite. Parents, teachers and other caring adults who know the child are in the best position to notice these changes.
- Do not wait for the child to come to you. Ask questions such as "Are you having trouble sleeping?" or "Are you feeling less safe than before?"
- Some children are more likely to have emotional reactions to the events, including:
- Children who witnessed the event firsthand or whose parent, relative or friend was killed or injured;
- Children who are displaced from their home or schools;
- Children who have a past history of emotional problems;
- Children who have a past history of trauma, either as a victim or as a witness to violence or abuse; or
- Children with an adult in their life who is having difficulty with their emotions, or who is a witness to violence or a victim of domestic violence.
The chart that follows outlines psychological characteristics of various aged children and suggests caregiver behaviors that support successful interactions. Not all children exhibit all symptoms and their reactions may change over the first days or weeks following a crisis.
|Age||Characteristics||Typical Reactions||Keys to Successful Interactions|
|Newborn: Birth to 1 Month||
|Infant: 1 to 12 months||
|Toddler: 1 to 3 years||
|Preschooler: 3 to 6 years||
|School-Aged: 6 to 12 years||
|Adolescent: 12 to 18 years||
Development-specific Guidelines for Treating Children in the Hospital
- Try to let a parent/caregiver stay with the baby during medical procedures and, when possible, to hold the baby during that time.
- Use familiar objects from home such as a stuffed animal, blanket, music box or toy to help comfort the baby before, during or after a procedure.
Toddlers and Preschool-aged Children
- Try not to have conversations about the child's care in their presence unless you are including them in the conversation. Children overhear much more than adults think and without any explanation, the information may seem terribly frightening.
- Let a parent/caregiver stay overnight with the child if possible. If appropriate, let other family members, including brothers and sisters, come and visit or stay.
- Reassure the child that the hospitalization is not a punishment. Try to avoid using good/bad labels particularly during a procedure. For example, do not say, "See, you were so good, the doctor only had to do this once." Instead, you can say, "You did such a good job of sitting still. I know that was hard."
- Children learn best through play and 'medical play' that can be particularly useful. Allow them to handle some medical equipment such as a stethoscope, blood pressure cuff, etc. Allow them to practice the procedure on a doll.
- Allow the child to make choices whenever possible, but never offer a choice when none exists. For example, do not say, "Would you like to come into the treatment room now so the doctor can look at you?" It would be better to say, "Do you want to bring your bear or blanket with you into the treatment room?"
All Children Under Age 5
- Try to keep to normal routines and favorite rituals as much as possible.
- Limit exposure to TV programs and adult conversations about the events.
- Ask what makes them feel better.
- Give plenty of hugs and physical reassurance.
- Provide opportunities for them to be creative and find other ways to express themselves.
- School-aged children can be given more specific information about what is going to happen to them. Many medical terms can be confusing for children. For example, the term 'IV' could be confused with the word 'ivy' or 'dye' with 'die.' Give simple, specific explanations for procedures.
- This is a great age for medical play, which involves children communicating their understanding and fears through play with medical equipment. Allow the child the opportunity to reenact events through play with different kinds of toys or art materials. This is an important way for school-aged children to express their feelings and gain a sense of control over what is happening to them.
- Always respect the child's privacy and encourage others to do the same by knocking before entering the room and being sensitive to who is around when examinations are being conducted.
- Sometimes, when in a stressful situation like being in a hospital, children at this age regress, or begin exhibiting behaviors that they had grown out of, like thumb sucking and bed-wetting. Do not berate them ("Come on, you're a big girl now!") or punish them for this behavior. Encourage the child to express his/her feelings and discharge emotions through play.
- Do not be afraid to ask them directly what is on their mind and answer their questions honestly.
- Listen to the child's repeated retelling of the event.
- Talk to them about any news that they have seen and any adult conversations that they have heard.
- Make sure they have opportunities to talk with peers if possible.
- Set gentle but firm limits for acting out behavior.
- Encourage verbal and play expression of thoughts and feelings.
- Try not to have conversations about a teen's care in his/her presence unless you are including him/her in the conversation. Adolescents can understand much more about their bodies and what is happening to them than can younger children; because of this they may resent not being included in discussions about their condition or treatment.
- Do not assume that teens manage their emotions the same way as adults do. Give them opportunities to discuss what is happening with staff both with and without the parent/caregiver being present, so they can ask questions. Do not treat the teen's questions as silly or outlandish.
- Respect the teen's privacy and encourage others to do the same by knocking before entering the room and being sensitive to who is around when examinations are being conducted.
- Adolescents are particularly concerned about body image. They do not want to be perceived as different from peers because of an illness or injury. Be especially sensitive to the physical changes the adolescent may experience when explaining any procedures, injuries or treatments they may have.
Supporting Families Following a Disaster
It is important to understand that caregivers have the potential to positively influence their child's post-disaster functioning. It follows that assisting families can have a beneficial impact on the mental health of their children who have experienced the disaster.
In assisting families following a disaster, keep the following in mind in order for your efforts to have the most positive impact:
- Make sure that you do not undermine the caregiver's authority.
- Support caregivers by listening, answering questions, and providing needed information.
- Point out the family's strengths.
- Encourage caregivers to take care of themselves in order to feel their best and care for the child.
- Connect families with resources in their communities for needed assistance and services.
- Inform caregivers about general trauma-related stress symptoms* that their children may experience, such as:
- Reenacting the disaster/trauma in play
- Intrusive imagery such as flashbacks
- Sleep disturbances
- Somatic complaints
- Anxiety responses (e.g., hypervigilance, avoidance, fear)
- Strong emotions such as guilt and anger
- Disruption in normal social and developmental tasks or performance
- Normalize children's potential responses to trauma with their caregivers
- Some children may never experience problematic symptoms post-disaster, whereas other children will have symptoms immediately or months/years later
- Provide caregivers with factual information
- Instill hope about treatment and recovery
* These symptoms may also indicate post-traumatic stress disorder in children.
Family Coping after a Disaster
Following a disaster, families may cope very differently with the loss and/or devastation that they are facing based upon their socioeconomic status (SES) or other personal/demographic factors. SES can carry with it both assets and liabilities in terms of a family's capacity to deal with the disaster's impact on their family. For instance, a family of low SES has likely encountered past loss and destruction so may feel empowered through past ability to survive in the face of loss; however, they may feel powerless and unable to obtain adequate assistance in facing their situation. In this scenario, a helper can acknowledge family resources, ensure that basic needs are met, and help family caregivers obtain needed services while maintaining a positive focus on family strengths. On the contrary, a family of higher SES may not have encountered any loss or destruction on this scale in the past, yet may have a potential asset in access to resources. A high SES family may be reluctant to seek assistance, but helpers can try to normalize the family's experiences, help caregivers utilize resources, and again, focus on the family's strengths.
Mental Health Assessment and Intervention
Following a disaster, various assessments and interventions can be employed to determine mental health status of children/families. The particular intervention is dependent on each unique situation (e.g., intensity of mental health impact from the disaster). Consider that a child may not show overt symptoms of having experienced a traumatic event, but may have internalized, repressed or dissociated symptoms that may surface later. Descriptions and an overview of these assessment and intervention types follow:
- Assesses both the child's and family's post-disaster functioning
- Surveys, indexes, inventories, checklists and questionnaires
- Assesses both the child's and family's post-disaster functioning
- May require additional training
The selected intervention type should depend on when help is being offered, the scope of the intervention(s), and the needs of the survivors and community.
- Promote positive coping
- Address commonly occurring worries/emotions of a community
- Involve working with families to assist children by:
- Reuniting children with their families and supportive adults
- Supplying children and their families with food, water, and shelter
- Providing caregivers with information regarding disaster and recovery
- Offering caregivers techniques to help their child's mental health
- Referring children and their families to appropriate resources
For example, Psychological First Aid (PFA) is the universal intervention of choice in the immediate aftermath of traumatic events. The PFA strategy is to assist children's caregivers and families so that the families can help the children.
- Used when universal interventions have not reduced the child's distress
- Appropriate for children who show marked signs of distress that interfere with social behavior, psychological functioning, and/or school work
- Require specialized training, but disaster responders should be aware of these interventions so that they can refer children to specialists and educate children's caregivers
- May be done in group or family settings in order to restore personal safety, normalize experiences, help disaster survivors feel heard/validated and reduce stress
- Used as the most immediate and intense type of intervention, appropriate for:
- Those with comorbid issues pre-disaster
- Those exhibiting extremely impaired mental functioning
- Those at acute risk of hurting their self or others
- Those with life-threatening medical issues
- Should be activated as part of a full range of intervention types for these children
Note: The preceding content, Supporting Families Following a Disaster, was gleaned from Disaster Mental Health: Assisting Children and Families, a PowerPoint training presentation developed by the Institute for Disaster Mental Health at SUNY New Paltz and funded by the New York State Department of Health.
Understanding Death - Developmental and Cultural Considerations
Children and teens need to understand the cause of a death and the meaning of death itself. Understanding the meaning of death includes understanding non-functionality, irreversibility and universality. An example of non-functionality that is helpful for young children is "when someone dies we mean their body totally stops working and it cannot be reversed."
Pre-verbal: Children under 2 years of age cannot articulate their own feelings verbally, nor easily understand even a simple explanation of death. However, these children do respond to the emotional state of those around them, especially their caregivers. Physical connections are important, as are simply labeling behaviors and feelings (crying, sadness). When a pre-verbal child has lost a parent or family member, it is important to provide as much familiarity and consistency as possible.
Preschool (2 to 5 years): Preschool children think death is reversible and temporary, like going to sleep or when a parent goes to work. The child believes that people who die will come back. They require simple explanations with continual review and reinforcement.
School-aged children (5 to 9 years): Children begin to understand the finality of death; some do and some may not. Make sure the child does not feel responsible in any way for the death.
Latency (9 to 13 years): Children's understanding is nearer to adult understanding of death. They are more aware of the finality of death and the impact the death has on them.
Teens (13 to 18 years): Adolescents generally have an adult understanding about death. They are very reliant on support from their peer group.
Giving bad news: The child or teen's developmental and cognitive levels should be taken into consideration when giving information about the death of a parent or family member. For younger children or in the case of a violent, unexpected death, distilling the information in small pieces makes it more understandable cognitively and manageable psychologically.
Cultural Differences in Dealing with Death and Dying
Every culture has its own rituals and manner of mourning. Over time and through immigration and contact between different groups in the US, mourning patterns of ethnic groups have changed and continue to change constantly. Clinicians should be careful about definitions of "normality" in assessing families' responses to death. Additionally, healthcare providers should remember not to assume people within any particular cultural group fit a pattern when mourning. Each family unit and each individual needs to be treated and assessed on an individual case-by-case basis.
- It is important for staff to appreciate an ethnic group's particular attitudes about mourning and to find out from a family member what its ethnic group believes about the nature of death, the rituals that should surround it, and the expectations of afterlife.
- A failure to carry out death rituals often contributes to a family's experience of unresolved loss.
- Helping family members deal with a loss often means showing respect for their particular cultural heritage and actively encouraging them to determine how they will commemorate the death of a relative.
- While it is generally better to encourage families toward openness about death, it is also crucial to respect their cultural values and timing for dealing with the emotional aftermath of a loss.
- Staff may inquire the following:
- What are the prescribed rituals for handling dying, disposition of the body and to commemorate the loss?
- What are the group's beliefs about what happens after death?
- What are the group's beliefs about appropriate emotional expressions?
- What are the gender roles for handling the death?
- Staff should identify personnel in their setting who may be able to provide more details regarding specific cultural groups such as Pastoral Care, Social Work or even particular staff members from various cultural groups.
When to Consult a Mental Health Professional
Consultation with a mental health professional may be useful at any of these times. However, psychiatric consultation should be sought if any of the following is exhibited:
- Excessive fear of something terrible happening to their parents or loved ones;
- Excessive and uncontrollable worry about things, such as unfamiliar people, places or activities;
- Fear of not being able to escape if something goes wrong;
- Suicidal thoughts or the desire to hurt others; or
- Hallucinations expressing the feeling of being helpless, hopeless, and worthless.
The following are legal questions and issues that may arise during a disaster. Having policies and procedures in place prior to an event should be considered.
- For unaccompanied children during a disaster, consent is not needed to treat for a life- or limb-threatening situation. Is parental consent needed to treat a child victim with minor injuries? With psychological injuries?
- Is parental consent required to decontaminate an unaccompanied child? What if the child is asymptomatic? What if the child is refusing?
- What medical or social information can be released and to whom can it be released during a disaster?
- Check HIPAA rules and your legal counsel's guidance concerning unidentified patient locator protocols, such as posting Polaroid photographs of unidentified children.
- To whom can children be released, and if planning to release to someone other than the parent or caregiver, what permission or information is first needed? What is your protocol for releasing children if no legal guardian or parent can be found or if no permission document is provided?
Obtaining Mental Health Services in the Community
Every child experiences emotional difficulties from time to time, but at some point, a child's problems may warrant professional attention.
Community mental health resources must be addressed during the disaster planning phase so that the healthcare provider can be confident that a referral will be appropriate. If the facility does not have mental health resources, it is recommended to have referral agreements in place.
In the planning phase, it is important to ascertain the capacity of various mental health providers/facilities for treating families and children of various ages. Contacting the child's pediatrician for a referral to a mental health professional or clinic may also be helpful.
After a Disaster - a Guide for Parents and Caregivers
Fact Sheet-From the National Institute of Mental Health
Natural disasters such as tornados or man-made tragedies such as bombings can leave children feeling frightened, confused and insecure. Whether a child has personally experienced trauma, has merely seen the event on television, or heard it discussed by adults, it is important for parents, caregivers and teachers to be informed and ready to help if reactions to stress begin to occur.
Children respond to trauma in many different ways. Some may have reactions very soon after the event; others may seem to be doing fine for weeks or months, and then begin to show worrisome behavior. Knowing the signs that are common at different ages can help parents and teachers to recognize problems and respond appropriately.
Children from one to 5 years of age find it particularly hard to adjust to change and loss. In addition, these youngsters have not yet developed their own coping skills, so they must depend on parents, family members and teachers to help them through difficult times.
Very young children may regress to an earlier behavioral stage after a traumatic event. For example, preschoolers may resume thumb sucking or bedwetting or may become afraid of strangers, animals, darkness, or 'monsters.' They may cling to a parent or teacher or become very attached to a place where they feel safe.
Changes in eating and sleeping habits are common, as are unexplainable aches and pains. Other symptoms to watch for are disobedience, hyperactivity, speech difficulties, and aggressive or withdrawn behavior. Preschoolers may tell exaggerated stories about the traumatic event or may speak of it repeatedly.
Children aged 5 to 11 may have some of the same reactions as younger boys and girls. In addition, they may withdraw from playgroups and friends, compete more for the attention of parents, fear going to school, allow school performance to drop, become aggressive, or find it hard to concentrate. These children may also return to behaviors that are 'more childish'; for example, they may ask to be fed or dressed.
Children aged 12 to 14 are likely to have vague physical complaints when under stress and may abandon chores, schoolwork and other responsibilities they previously handled. While on the one hand they may compete vigorously for attention from parents and teachers, they may also withdraw, resist authority, become disruptive at home or in the classroom, or even begin to experiment with high-risk behaviors such as drinking or drug abuse. These young people are at a developmental stage in which the opinions of others are very important. They need to be thought of as 'normal' by their friends and are less concerned about relating well with adults or participating in recreation or family activities they once enjoyed. In later adolescence, teens may experience feelings of helplessness and guilt because they are unable to assume full adult responsibilities as the community responds to the disaster. Older teens may also deny the extent of their emotional reactions to the traumatic event.
Helping Children Cope with Fear and Anxiety
Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death and disasters can cause.
Listening and talking to children about their concerns can reassure them that they will be safe. Start by encouraging them to discuss how they have been affected by what is happening around them. Even young children may have specific questions about tragedies. Children react to stress at their own developmental level.
The Caring for Every Child's Mental Health communications campaign offers these pointers for parents/caregivers:
- Encourage children to ask questions. Listen to what they say. Provide comfort and assurance that address their specific fears. It is OK to admit you cannot answer all of their questions.
- Talk on their level. Communicate with your children in a way they can understand. Do not get too technical or complicated.
- Find out what frightens them. Encourage your children to talk about fears they may have. They may worry that someone will harm them at school or that someone will try to hurt you.
- Focus on the positive. Reinforce the fact that most people are kind and caring. Remind your child of the heroic actions taken by ordinary people to help victims of tragedy.
- Pay attention. Your children's play and drawings may give you a glimpse into their questions or concerns. Ask them to tell you what is going on in the game or the picture. It is an opportunity to clarify any misconceptions, answer questions, and give reassurance.
- Develop a plan. Establish a family emergency plan for the future, such as a meeting place where everyone should gather if something unexpected happens in your family or neighborhood. It can help you and your children feel safer.
If you are concerned about your child's reaction to stress or trauma, call your physician or a community mental health center.
The Caring for Every Child's Mental Health communications campaign is part of The Comprehensive Community Mental Health Services for Children and Their Families Program of the Federal Center for Mental Health Services Administration, U.S. Department of Health and Human Services. Parents and caregivers who wish to learn more about mental well-being in children should call 1-800-789-2647 (toll-free) or visit the Caring for Every Child's Mental Health communications campaign (http://mentalhealth.samhsa.gov/child/) to download a free publications catalog (Order No. CA-0000).
How to Help
Reassurance is the key to helping children through a traumatic time. Very young children need a lot of cuddling, as well as verbal support. Answer questions about the disaster honestly, but do not dwell on frightening details or allow the subject to dominate family or classroom time indefinitely. Encourage children of all ages to express emotions through conversation, drawing, or playing and to find a way to help others who were affected by the disaster.
Try to maintain normal routines and encourage children to participate in enjoyable activities. Reduce expectations temporarily about performance in school or at home, perhaps by substituting less demanding responsibilities for normal chores. Finally, acknowledge that you too may have reactions associated with the traumatic event and take steps to promote your own physical and emotional healing.
When to Seek More Help
Consultation with a mental health professional may be useful at any of these times. However, psychiatric consultation should be sought if any of the following is exhibited:
- Excessive fear of something terrible happening to their parents or loved ones.
- Excessive and uncontrollable worry about things, such as unfamiliar people, places or activities.
- Fear of not being able to escape if something goes wrong.
- Suicidal thoughts or the desire to hurt others.
- If the child has hallucinations.
- Expressing feelings of being helpless, hopeless, and worthless.
Online Resources for Pediatric Psychosocial Issues
American Academy of Pediatrics
Children, Terrorism and Disaster. Useful website with multiple documents related to children's needs during disasters.
American Academy of Pediatrics
Child Deaths Hit Communities Hard: Disasters Demand Psychological Triage. News article.
American Academy of Pediatrics
How Pediatricians Can Respond to the Psychosocial Implications of Disasters. Policy statement.
American Academy of Child and Adolescent Psychiatry
Family Readiness Kit-Preparing to Handle Disaster
Helping Children after a Disaster
Federal Emergency Management Agency (FEMA)
Website with multiple games, coloring books, and materials aimed at younger, computer-savvy children.
National Advisory Committee on Children and Terrorism
National Child Traumatic Stress Network
National Mental Health Information Center
Publications on Disaster and Trauma
Substance Abuse and Mental Health Services Administration (SAMHSA)
Tips for Talking about Disasters
AAP and US Center for Mental Health Services
Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician
New York State Office of Mental Health
New York University Child Study Center
Congress EP. Clinical work with culturally diverse dying patients. Ethics Network News. 1997; 4(3):5-6. Available at: http://www.angelfire.com/on/NYCLTCethicsnetwork/econgress.html. Accessed February 8, 2010.
National Center for Post-traumatic Stress Disorder
Terrorist Attacks and Children Web site