Care of Children Exposed to the Traumatic Effects of DisasterDeepak Prabhakar, MD, MPH
Detroit Medical Center, Wayne State University, Detroit, MI, USA
By Jon A. Shaw, Zelde Espinel, and James M. Shultz. Arlington, VA: American Psychiatric Publishing, Inc.; 2012; ISBN: 978-1-585-624263; pp 243; $54 (paperback).
Almost daily we are exposed to news of either human-generated or natural disasters. Even though one may not be directly impacted, media coverage of disasters such as earthquakes, hurricanes, tornadoes, violence, nuclear disasters, and accidents has implanted worse consequences in our collective conscious. According to the United Nations Office for Disaster Risk Reduction, children make up 50% of all those affected by disasters worldwide.1 Although children generally are exposed to similar adversity as adults, they process it differently, according to their own individual developmental level. It is pertinent that the traumatic effects of disaster on children are understood separately in the context of development.
Care of Children sets out with a goal to facilitate understanding of traumatic effects of disasters on children in an effort to equip its readers with strategies to support children and their families cope with the aftermath of disasters. The authors of this book all are part of the Miller School of Medicine of the University of Miami (Miami, FL, USA) and have expertise in disaster-preparedness, disaster-epidemiology, and disaster-behavioral health. The book’s content is divided into a Preface and 9 chapters. Each chapter begins with a set of learning objectives and ends with key clinical points.
In the first chapter, the authors define disaster and classify it under the categories of natural, human-generated, and multidimensional disasters, eg the March 2011 tsunami and subsequent Fukushima Daiichi Nuclear Power Plant failure in Japan. Stress is discussed in relative detail by describing spectrum of stressors, stress response, and psychobiological responses to chronic stress in children. The authors underscore the importance of subjective appraisal of stress response: “From a cognitive perspective, stress, like beauty, is often in the eye of beholder” (p 5). They also effectively debunk the myth “that which does not kill us makes us stronger” (p 14) by pointing to the contrary evidence of higher likelihood of developing posttraumatic stress symptoms with increased frequency of traumatic exposure.
The second chapter details natural and human-generated disasters. While discussing distinctive definitions of disaster, the authors point to the common theme of “disproportionate demand on the population” (p 19). The authors use Hurricane Katrina as an example to draw a distinction between disaster and catastrophe because of certain elements—unresponsive emergency systems, leadership failure, destruction of community services, cessation of local mass media coverage, and conflicts around class and race or ethnicity—that were rampant in post-Katrina response. The discussion on disaster life cycle is a sobering reminder that recovery may take years not days—eg, the May 2011 execution of 9/11-mastermind Osama bin Laden triggered unsettling, as well as joyous, emotions across the United States. Each major category of disaster is discussed in detail with preimpact, impact, and postimpact stressors. Though some of these factors are unique, the general discussion becomes redundant and the chapter may have benefited from consolidating some of this content under major disaster categories rather than each and every individual disaster. Although some will argue gun violence in schools as “disasters,” readers may have benefited from the author’s insight into this important issue and are likely to miss this content.
Discussion on the context of trauma, particularly the disaster ecology model, is valuable. Children’s responses to stressors are influenced greatly by the interaction of risk and protective factors encompassing the ecologic context. For maximal positive impact in the postdisaster phase, children would benefit if responders correctly assess the interplay between all the variables at an ecologic level, rather than an individual one. The authors also effectively depict risk disparities for ethnic minorities in a tabular fashion, after all, “disasters are income neutral and color-blind. Their impacts, however, are not” (p 77).
From a clinical standpoint, the chapter on children’s psychological responses leaves a lot to be desired. This chapter begins with discussing the unique needs of children in disasters and developmental effects. However, the discussion is limited in depth, especially on stress reactions and trauma-specific disorders. Sleeper effect is mentioned ephemerally without any text references. Similarly, readers would have benefited from a more detailed discussion on “resilience,” specifically progress or lack thereof in our understanding of the role that gene-environment interaction plays towards a resilient disposition. The discussion on posttraumatic growth should have been paired with the earlier discussion on the adverse impact of repetitive trauma, with accompanying evidence supporting and refuting both models. Nevertheless, readers who are looking for a brief synopsis of this topic will benefit from the discussion.
The chapter on children with special needs during disasters highlights the key point that as a sub-group, children themselves are a special population. Recommendations of the National Commission on Children and Disasters are listed in a tabular format for easy review. The authors also underscore that children with cognitive limitations have unique difficulties, and may be exposed to additional harm due to their limitations in following directions and difficulty understanding. The discussion on traumatic bereavement in a developmental context is very useful. Readers who see these children in a clinical setting as well as their natural supports will find the discussion on children’s understanding of death and symptoms of grief valuable. The chapter on child and family assessment discusses screening and clinical assessment in a succinct manner. Clinicians will find the discussion and listing of various assessment tools informative and useful for application in practice.
The chapters on interventions and generally accepted truths are well written and concise. Interventions such as psychological first aid and skills for psychological recovery (SPR) are described in a clinically useful manner and the discussion is punctuated with tables highlighting the key points such as basic assumptions and goals of SPR. Similarly, readers from diverse backgrounds will find the discussion on psychoeducation for parents informative. Where applicable, the authors also discuss limitations of intervention strategies, eg, “limited empirical data are available on psychological debriefing with children” (p 196). The authors also underscore the importance of school-based interventions, even with treatments that are effective equally, children are more accepting of the ones that are offered in school. Furthermore, they also point to the importance of “rapid restoration” of the school system for children postdisaster.
Despite some of its limitations, this book is clinically useful. The developmentally sensitive discussion about disaster and its impact on children of different age groups is bound to resonate not only with clinicians dealing with children but also with parents and stakeholders such as school teachers and administration, emergency responders, and community leaders. The book includes useful suggestions for providers ready for immediate application. It may serve as a practical reference for an unfortunate disaster that we all wish never arrives, yet it is highly likely that at some point we may find ourselves in the midst of it.
- UNICEF. Disaster risk reduction: programme guidance note. http://www.unicef.org/mozambique/FinalProgrammeGuidance-DRR10_2_2011.pdf. Published February 10, 2011. Accessed July 1, 2013.
Annals of Clinical Psychiatry ©2013 Frontline Medical Communications Inc.