PEDIATRICS Vol. 103 No. 2 February 1999, pp. 521-523

AMERICAN ACADEMY OF PEDIATRICS:
How Pediatricians Can Respond to the Psychosocial Implications of Disasters

Committee on Psychosocial Aspects of Child and Family Health

	ABSTRACT

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Natural and human-caused disasters, violence with weapons, and terrorist acts have touched directly the lives of thousands of families with children in the United States.¹ Media coverage of disasters has brought images of floods, hurricanes, and airplane crashes into the living rooms of most American families, with limited censorship for vulnerable young children. Therefore, children may be exposed to disastrous events in ways that previous generations never or rarely experienced. Pediatricians should serve as important resources to the community in preparing for disasters, as well as acting in its behalf during and after such events.

	THE ROLES OF PEDIATRICIANS

Pediatricians have important roles before, during, and after a disaster. Not only should pediatricians be involved directly with children and their families, but they also may be asked to serve a more general community role in disaster preparedness.²

Before a Disaster

Disaster preparedness is important throughout the United States. The pediatrician may help determine and arrange for the organization and availability of necessary pediatric equipment in shelters, local hospital emergency departments, and emergency vehicles.

As part of anticipatory guidance at health supervision visits, pediatricians can help families by reviewing how to help their children understand what to do for the types of disasters they are likely to encounter, how to identify local shelters, and what resources to contact for more help if needed. Pediatricians also may be asked to discuss disaster preparedness with school personnel, police, and emergency medical services personnel and should help organize and participate in disaster preparedness drills.

During a Disaster

During a disaster, pediatricians are an integral part of the health care delivery team. They are a major source of support and information to children, families, and the community. Pediatricians may be needed to treat patients with inadequate supplies in suboptimal settings under conditions they have rarely, if ever, experienced.

After a Disaster

The pediatrician has a unique perspective in recognizing a child's appropriate reaction to an uncontrollable event such as a disaster and for educating parents, caregivers, and school personnel.^3,4 Most healthy children who have experienced a situation beyond the usual scope of human experience may overreact or underreact to the resultant stress, trauma, and loss. Providing families with supportive community resources legitimizes their feelings of grief and loss.

A child's cognitive, physical, educational, and social developmental level and experience will determine the perception of the trauma resulting from the disaster.⁵ The emotional state of the child and the family before the disaster provide the background for how the child may react to the disaster. Thus, the pediatrician's knowledge of the child and family is crucial in helping them to adjust after a disaster. Other factors can influence the effect of a disaster on a child's wellbeing, including physical injury sustained, proximity to the impact zone, witnessing the injury or death of a family member or friend, duration of life disruption, parental reactions, and family disruption.¹

The most important effect of a disaster on children and adolescents is the disruption of the normal routine through personal injury; destruction of their home, school, or community; or injury or death of friends or relatives. In addition, the loss of predictability and control of their environment affects children of different ages in distinct ways.

Toddlers usually respond to the disruption by increased dependence on caregivers, sleep disturbances, and developmental regression. School children and preteens may show hostility toward peers and family members, reenact the trauma during play, regress in developmental milestones, and avoid activities enjoyed previously.⁶ Adolescents also may have sleep disturbances, lack pleasure in activities enjoyed previously, show fatigue, and begin abusing illicit substances.⁷ Children and adolescents also may display anxiety, depression, guilt, and symptoms of posttraumatic stress disorder, such as nightmares, sleep disruption, avoidance of reminders of the disaster, and irritability.^8,9

Pediatrician assessment of the child and family, reassurance, and information can ensure family communication, keep the family working together, and provide emotional support.¹⁰ Maintenance of friendships and peer support should be encouraged.¹⁰ The reactions of children and adolescents to the trauma and resultant adjustment period usually last 1 to 2 months after a disaster. If symptoms such as depression, sleep disturbances, or maladaptive behavior persist, referral to a mental health professional should be considered.

	COMMUNITY ROLES FOR THE PEDIATRICIAN

Schools and Child Care Settings

Schools and child care programs are ideal sites for monitoring and influencing child and adolescent behavior after a disaster. Pediatricians may be asked by school and early childhood personnel to evaluate certain students. Pediatricians may educate faculty, helping them to understand what to expect from students after a disaster and assisting in compiling referral sources.¹¹ In addition, the pediatrician may participate in the evaluation of children with adjustment difficulties.

Schools and child care centers may serve as temporary shelters and may be a base for dissemination of written information for parents and students. Pediatricians have an important role in the development of these materials. Counseling programs for children and families can be established at schools and child care facilities in partnership with pediatricians.

Mass Media

Pediatricians may be asked to assist the media in designing public service announcements or setting up disaster hotlines. The local media may ask pediatricians to write about or discuss the psychological sequelae of disasters on children and adolescents. As an advocate for children and families, pediatricians also may discourage inappropriate exploitative media coverage of the community in which the disaster occurred.¹²

Community and Religious Groups

Local clergy and other neighborhood leaders may ask pediatricians to help in their efforts to assist children and families who are coping with grief and loss. Pediatricians may be asked to speak at community organizations about the psychosocial and health effects of disasters on children and adolescents.

Resources

As a brief and concise reference, the American Academy of Pediatrics, under a contract with the US Center for Mental Health Services, Washington, DC, has developed a document detailing the needs of children and adolescents who have been victims of a disaster and the role of the pediatrician in addressing these needs. Copies of this document, "Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician," can be obtained by contacting the National Mental Health Services Knowledge Exchange Network, Washington, DC (800-789-2647), or the Division of Child and Adolescent Health, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60009-0927. This document can help pediatricians prepare for a disaster situation and serves as a valuable resource in the event that they become involved in an emergency situation.

In addition, state and local mental health agencies may provide outreach programs for children and families, as may schools and child care centers. The American Red Cross provides for immediate basic needs, as well as for long-term intervention programs for disaster victims. Professional organizations such as the American Academy of Child and Adolescent Psychiatry in Washington, DC, and most local mental health boards, in association with the American Red Cross, have developed a network to provide trained psychologists for emergency crisis intervention. The Society for Developmental and Behavioral Pediatrics, Philadelphia, PA, is in the process of establishing a standby team of child health and development specialists to be available to help with humanitarian emergencies or disasters.

	THE EFFECTS OF A DISASTER ON THE PEDIATRICIAN

During and after a disaster, pediatricians may be coping with their own personal and professional stressors.¹³ With the disruption of school routines and the destruction of the community's buildings, day-to-day schedules change.² The pediatrician may experience the injury or death of a loved one.¹ Coping with the death of a patient, the loss of income, or the physical structure of the private practice or clinic may be extremely difficult.

	SUMMARY

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Implications for the Pediatrician

Before a disaster, the pediatrician might:

• Assess a community's resources to manage a disaster;
• Determine and advise emergency services to arrange for pediatric equipment in shelters, emergency departments, and ambulances;
• Review disaster preparedness with families, schools, and groups, especially in areas more vulnerable to natural disasters;
• Be aware of available resources provided by professional organizations and local specialists concerning disasters; and
• Participate in disaster drills as the children's advocate.

During a disaster, as an integral member of the health care delivery team, the pediatrician should:

• Be a source of information for patients and families;
• Counsel families experiencing acute psychosocial problems;
• Treat injured children and adolescents; and
• Design local public service announcements and help establish a community hotline addressing concerns of parents.

After a disaster, the pediatrician should:

• Educate parents about the range of normal reactions they may expect from their children;
• Recognize prolonged reactions to the trauma and provide mental health referrals;
• Help evaluate children at school and child care facilities and educate school and child care staff about acute and normal delayed reactions to disasters; and
• Address community and religious organizations on the psychological aftermath of a disaster for children and adolescents.

COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, 1998-1999
Mark L. Wolraich, MD, Chairperson
Javier Aceves, MD
Heidi M. Feldman, PhD, MD
Joseph F. Hagan, Jr, MD
Barbara J. Howard, MD
Ana Navarro, MD
Anthony J. Richtsmeier, MD
Hyman C. Tolmas, MD

LIAISON REPRESENTATIVES
F. Daniel Armstrong, PhD
  Society of Pediatric Psychology
David R. DeMaso, MD
  American Academy of Child & Adolescent Psychiatry
William J. Mahoney, MD
  Canadian Pediatric Society
Peggy Gilbertson, RN, MPH, CPNP
  National Association of Pediatric Nurse Associates   and Practitioners

CONSULTANTS
Elizabeth M. Alderman, MD
Stanford B. Friedman, MD
George J. Cohen, MD
  National Consortium for Child Mental Health Services

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	REFERENCES

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2. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Emergency Medical Services for Children: The Role of the Primary Care Provider. Elk Grove Village, IL: American Academy of Pediatrics; 1992:96-98
3. Sugar M Children in a disaster: an overview. Child Psychiatry Hum Dev. 1989; 19:163-179 [Medline]
4. Sugar M. Disasters. In: Levine MD, Carey WB, Crocker AC, eds. Developmental-Behavioral Pediatrics. 2nd ed. Philadelphia, PA: WB Saunders Co; 1992:178-181
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6. Saylor CF, Swenson C, Powell P Hurricane Hugo blows down the broccoli: pre-schoolers post-disaster and adjustment. Child Psychiatry Hum Dev. 1992; 22:139-149 [Medline]
7. Sugar M. Adolescents and their reactions to disaster. Presented at the annual meeting of the American Society for Adolescent Psychiatry; San Francisco, CA; May 1992
8. Sugar M A preschooler in a disaster. Am J Psychother. 1988; 42:619-629 [Medline]
9. Shannon MP, Lonigan CJ, Finch AJ Jr, Taylor CM Children exposed to disaster. I. Epidemiology of post-traumatic symptoms and symptom profiles. J Am Acad Child Adolesc Psychiatry. 1994; 33:80-93 [Medline]
10. American Academy of Pediatrics, Work Group on Disasters. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Elk Grove Village, IL: American Academy of Pediatrics; 1995
11. La Greca AM, Vernberg EM, Silverman WK, Vogel AL, Prinstein MJ. Helping Children Prepare for and Cope With Disasters: A Manual for Professionals Working With Elementary School Children. Coral Gables, FL: University of Miami; 1993
12. Sugar M. Children and the multiple trauma in a disaster. In: Anthony EJ, Chiland C, eds. The Child in His Family. Perilous Development: Child Raising and Identity Formation Under Stress New York, NY: John Wiley & Sons, Inc; 1988:429-442
13. Stuart GW, Huggins E Caring for the caretakers in times of disaster. J Child Adolesc Psychiatry Ment Health Nurs. 1990; 3:144-147