The Impact of Hurricane Katrina on Children and Adolescents: Conceptual and Methodological Implications for Assessment and Intervention
Hurricane Katrina was one of the most devastating natural disasters the United States has ever encountered. Although many were adversely affected by Hurricane Katrina, this chapter focuses on children and the role traumatic events can play on their mental health. The chapter begins with an overview of the immediate and ongoing efforts of the first author and his associates in the wake of Katrina. These efforts include deployments to the Gulf Coast and his briefing of the then First Lady, Laura Bush, on the psychological ramifications that traumatic events can have on children and adolescents. A review of the research literature regarding the impact of Hurricane Katrina on youth survivors follows. Recommendations for assessment and post-disaster intervention efforts are made within the context of the dose–response model. This conceptual model illustrates the roles of many risk and protective factors, including exposure, social support, coping, race/ethnicity, age, gender, parent–child interaction. The chapter concludes with recommendations for future clinical and research initiatives.
I’ve got a hole in my roof, but a greater hole in my heart because no one is looking out for the kids.
–Jeanne Brooks (October 2006)
On August 29, 2005, Hurricane Katrina hit southeast Louisiana as a Category 3 hurricane, becoming the third most intense hurricane to make landfall in the United States. As it moved up the coast of Mississippi, its devastating winds and destructive powers resulted in Hurricane Katrina becoming the nation’s most economically damaging storm in history (National Oceanic & Atmospheric Administration, 2006). Thousands lost their homes and loved ones, and relief efforts were made on a local, state, and national level. Although numerous relief efforts were activated, the enormity of the storms rendered many such efforts inadequate. Once again, clinical psychologists were called upon to aid our nation in the midst of yet another crisis. In terms of natural and technological disasters, this one proved to be the most challenging by far. Katrina was indeed a new benchmark for such natural disasters on American soil.
This chapter is organized as follows. The immediate and ongoing efforts of the first author and members of his team will be highlighted first. A review of available assessment and intervention research efforts targeting children and adolescents is presented next. The relative contribution of these scientific investigations to the growing literature, documenting the impact of disasters on the functioning of youths, is discussed. Recommendations for future research targeting the aftermath of disaster are discussed within the context of the dose–response model. The chapter concludes with recommendations for future clinical and research initiatives.
Clinical Initiatives and Deployments to the Gulf Coast
The first author’s initial activities included consultation with local, state, and national agencies, advising the White House, and building capacity among mental health workers and volunteers living in the Gulf Coast in the domains of disaster behavioral health and cultural competence. During this time, a partnership with the lab in the Psychology Department at Virginia Tech and the Hurricane Katrina Community Advisory Group was forged with the purpose of assessing the impact of the storm on residents of the Gulf Coast. The first author’s membership in the Disaster Technical Assistance Cadre (DTAC), sponsored by the Substance Abuse Mental Health Administration (SAMHSA, a division of the Department of Health and Human Services), facilitated several of these timely and innovative ventures. A brief overview of his deployments to cities in the Gulf Coast region is given next to contextualize the discussion and provide insight into active partnerships that may be useful for future disaster planning and management.
Deployments to the Gulf Coast
The first two deployments were to Baton Rouge, Louisiana, 2½ weeks post-Katrina and Jackson, Mississippi, 6 weeks post-Katrina. The major objectives of these deployments were to assist state emergency directors in coordinating the mental health response to Hurricane Katrina. During this initial deployment, members of the mental health team toured New Orleans to get a firsthand view of the devastation wrought by the storm. Ongoing meetings were attended with mental and public health professionals, as well as with military personnel. Many of these meetings took place in temporary shelters, centers, and military command posts. Experts from organizations, including the Federal Emergency Management Agency (FEMA), the American Red Cross (ARC), and the Centers for Disease Control and Prevention (CDCP), provided input and guidance for several of our initial endeavors.
As team leader of the second deployment, the first author’s primary goals were to provide guidance for team members’ day-to-day activities and to ensure their overall safety and well-being. Too often mental heath workers have been guilty of taking care of others and not taking care of themselves. It was the first author’s hope that this “practice” would not be repeated in this situation. An additional task was to establish parameters for clinical assessment in order to determine the extent of loss, displacement, and distress incurred by residents of the Gulf Coast. Furthermore, numerous efforts targeting screening, assessment, and intervention of impacted individuals and communities were discussed and implemented at varying levels.
An important effort at the national level was participation in workshops sponsored by the United States Department of Education. This effort, spearheaded by Secretary Margaret Spellings, was designed to educate school teachers and administrators about how to respond to the needs of students, who had been either directly or indirectly impacted by the storm. As a follow-up to this initiative, the first author is currently serving as a member of an advisory committee for the Department of Education, where issues related to the negative impact of a variety of traumas on students’ academic and social functioning are being discussed. For example, prior to an event attended by children and their parents in Metairie, Louisiana, the first author briefed the First Lady, Laura Bush, on research findings pertaining to issues of loss, disruption, and how children best cope during recovery phases of disasters. This discussion provided an invaluable opportunity to share knowledge and expertise from the disciplines of clinical and community psychology, as well as principles of disaster behavioral health. Subsequent to this encounter, a discussion of related ventures with a member of her staff at her office in the White House ensued. Updates on various initiatives with children and their parents on the Gulf Coast have been made since that time.
Of particular interest to the first author, given his many years of research and clinical efforts in the area of minority mental health, were efforts targeting cultural competence and disaster behavioral health. The objective of these efforts was to enhance the skill sets and proficiency of indigenous mental health experts and volunteers within the domains of cultural competence and disaster behavioral health. While many of these individuals possessed varying levels of knowledge in these areas, given the massive needs of survivors, it was thought that additional training would be beneficial.
The first step in this process was to initiate focus groups with crisis counselors to determine their levels of proficiency in the areas of disaster mental health and cultural competence, as well as to determine the needs of their clients.
In March 2006, the Louisiana Department of Mental Health tasked four professionals with expertise in the areas of disaster behavioral mental health and cultural competency to develop and implement a training curriculum designed to enhance the skills of crisis workers in delivering effective and culturally and linguistically appropriate strategies and interventions (see Jones, Immel, Moore, & Hadder, 2008). The first author was a member of this team. Specific objectives of the focus groups were as follows: (a) to ascertain the degree to which survivors had received services and demonstrated progress toward recovery; (b) to identify the most salient concerns facing survivors; (c) to determine the types of assistance required by trainees to enhance their capacity to provide culturally and linguistically competent disaster behavioral health-care services; (d) to assess the demographics and cultural strengths of respondents; and (e) to determine the extent to which mental health crisis workers were to provide disaster behavioral health services within the context of the cultures of individuals served. During these focus groups, data were obtained by facilitators which were then used to develop a training manual. Training was guided by this manual during two, 2-day seminars presented in Baton Rouge and New Orleans, Louisiana, in 2006. Copies of the manual may be obtained from the first author upon request. In short, the above efforts exemplify how psychologists and other mental and public health professionals can apply their knowledge, expertise, and skills to challenges faced in the aftermath of disasters (see Chapter 12 for a related discussion).
With regard to research, a partnership between the Hurricane Katrina Community Advisory Group (spearheaded by Dr. Ronald Kessler at Harvard University) and the Recovery Effort After Child Trauma (R.E.A.C.T.) team was established in November 2005. The objective corollary of this collaboration was to carry out a series of studies assessing the short- and long-term mental health impacts of the storm on children and adults. While the child data are still being analyzed, two studies targeting adults have important implications for young children. The compelling results of the two products from this initiative will be discussed later.
Review of the Literature on Reactions to Katrina
A review of several assessment and intervention research efforts targeting children and adolescents will be presented. A total of 12 investigations (9 assessments and 3 interventions) are discussed below.
Children. Scheeringa and Zeanah (2008) examined the psychological impact of Hurricane Katrina on preschool children and their caregivers in the New Orleans metropolitan area. Children between the ages of 3 and 6 and his/her primary female caregiver participated in the study. Ethnically, 57.1% of the participants were African American, 31.4% were white, 8.6% were “black–white mix,” and 2.9% were “other.” Using age-modified criteria, the participants were interviewed with the Diagnostic Interview Schedule for Children, the Preschool Age Psychiatric Assessment, and a disaster experiences questionnaire. Fifty percent of the children were diagnosed with posttraumatic stress disorder (PTSD), and 86.6% of those diagnosed with PTSD were also found to have at least one comorbid disorder, the most common of which were oppositional defiant disorder and separation anxiety. It was found that those who evacuated before the storm were just as likely to develop PTSD compared to those who were unable to leave the New Orleans area. Consistent with previous research (i.e., Laor et al., 1997), the children’s new symptoms were also strongly correlated with their caregiver’s new symptoms of PSTD.
Notwithstanding these findings, several shortcomings should be noted. It is not clear whether or not children’s level of exposure was obtained. This has been found to be an important component for post-disaster investigations (Jones & Ollendick, 2002). There is no mention of the psychometrics of the instruments on this target sample. For example, no internal consistency was reported for the exposure measure. The relative impact of race on these findings was also not systematically explored. Additionally, as the author reported, the self-selected nature of participants may have led to an overestimate of psychopathology. The fact that self-selected participants are often more motivated than other participants may have also led to biases. Nonetheless, this study is valuable in that it examined that impact of Hurricane Katrina on young children via their caregivers. Relationships between parent and child interactions and psychopathology will be discussed in more detail later in this chapter.
In another study, Sprung (2008) examined 183 young children’s cognitive reactions to Hurricane Katrina. Five- to eight-year-old children from the Mississippi area were questioned using a non-structured self-report interview to study the immediacy, persistency, frequency, and content of their intrusive thoughts, as well as their level of cognitive functioning, 7 months following the natural disaster. The sample consisted of both male and female participants who were categorized as “white,” “black,” or “other” ethnicity. Using children from Boston as a control group, hurricane-affected children experienced more negative intrusive thoughts (i.e., “didn’t want to think about it”). In addition, children in the major loss–disruption group experienced more recurring negative intrusive thoughts and attempted to suppress these thoughts. A major shortcoming of this effort was that the children’s subjective appraisal of the storms was not assessed. Additionally, the extent to which children’s premorbid functioning may have impacted their degree of intrusive thoughts was not ascertained. While the impact of race was examined as a covariate, discussion of its potential unique impact on this target population may have been insightful given the dearth of consistent findings on race following disasters.
Cohen and colleagues (2008) assessed the impact of Hurricane Katrina 15 months post-disaster in children from the New Orleans area using a series of self-report questionnaires. The 195 boys and girls who participated were between fourth and eighth grades (with a mean age of 11.6) from New Orleans and Metairie, LA. Ethnically, the sample was 48% white, 46% African American, 5% Hispanic, and 2% were categorized as “other.” This study measured hurricane exposure, lifetime trauma exposure, social support systems, and PTSD and depression symptoms. Teachers were also asked to report children’s behavioral problems in school. The child’s lifetime exposure to trauma was found to predict both PTSD and depression symptoms. Results revealed that both PTSD and depression were significant problems following this traumatic event; 23.6% of the participants had mild PTSD symptoms and 36.9% reported moderate to severe PTSD symptoms. One of the many strengths of this study, as opposed to similar studies, was that it examined lifetime exposure to trauma and both domestic and school violence across the lifespan.
Pina et al. (2008) examined several predictors of youth’s posttraumatic stress reactions using several self-report assessment measures. Forty-six children completed a number of pre- and post-Katrina assessments, among whom 67% were European American and 33% were African American. First, social support was linked to mental health and was examined because the evacuation process likely disturbed the existing social network in the New Orleans area. Next, discrimination was studied in that perceived discrimination was elevated in the New Orleans area and has been found to lead to poor mental health in previous research. This research was significant in that it was one of the first to examine the role of discrimination among children following traumatic exposure. Lastly, coping strategies were examined in this empirical study. It was found that increased levels of social support resulted in fewer posttraumatic stress symptoms, signifying that extrafamilial social support served as a protective factor. Furthermore, children who engaged in avoidant coping were more likely to experience both PSTD and anxiety symptoms. Lastly, discrimination and active coping did not predict posttraumatic stress reactions. While the authors pointed out several shortcomings including children not being directly asked about the impact of social support and discrimination, an additional limitation was the absence of information on the role of resource loss on outcome. That is, while several studies measure the relative impact of exposure on outcome, they fail to mention the specific role of resource loss independent of exposure (Hobfoll, 1988). More research on the differentiation of these two overlapping constructs needs to be explored (see Hadder, 2008). Additionally, the relative moderational and mediation role of constructs explored was not examined.
Scaramella, Sohr-Preston, Callahan, and Mirabile (2008) assessed the impact of stress on low-income families, as well as any additional stress the hurricane may have added to the parents’ and children’s mood, behavior, and adjustment. Pairs of mothers and their 2-year-old child were recruited from the Head Start program in the New Orleans area pre- and post-Katrina and were assessed using a structured interview as well as several self-report surveys. Fifty-five mother–child pairs participated in the study prior to Hurricane Katrina, and an additional 47 pairs joined the study after Hurricane Katrina hit. The participants were mostly African American (about 80%) with mostly single mothers (average age of about 26 years); overall, 41 boys and 61 girls took part in the study. Surprisingly, no significant differences existed pre- and post-Katrina with perceived financial, social, or environmental stressors, indicating that the chronic stress of living in poverty was more substantial than the losses experienced from Hurricane Katrina. Results also indicated that family financial strain caused distress for the parents, weakening his/her parenting efforts, and the child is consequently more likely to exhibit behavioral problems. As pointed out by the authors, the need to actually obtain children’s perceptions of the consequences of the disasters is essential for future research. The need for precise measures of social support is also in order. The validity of the family stress model in disaster situations should be explored at a more fine-grained level.
Weems et al. (2007) assessed the psychological impact on 52 children from the New Orleans area following Hurricane Katrina using a series of self-report questionnaires. Among the participants, 64% were European American, 29% were African American, and 7% were “other,” with a mean age of 11.35. Each child’s PTSD, trait anxiety, general anxiety, and depression symptoms were examined to determine pre- and post-Katrina mental health. Consistent with previous trauma literature, hurricane exposure predicted the number of PTSD symptoms. After controlling for hurricane exposure, trait anxiety and negative affect were found to be predictors of both PTSD symptoms and general anxiety symptoms following the disaster. Furthermore, females were more at risk for developing PTSD, general anxiety disorder, and depressive symptoms following a traumatic event. Shortcomings, including the reliance on youths’ self-reports and the sole usage of self-report measures (rather than interviews), were aptly pointed out by the authors. Additionally, the need to determine the impact of varying time frames of data collections is essential to more clearly determine the impact of disasters on individuals’ post-disaster functioning (see King et al., 2006).
To assess the impact of a mother’s psychopathology on her child’s distress following Hurricane Katrina, Spell and colleagues (2008) sampled 260 mother–child pairs who were displaced after the disaster with a series of self-report assessment tools. The children’s ages ranged from 8 to 16 years of age, with 43% boys and 57% girls. Ethnically, 68% were African American, 24% were Caucasian, and 8% were categorized as other ethnicities (Asian, Hispanic, and Native American). Similar to other findings (Hensley & Varela, 2008), hurricane exposure, children’s symptoms of posttraumatic stress disorder, and children’s internalizing problems were related. Maternal psychological distress and PTSD were found to moderate the relationship between child hurricane exposure and mother-reported internalizing and externalizing problems. As alluded to earlier, a major shortcoming of this report was the lack of a more concise measure of loss and exposure. The advocacy for such a practice has been spelled by several authors (e.g., Jones & Ollendick, 2002; Hadder, 2008). Also, the importance of not over-generalizing these findings to non-Katrina samples is paramount.
Adolescents. Five to eight months following Hurricane Katrina, Hensley and Varela (2008) surveyed 302 sixth and seventh grade boys and girls in the New Orleans area with several self-report assessment measures. The sample consisted of 46% African Americans, 37% white, 8% Hispanic, 6% Asian/Pacific Islander, and 3% who chose not to respond. One of the major findings of this study was the impact of disaster on somatic complaints (e.g., headaches, dizziness, chest pain). Furthermore, anxiety sensitivity regarding social concerns moderated the relationship between symptoms of PTSD and trait anxiety, as well as the relationship between somatic symptoms and trait anxiety. While this is one of the few trauma-related studies examining the somatic complaints, as pointed by the authors, the use of self-report versus clinical interviews is essential to obtain more precise measures of functioning.
In a study examining the impact of Hurricane Katrina on adolescents in Mississippi, Marsee (2008) found associations between exposure, posttraumatic symptoms, and reactive aggression among 166 male and female students between 14 and 18 years of age using a series of self-report questionnaires. The sample consisted of 63% Caucasian, 30% African American, 2% Native American, 1% Hispanic, 1% Asian, and 2% other (the last 1% failed to disclose this information). Adolescents with increased exposure were more likely to exhibit symptoms for PTSD. Reactive aggression was also found to correlate with emotional dysregulation as well as symptoms of PTSD. Additionally, all minorities were more likely to experience emotional dysregulation when compared to Caucasians. The need to assess premorbid functioning, and to engagement in interviews rather than use self-reports instrument, was aptly pointed out by these authors. However, the use of culturally competent clinicians and researchers in carrying out this study is not mentioned. The extent to which such individuals were not involved in this investigation may provide an explanation for the relatively low level of participation (see Jones, Hadder, Carvajal, Chapman, & Alexander, 2006).
Summary and Clinical Implications. While all of these studies represent pioneering efforts in the face of overwhelming challenges in the acute aftermath of the storm, there are several shortcomings. Specifically, many studies employed self-report instruments rather than structured diagnostic interviews and, hence, raise the possibility that participants could have been falsely diagnosed. Additionally, the possibility of attenuating the associations between risk factors and outcomes is greatly enhanced. The retrospective nature of the methods used to assess hurricane-related stressors may lead to subject recall bias. In the majority of studies reviewed, there was no differentiation made regarding the relative impact of the three storms (i.e., Katrina, Rita, and Wilma). Many of these studies failed to identify a conceptual model used to guide their efforts. The need to articulate the logical underpinnings for their thinking, as well as to develop testable hypotheses, is essential even under the most challenging conditions. Several studies failed to assess premorbid functioning and reactions over time. Despite the shortcomings, these studies provide important insights into our understanding of children’s functioning following catastrophic natural disasters.
Three studies that provided treatment for children and adolescents are discussed next.
Children. Scheeringa and colleagues (2007) reported two case studies in which cognitive–behavioral training was found to be successful in treating preschool children. One child was traumatized in an automobile accident and the other was a Hurricane Katrina survivor. Both children met the age-modified criteria for PTSD using the Diagnostic Interview Schedule and began cognitive–behavioral treatment, testing a 12-session manualized protocol for preschool children. During these sessions, the children were taught how to identify their feelings, practiced relaxation skills and exposure, techniques as well as learned relapse prevention techniques. Both cases indicate that preschool children possess the capability to engage in a structured therapy as well as learn and demonstrate relaxation techniques. While this intervention effort represents an important first step in assisting children to cope with the aftermath of Katrina, no threats to internal or external validity are mentioned.
Fifteen months following Katrina, an intervention study was implemented for children in the New Orleans area. Children who met criteria for PTSD using various self-report assessment tools were randomly selected to receive either group cognitive–behavioral interventions for trauma in school or individual trauma-focused, cognitive–behavioral therapy at a local mental health clinic. Both treatments included cognitive–behavioral strategies to deal with reexposure, anxiety symptoms, and negative mood symptoms, as well as to improve one’s coping strategies. The in-school treatment, however, was less individually tailored than the mental health clinic intervention. The 195 boys and girls who participated were between fourth and eighth grades (with a mean age of 11.6) from New Orleans and Metairie, LA. Ethnically, the sample was 48% white, 46% African American, 5% Hispanic, and 2% were categorized as “other.” Jaycox et al. (2005) discovered both treatments resulted in fewer PTSD symptoms at the 10-month follow-up; nonetheless, access to the mental health clinic was a significant conflict. It was shown that participants were more likely to seek out mental health services at school as opposed to traveling to the mental health clinic; 96% of students received treatment through the school, whereas only 35% of the children began treatment at the mental health clinic. In addition, family support and fewer new exposures during the in-school group therapy led to fewer PTSD symptoms at the 10-month follow-up. The overall findings suggest a need to implement a school-based intervention treatment following natural disasters. Among the shortcomings of this cleverly designed study was the lack of differentiation between loss and exposure, as mentioned earlier. Additionally, the race and ethnicity of therapists and assessors were not mentioned. Again, the extent of cultural sensitivity to this target population remains unknown. Participation rates by race may have been impacted by this lack of attention to cultural issues.
Adolescents. Weems et al. (in press) employed a school-based test anxiety intervention study to minority (African American, Asian American, Caribbean American, European American, and other) male and female ninth graders in New Orleans. Those students who reported high levels of test anxiety using self-report questionnaires received in-school group therapy. The treatment focused on improving self-efficacy, learning relaxation techniques, and hierarchy exposure to test anxiety. The intervention was found to lessen test anxiety, improve academic performance, and even yielded positive effects on posttraumatic stress symptoms. Results indicate that school-based test anxiety interventions can be used to lessen general anxiety, as well as trauma-based anxiety, which adds to the existing literature. Although this study targets skills to cope with trauma-based anxiety in minority children, the lack of randomization to groups and the sole reliance on self-report measures represent major shortcomings, as pointed out by the authors. While these early efforts are quite remarkable and add to our growing knowledge of the adequacy of cognitive–behavioral and school-based interventions following massive disasters, more evidence-informed and evidence-based research targeting intervention needs to be conducted.
Summary and Clinical Implications. A major shortcoming of several of the assessment and intervention studies was the relative lack of attention to issues related to culture, race, and ethnicity. A theme that resurfaced during deployments to the Gulf Coast was that culture, race, and ethnicity count. The necessity to consider issues related to these very important constructs is brought to attention by Jones et al. (2006). More specifically, (1) there is an insufficient number of ethnic and minority members represented in trauma-related research. Not only does this lessen the likelihood of gaining greater understanding and appreciation of these understudied target groups, sufficient power to ascertain their potentially unique reactions to disaster is obviated. (2) Data suggest that the prevalence of exposure to pre-disaster trauma is likely to be greater than the average among economically disadvantaged environments (see Breslau et al., 1998; Selner-O’Hagan, Kindlon, Buka, Raudenbush, & Earls, 1998). Hence, the greater likelihood of pre-disaster trauma-related psychopathology exists. (3) The underutilization of mental health services by members of minority and marginalized communities presents a need for further research investigation. Potential barriers, which include mistrust, racism, discrimination, and access to mental health services, should be examined in future ventures. (4) The effectiveness and efficacy of intervention strategies used with these target populations is virtually unknown. Future efforts should address issues related to treatment outcome. (5) Symptom expression of psychiatric disorders among ethnic and racial groups has seldom been addressed in disaster mental health research. A knowledge base discussing the intricacies of symptom presentation is sorely needed. Materials presented on the National Child Traumatic Stress web site that address issues of culture provide important guidelines for targeting several of these concerns.
What follows is a brief description of major conceptual models used to interpret children’s post-disaster functioning. Of these models, the dose–response model will be advocated as the model of choice for future efforts given the bulk of empirical findings that support this approach. Previous studies identifying risk and protective factors advocated by this model will be briefly reviewed. Following this review will be a discussion of the relative contributions of these early studies to the existing literature.
Conceptualization of Children’s Functioning Following Traumatic Experiences
While the dominant conceptual model on stress and mental illness is the diathesis–stress model, originated by Zubin and Spring (1977), the vulnerability–stress model has targeted the understanding and development of psychopathology (Ingram & Luxton, 2005). Perhaps the most frequently employed and empirically supported model used to predict youth’s functioning following traumatic events is the dose–response model (Green, Korol, Grace, & Vary, 1991; La Greca, Silverman, Vernberg, & Prinstein, 1996; Pynoos & Nader, 1988). Within this conceptualization, both risk and protective factors, as well as their relationship to outcomes, are described. More specifically, factors including preexisting characteristics (e.g., age, sex, race/ethnicity, socioeconomic status), exposure (e.g., life threat, disruption, chronic poverty, community/interpersonal violence), resource loss (e.g., condition, object, personal, energy), coping mechanisms (e.g., active, avoidant, distraction, social support seeking), previous life events (e.g., traumas), and social support (e.g., parent, peer, family members, teachers). The following section highlights the existing research examining mediators and moderators of children’s mental health as well as other important factors that emerge in the wake of disaster. Additionally, the contributions of recent efforts targeting Hurricane Katrina are discussed.
Exposure. Exposure to a natural disaster has been conceptualized in two distinctive ways. The first definition examines the number of stressors experienced, as well as the relative severity of each stressor (Norris & Elrod, 2006). In general, research has supported the notion that as the number of stressors increase, so do an individual’s symptoms of psychopathology. It has also been shown that certain factors predict greater psychological distress, such as bereavement, injury to self or family member, life threat, and panic, during the disaster (Norris & Elrod, 2006).
The second definition of exposure includes the presence of certain factors during a hurricane or other trauma that may lead to increased levels of psychopathology, such as thoughts that one might die, thoughts that another might die, or physical proximity to the event. A summary of several studies that examined the role of exposure following disasters follows.
Following Hurricane Hugo, La Greca et al. (1996) sought to determine the role of exposure in predicting PTSD in 442 children. These children were selected from three elementary schools located in Dade County, Florida, where the greatest levels of destruction from the Hurricane occurred. Exposure, defined as variables such as perceived life threat, and life-threatening events occurring during the hurricane, accounted for the greatest percentage of variance (15%) in PTSD symptoms of the variables assessed. Consistent with both definitions of exposure, the highest levels of distress were found in children who reported that they believed that their life was in danger, as well as those who reported the highest number of stressors as a result of the hurricane.
Exposure was also found to be the strongest predictor of PTSD symptoms in 558 ethnically diverse children following Hurricane Andrew (Vernberg, La Greca, Silverman, & Prinstein, 1996). Exposure variables predicted 35% of the variation in children’s PTSD symptoms. Within exposure, it was found that loss–disruption variables accounted for the most unique variance (9%) and were related to greater numbers of PTSD symptoms.
Level of exposure was also found to be a major predictor of distress in children following a wildfire. In a study of 222 children, aged 8–18, all of whom had been exposed to a wildfire, the highest levels of distress were observed in those who thought they or a family member might die, who were within 50 m of the fire, who saw flames, or who were home alone during the fire (McDermott, Lee, Judd, & Gibbon, 2005). Once again, life-threatening variables such as the belief that they or a family member might die were found to predict the highest levels of distress. In addition, a measure of how frightening the day had been for the child was found to be significantly positively correlated (r = 0.42) with the development of PTSD symptoms.
Contribution. Several findings from the recent efforts described above confirm earlier findings. Specifically, Cohen and colleagues’ (2008) finding that the child’s lifetime exposure predicted both PTSD and depression symptoms partially replicate these conclusions. Similar findings were obtained by Hensley and Varela (2008), where it was found that immediate exposure also predicted PTSD. In addition, Marsee (2008) concludes that adolescents’ increased exposure leads to symptoms of PTSD and reactive aggression. Exposure was also found to correlate with emotional dysregulation.
Social Support. Social support has been defined as social interactions or relationships that provide individuals with actual assistance or that embed individuals within a social system believed to provide love, care, or sense of attachment to a valued social group or dyad (Hobfoll & Stokes, 1988; see also Chapter 7). Social support has been found to be an important predictor of outcome following a disaster. Specifically, social support often acts as a protective factor; the higher the level of social support, the lower the levels of PTSD symptoms. Following a disaster such as Hurricane Andrew, Vernberg et al. (1996) found that social support variables (i.e., support from parents, friends, teachers, and classmates) each accounted for small but significant amounts of variance in symptoms in children. Specifically, children who perceived the highest level of support from others had the least amount of distress following the hurricane. Social support has also been shown to be a significant factor in predicting positive outcomes following a trauma. Specifically, in a study of 46 children following Hurricane Floyd, social support was found to be a significant contributor to positive outcomes (i.e., posttraumatic growth) (Cryder, Kilmer, Tedeschi, & Calhoun, 2006).
Social support also moderated the relationship of exposure and mental health outcomes (Hammack, Richards, Luo, Edlynn, & Roy, 2004; Pengilly & Dowd, 2000). For example, Hammack et al. (2004) found that social support served as a protective stabilizing factor when individuals were faced with the most severe levels of exposure to violence. It was found that there were no increases in psychopathology in the presence of social support, despite progressively higher levels of exposure. These support networks then lead to lower levels of psychological distress through their ability to help an individual deal with the accompanying emotions and challenges that one faces following a traumatic event.
Similarly, this construct was found to moderate the relationship between negative life events and mental health outcomes (Pengilly & Dowd, 2000). Specifically, for those with low support, high-stress individuals were found to be more depressed than low-stress individuals. The relationship between exposure and PTSD symptoms has also been found to be moderated by social support. Social support was found to moderate the relationship between trauma and PTSD, particularly for girls who had experienced high levels of distress during the Kuwait crisis (Llabre & Hadi, 1997). In fact, social support appeared to buffer the effects of stress. Results of this study indicated that, despite experiencing high levels of exposure, those with high levels of social support had comparable levels of PTSD to those in the control group who did not experience such trauma.
Contribution. Contributions from Hurricane Katrina dictated that extrafamilial support such as professional support services like social services and mental health professionals served as a protective factor following the disaster, but familial support did not. It is surprising that familial support was not a protective factor, but it is theorized that the severity of Hurricane Katrina negatively impacted the family as a whole, and thus the family was unable to serve as a source of help in the recovery process (Pina et al., 2008). These findings are a unique addition to the trauma literature, and further research regarding social support in the wake of massive traumatic events, such as Katrina, is indeed needed.
Coping. Coping can be defined as cognitive and behavioral efforts to manage environmental and internal demands that are appraised as taxing or exceeding personal resources (Folkman, Lazarus, Gruen, & DeLongis, 1986). Coping helps the individual deal with the problem that is causing the distress as well as aids in the regulation of the accompanying negative emotions that arise (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001). Researchers have viewed coping as either active (i.e., seeking social support, problem solving) or avoidant (i.e., efforts to avoid the emotions associated with a stressor). Specifically, it has been found that engaging in avoidant coping behaviors is a major predictor of posttraumatic stress (Foa, Steketee, & Rothbaum, 1989), whereas those who engage in active coping strategies tend to experience less distress (Wadsworth et al., 2004). Other evidence has shown that those who utilize active coping strategies are more resilient in the aftermath of a traumatic event (Armstrong, Birnie-Lefcovitch, & Ungar, 2005; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007).
In a study of 143 children and parents following the September 11, 2001 terrorist attacks, avoidant coping behaviors, specifically those related directly to the trauma, predicted greater posttraumatic stress (Lengua, Long, & Meltzoff, 2006). It is important to note, however, that while avoidant coping behaviors are most predictive of PTSD symptoms, they are often utilized the least (Russoniello et al., 2002). For example, following Hurricane Floyd, the least used coping strategies included “social withdrawal,” “resignation,” “blaming others,” and “self-criticism,” yet these coping strategies were most related to PTSD symptoms. In contrast, active coping strategies such as “cognitive restructuring” and “social support” were less likely to lead to PTSD.
Although avoidant coping behaviors often lead to PSTD, active coping behaviors have also been shown to contribute to negative outcomes. Following Hurricane Andrew, La Greca et al. (1996) found that higher levels of all types of coping (i.e., positive coping, blame/anger, and social withdrawal) were associated with the highest levels of distress. Although blame/anger contributed the greatest amount of variance in symptoms, there was also a strong relationship between positive coping behaviors and PTSD. Although counterintuitive, this relationship may exist because those children who experience the most severe levels of trauma must mobilize the greatest amount of coping behaviors. Therefore, despite engagement in positive coping behaviors the severity of the trauma overwhelms the child’s ability to cope.
In addition to predicting levels of distress, coping may moderate the relationship between exposure and distress. For example, Haden, Scarpa, Jones, and Ollendick (2007) tested the hypothesis that active coping strategies, particularly interpersonal strategies, moderate the relationship between injury (i.e., perceived injury severity) and the development of PTSD. They found that for undergraduates who had all experienced a traumatic event, a stronger relationship existed between perceived trauma severity and PTSD for those who failed to utilize interpersonal coping strategies as compared to those who utilized these strategies. Those who perceived a severe injury and utilized few interpersonal coping strategies were most likely to develop PTSD. In sum, given the preceding findings, the potential mediating role of active and avoidant coping should be examined in a disaster context.
Lastly, Jones and Ollendick (2005) assessed the psychological well-being of 46 children and adolescents who experienced a residential fire using a series of self-report questionnaires. The participants were an average age of 11 years, 10 months, and were ethnically divided as follows: 52.2% Caucasian, 43.5% African American, 2.2% Hispanic, and 2.2% biracial. In this study, 41.3% of the mothers reported low education levels (seventh grade to high-school graduate), whereas 58.7% reported high education levels (college or graduate degree). Negative life events were related to children’s level of fear for those whose mothers had lower education levels. On the other hand, avoidant coping and negative attributional styles were associated with levels of fear in children with mothers who had higher education levels. Thus, maternal education was found to play a moderating role in this study; having a higher level of education lessened the impact of negative life events.
Contribution. Only one study from the Katrina efforts examined avoidant coping. Consistent with previous findings, Pina et al. (2008) concluded that children who engaged in avoidant coping were more likely to experience both PSTD and anxiety symptoms, whereas active coping was not found to mediate psychological stress. Perhaps the severity of the storm and the traumatic stressors following it degraded the child’s ability to cope. The need for further research on coping is needed.
Resource Loss. Resource loss can be defined as the loss of personal and social resources which results in diminished coping capacity and psychological distress (Freedy, Shaw, Jarrell, & Masters, 1992). According to the Conservation of Resources theory (Hobfoll, 1988), resources include objects (i.e., homes, physical possessions), conditions (i.e., health, employment, social support), personal characteristics (i.e., skills and personal traits), and energies (i.e., money, knowledge). All resources are valued for individual’s survival although this relationship may be either direct or indirect. Resources fulfill both an individual’s psychological and physical needs by allowing them to gain a sense of competence and mastery. As a result, it is suggested that the driving mechanism behind the psychological distress following a trauma is the loss of resources. Traumatic events, such as a natural disaster, often lead to a global loss of resources encompassing all four categories, which often leads to difficulties adjusting post-disaster. In addition, a loss of competency often occurs following a natural disaster as a result of this loss.
Overall, the literature has continued to support the influence of resource loss on psychological distress and development of PTSD following a disaster (Burke, Moccia, Borus, & Burns, 1986; Green et al., 1991; Lonigan, Shannon, Finch, & Daugherty, 1991).
The adult trauma literature has repeatedly supported the notion that resource loss is one of the strongest predictors of PTSD following a disaster (Freedy et al., 1992). Specifically, a loss of resources following a natural disaster has been found to be a major predictor of psychological distress and PTSD. Resource loss was found to have a significant positive correlation with psychological distress (r = 0.64) following Hurricane Hugo (Freedy et al., 1992). In order to assess functioning following the hurricane, 418 faculty and staff members at the Medical University of South Carolina in Charleston, South Carolina, were surveyed regarding their resource loss, coping behavior, and psychological distress after the hurricane. Resource loss was found to be the single, strongest predictor of distress after accounting for gender, age, ethnicity, income, previous trauma history, other life events, and life threat. Specifically, resource loss alone was found to contribute to 11% of the variance in psychological distress following the hurricane (Freedy, Saladin, Kilpatrick, & Resnick, 1994).
It appears that the effects of resource loss operate similarly in children. Following a wildfire in California, it was found that children, aged 7–12, who experienced high levels of loss experienced more distress than those in the low-loss group (Jones, Ribbe, Cunningham, Weddle, & Langley, 2002). Although the high-loss (HL) and low-loss (LL) groups were comparable on all major demographic variables, such as gender, income level, fire insurance, and age, PTSD symptoms were significantly more common in the HL group as compared to the LL group. Specifically, 92% of children who experienced high levels of loss were rated as having high PTSD symptom levels as compared to 56% of their peers who experienced lower levels of loss. In addition, there was a significant correlation between PTSD symptoms and resource loss (r = 0.51). Further supporting the importance of resource loss following Hurricane Floyd, loss, as measured by flooding in the home, was the variable that was found to be most related to severe symptomatology (Russoniello et al., 2002). Resource loss has also been found to be a greater predictor of distress than direct exposure following a severe earthquake in Southern California (Asarnow et al., 1999). This finding highlights the importance of both loss and the subjective evaluations of loss following a natural disaster.
Contributions. While no study of youth following Katrina examined factors related to resource loss, Galea et al. (2007) provide an excellent study demonstrating the impact of property loss on outcome. That is, in addition to physical illness, injury, and physical adversity, property loss was found to predict anxiety–mood disorders to residents in the New Orleans metropolitan area. The importance of differentiating exposure from resource loss is of paramount importance if the relative contribution of each construct is to be ascertained (see Hadder, 2008).
The Role of Ethnicity. Ethnicity is a complex variable which is thought to operate through a variety of proximal variables (i.e., minority status, SES) rather than having a unique affect on adaptation (Alvidrez, Azocar, & Miranda, 1996). However, ethnicity is often measured as a proximal variable and, following disasters, ethnic differences have emerged. It is generally supported that African-American children experience higher levels of psychological distress than Caucasian children. For example, following Hurricane Hugo, African-American youths reported more psychological distress, as measured by PTSD symptoms, than other minority youths or Caucasian youths (Lonigan et al., 1991; Lonigan, Shannon, Taylor, & Finch, 1994). In addition to experiencing higher levels of distress overall, it has also been found that, following Hurricane Andrew, minority youths were less likely to experience declines in levels of PTSD (La Greca et al., 1996).
Trauma literature has generally supported that African-American youths are more likely to develop PTSD, possibly due to higher levels of exposure to violence and psychological distress; however, it has also been found that they exhibit greater resilience in the face of these stressors (McLeod & Nonnemaker, 2000). This seemingly unexpected finding may be explained by greater access to more close-knit support systems which enables them to exhibit greater resilience in the face of stress (Wickrama, Noh, & Bryant, 2005) or perhaps that African-American families are better able to protect their members from the effects of outside stressors as compared to Caucasian families (Wadsworth & Santiago, 2008).
Contribution. These preexisting empirical findings may explain the Pina et al. (2008) findings where discrimination was not found to be a predictive factor of psychological distress following Hurricane Katrina among youths. However, it should be noted that Chia-Chen Chen, Keith, Airriess, Li, and Leong (2007) indicated that adult survivors experienced higher levels of racial discrimination during Katrina and higher levels of financial distress following the hurricane. These stressors were found to be associated with PTSD symptoms. It was also found that African-American females experienced more symptoms of PTSD compared to their male counterparts. Hence, both minorities and females seem to be at-risk populations and further research is needed to determine appropriate intervention strategies for these groups.
Age and Gender. Findings regarding age effects in PTSD are mixed. The majority of studies have found that younger children have a greater risk of developing PTSD symptoms following a disaster (Lonigan et al., 1991, 1994; McDermott et al., 2005; Stoppelbein & Greening, 2000). However, it has also been shown that those who are older are more likely to develop PTSD (Khamis, 2005). Other studies have failed to find a significant relationship between age and PTSD symptoms (Evans & Oehler-Stinnett, 2006; Green et al., 1991). Further research on the relationship between age and psychological distress is needed.
Despite the vast amount of research examining the influence of gender in the development of PTSD, no clear consensus has emerged. Although there appear to be differential effects in exposure to traumatic events, which would lead to a greater incidence of PTSD in boys (Khamis, 2005), many studies find that either girls are more likely to develop PTSD or that no significant gender differences exist. In studies of children following Hurricane Hugo, girls were significantly more likely to develop PTSD as compared to boys (Freedy et al., 1992; Russoniello et al., 2002). Specifically, being female was found to be the strongest predictor of PTSD, followed by loss incurred from the hurricane (Russoniello et al., 2002). Following the sinking of “Juniper,” a cruise ship, girls were also more likely to develop PTSD symptoms (Udwin, Boyle, Yule, Bolton, & O’Ryan, 2000). Other research suggests that gender differences in the development of PTSD following a disaster do not exist. For example, following Hurricane Andrew, no gender differences were found (La Greca et al., 1996). Evans and Oehler-Stinnett (2006) also found no gender differences in PTSD symptoms in an ethnically diverse sample following a severe tornado in rural Oklahoma.
Several studies have implicated a child’s gender as a potential moderator for psychological distress following a traumatic event (e.g., Mirza, Bhadrinath, Goodyer, & Gilmer, 1998; Stallard, Velleman, & Baldwin, 1998). The general consensus is that girls are more likely to develop subsequent psychopathology after experiencing a traumatic event; however, it is not clear as to why this occurs. For example, a prospective study (Stallard, Salter, & Velleman, 2004) found that girls were significantly more likely to develop PTSD following road traffic accidents compared to same-age boys. Similarly, the Board of Education study (Hoven et al., 2005) found that girls were at an increased risk for developing negative posttrauma symptomatology as compared to boys for many probable disorders beyond PTSD, such as generalized anxiety, separation anxiety, agoraphobia, and depressive disorders, with the exception of conduct and alcohol abuse/dependence problems. Further, Stallard and Smith (2007) found child gender to be the only non-cognitive variable that significantly predicted posttraumatic stress symptoms, explaining 5–6% of the variance.
In an effort to better understand these findings, Groome and Soureti (2004) theorized that girls might be more willing to report negative symptomatology, but they also implicate the role of cultural and/or biological reasons as to why girls appear to be more susceptible to disorders of posttraumatic stress and anxiety. Another possibility is that girls might adopt fatalistic attitudes and feelings of helplessness in response to a trauma when compared to the attitudes of boys, but the exact mechanisms for these responses are currently under dispute. Despite some uncertainties in the field, evidence continues to support this gender moderation.
Contribution. Following Hurricane Katrina and Hurricane Ivan, Lisa (2008) found that a child’s cognitive age was correlated with the presence of PTSD symptoms. Weems et al. (2007) also determined that girls were at risk for having poor adaptive reactions following Hurricane Katrina. They were more likely to develop PTSD, generalized anxiety disorder, and depression following a traumatic event. These findings document the need to continue to examine the important role of age and gender following disaster.
Parent–Child Interaction. While the impact of a parent’s behavior on their child’s functioning has not been typically conceptualized as a formal risk or protective factor, it has been found to play a salient role in post-disaster environments (see Chapter 3 for a related discussion). Prior research in non-disaster contexts confirms the influence of parent–child interactions across the lifespan. For instance, children of depressed mothers are more likely to suffer from a variety of problems, such as psychological disturbances, social–emotional maladjustment, cognitive deficits, and neurological dysfunction (Gotlib & Goodman, 1999). Additionally, depressed mothers have impaired interactions with their children (Broth, Goodman, Hall, & Raynor, 2004; Zahn-Waxler & Wagner, 1993).
Disaster-specific investigations also document the negative impact that parents’ post-disaster functioning can have on their offspring. For example, Laor et al. (1997) found that children’s symptoms of PTSD were significantly correlated with their mothers’ intrusive and avoidant symptomatology. More specifically, 3-year-old Israeli children appeared to model the anxiety symptoms of their mothers. Similarly, increases in mothers’ depressive symptoms were found to correlate with declines in attentiveness, support, and positive emotions toward their children. Related findings were obtained when examining relationships between children and their parents following Katrina. For example, children between the ages of 3 and 6 who were not directly exposed to the storm exhibited symptoms of PTSD that were found to be highly correlated with their caregiver’s (Scheeringa & Zeanah, 2008). In sum, these data attest to the fact that parental trauma reactions clearly affect child outcomes, especially for younger children.
Contributions. These findings become even more compelling in light of the documented impact of Katrina on adults following the storm. The next two studies from the Hurricane Katrina Advisory Group substantiate this claim. In assessing the prevalence of distress among a sample of 1043 adults following Hurricane Katrina, Kessler, Galea, Jones, and Parker (2006) found that the estimated prevalence of a serious mental illness increased from 6.1 to 11.3%, and mild to moderate mental illness increased from 9.7 to 19.9%. Similarly, in a follow-up study, exposure to trauma was strongly related to mental health. Adult residents from the New Orleans metropolitan area were estimated to have 49.1% prevalence of any DSM-IV anxiety–mood disorder with a 30.3% estimated prevalence of PTSD, while the remaining participants reported 26.4% estimated prevalence of an anxiety–mood disorder and a 12.5% estimated prevalence of PTSD (Galea et al., 2007). In sum, these findings point to the importance of examining the impact of parental functioning on children during the aftermath of disasters.
Future Research: Complimentary Models
While the utility of the dose–response model has been demonstrated in the above investigations, additional models may also be beneficial (see Chapter 2). What follows is a description of three complimentary models that may shed additional light on issues related to children and adolescents’ post-disaster functioning.
A prominent example of a process-oriented model is the transactional stress and coping model(TSC), put forth by Thompson, Gustafon, Hamlett, and Spock (1992) and Thompson, Gil, Burbach, Keith, and Kinney (1993). The TSC model highlights the interaction of the person (e.g., demographic, cognitive, and coping processes) and situational variables (e.g., family environment/family functioning) related to adjustment (e.g., depression, anxiety, PTSD symptoms) following a stressor. Traditionally, trauma literature has followed Lazarus and Folkman’s (1984) model to capture differences in child adjustment, while the TSC model has been utilized primarily within children’s health literature to demonstrate the impact of family environment on child and family adjustment to a chronic illness.
In a recent application of this approach, Moore, Jones, and Ollendick (2008) applied the TSC model to understand child and adolescent adjustment outcomes following a residential fire. The sample in this study was comprised of 144 children and adolescents in the ages 12–18, 53% of whom were African American and 47% of whom were European American. Moore et al. (2008) found key relationships between family and child factors that support the transactional nature of child adjustment outcomes following trauma events. Higher levels of family conflict were predictive of higher levels of (parent-reported) later internalizing symptoms for children and adolescents. Children and adolescents’ greater use of avoidant coping strategies was also found to predict higher levels of (self-reported) PTSD symptoms. In addition, an interaction was found between parent reports of children and adolescents’ internalizing symptoms and children and adolescents’ self-reports of religious avoidance. In other words, the positive relationship between internalizing symptoms and anxiety/depression is strongest for those children and adolescents who also reported high religious avoidance. A second moderation effect was found between children and adolescents’ self-reports of their overall adjustment and self-reports of their active coping strategies. The positive relationship between internalizing symptoms and children and adolescents’ overall adjustment is strongest for those who also reported a higher use of active coping strategies. Overall then, individual and contextual factors had an identifiable impact on individual adjustment outcomes.
These findings highlight the need to specifically consider individual and contextual factors in the research and treatment literature of psychological difficulties following residential fires. Investigations into the coping and adjustment processes of children and adolescents following residential fires remain in need of novel explorations. It is important for the field to continue to broaden the understanding of how children, adolescents, and their families adjust to trauma by testing innovative additions to current models. Another important area of investigation is the longitudinal psychological adjustment of children and adolescents following trauma. Empirical findings can be translated into greater practical utility with a deeper understanding of the timeline and composition of cognitive appraisal, coping methods, and the role of family processes and how these may impact adjustment over time.
Several possible targets for clinical intervention may include not only individual processes such as coping strategies but also contextual variables such as the family environment. As has been shown in the child chronic health literature, family-based cognitive–behavioral interventions and behavioral family systems therapy show promise in improving family communication, problem-solving strategies, and family and structural interventions (improvements in parent–child or parent–adolescent relationships) (Hocking & Lochman, 2005). These interventions may be equally promising strategies for children and families who have experienced trauma. Furthermore, trauma-focused coping skills training that targets problem-solving, cognitive–behavioral modification, and conflict resolution may be other avenues to explore. While the TSC model shows utility in identifying the psychosocial processes comprising adaptive outcomes to trauma, a similar application to treatment processes remains unexplored. Relatively few studies have empirically tested the effects of interventions for children and adolescents following disasters. Future studies employing large sample sizes are needed to establish the treatment approaches that effectively improve adjustment to residential fire. Finally, these findings may have more broad-based implications for treatment and intervention efforts following other mass trauma experiences.
A second complimentary model is the Resilience model. By definition, resilience refers to positive patterns of functioning during or following an adversity (Masten, 2006). In order to fulfill this definition, two criteria must be met. First, an individual must be functioning at a level that is at or above what would be deemed developmentally appropriate for their age. The second criterion states that the individual must have been exposed to a threat or adversity. If an individual is functioning at an appropriate level but has not been faced with an adversity, they are considered competent or successful, rather than resilient (see also Chapter 9). A risk or adversity can range from a single event, such as a hurricane or fire, to ongoing stressors, including physical abuse or neglect. In addition, these stressors often occur in combinations, leading to increased overall stress levels.
Traditionally, the resilience literature has neglected to include mental health outcomes in the conceptualization of resilience. Although mental health measures were occasionally examined in addition to behavioral competence when studying resilience (Carle & Chassin, 2004; D’Imperio, Dubow, & Ippolito, 2000; Luthar, 1991; Luthar & Zigler, 1991), only recently have mental health outcomes been included in the conceptualization of resilience.
A recent study in our lab investigated the moderational role of competence in the link between overall loss following a residential fire and the development of PTSD. Competence is thought to operate as a protective factor following a trauma and may be an important variable constituting resiliency. The sample consisted of 64 children (42% Caucasian, 45% African American, and 13% “other”) and their primary caregivers, all of whom had experienced a residential fire during which at least 15% of their house or belongings were lost. The children and adolescents were administered a combination of interviews and self-report questionnaires assessing loss following the fire, social support, coping mechanisms used, and basic demographic information. The findings of this study revealed that competence did not moderate the relationship between resource loss following the fire and PTSD. Implications for this study indicate that competence following a fire may not fully capture positive development following a trauma. When examining resiliency following a trauma, a more complete method of assessing positive adaptation may be needed.
A final model developed by Schnurr and Green (2004) may provide utility in explaining health outcomes following traumatic events. The model proposes that PTSD is the primary pathway by which trauma leads to negative health outcomes. It lists eight factors: trauma exposure, PTSD, biological alterations, psychological alterations, attentional processes, health risk behaviors, illness behaviors, and morbidity and mortality. For instance, given the physiological activation/deactivation of survivors both during and following a traumatic event, it is important to understand the biological alterations the body sustains following a traumatic event. In the literature review regarding biological abnormalities associated with PTSD, Yehuda and McFarlane (1997) and Friedman and McEwen (2004) noted several aversive alterations, particularly to the HPA axis system, which resulted in increases in the corticotropin-releasing factor, alterations in cortisol levels, and an increase in glucocorticoid receptors, which influence the regulation of cortisol. Influences on the sympathetic nervous system, arousal symptoms, including increased startle responses and disturbed sleep, were also cited.
Another recent study from our lab reported on a sample of 56 (48 women, 8 men) residential fire survivors, examining the mediating effect of PTSD between exposure and somatic symptoms. Participants were interviewed 4 months after a residential fire and were assessed on levels of exposure to the fire, PTSD symptomology, and somatic health complaints. Consistent with previous findings, PTSD was found to mediate the relationship between exposure to a traumatic event and reporting of somatic symptoms. Furthermore, increased arousal was found to mediate the aforementioned relationship, and avoidance symptoms were also found to partially mediate the same relationship between trauma exposure and the reporting of somatic symptoms. These results may have prominent implications for those who continue to experience distress, both somatic and otherwise, in the gulf region (Immel & Jones, 2009).
Current and Future Challenges
Several recommendations put forth by Jones et al. (2008) when discussing the role of psychologists following Hurricane Katrina are presented next.
Lessons Learned and Recommendations
Getting into the Field. Following a traumatic event, there are many obstacles and challenges mental health responders encounter as they begin to “enter the field.” First, it is critical to facilitate rapid deployment in the wake of a natural disaster such as Katrina. A 3-day workshop such as the DTAC program for mental health professionals in May 2005 served as an enhancement tool for assisting them in such severe crisis situations. A lack of structure and coordination was seen following Hurricane Katrina, and perhaps, in the future, psychologists should contact whichever agency is responsible for deploying mental health professionals in order to be sent where assistance is needed most. Licensure, the impact of independent practice, and travel expenses are also challenges many psychologists will encounter in the face of a national crisis. Another lesson learned following Hurricane Katrina is the importance of communication systems. For example, the use of landlines and cell phones was impaired following the hurricane, so establishing more sophisticated and effective communication systems by collaborating with first responders is a recommendation to consider for future disasters.
Issues Related to Safety, General Well-Being, and Vicarious Traumatization. While psychologists are inspired to help others, it is critical to consider one’s own safety when responding to any disaster. Health concerns, environmental toxins, and other dangers in affected areas can lead to sickness or disease. In addition to physical health, it is important to keep one’s mental health in mind. Working with a community suffering from loss and distress can lead to “vicarious traumatization,” also known as “burnout.” It is critical for psychologists to engage in self-care while in the field in order to avoid negative results such as anxiety and depression.
Issues Related to Intervention. There are many factors which influence the reaction to a traumatic event. For example, both social support and coping strategies have been found to be protective factors following a traumatic event. Being familiar with these factors and existing literatures will assist in evaluating the impact following a natural disaster such as Katrina. It is also critical to consider the timing of intervention following a disaster. Even though many suffer negative consequences following a traumatic event, it is important to allow the community time to naturally heal before implementing psychological intervention strategies.
Cultural Sensitivity for Psychologists Working in Disaster Relief. Given that 67% of communities impacted by Hurricane Katrina were predominately African American, the need for cultural competence training is clear. Following the hurricane, issues of trust, access to resources, and cultural differences were present among many survivors. These issues, along with cultural differences across ethnicities, lead to the recommendation for psychologists to implement culturally sensitive screening and assessment instruments. Many individuals tend to feel more comfortable receiving assistance from someone they have already formed a relationship prior to the traumatic event. As a result, psychologists should consider collaborating with community organizations as well as other minority organizations such as the National Association of Black Psychologists to increase a sense of comfort for minority groups in the wake of a natural disaster.
The Social Sciences. The social sciences play a critical role in disaster relief efforts. After the first author’s initial deployments to the Gulf Coast, he realized that “to achieve success with this daunting effort it will take our best science and utmost sensitivity.” That is, the need to be culturally sensitive to target populations, as well as to integrate standards and guidelines based on our scientific clinical work and research, is essential. A complimentary set of recommendations incorporating aspects of the above-stated goals were developed by a group of national and international disaster mental health specialists, including the first author. This took place at a conference entitled “Mental Health and Mass Violence” in response to the September 11, 2001 terrorist attacks and was funded by the National Institute of Mental Health (NIMH). The recommendations are as follows: (a) mental health disaster response requires both research and program evaluation; (b) the scientific community has a responsibility to assess intervention efficiency; (c) there is a need to develop and employ a national strategy in order to guarantee systematic collection of data, evaluation, and research during and after traumatic events such as mass violence and disasters; (d) it is necessary to perform sound research and improve intervention strategies if the most favorable type of intervention is not yet known; (e) mental health professionals should be involved in systematic evaluation activities; (f) research needs to create a standard taxonomy; (g) there is a need to notify the broader research community concerning the magnitude of conducting research on disasters and mass violence; (h) empirically informed and evidence-based interventions are crucial; and (i) researchers are ethically responsible to discourage the use of ineffective or unsafe techniques (Friedman, 2006). It is our hope that these recommendations will continue to be followed by clinicians and researchers, as well as mental health and public health professionals.
Following Hurricane Katrina, a literal and figurative breach unfolded. One ruptured the levee system of New Orleans, putting its inhabitants in grave danger, and another, perhaps more painful, breach emerged between the citizens’ expectations and the somewhat disappointing realities of the government’s short-term and long-term responses to this natural disaster and national tragedy ((Carruthers & Jackson, 2006). Thus, several recommendations are discussed below to address current and future challenges resulting from traumatic experiences.
Disaster and Relief Issues. Those impacted by Hurricane Katrina need to share their stories of struggle and survival for others to hear and learn from. Such a tragedy should not be forgotten – being able to talk about a traumatic event can be painful, but it is a helpful coping strategy.
It is essential that national organizations such as FEMA coordinate emergency plans on local, state, and national levels, with an emphasis on the coastal areas that are most likely to be impacted by another natural disaster in the future (see Chapter 6 for a related discussion). Furthermore, this emergency plan, including evacuation procedures, must be made well known to the general public, especially to at-risk populations such as minority groups or those with low socioeconomic statuses. Organizations assisting with the recovery process should also improve their communication strategies with evacuees. For example, many reported having difficulty reaching FEMA operators or receiving helpful information in the wake of Hurricane Katrina.
Another recommendation is to begin forming new partnerships with churches and other community-based organizations; working within the confines of the community ensures more effective resource allocation as well as a potentially more ethnically diverse staff, giving survivors an elevated sense of connectedness and hope. Another policy to ensure an expedited reunification with family members is extremely important, especially for children; being separated from one’s family for too long can lead to psychological discomfort.
Restoration Issues. The guidelines mentioned in the U.S. State Department for Internally Displaced Persons should be implemented for all Hurricane Katrina survivors; they should also be considered in all emergency planning committees throughout the nation. In addition, the Hurricane Katrina Recovery, Reclamation, Restoration, Reconstruction, and Reunion Act of 2005 should be passed, guaranteeing any evacuee from Hurricane Katrina who wishes to return can do so and be restored to their “status quo ante.” The media also plays an important role in the recovery process and perceptions of a traumatic event, and their influence should be critically reviewed.
Public Policy Issues. Many legislation recommendations have been proposed, such as authority, accountability, and coordination procedures for future disasters, as well as initiatives that would ensure health care for every child in America, especially for minorities or those with parents in low socioeconomic status groups who cannot afford health care.
African-American Church and Community-Based Organizations Preparedness. Many sources recommend disaster mental health responders to receive cultural competence training in order to better understand the barriers minority groups face in recovering from a traumatic event. Similarly, training programs should be implemented in churches as well as other community-based organizations to emphasize the diversity present within communities, as well as to encourage the community to play a role in the restoration process following a disaster such as Hurricane Katrina. Churches and other organizations that survivors have established a relationship with prior to the disaster can play a tremendous role in coping with loss.
Recommendations for Interventions
Intervention following disasters is one of the many crucial yet understudied aspects of trauma. Thus, Hobfoll et al. (2007) recognized five evidence-informed principles to guide community and individual intervention. It is essential to promote a sense of safety, calming, a sense of self and community efficacy, hope, and connectedness following a traumatic event.
More specifically, in the wake of a disaster, children and their families are likely to experience a sense of threat or danger, disrupting their “protective shield” (Pynoos, Steinberg, & Wraith, 1995), which can lead to a variety of negative impacts for the family and surrounding community. It has been found that those who have rebuilt a sense of safety following a traumatic event, however, have a lower risk of developing PTSD than those who have not (Bleich, Gelkopf, & Solomon, 2003; Grieger, Fullerton, & Uranso, 2003). Similarly, promoting a sense of calmness is extremely important and has been found to be a protective factor for those recovering from a disaster; those who have failed to establish a sense of control or calmness are at higher risk of developing PSTD (McNally, Bryant, & Ehlers, 2003; Shalev & Freedman, 2005).
Another important principle to consider in intervention research is promoting a sense of self and collective efficacy. For example, Benight and Harper (2002) found it is advantageous to believe one can manage and solve trauma-related problems following disaster. Likewise, instilling hope in the aftermath of a disaster is essential to effective recovery after a traumatic event. Developing and maintaining an optimistic outlook among individuals and the community must take place in distressful situations. Lastly, Hagan (2005) recognizes the importance for children to form a connection with others and thus emphasizes the need for intervention strategies to reestablish connectedness between children and their families following a traumatic event. These five principles are critical factors for intervention and prevention strategies following a traumatic event on an individual and community-wide level. Thus, collaboration between mental health professionals, physicians, education and political systems, and many other gatekeepers must occur for successful intervention to help those recovering from traumatic events.
Hurricane Katrina was one of the most devastating natural disasters the United States has ever encountered. It tested the abilities of survivors and mental health professionals on local, state, and national levels. Although many were adversely affected by Hurricane Katrina in a myriad of ways, this chapter focused on children and the role traumatic events can play on their mental health. Recent empirical studies regarding the impact of Hurricane Katrina on youth survivors were reviewed and the contribution these scientific findings bring to the growing trauma literature was discussed. Although some studies contradict preexisting trauma literature, many support it, and some even bring new findings to the table of trauma research. The dose–response conceptual model emphasizes the roles of many risk and protective factors (i.e., exposure, social support, coping, race/ethnicity, age, gender, parent–child interaction), providing valuable insights for future direction for clinical and research initiatives.
A special thanks is extended to first lady Laura Bush for the valuable contributions to the children affected by Hurricane Katrina. Thanks are also extended to the following individuals: Al Marie Ford, MSW (Mental Health Cultural Competence Office), Cheryll Bowers-Stephens, MD, MBA (Assistant Secretary for the Office of Mental Health), Gilda Armstrong-Butler,MSW (Assistant Director of Louisiana Spirit), Anthony Speier, PhD (Louisiana Office of Mental Health; Director of Disaster Services), and Jeanne Brooks, MA (Charles B. Murphy Middle School Teacher and Librarian).
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