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When disaster strikes--the need to be "wise before the event": crisis intervention with children and adolescents. (eng) By Yule W, Advances In Mind-Body Medicine [Adv Mind Body Med], ISSN: 1470-3556, 2001 Summer; Vol. 17 (3), pp. 191-6; PMID: 11572847

There will never be a single manual that provides foolproof, evidence-based advise on how to deal with the emotional sequelae of a traumatic event. Most traumatic events are unexpected, and where large numbers are involved, chaos often reigns for hours, days, or even weeks afterwards. This paper addresses some of the issues involved in providing first aid or crisis intervention to children and adolescents affected by a traumatic event. There are a number of overlapping aims in seeking to provide psychological help to children as soon as possible after such an event. The immediate distress associated with exposure to traumatic events is a powerful motivator to act. As Raphael et al. (1995) point out, early intervention strategies may serve a variety of needs simultaneously, including: the need for people to provide assistance and to show concern; the need of survivors to talk about and understand what has happened and to gain control; and the need of those not directly affected to overcome feelings of helplessness, guilt at having survived, and to experience and master vicariously the traumatic encounter with death. As far as children are concerned, there is also the need to reunite the children with their parents or other family members. Thus, there is an imperative to do something and, in this increasingly litigious society, to be seen to be doing something. Over a very short period, survivors of disasters have come to expect that some form of counseling will be provided for them.
All this is based on the recognition that following major life-threatening incidents as many as half the children may go on to develop posttraumatic stress disorder and many more develop other forms of distress that may not follow such a chronic course (Yule et al. 2000; Bolton et al. 2000). Even after road traffic accidents, some 25 to 33% of child survivors may develop posttraumatic stress disorder (Yule 2000a). So, given that morbidity can be so great, what can child and adolescent mental health services do to respond effectively?

The need for risk analysis and preparation

Although disasters may be unexpected, all those in communities who have responsibility for children's welfare have a duty to undertake risk analyses as to what might befall their children, and to plan ahead accordingly. Planning never causes a disaster to happen! Yet many people are incredibly superstitious that by considering what might happen, they will bring it about--and as a result, they often do not take their duties seriously.
Some years ago, in the wake of a number of disasters that happened in the UK, we developed an outline plan advising schools on how to cope with crises on the school premises (Yule & Gold 1993). In most industrialized societies, children spend a significant proportion of their lives at school, and thus school is an obvious place on which to focus service delivery following a disaster. Indeed, schools are at risk of having many accidents, violent attacks, and deaths befall them. Rather than pretend such things never happen, school personnel will be far better able to cope with a crisis if they have thought through beforehand who should be responsible for dealing with different aspects of the situation.
We put ourselves in the place of the head-teacher (school principal) and thought through what tasks would have to be accomplished immediately and in the medium, short, and long-term. For example, the biggest need immediately is to ensure that children are safe and their physical needs are looked after. Then the worries of parents, pupils, and the public have to be dealt with, and there is a great need to be able to get accurate information in and out of the school. This has been made easier with the advent of mobile telephones, but one person cannot undertake all tasks. Planning and delegation are needed. Where children may have been killed, then immediately the school's policy on attendance of other pupils at funerals needs to be implemented as, in our modem multi-faith/no faith society, some communities bury their dead within 24 hours, and there is no time to consult other parents as to their wishes--a simple example of how planning ahead can lead to a clear policy that saves a great deal of unnecessary angst should the worst happen.
Senior staff then need to implement their previously thought out plans on how to inform children in school and how to deal with the distress of all pupils, as well as set up psychosocial help for those directly involved in the incident. There are now a number of good guidelines on the issues to think through and the procedures to adopt (Dyregrov 1999; Farberow & Gordon 1981; Pynoos & Nader 1993; Yule & Gold 1993).

A cress-agency disaster plan

Promoting good child mental health involves many different statutory and voluntary agencies. The exact mixture will vary from country to country. Child psychiatrists, psychologists, social workers, and psychotherapists are not always the professionals best prepared to provide the necessary advice and help needed after a large-scale emergency. They are too used to thinking of seeing families by appointment, managing waiting lists, and doing long-term individual interventions that are simply inappropriate for dealing with the masses affected by a large incident (even if there were any empirical evidence that what is done in most child guidance clinics has any beneficial effects!). If such child mental health workers venture out from their clinics for the first time in response to an emergency, they are bound to make many mistakes.
Rather, we advise that head-teachers and other responsible officials get together with representatives of all the varying child agencies and discuss how they can work together when an emergency occurs. Simply knowing each other beforehand is of value--even better if they have agreed upon a division of responsibilities and clear lines of communication.
In the UK, a working party reported to the Department of Health in 1991, recommending that Social Services should be the lead agency in organizing psychosocial responses to disasters, but the report has never been formally implemented (Disasters Working Party 1991).

Differing scenarios

The above outline assumed that some accident or disaster had happened to children either in school or during a school-related activity, and that the infrastructure, both physical and social, of the school remained intact. Where buildings are razed by earthquake or warfare, different strategies and tactics will need to be worked out, but often similar needs of child survivors have to be met.
The biggest challenge to meeting psychological needs of children affected by war is that of finding suitable local personnel who can go beyond normal human responses of succor and comfort and deal with the children's reactions to the horrors they have witnessed. Finding such people calls for coordinated efforts by national and international agencies to provide evidence-based intervention packages suitable for implementation by local people with a modicum of training and on-going supervision. Too many packages are implemented without evidence for their efficacy. Some are now being developed that are better evaluated (Smith et al. 1999; De Jong & Clarke 1996).

Psychological debriefing for children

First of all, it must be stressed that there are many possible forms of crisis intervention. Thus, it is absolutely vital that the exact form of the intervention used be operationalized and described. Secondly, the intervention of Critical Incident Stress Debriefing was developed by Mitchell (1983) for application to groups of emergency workers not primary victims. Thirdly, "psychological debriefing" as described by Dyregrov (1991,1997) was developed for use with groups of survivors, and it makes group processes central to the whole intervention. Fourthly, the recently attempted meta-analyses of published random control trials have mainly examined very brief, individual crisis interventions bearing little resemblance to psychological debriefing and at times applied to situations where major stress reactions are not even expected (Bisson, et al. 2000; Dyregrov 1998; Yule 2001a).
It has to be admitted that there are very few studies that evaluate the effects of psychological debriefing with children. It has also to be faced that inappropriate intervention given by inadequately experienced people and given at the wrong time can possibly slow down natural recovery if not actually make things worse. There is a responsibility on child mental health services to undertake proper evaluations of crisis interventions.
Having said that, there is a need to respond to children traumatized by an emergency event. What should be done? There are two studies that have generally positive outcomes. Yule and Udwin (1991) screened some survivors from a shipping disaster--children from the same school--and provided a structured psychological debriefing 10 days after the incident. The children were offered help individually or in small groups, and it was found that those who scored highest on the screening battery were those who availed themselves of the offer. Five months later, the children were doing better than those in a neighboring school that had not arranged crisis help for their charges. However, in this natural experiment that was not planned, debriefing and early intervention are confounded.
Stallard and Law (1993) show more convincing evidence that debriefing greatly reduced the distress of girls who survived a school bus crash. The researchers provided help a few weeks after the crash, and the girls responded positively to only two group sessions.
However, we still do not know when best to offer such debriefing to survivors of a disaster, nor indeed whether all survivors benefit. There is evidence from work undertaken in the Armenian earthquake (Pynoos et al. 1993), in many action research studies undertaken under the auspices of UNICEF in Bosnia, and more recently from the Turkish and Greek earthquakes (Giannopolou 2000; Yule 2001b), that group interventions many months after an event can still greatly reduce psychological suffering.
Based on this slowly emerging evidence, on my own experience, and on many fruitful discussions with colleagues around the world, I make the following recommendations:
  • Schools and other agencies should undertake risk analyses and prepare to deal with emergencies.
  • Agencies charged with meeting the psychosocial needs of children after disasters should invest in training key staff.
  • Key staff also need to have experience in helping children who experience bereavement.
  • Children's safety, security, medical, and other physical needs need to be met before psychological interventions are offered.
  • There is little point in starting any psychosocial help until children are coming out of shock, dissociation, and disbelief.
  • This means that group help should not be arranged during the first few days: 5-to-10 days after the incident seems optimal. Some contact needs to be made indirectly immediately; this can be by way of suitable leaflets.
  • Groups should be led by suitably prepared individuals with access to supervision.
  • Manuals based on good outcome studies should be used in preference to home-grown manuals.
  • Psychosocial interventions should not be confined to "one-off"--single occasion--meetings.
  • Children should be screened and monitored, and appropriate further help arranged as necessary.

The current debate regarding crisis intervention for primary survivors of disasters centers around the timing of the initial intervention. My argument is that during the first few days, children are likely to be in shock. They need reassurance and to be reunited with their parents. Thought should be given to such reunion occurring at the scene of the disaster, so that children can better link a variety of reminders with safety signals. Some contact should be made by mental health professionals, but the adult literature strongly suggests that the wrong sort of contact in the first few days may be harmful--hence, the recommendation that 5-to-10 days afterwards is probably optimal. Obviously, an issue as important as this should be settled by evidence rather than theorizing.

The need for better studies

The key to improvements in crisis interventions has to be forward planning and better criterion (outcome) measurement. To deal with the latter, it is only in the past 15 years or so that much attention has been paid to developing appropriate measures of stress reactions in children--instruments that are reliable, valid, easy to administer to large groups, and sensitive to change. These requirements have meant that people have, to date, concentrated on instruments that require that children can read independently. There have been considerable advances in the field so that the battery we first used with child survivors of the Herald of Free Enterprise and the Jupiter shipping disasters (Yule & Udwin 1991) has been developed, improved, and applied in larger-scale disasters and war situations, and found to be practical, applicable in different languages and cultures, and sensitive to change. Of course, we still need better instruments, but there is a great need at present to improve on measures that can be used with younger school children and pre-school children.
Given the poor database, there is a strong case for undertaking experimental studies of different types of crisis intervention. These will be very difficult to sell to people caught up in the crises unless there have been detailed discussions well in advance. In other words, we need to be discussing now with United Nations agencies, non-governmental organizations, and national and local governments how they can best discharge their duties by investing in forward planning and evaluative studies.
Since there is no knowing with any degree of certainty where the next crisis will occur, we need to consider a wide variety of scenarios, and then decide what studies based on each of these can add to our knowledge base. For instance, it was widely accepted that very young children act out their traumatic experiences in play and drawings-but where are the data to support this belief? As I discovered when I tried to track down drawings children had made after a school fire, adults do not always realize the significance of these products, and the drawings had not been kept. Hence my advice to colleagues after an incident outside a nursery school to collect the drawings systematically.
We know there will be more earthquakes. We know that children will be killed and maimed and that survivors will be terrified of sleeping indoors for ages afterwards. How best can we alleviate these fears? I still advocate a swift return to regular school as a way of occupying children, and providing stability and predictability into their lives and a focus for psychosocial interventions. Whether the school is in a tent, a portakabin, a one-story building, or somewhere else will depend on local circumstances. It is simply imperative that children's right to education is met.
Having said that, we can surely improve on measures of children's experiences and reactions in relation to earthquakes. We know that they are likely to have seen loved ones killed, and so issues of traumatic bereavement are raised. We need-- and are currently developing--better scales to track these experiences. That way we can better evaluate ways of helping children come to terms with their losses. All non-governmental organizations providing psychosocial care must account to their sponsors and donors-as well as the children and their families--for the work they undertake. The international clinical research community can help by developing appropriate measures, manualized interventions, and better research designs.
In the earthquakes in Turkey, Taiwan, and India recently, the numbers affected are so great that no amount of national and international aid can be delivered simultaneously to all those who need help. Of necessity, some will have to wait. This, then, is as near as possible to a natural experimental situation for comparing rapid interventions with wait list controls--provided people understand the necessity for this, both practically and scientifically. There is still a need to obtain informed consent to undertake interventions and evaluations, but this should be second nature to all clinicians in any case.
As theories improve, then better predictions should be possible regarding alternative ways of intervening. If groups homogeneous according to age, gender, and experiences are formed during the crisis, the following practical questions can be posed: How long after an event should intervention commence? What sort of information leaflets help most people? Where children are troubled by dreams and nightmares of the horrific events that actually happened to them, when should they be encouraged to share the details within the group and when asked to talk individually? Indeed, are children retraumatized by hearing others' stories or comforted to share them? How far can modern information technology be used to assist recovery? Does recording one's narrative on video benefit or retard recovery? Are there simple physiological or biochemical measures that can be taken to provide more objective measures of children's stress reactions?
The wish list could grow. The point is that by articulating it and by discussing research designs well in advance of any crisis, there is a greater chance of being able to contribute to improving children's mental health and adjustment by improving the techniques we have for crisis intervention.

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