Cuban Medical Literature
Importance of Protective Factors
for the Mental Health of Children
and Adolescents in Emergencies and Disasters

Cristobal Martínez Gómez, MD

INTRODUCTION

Children and adolescents are at a higher risk of becoming victims and suffering the losses resulting from disasters. They are much more vulnerable; the younger they are the more difficult it is for them to understand what has happened. Historically, the effects of such events on mental health and the way to prevent and eliminate such consequences have been considered of little importance.

In many countries educational programs aimed at preparing people to protect children before, during and after a disaster do not exist. Governmental and non-governmental institutions do not coordinate their efforts.

Psychologists, psychiatrists, psychotherapists and psycho-educationalists have not been trained adequately at their institutions in order to prevent and attend to the disorders of affected children and teenagers.

It is necessary and practical to emphasize prevention, to focus on actions to promote health and prevent disorders that disasters may cause.

The social system should offer the following protective factors:

• Timely, detailed and systematic information about the proximity, intensity, possible damage and risks for the people and the protective actions to be taken.
• Means of evacuation, if necessary.
• Material resources to protect houses and buildings.
• Assurances for medical assistance, both physical and psychological
• Confidence in the qualification of formal and informal leaders to manage the activities related to the protection and recovery of health and welfare of affected people.

THE RESILIENCY APPROACH

Most recently, both theory and practice identify “prevention” as the highest priority when confronting disaster situations, taking into account the following premises: investigate the vulnerability factors, increase the resilience of the population, reduce risks and promote equity and subsistence (before, during and after the event). It is important to take into account that resilience in this regard is defined as the capacity of human beings to face and overcome life's adversities and become transformed in a positive manner by them. Resilience is determined by protective factors defined as: conditions or environments capable of encouraging the development of individuals and groups, while generally reducing the effects of unfavorable conditions. Protective factors are the opposite of risk factors, defined as characteristics or qualities of a person or community linked to a high probability to cause health damage.

It has been proven that women and children are the main users of health services in disaster situations. Cultural factors and customs of the population also influence mental health and the special needs of vulnerable persons.

Therefore, in any evaluation designed to prevent and detect health problems, it is necessary to include all the traumatic mental effects that may appear in children and adolescents. This is reinforced by the universally accepted criterion that these age groups are more vulnerable and sensitive, but also more receptive and flexible. Thus, systems must be created which provide information and education and allow for the identification of problems/issues and then follow-up in terms of appropriate promotional, preventive, monitoring and rehabilitation activities.

It would be best to establish the highest possible “predictability” of events. If there is an event pattern, there is also an emergency pattern. For example, we are aware that stress will appear; then it is necessary to establish means to prevent and reduce it and also avoid its consequences. The reinforcement of protective factors previously identified provides for effective, necessary and productive actions.

In the three-phases of a disaster (before, during and after), the preparation of the population will be a determinant factor in diminishing mental health damage/consequences in the child and adolescent population.

WHAT TO DO?

Before

The reduction of vulnerability in this age group is most effectively accomplished prior to the disaster by preparing the population in general, especially in terms of education and training, consonant with the prevailing social/psychological and cultural characteristics present. Fully informed knowledge on the best way to evacuate and accommodate children and teenagers reduces their vulnerability and diminishes the impact on their psyche. Adults and aid personnel should transmit safety and calm to successfully contribute to those purposes. Unnecessary and unjustifiable terror and fright are more harmful than a real danger.

There should be a previously planned response activated or enabled from the moment the phenomenon begins to occur. For that, the population should have received prior appropriate and opportune education and training to ensure qualification for the task at hand. Personnel should be trained to give “psychological first aid.” Personnel trained in emergency care psychiatry should be included in medical aid brigades. The impact on children/teenagers mental health should be evaluated. During the evacuation and at the site of already existing emergency housing or settlements/camps, family separation should be avoided as a top priority in order to guarantee a less hostile and/or unnatural environment for children. If a previous evacuation was not carried out, the same criteria should be considered to proceed, remembering that gender segregation disrupts families.

After

Damage will be evaluated afterwards by means of a “diagnosis” or diagnostic evaluation of the mental health state of the children and adolescents. A response plan designed to assist and rehabilitate the affected population should be established. Every attempt should be made to guarantee the possibility of attending some type of school and ensuring adequate time and space for play. The participation of the population in recovery activities as a key factor for mental health should be duly noted and implemented. Consciousness-raising is important so that the idea of recovery and return to normal conditions is perceived as a common effort, to be handled in a coordinated, united manner as everyone’s task (government, nongovernmental organizations, industry, services, school, family, neighbors). Thus the importance of prior psychological qualifications and preparedness.

HOW?

Before

By means of:

• Educational, preventive, promotional and/or other kind of programs, habitually performed during the “PRE-IMPACT” phase.
• Population training in organizing different activities, such as: play-related, school, recreation and others, according to the children/teenagers needs in both normal and disaster situations.
• Clear establishment of standard instructions for evacuation, temporary camps, refugee status, etc. specific to the situation of children and teenagers in emergencies and disasters.
• Clear establishment of the role of communities and institutions in order to satisfy the most important needs in disasters, aimed to favor optimal child/adolescent and family mental health.

Adequate monitoring and evaluation should be planned for and carried out from the beginning of the program. Results can be applied to future training programs and for the qualification of the coordinating commission, donors, local government officers, formal and non-formal community leaders, children/teenagers and their parents – all of whom contribute to achieve the social, financial and political support necessary for the success of the program.

During

Taking into account the first impact on child and adolescent mental health in emergencies and disaster situations, it is necessary to have very well planned life-saving and rescue activities. In order to develop the aims of the program within this context, it is important to understand the specific social/cultural reality of the child/teen population in question. Social and cultural factors significantly influence the way young people will behave during the disaster. Among these, those that exert the greatest influence, due to the fact that they are considered protective factors are:

• Individual characteristics (knowledge, attitude, beliefs, values, motivations and experience)
• Families and adults of the community
• Institutions (school, workplaces, religious and social organizations)

The results help to improve community understanding about the current and potential benefits of the program, the development of a sense of belonging through participation, the improvement of coordination and the development of incentives specifically geared toward support of children and teenagers. Another aspect that should be taken into account is that infancy, childhood and adolescence are experienced in different manners in every society and often even within the same one; many differences may exist in terms of how each of these critical life stages are dealt with.

After

It will be necessary to create a specially trained team to evaluate damages by means of a diagnostic overview of the child/adolescent mental health situation. Thus it is important to have performed a previous qualification/training process with the available personnel to carry out the response plan already designed. The community should be organized to create emerging classrooms and open-spaces to guarantee school attendance and areas designated and appropriate for play and recreation. Participation of the population in reconstruction/recovery activities should be encouraged in collaboration with social, religious and political institutions, generating the awareness/consciousness that this should be a common task involving everybody.

Factors which create obstacles to the best development of these activities are:

- Having no basic information regarding the target population’s situation
- Inadequate recovery information
- Lack of coordination and/or advance planning to ensure program strategy improvements

Factors facilitating the best development of the activities are:

- Knowing the system will offer what is expected
- Having tried the elements contributing to program efficacy
- Establishment of a genuinely participative commitment among the given community
- Having assured data collection
- Being creative and flexible
- Having defined aims and a realistic approach
- Having previously established a monitoring and evaluation system to measure
   changes and efficacy
- Limiting costs

ACTIONS REQUIRING PROFESSIONAL PERSONNEL TRAINING

• Crisis Intervention
• Death, loss and mourning counseling
• Knowledge of family functioning/dysfunction
• Social communication.
• Hospitalization (partial, total)
• Outpatient care
• Psychopharmacology
• Social, humanitarian and community support systems and resources in place, specifically geared to children and teenagers during emergencies and disasters.
• Psychological evaluation
• Specialized psychological interventions: psychotherapy or other techniques, specifically focused on children and teenagers and specific to emergency/disaster situations.

INFORMATION INTENDED FOR NON-PROFESSIONAL PERSONNEL AND FAMILIES

The days and weeks after the event will be difficult. Besides thinking about physical health, it is necessary to take some time to think about mental health. It is normal to suffer some insomnia, anxiety, anger, hyperactivity, depression or lethargy, but these should disappear in a relatively short time. If any of these symptoms become acute, seek professional help. Do not forget that before, during and after “the storm,” children need special care and extra attention. To help maintain their sense of security and safety, try to ensure that they have a favorite toy or other personal items to keep with them and/or have close at hand. State or local health departments should be prepared to help you find the necessary local resources you might need, from food and/or housing assistance to hospitals or health service suppliers.

A catastrophe like an earthquake, hurricane, tornado, fire, flood or a violent act is a terrifying experience for children, adolescents and adults. When talking to children about the incident, it is very important to recognize which elements of the disaster caused fear in everybody. Reducing danger or minimizing the extent or significance of potential danger(s) will not eliminate child concerns nor will this approach be particularly helpful or reassuring. A number of factors affect child reaction when he/she faces a disaster. It is very important to bear in mind just how the child sees and interprets his/her parents’ reactions and the reactions of others in the family and the community. Usually, children not only perceive their parents’ concerns, but are also particularly sensitive during a crisis. Parents should be open with their children and allow them to know that they are concerned but at the same time, they should emphasize their confidence in their own and the community’s abilities to confront the situation.

Child reaction also depends upon the magnitude of the destruction and/or death he or she sees during or after the disaster. It is highly probable that a child will have serious difficulties if a friend or relative is hurt or dies or if his/her home or school, for example, is severely damaged.

The child’s age also affects his/her reaction in the face of a disaster. For example, a six-year old can show his reaction to the catastrophe by refusing to go to school, while a teenager might minimize (deny) the importance of the tragedy, but show signs of increased irritability, starting fights with siblings or parents and/or doing less well academically. It is very important to explain and discuss the event using words the child can understand, and to listen closely to questions in order to give the specific “answers” or information being sought. 

STRESS-PROVOKED DISORDERS

After a catastrophe, people can develop acute or post-traumatic stress disorders, which is psychological damage as a result of having experienced or being witness to an extremely traumatic and/or terrifying event. If those manifestations appear immediately after the event, then it is generally referred to as Acute Stress Syndrome, but if they appear sometime later, the terminology used is “Post-traumatic Stress Syndrome.”

Children with this disorder generally have repetitive episodes in which they suffer from a series of symptoms and signs, including a reliving or re-experiencing of the traumatic experience. These children often revive the trauma by re-enacting it, sometimes repeatedly, when they play. Small children may exhibit disturbed sleep with apparently troubling dreams about the event which can develop into ongoing nightmares invoking the disaster itself and/or involving monsters, rescue activities or threats to themselves and/or others.

Parents should be especially alert to the following changes in child behavior:

• Refuses to go back to school; increased attachment to Mom or Dad, including acting like their “shadow”, following them around the house, etc.
• Persistent fears related to the catastrophe (like fear or permanent separation from their parents, for example)
• Sleep disturbances, like nightmares, shouting during sleeping, bed-wetting, persisting for more than several days after the event
• Lack of concentration, irritability, increased hyperactivity
• Easily frightened, nervous, heightened startle response
• Behavioral problems; for example, inadequate or inappropriate behavior at school or home (not seen before) – atypical for the particular child
• Complaints about physical discomfort (stomachache or headache, dizziness, etc.) without any apparent physical origin
• Isolation from family and friends, sadness, apathy, low activity and concern about disaster events

Professional advice or treatment should be sought to prevent or minimize the development of disorders in children affected by a catastrophe, especially for those who have experienced destruction, death, major loss or physical/medical consequences. Parents concerned about their children can request the pediatrician or the family doctor to refer them to a psychiatrist who specializes in children and adolescents. 

MOURNING IN CHILDREN AND TEENAGERS

Any modification of the role of a family member will induce a change in the other members. Therefore, the death of any member involves reorganization in family relationships. Such rearrangement starts a long time before the loss, along the entire terminal phase if, of course, the outcome is known beforehand or anticipated. The process will proceed differently but just as dramatically in the case of an accident or unanticipated loss.

Mourning as a process is standardized in all cultures. Every culture has it’s own process or processes for mourning - wake/funeral, familial outcry and manifest bereavement, burial/cremation, etc. – all accompanied by a series of different rituals. All societies develop and establish such rituals as the expression of an apparently uniquely human need. Human beings need to cry for their dead and for their loss. Popular wisdom in many cultures identifies this need to cry for the dead because crying brings relief. Non-expressed sadness does damage to our mind and spirit as well as affecting our physiological functions and systems. The entire body/mind/organism is disturbed and these disturbances can be expressed in many ways - from tachycardia (increased heart rate), stomach disorders, hypertension, skin reactions, to sexual dysfunctions, major depression, aggression, etc. Nevertheless, the primary manifestations of grief seem to be at the level of the psyche.

Loss and separation from parents, family or the social and school environment represent risk factors in infancy, childhood and adolescence, aggravated by the lack of psychological resources common to these age groups. In disaster situations children and teenagers bear an additional or greater burden of shock, confusion and suffering due to loss. As well, they often lack much needed appropriate/adequate support from other relatives who are also suffering from the same tragedy and thus unable to assume responsibility for these children in the absence, for example of the protection of significant adults who have disappeared, died and/or are otherwise unaccounted for.

Children elaborate mourning in a very curious way, different from that of adults. Sometimes they do not cry at all or they may begin with a furious crying, accompanied by very or not so aggressive actions. Gradually, this violent crying becomes milder but may be continuous. Then, the child may ask why his loved relative “is gone”, when he/she will come back, or if he/she (the child) has some responsibility for his/her absence. Sometimes they ask if the dead person will come back, and say: “When he/she comes back….”, or “when he/she lives again….” Often these questions go unasked, but usually they are prominent in the thinking of the child.

Often, especially in younger children, there are feelings of responsibility and/or guilt related to the loss. We had the painful experience of a three-year old child who continuously said to his mother “when my father comes back I will tell him that you did this [or that…] to me”. In children, guilty feelings are often related to the fact that sometimes they “wished” some relative would die, and when he/she really dies, they believe in their own magic thoughts and think of themselves as responsible.

Although mourning is triggered by something idiosyncratic in each person, there are situations that trigger mourning in all people and involve risk factors. Logically, those risk factors will be different according to the life stage the person is living. In young adults, the most frequent factors are: divorce, first pregnancy, abortion/miscarriage (especially if it is repeated), giving birth to a disabled child, unemployment, loss of a parent and migration. In adults and elderly people the most frequent factors are: retirement, lack of functional capability, loss of relatives, close friends or familiar environment, and illness or disability of other family members.

The way mourning develops is decisive for re-adapting to the environment and to one’s life. The attitude we should assume to treat mourning in primary health care settings should be receptive and observational, with maximum effort devoted to empathic listening. Evaluate risk factors as well as sleep disturbances. It is very important to distinguish between normal and pathological mourning.

In the case of normal mourning, a six-month follow-up period should suffice, although each individual is different. If risk factors are present professional help should last from six to twelve months, depending, again, on the individual and circumstances. In the case of “pathological mourning” it is necessary to establish a process and “treatment plan” for mourning and grief counselling with closer follow-up and if the problem is very serious or chronic, specific treatments for the existing and/or underlying disorders should be considered.

Children facing death

Children’s reactions to a loved one’s death is very different from adult reaction.

Preschool children tend to believe that death is temporary and reversible. This idea is reinforced by comics/cartoons and children’s literature, where the protagonists often “die” and then “come back to life” again. Children between the ages of five and nine years old, more or less, begin to think about death more similarly to adults, as the concept becomes more real to them. Nevertheless, they may begin to think or imagine, in an ongoing way, that they or some other close person could die. Parents should be conscious and attentive to their children’s reactions to death and understand which reactions are “normal” and which signify the possibility of exaggerated symptoms or danger signals. It is normal that several weeks or more after a relative’s death, for example, some children experience a deep sadness, or they may seem to believe that the relative is still alive. Long-lasting denial or the persistent avoidance of feelings of sadness is not healthy and can result in serious problems in the future.

Frightened children should not be forced to go to the funeral or burial, nor should they be denied participation – it depends on the child and the family context. Always, however, it is a good idea to allow children to participate in some type of symbolic ceremony or ritual, such as lighting a candle, praying or visiting the grave. When the child accepts death, it is normal that he/she demonstrates his/her sadness for a long period of time, sometimes at unexpected moments.

Family members and close friends should spend as much time together with the child as necessary, and clearly let him know that he is allowed to manifest his/her feelings freely and openly. If the dead person was essential to the child’s stability, then anger is a natural reaction. It can be manifested by means of violent playing, nightmares, irritability and/or a variety of other behaviors . This aggressiveness is sometimes directed at other family members. After the death of a parent, many children act more childlike, wanting to be fed, taken care of and/or cuddled like a “baby.”

Small children believe they are the cause of many things that happen around them, they perceive themselves as the center of their world. Thus, they can think that the person died because of something they did or said or even wished for or thought about…They feel guilty because they believe their wish was “fulfilled” and/or that they could or should have been able to prevent the death.

Danger signals

• Prolonged period of depression, where the child loses interest in his/her activities and daily happenings.
• Insomnia, loss of appetite or prolonged fear of being alone.
• Regression to an earlier age for a long period.
• Excessive imitation of the dead person.
• Frequently saying he/she wants to go away with the dead person.
• Being isolated from his/her friends.
• Significant deterioration in his/her studies, refusing to go to school.

These warning symptoms can indicate that specialized attention is needed. A child and adolescent psychiatrist or specialized psychologist can help with the process of accepting death and teach other survivors how to help the child in his/her process of grief and mourning.

CONCLUSIONS

• Knowledge of protective factors and their use is the most effective action to avoid psycho-affective damage in children and teenagers, during disasters and in general.
• Organize young people (peer counselors), women, teachers and community personnel groups with the aim of developing a corps of community-based people who can work and give advice before, during and after the disaster.
• Qualify the personnel designated to assist children, emphasizing those aspects involving the promotion of protective factors, avoidance of or attention to risk factors, early detection of disorders and actions for their eradication.
• Governmental and non-governmental community-based organizations and institutions should be the strategic center to organize all activity and tasks in a systematic and coordinated way.
• Separating children from their parents or another significant adult should be avoided.
• Families should understand the importance of maintaining emotional/affective contact, touching and hugging the child frequently, particularly at bedtime.
• Families should be kept together as a unit, not separated, and should be helped to maintain as much of the usual family activities as possible.
• Constantly reinforce the idea that they (the children) are safe and protected by and within the family.
• Establish clear, direct and simple communication; inform children how they can be affected and keep them abreast of what is going on and/or what could happen within limits dictated by age and developmental level.
• Listen carefully and patiently to their feelings and questions, and help them to understand what happened. Address their fears and concerns, allowing them to cry if they wish. Reaffirm that their fears, painful dreams, sadness and fantasy are normal reactions. If they do not express themselves spontaneously, ask them what they think about other children’s feelings.
• Encourage children to play. If they play/re-enact the “disaster” then help them find positive outcomes and/or resolutions to problems.
• Going back to school should be a top priority.
• Encourage productive activities, taking part in simple reconstruction jobs, according to their ages, aimed to facilitate the return to normality and to enable participation in recovery.
• In case of death, it should be faced in an honest, open manner, saying that it is normal to be sad, and using simple words according to the child’s age. Never blame a child for someone’s death and be attentive to the possibility that he/she may be blaming themselves and counteract that notion. It is not generally considered to be a good idea to say that the dead person is happy in heaven, because in many cases the child could begin then to wish to die in order to go to heaven to be with his/her lost loved one.

THE AUTHOR

• National Director for Child and Adolescent Psychiatry, MINSAP
• Full Professor of Child and Adolescent Psychiatry, Institute of Medical Sciences/ Havana Medical School/ “Pedro Borras” Pediatric Hospital
• Consulting Child and Adolescent Psychiatrist for the Latin American Center for Disaster Medicine (CLAMED)