Types of trauma post disaster u Acute Stress Disorder u Adjustment - - PowerPoint PPT Presentation

Presenters (in order of appearance)

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Asim Shah, MD

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Professor and Executive Chair of Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

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Chief of Psychiatry, Harris Health System and Ben Taub Hospital

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Nizete Ly-Valles, PhD

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Assistant Professor of Child and Adolescent Psychology at Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

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Stephanie Hernandez, DO

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Assistant Professor of Child and Adolescent Psychiatry at Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

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Asna Matin, MD

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Assistant Professor of Child Adolescent Psychiatry at Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

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Director, Child and Adolescent Clinic; Detention Psychiatric Unit, Harris County Juvenile Justice Center

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Sophia Banu, MD

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Assistant Professor of Child Adolescent Psychiatry at Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

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Deputy Chief Ambulatory Services at Ben Taub Hospital

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Medical Director Adolescent in Motion (IOP)

Types of trauma post disaster

u Acute Stress Disorder u Adjustment Disorders u Post Traumatic Stress Disorders

What is PTSD?

u Posttraumatic stress disorder, or PTSD, is perhaps best known as a mental

health condition that many soldiers experience after war, but it's a problem that stretches far beyond the military to affect 5%-10% of all men and 7%- 14% of all women in this country

u Stress results in acute and chronic changes in neurochemical systems and

specific brain regions, which result in long term changes in brain “circuits,” involved in the stress response. Brain regions that are felt to play an important role in PTSD include hippocampus, amygdala, and medial prefrontal cortex.

To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

u At least one re-experiencing symptom u At least one avoidance symptom u At least two arousal and reactivity symptoms u At least two cognition and mood symptoms

Re-experiencing symptoms

u Flashbacks—reliving the trauma over and over, including physical

symptoms like a racing heart or sweating

u Bad dreams u Frightening thoughts u Re-experiencing symptoms may cause problems in a person’s everyday

• routine. They can start from the person’s own thoughts and feelings.

Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms

Avoidance symptoms

u Staying away from places, events, or objects that are reminders of the

experience

u Avoiding thoughts or feelings related to the traumatic event u Things or situations that remind a person of the traumatic event can trigger

avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car

Arousal and reactivity symptoms

u Being easily startled u Feeling tense or “on edge” u Having difficulty sleeping, and/or having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by something that brings back memories of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Cognition and mood symptoms

u Trouble remembering key features of the traumatic event u Negative thoughts about oneself or the world u Distorted feelings like guilt or blame u Loss of interest in enjoyable activities

Cognition and mood symptoms can begin or worsen after the traumatic

• event. These symptoms can make the person feel alienated or detached

from friends or family members.

u Symptoms usually begin within 3 months of the traumatic incident, but

sometimes they begin later. For symptoms to be considered PTSD, they must last more than a month and be severe enough to interfere with functioning in relationships or work. The course of the illness varies from person to person. Some people recover within 6 months, while

• thers have symptoms that last much longer.

Psychological first aid (PFA)

What is PFA?

u PFA is supported by disaster mental experts as the “acute intervention of

choice”, while responding to psychological needs of children, adolescents, adults and families affected by disaster and terrorism.

u PFA does not assume that all individuals will develop severe mental health

problems, but it is based on understanding that disaster survivors face broad range of early reactions.

Some PFA coping skills

u Talking to another person for support or spending time with others u Engaging in positive distracting activities (sports, hobbies, reading) u Getting adequate rest and eating healthy meals u Trying to maintain a normal schedule u Scheduling pleasant activities u Taking breaks

PFA coping skills, continued

u Reminiscing about a loved one who has died u Focusing on something practical that you can do right now to manage

the situation better

u Using relaxation methods (breathing exercises, meditation, calming

self-talk, soothing music)

u Participating in a support group u Exercising in moderation u Keeping a journal u Seeking counseling

What doesn’t help

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Using alcohol or drugs to cope

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Extreme avoidance of thinking or talking about the event or a death of a loved one

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Violence or conflict

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Overeating or failing to eat

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Excessive TV or computer games

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Blaming others

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Working too much

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Extreme withdrawal from family or friends

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Not taking care of yourself

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Doing risky things (driving recklessly, substance abuse, not taking adequate precautions)

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Withdrawing from pleasant activities

Preschoolers: 3-5 year-olds

Nizete-Ly Valles, PhD

Cognitive development (3-4 year-olds)

u Make predictions (4 year-olds) u Can begin to resolve conflicts u Cannot often distinguish between

fantasy and reality

u Death is not final

Social-emotional development (3-4 year-olds)

u Cooperative play u Show concern for others u Play make believe u Show a range of emotions u Difficulty with transitions

Cognitive development (5 year-olds)

u Can tell stories u Egocentric u Overgeneralize u Question everything u Believe in magic

Social-emotional development (5 year-olds)

u Differentiate between reality and fantasy u Want to please and imitate friends u Increasing independence from adults u Can tell stories with beginning, middle,

and end

u Demanding

Trauma and development

u Trauma is an event that is perceived by the child as being harmful to

them or a loved one and exceeds the child’s capacity for coping

u Exacerbates common childhood anxieties

u Trauma can have a negative impact on development at any age u We expect that most children will have a natural traumatic stress

response

u This is only temporary

u For some, this reaction extends beyond one month

u Can also have a delayed traumatic response

Trauma and development, continued

u

Trauma can lead to:

u Intense feeling of terror, helplessness, lack of safety u Physiological symptoms (e.g. rapid breathing, shaking, somatic concerns) u Negative beliefs about: self, others, and the world u Fight, flight, freeze, attach reactions u Behavioral changes u Disruptions in academic functioning

Children at particular risk for PTSD

u Physical injury (to self or loved one) u Direct exposure

u Flooding, evacuation, loss of personal items

u Death of a loved one u History of traumatic events u History of anxiety or shyness u Lack of support

What to Look For

Anxiety Mood Behavior Academic Difficulty separating Increased sadness Regressions Cannot focus Excessive worry about natural disasters Loss of interest or less enjoyment Aggressive (physical, verbal, relational) Not completing tasks School refusal Withdrawn or isolated Noncompliant Refusing/avoiding schoolwork Overly clingy Irritable Disrespectful Careless mistakes Worsening shyness Crying spells Reenactments in play Not understanding the task “Silent Sufferers” Difficulties sleeping

• r eating

What you can do to help…

Restore Sense of Safety

• Build supportive

relationship, allow children to ask questions or share their story, help them help each

• ther, help them

create meaning of what happened

Provide Structure

• Provide

predictable routines and transitions

• Use visual

cues, verbal reminders, signal upcoming transitions

Offer Praise

• Offer lots of

specific labeled praise

• “Juan, I love

how you worked hard to solve that problem.”

Sense of Mastery

• Classroom

responsibilityity (line leader, homework collector, greeter, classroom beautification project, school garden, community project)

Social emotional development in the classroom

u Create a “keep it cool” corner

u Use sensory objects

u Offer “brain breaks”

u Yoga stretches, mindfulness activities, recess,

movement breaks

u Solutions wall u Feelings and coping stories (e.g., Flood book) u Teach relaxation

u Deep breathing

Tucker the Turtle

Tucker the Turtle

Tucker the Turtle

Tucker the Turtle

Tucker the Turtle

Wall of Solutions

Helping displaced students

u Encourage social interactions

u “Peer Bench”

u Pair the child with a socially appropriate classmate u Provide reassurance as needed u Watch out for bullying and teasing

u Intervene immediately

u Create a welcoming culture

How to respond to a child in distress

u Stay calm and listen u Keep child and other students safe

u “I’m right here and will keep things safe for you”

u Label feeling (use gentle voice) u Offer suggestions for relaxation u Model use of relaxation strategy u Sometimes silence is best u Problem solve once child is calm u Goal is to help child restore equilibrium u Remember: “This is a child who can’t. Not a child who won’t.”

How else can you help…

u Create a classroom where talking about the trauma is okay

u All you need to do is listen

u Be aware of trauma triggers u Be mindful of professional limits and boundaries u Communicate your concerns with parents u Self-care u Refer as needed

u School counselor

Remember…

Children look to significant adults in their lives for guidance on how to manage their reactions after the immediate threat is over. Schools can play an important role in this process by providing a stable, familiar

• environment. Through the support of caring adults school

personnel can help children return to normal activities and routines (to the extent possible), and provide an

• pportunity to transform a frightening event into a

learning experience.

Lazarus, Jimerson and Brock (2003)

Resources

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Social Emotional Foundations for Early Learning

u http://csefel.vanderbilt.edu/resources/strategies.html#teachingskills

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Tips and Resources for teaching Hurricane Harvey

u https://www.literacyworldwide.org/blog/literacy-daily/2017/09/05/back-to-

school-after-a-natural-disaster-teaching-hurricane-harvey

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National Child Traumatic Stress Network

u www.nctsn.org

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Disaster Related Sources:

u https://www.naeyc.org/newsroom/ u https://www.acf.hhs.gov/ohsepr/children-and-

familiesResources_on_coping_with_disasters

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Tips for Helping Students After a Trauma

u https://www2.ed.gov/parents/academic/help/recovering/recovering.pdf

Replace #Houston with #yournameStrong and draw a picture of how YOU are strong

YOUR NAME

What’s in your heart?

School aged youth: 5-11 year-olds

Stephanie Hernandez, DO

How and why would you use these exercises for school aged children?

Objectives

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Identify coping skills appropriate for school aged youth

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Discuss normal emotional and cognitive development in school aged youth

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Identify characteristics of students at risk for longer term problems

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Discuss typical reactions after a natural disaster in school aged youth

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Identify ways to help students bounce back

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Discuss ideas to rebuild the classroom

Coping skills…what do they help with?

u Improves self confidence and self-esteem u Increases student independence u Helps with self-assertion and agency u Decreases time it takes to deal with students’ crises, issues,

meltdowns

u Good life long skills u Improves problem solving skills

Deep breathing: for school aged youth

u How can we teach deep breathing for school aged children?

Normal development: cognitive

u By 5 years old…

uEgo-centrism weakens, “decentration” uLanguage, memory, imagination uUnderstand and express the past and future uTransductive reasoning

Concrete operational stage (7-11 year olds)

u Increased awareness of external events u Reason about tangible objects u Think logically with practical aids u Conservation, inductive reasoning

Psychosocial stage of development: Industry vs Inferiority

u Development of competencies u Learn, create and accomplish new skills, knowledge u Very social stage of development u Self comparisons u Caution for unresolved feelings of inadequacy and inferiority amongst peers: self esteem,

social, academic

u More significant relationship with school and neighborhood: competitive, cooperative,

empathic

u Parents are still important, but not the absolute authority

Emotion identification: school age youth are learning to…

u Name feelings u Describe feelings u Regulate their feelings

A study of long-term effects

0% 15% 30% 45% 60% Month 3 Month 7 Month 10

Hurricane Andrew: 3-5 grade student PTSD rates (moderate)

PTSD symptoms

Helping children cope with disasters: a manual for professionals working with elementary school children: LaGreca et al 1994.

Melody: pre-hurricane

u Melody is a 7-year-old Hispanic female whose home is a 3-bedroom apartment that she

shares with her 11-year-old brother and biologic parents. She has shared in class that she will be a “big sister” soon.

u In class, she tends to be more reserved than her peers, appears to be learning at grade

level and has friends that she sits with at lunch and plays with at recess.

Melody: post-hurricane

u Melody’s attendance has been variable, and when she does come to school she

frequently is late and does not have her homework.

u She remains appropriately dressed with good grooming and basic hygiene. u She is more giggly and almost hyperactive in the classroom needing some

redirection.

u Her father, instead of mother who typically comes to parent teacher conferences,

meets you in the fall to discuss Melody’s progress in school.

Discussion: What are your concerns for…

u School u Home u Thoughts about how to approach Melody

Melody: pre-hurricane

u Melody is a 7-year-old Hispanic female whose home is a 3-bedroom apartment that she

shares with her 11-year-old brother and biologic parents. She has shared in class that she will be a “big sister” soon.

u In class, she tends to be more reserved than her peers, appears to be learning at grade

level and has friends that she sits with at lunch and plays with at recess.

Melody: post-hurricane

u Melody’s attendance has been more variable, and when she does come to

school she frequently is late and does not have her homework.

u She remains appropriately dressed with good grooming and basic hygiene. u She is more giggly and almost hyperactive in the classroom needing some

redirection.

u Her father, instead of mother who typically comes to parent teacher

conferences, meets you in the fall to discuss Melody’s progress in school.

Characteristics of at-risk students

u Gender u Disrupted daily life

u Threatened physical safety, loss of possessions, relocation u School, friends, family u Other major stressful events post-Harvey

u Change in support

Helping children cope with disasters: a manual for professionals working with elementary school children: LaGreca et al 1994.

Characteristics of at-risk students

u Significant psychologic distress

u PTSD-related symptoms u Limited skills coping skills u “I wish bad things never happen” u “I try to forget all the time”

u

Behavioral changes

u Aggressive outbursts u Decline in academics u Withdrawal or avoiding being alone u School refusal

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Physical

u Reports of nausea, stomachache and headaches

Helping children cope with disasters: a manual for professionals working with elementary school children: LaGreca et al 1994.

Typical reactions

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Concentration difficulties

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Academic achievement declines

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Refusal to attend school

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Aggressive, excessively silly, hyperactive

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Difficulty sharing & separation

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Stomachaches, headaches

Reactions to watch for: Depressive symptoms

u Sadness, crying, irritability u Loss of interest u Appetite changes u Isolating/withdrawal u Sleep (insomnia, not wanting to sleep alone, nightmares)

Reactions to watch for: PTSD-related symptoms

u Re-experiencing: play, dreams, flashbacks u Avoidance: reminders of the disaster, general numbness to emotional topics u Arousal: sleep, irritability, concentration

Possible internal thoughts and fears

u Feeling more alone, nervous or separated from family u That something will happen them and/or their family u Of the dark, upcoming storms, being alone u That they caused a part of the disaster

Start a discussion

How would you approach a child you’re concerned about?

Rebuilding the classroom

Aiding in student recovery

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Re-establish routines

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Strengthen friendships and peer support

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Support what is developing and encourage strengths

u Be curious and inquire, educate and help advocate

u Remind families: monitor children’s exposure to media & adult conversations

Julie Ballew (5th grade teacher) Scholastic.com

Encouraging strengths: develop positive self-images

Explore feelings…

Develop coping skills and help identify support

Educate

“Helping your students deal with Hurricane Harvey,” by teacher Hannah Hill on “Teachers Pay Teachers”

Help advocate

u Brainstorm ways to help the community u Writing letters, poems about feelings and to other

students, teachers, families

u Donations u Make a classroom “fight song”

Teacher Julie Ballew at Scholastic.com

"Rise Up" by Andra Day

u Take care of yourself u Use your community for ideas and support!

Sources and supplemental teaching products

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National Association of School Psychologists (NASP)

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Federal Emergency Management Agency (FEMA)

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The National Child Traumatic Stress Network (NCTSN)

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American Psychological Association (APA)

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La Greca, A. M., Silverman, W. K., Vernberg, E. M., & Roberts, M.C. (Eds.) (2001, in press). Helping children cope with disasters: Integrating research and practice. Washington, DC: American Psychological Association Press.

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La Greca et al. 1994. Helping Children Cope with Disasters: a manual for professionals working with elementary school children. Miami, FL: 1994.

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https://www.teacherspayteachers.com/Product/Help-Your-Students-Deal-with-Hurricane-Harvey-3385989 Hanna Hill, teacher in Katy, TX

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https://www.scholastic.com/teachers/blog-posts/julie-ballew/17-18/rebuilding-our-classroom-community- after-hurricane-harvey/ Julie Ballew, teacher

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https://www.teacherspayteachers.com/Product/Help-Your-Students-Deal-with-Hurricane-Harvey-3385989 published by Hannah Hill, elementary school teacher in Katy, TX at “teacherspayteachers.com”

u

http://www.7-dippity.com/docs/After_The_Storm_(2008_Internet_Edition).pdf from the Smithsonian

Adolescents: 12-18 year-olds

Asna Matin, MD and Sophia Banu, MD

Objectives

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Discuss normal cognitive and emotional development in adolescents

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Identify typical reactions after a natural disaster in adolescents

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Identify characteristics of students at risk

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Identify coping skills appropriate for adolescents

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Discuss ideas for rebuilding the classroom

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Discuss resiliency and self care

What’s “Normal?”

u Movement towards independence - ‘Who am I?’

u Struggle with sense of identity, feeling awkward u Alternating between high expectations and poor self esteem u Peer influence u Parents are not perfect. Less overt affection, with occasional rudeness u Tendency to return to childish behavior, particularly when stressed

u Cognitive changes, future interests

u Interest in the present, limited thoughts of the future u Intellectual interests expand and gain in importance u Greater ability to do work (physical, mental, emotional)

AACAP Facts for Families

What’s “Normal?”

u Sexuality u Shyness, blushing, increased interest in sex u Concerns regarding physical/sexual attractiveness to others u Worries about being normal u Morals, values, self-direction u Rule and limit testing u Abstract thinking - hypotheticals u Develop ideals and select role models u Experimentation with sex and drugs u Physiological u Hormonal changes; puberty - growth spurt, acne, secondary sex characteristics

AACAP Facts for Families

http://www.specialneedsdigest.com/2015/11/the-adolescent-brain-subject-of-long.html

It's in your…

Changes to observe

u irritability u increased somatic complaints u avoidance behaviors u over/under reacting to sounds,

sudden movements

u decreased attention u declining grades u absences

NCTSN

• oppositional defiant behaviors with

authority figures

• withdrawal/isolation
• angry outbursts
• restlessness (hyperactive)
• emotional numbing
• aggressive reckless or self-

destructive behavior.

• increased drug use

Reactions of Adolescents to Disasters

u Detachment, shame, guilt u Self-consciousness u Acting out behaviors u Fear of recurrence u Abrupt shifts in interpersonal relationships u Premature entrance into adulthood u Concern for other survivors and families

NCTSN

What can teachers do?

u Understanding potential behavior related to trauma/stress leads to: u Intervene appropriately rather than escalate the situation

u Realize that its not necessarily intentional! u Partner with caregivers/counselors to provide preventative education,

effective interventions for recovery

u Consider IEP, 504 accommodations

NCTSN

Why?

u With support and intervention

u For some, recovery can occur within weeks to months u Some may need more time to heal - refer to counseling, mental health

providers

u Some may have intermittent recurrent symptoms (e.g. anniversaries,

media coverage)

NCTSN

Role of Counseling

Adolescents have stronger language capacity

u So, they may be able to better express their emotions u BUT, they are still learning to identify, label and communicate their

emotions

Role of Counseling

u Help adolescents and caregivers re-establish a sense of safety u Have a nonjudgmental space to make sense of their traumatic

experience

u Learn about impact of trauma u Learn techniques for dealing with overwhelming emotional reactions

Joe: pre-hurricane

u You are Joe’s counselor, though you only see him about 4 times a year and do not

know much about his home life.

u He is a 14 year old male, repeating the 9th grade at Lee High School under current

assessment for possible IEP plan, as he failed his STARR exam and some classes last year.

u He was on the basketball team, but since he needs to repeat the grade, is not

eligible to participate this year.

u You see him in the hallways laughing with peers and appears to be well-liked by

• thers.

Joe: post-hurricane

u Joe has not been coming to class and is in danger of exceeding the total amount

• f days missed allowed.

u When you do see him, he appears tired, somewhat heavier in weight, though he

is smiling and seen with peers.

u His grades remain in the C/D range, though they are dropping.

Discussion

u What are your concerns? u How would you approach Joe?

Joe: pre-hurricane

u You are Joe’s counselor, though you only see him about 4 times a year and do not

know much about his home life.

u He is a 14 year old male, repeating the 9th grade at Lee High School under current

assessment for possible IEP plan, as he failed his STARR exam and some classes last year.

u He was on the basketball team, but since he needs to repeat the grade, is not

eligible to participate this year.

u He see him in the hallways laughing with peers and appears to be well-liked by

• thers.

Joe: post-hurricane

u Joe has not been coming to class and is in danger of exceeding the total amount

• f days missed allowed.

u When you do see him, he appears tired, somewhat heavier in weight, though he

is smiling and seen with peers.

u His grades remain in the C/D range, though they are dropping.

Consider….

u If a child is daydreaming? intrusive thoughts? and you touch him from

back he may react out of proportion

u It's not all PTSD u inattention… u anxiety? u depression? u ADHD?

u It's not necessarily a choice!!

Rebuilding in the classroom

u Creating a safe space and school culture u Maintain usual routine u Physical activities u Hobbies, projects u Encourage volunteering u Encourage creative expression - art, journaling, story telling, music u Deep breathing exercises, counting, etc.

Deep breathing

u Diaphragm breathing u Where is my diaphragm?

u

a big band of muscle across the bottom of your lungs

u

and above your stomach.

u Put your little fingers near your belly button and the rest of your fingers on your stomach. Sniff!

Your diaphragm can be felt moving when you sniff

How it works

Why it works

u What does breathing do…

u To your heart rate? u To your body temperature? u To your breathing? u To your thoughts?

Resilience

u It's not all gloom and doom u Children are resilient u Resiliency increases when community is supportive u Studies have shown that children and caregivers who use the community

resources are more resilient than ones who do not use them.

Self-care

u What is secondary or vicarious trauma? Compassion fatigue? u Recognize the signs –

u Increased irritability, impatience u Difficulty planning classroom activities u Decreased concentration u Feeling numb or detached u Intense feelings

Self-care

u Do:

u Engage in fun activities, u Take a break during the work day, u Self-reflect, meditation, u Eat well, exercise, u Allow yourself to cry.

Self-care

u Get support

u Talk to colleagues while respecting confidentiality of students u Support from administrators u Create a support group amongst your peers u Seek professional help if signs persist for over 2-3 weeks

Resources

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American Academy of Child and Adolescent Psychiatry (AACAP)

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The National Child Traumatic Stress Network (NCTSN)

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Psychological First Aid (PFA)

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National Association of Mental Illness (NAMI)

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Acceptance and Commitment Therapy (ACT)

Exercise for Audience!

Thank you!