Intervention Programs for Children

Intervention Programs for Children

RAQUEL E.COHEN

reprinted from MENTAL HEALTH RESPONSE TO MASS EMERGENCIES, edited by Mary Lystad, Ph.D., Brunner/ Mazel, New York, 1988.

Worldwide catastrophic events are flashed daily by our press and communication media. We become aware of the effects of traumatic events when we see human faces contorted by pain and tragic expressions of grief. A small voice not generally heard is the child's voice, although we are told that children are part of the population affected. Child victims-refugees in lands torn by war or natural disasters who become displaced together with their families or wander as orphans—will be the subjects of this chapter. Therapeutic intervention approaches will be proposed based on theoretical constructs and clinical practices. The knowledge base to guide the operations will be obtained from contemporary research, clinical crisis intervention practices, and recorded multidisciplinary disaster activities (Orbaschel et al., 1980; Frederick, 1985).

Published descriptions of clinical and behavioral manifestations of children's reactions to traumatic events focus on biological, psychological, and social perspectives. Documented observations of post-traumatic child reactions suffer from the lack of research data and add to the difficulty of developing a comprehensive frame of reference (Garmezy, 1986),

In general, documented children's reactions after disasters are sketchy and fragmented because they are based on the experiences of different professionals who have reported them in their own style and perspective (Ahearn & Cohen, 1984; Eth & Pynoos, 1985). Missing from many publications are the descriptions of children's reactions and behavior patterns during the various time phases which are characteristic of the developmental crisis resolution process.

Scientific measures and methods to assess children's reactions are beginning to be employed (Comely & Bromet, in press). A range of formats, including interviews, questionnaires and analyses of drawings, are being developed. Because the conceptualization of children's reactions is influenced by 1) the event itself; 2) the degree of disorganization of the family; 3) the impact on the social structures; and 4) the attention given to the children's subsequent needs, it is difficult to design a study which identifies and correlates all factors influencing child behavior. The importance of parental response to children's level of distress has been identified as a powerful influence, so this, too, has to be evaluated (Handford et al., 1986; Silber et al., 1957).

Increased attention by mental health professionals to this young, vulnerable population is due, in part, to several theoretical and research advances in the behavioral sciences. Among them are the following:

1. Increased knowledge of preventive programs following stressful life events in children.

2. Increased knowledge of the effects of stressors on health and illness (Rutter, 1981b).

3. Better understanding of interpersonal bond attachment processes and support systems (Bowlby, 1980).

4. New conceptualizations about the developmental perspectives of cognitive and affective systems (Kagan, 1984; Fisher, 1980).

5. New awareness of early appearance of children's capacities to process information and interact with their environment (Stern, 1985).

6. Further understanding of the effect of psychic trauma and emotional disorders in children, as differentiated from the outcome of grieving and mourning (Eth & Pynoos, 1985; Szapocznik, Cohen, & Hernandez, 1985).

7. Further accounts of children's postdisaster reactions (Burke, 1982;

Comely & Bromet, in press).

THEORETICAL BASES FOR APPROACH

Knowledge about what should be construed as a "healthy environment" for the development of a child stands in dramatic contrast to what has been learned about children in post-disaster situations (Cohen, 1976). The need to plan, develop, and offer assistance to the victims of these injurious events is promoting further study of programs designed to prevent pathological effects on the child's health and negative emotional consequences (Garmezy & Rutter, 1985).

The emerging knowledge about psychosocial processes that assist in adaptation at different levels of infantile development is very useful in disaster planning (Terr, 1984). Experiences are accumulating which are being shared, allowing professionals to develop tentative methods of intervention (Newman, 1976). Raising some questions about how to intervene with children after a disaster presents us with a classic dilemma in the clinical application of traditional theories. It is necessary to apply a consistent model to organize the obtained information, develop a diagnostic posture, and select the appropriate intervention approach. A useful conceptual approach in this specialized field of psychiatry can be obtained by focusing on the stressful situation in which the child finds himself and adopting a framework of understanding the child as an evolving interacting organism within a biopsychosociocultural model (Cohen, 1985).

There is a relation between the approaches by which problems are defined and the intervention which is chosen and then translated into action. Mental health problem definition reflects inferences and assumptions about the causes of the problem. In the case of post-traumatic stress reactions in children, the following can be conceptualized; The reactive-adaptive behavior that can be observed following the impact of the disaster is related to 1) the stage of development; 2) the gender of the child, ethnicity, economic status of the family; 3) usual coping defense style; 4) intensity of the stressor; 5) available and appropriate "fit" between the child's needs and support systems; 6) extent of dislocation; and 7) availability of relief and community disaster assistance resources. Collecting specific data about the victim and organizing the data to specify the problems produced by the situation in which the child finds himself offer guidance to develop the appropriate intervention. The way the data get organized, the unique characteristics that identify the victim, the hypothetical interaction among all the factors, and how they affect the child's capacity to cope are based on theoretical assumptions chosen by the therapist.

Several areas of theoretical knowledge will be highlighted because they are crucial to the understanding of behavior in post-disaster experiences and are key for intervention programs.

RELATION BETWEEN INFANTILE DEVELOPMENT STAGES AND POSTDISASTER REACTIONS

Periods of growth along developmental phases signal changes in several psychobiological systems. Depending on the age of the child traumatized by the event, the intervention should be designed by knowledge of the developmental stage of different systems—somatic, psychological, social, and behavioral. There is a relationship between the level achieved in these systems and the ability to deal with stressful events following the disaster. These adaptive processes can be understood as strategies, approaches, efforts that promote actions. The objective of these processes is to modify the impact of the stimuli unchained by the stressor and so tolerate, correct, modify, or diminish the effects on the organism and prevent reactive disorganization within the psychophysiological human system (Rutter, 1981a).

The manifestations of these adaptive skills and their effects on the vulnerable organism of the child will show a variety of behavior patterns. How we interpret these manifestations of the child's mechanism of adaptation, the social expectations toward him within the disorganized human environment, and the social and family conflicts that generally emerge in the crisis situation will all define diagnostic categories of healthy or pathological adaptation and, in turn, influence methods of assistance and intervention (Johnson, 1982).

The issues that need definition, for example, are as follows: How do children of different ages resolve a crisis? How do children of different ages adapt to bereavement and loss (Rutter, 1981)? How do children react to the experience of being lost and separated for specific periods of time from a mother and being cared for by strangers? What are the differences when the mother is dead, incapacitated, overwhelmed by the disaster, or wounded (Goodyear, Kolvin, & Gatzanis, 1985)?

It is well known, as a law of adaptation, that the child has to maintain his internal world and support the homeostatic systems functions. A working hypothesis considers the possibility that disruption of the systems produces effects on the social, psychological, and physiological levels of the organism (Longfellow & Belle, 1984). These changes will present behavior manifestations which are the expression of the organism's attempt to reduce tension by reestablishing a psychophysiologic balance. For instance, the reactions to an earthquake of a one-year-old child, who processes stimuli and information through an evolving, cognitive system, will be different from that of an older child, who will use a symbolic-linguistic mode of information processing (Block et al., 1956).

PSYCHIC TRAUMA AND DEVELOPMENTAL EXPRESSION OF MOURNING POSTDISASTER '

An important conceptual body of knowledge assists in the understanding of processes available to children during traumatic events that involve loss (Bowlby, 1963; Brown et al., 1985; Osterweis et al., 1984). For the child, the death or psychological unavailability of a nurturant person is not only a traumatic event, but also a developmental interference of a very serious nature (Bowlby, 1963). As the child advances through the multiple systems of growth, consolidating several psychological and emotional tasks needed to achieve maturity, a stimulating interaction with his love objects is essential (Bowlby, 1980).

Although the maturing developmental processes continue to surge ahead, the disruption to the interaction with the "synchronized" familiar stimuli will force the child to incorporate the abrupt, painful change while attempting to adapt to the shifting human environment. Depending on his stage of development and his cognitive/affective capacities, we will observe differing behavior patterns expressive of disrupted organization, regressive functions, infantile emotional manifestation and patterns of their cognitive functions that incorporate the developed level of their subunits— reality thinking, abstract reasoning, causality (Nagera, 1970).

In postdisaster experiences, in addition to consideration of the stage of development, there is a need to consider the dynamic implication of the loss and its interaction with reactive processes to the trauma set up by the disaster. All disasters are dramatic events accompanied by visual and auditory experiences that are incomprehensible at the moment of occurrence. The preliminary sounds of an earthquake, observing the earth opening up, and seeing buildings collapse produce anxiety reactions of different levels of intensity. There are concrete, frightening events that are mentally recorded and will be an internal traumatic repetitive stimuli to several infantile emotions (Terr, 1981). When these events are accompanied by a subsequent loss of a parent, it is difficult to sort out the child's reactions as belonging to psychic trauma or to early signs of mourning (Cohen, 1987; Eth & Pynoos, 1985).

Examples of affective displays are related to the nature of the relationship lost, the quality of the ambivalence, and the existence of hostile wishes with the accompanying guilt after the loss. If the survival need for nurturance is considered, it is evident that the child will demonstrate different needs during the maturing progression of his personality (Freud & Burlingham, 1943). Coupled with this differential need, the accompanying reactions to loss should be incorporated into the evaluation and intervention guidelines. The following points will bear on program planning:

1. Serious disruption of the developmental processes will produce disorganization in all psychological expressions.

2. Special significance of the event and postdisaster experiences will be related to the stage of development.

3. The quality of family relations will affect the expression of mourning manifestations.

4. Intensity of the physical and psychological trauma will influence the mourning process and lengthen the duration of the postdisaster reactions.

5. Special circumstances surrounding the life of the child predisaster (divorce, new school, surgery, immigration) will affect the child's reactions. ^;

6. The reactions to these events by other important adults in the child's life will affect the child.

7. The multiple changes in the child's environment due to the loss of his family following the disaster are of special importance.

8. Plasticity and resiliency of the child as protective factors are also significant.

INTERVENTION PROGRAMS FOR CHILDREN-CRISIS INTERVENTION, CONSULTATION AND EDUCATION POSTDISASTER

Development and implementation of mental health services to help children suffering from the psychological consequences of a disaster have to be designed within the context of the disaster, the time frame post-disaster, and the identified population (Cohen, 1986). Although infantile responses may differ from event to event, it is possible to develop a broad-based guide for the design and execution of postdisaster psychological services. In this chapter, the elements that enter into the design of a plan will focus only on the child population. It is assumed that a major complex mental health program with different multilevel services is going on and the child program is imbedded and coordinated with other services so as to render psychological aid effectively to all victims (Cohen & Ahearn, 1980). The objective of the program described will be the implementation of mental health intervention services for the child affected by a disaster or catastrophic event. This is done with the understanding that there are many other types of services needed in this situation, such as feeding, housing, medical, and recreational services.

1. Direct Mental Health Intervention—Early Phase

The mental health intervention program can be organized along two major areas of professional activities. The first is the direct, face-to-face intervention with families housed in emergency sheltered sites. Professionals who start working directly with the families in the relocation centers will be available to offer psychological help to a gathered group of families in need. Guided by the knowledge of the time phase, sequential manifestations of crisis phenomenology, the professional can identify and organize a number of approaches developed to assist the children and their families through the early phases of crisis, coping, and adaptation, As these families move through their evolving emergency housing and changing human settings, their psychophysiological phases of crisis resolution will show different behaviors and will express different needs. The professional will develop therapeutic procedures to meet the objective of returning the family and the child to a functional level of adaptation.

As mentioned before; the objective of mental health intervention is a successful use of techniques that 1) restore the capacity of the child to a previous level of functioning by assisting him in handling the stressful situation in which he finds himself; and 2) assist the family in reorganizing its world through social and psychological interaction with the mental health professional. This can be done by the collaboration of the mental health professional with other support, care-giving emergency assistance groups, and all the family agencies helping the child and his caregivers.

Therapeutic crisis intervention. Therapeutic crisis intervention encompasses all the activities by which the professional seeks to relieve the distress of the child and assist the family through psychological means. It encompasses all helping activities that are primarily, although not necessarily, based on verbal communication. Many of the families display a sense of hopelessness and demoralization. All forms of therapy use certain approaches to combat and control this painful effect. Demoralized families show behavior that reflects the feeling of being unable to cope with the multiple tasks that families have when taking care of children, and that others expect them to handle well. These families' sense of self can vary widely after a disaster. Among the signs of demoralization, the following family reactions can be expected:

1. Families express feelings of diminished self-confidence and have difficulty remembering their ability to handle the children's and their spouses' needs.

2. They believe that failure will be the outcome of their decisions and actions, and they appear to be struggling with feelings of guilt and shame as part of the adaptive regression.

3. Families feel alienated, depressed, and isolated, as if they had been singled out for the worst outcome.

4. Families become enmeshed in a sense of increased dependency on agency workers, who may have difficulty in understanding both the intrafamilial confused reactive feelings and the family value systems based on traditional ethnic ways of behaving in a novel situation.

Techniques to assist across developmental phases of crisis resolution. Several techniques are available to the professional intervening during the crisis sequential phases manifested by the family and children traumatized by the disaster. These initial techniques can be grouped under the heading of "Auxiliary First Aid Techniques." These early approaches are directed toward restoring the family functions and adapting to the early transition experience, and can be instrumental in reintegrating and returning the total family system to balance. Intervention procedures are related to helping the family assess, problem solve, and make decisions day by day as they move through the emergency situation, the reconstruction, and, finally, return to a living situation that becomes more permanent. These psychotherapeutic approaches are defined as any active interaction between the professional and the family that tends to supplement, complement, reinforce, and promote the family systems mechanisms in the novel setting. When one restores the family functions of adaptive strategies, the child is assisted in functioning more effectively. The following is an example of this approach.

A family composed of a mother (36 years old) and father (41 years old) with two children (8 and 12 years old) were found in one of the shelters. A major avalanche had buried their neighborhood a few hours after they had climbed safely on a nearby hill. They had to spend six to eight hours in the cold night and had been rescued by emergency workers who brought them to the shelter, where they were fed and given cots and blankets. The professional who met them observed that the mother was crying and appeared somewhat dazed and depressed, while the father was trying to actively organize the family activities and cheer everyone up. The children seemed to adapt to the new surroundings and although their faces expressed tension, they did not appear to show gross behavior disturbances.

Following a preliminary evaluation of the situation, it was obvious that the most expressive disturbance of feelings was manifested by the mother. A short evaluation proved that she had been unable to relax, was depressed, and felt hopeless and helpless. On the other hand, the father appeared to deny the reality of the situation and tried to encourage the family with false and unrealistic hopes. After a few days, the children began to lose their ability to cope, became more demanding and restless, had difficulty in eating and sleeping, and did not want to separate from the mother to go out into the playgrounds that had been organized for the children of the shelter.

The objective of the therapeutic intervention was designed to complement the mother's ability to feel more competent and to reinforce the father's sense of "being in charge" in a realistic way so that he, would not have to deny and distort reality to regain his composure. All family members were helped to express some of the sadness and feeling of disorientation by being provided with knowledge—daily news and explanations about what was going to happen in the present and in the next few days. The children were able to meet in small groups with other children, where they shared their memories about the event and were offered the possibility of expressing some of their fantasies through drawings so as to promote a sense of mastery of their feelings. The parents were asked to assist in the housekeeping of the shelter and to participate with organized adult activities.

The above process gives a prototypical example of the range of procedures (behavior, actions, speech, types of meetings, face-to-face interactions) through which process occurs and is adapted to the situation encountered. The child and his family in the early stages of relocation will express through behavior the manifestations of the crisis in psychophysio-logical disorganization. The resources available to the counselor will influence the procedures used, the time spent with the family, and the activities in the relocation center. The psychological assistance configuration varies in structure because the combination of factors differs according to the extent of the community disruption or the availability of resources. But the objective remains clear, as far as reconstituting the adaptive system of the family which, in turn, will help the child control the expected regressive behavior seen in all traumatized children.

Psychological assistance to children must be based on the ability to conceptualize and understand the crisis manifestations and the levels of infantile dysfunction during the various stages of postdisaster crisis resolution. The objectives of intervention are as follows:

1. To help the child develop an internal sense of perspective so that he will be able to organize his own environment.

2. To assist the recuperative process of sharing painful emotions provoked by the stressor events, helping the child (according to his age) put events in perspective.

3. To assist the child to reach out to both his family members and the professionals on the emergency teams in order to use the resources that are available to develop a sense of comfort, security and affection.

The professional can mobilize available internal resources of the child to help him participate with his family in reordering its environment and alleviating emotional conflicts between family members so as to diminish emotional discomfort.

Risk factors in post-traumatic crisis resolution. The level ofpsychobio-logical functional status of the child is related to the vulnerability of the child's developmental stage, to his biological health, and to his personality strength. If the child is showing high anxiety, depression, withdrawal, regression, disturbance of sleep and eating functions, this needs to be ascertained as a measure of the manifestation of disorganized psychobio-logical factors. To be able to measure these signals, the professional must investigate the following:

1. The psychosocial maturity or immaturity of the child.

2. The social expectations of performance behavior as judged by the child, his family, and others living with them.

3. Continued environmental postdisaster stress, both in social and physical accommodations throughout the period of transition.

4. Accidental crisis events occurring in the child's life either before or after the stressor event.

5. Social settings as postdisaster stressors.

The setting where the child is located is an important variable that will affect the choice of psychological intervention. This is based on the realistic, practical experience of housing victims in crowded sheltered settings. The rapid turnover of large numbers of victims in and out of the shelter and the small number of trained staff to stay for continued periods of time with the same family influence the type of intervention. What can be the best type of useful intervention within the specific setting with the number of professional resources available?

Steps and guidelines for crisis intervention. The crisis counselor establishes a relationship with the family and the child by explaining to the family the psychological processes following a disaster. The objectives of intervention are set by (1) obtaining the information needed to plan an intervention; (2) establishing confidence and credibility in the family's awareness; (3) describing the intervention plan; and (4) eliciting the family's cooperation with the plan. From all this data gathering, the crisis counselor arrives at a tentative formulation of the problem and/or the plan of action. The therapeutic objectives are first of all to alleviate the emotional distress in the family and the cognitive disorganization in the child.

The following key principles guide sequential steps of intervention:

Crisis counselors should assume that the families are potentially capable of handling their own problems, after being helped to recognize the areas of distress, and of redirecting their behavior towards exploring new solutions.

A counselor should allow the family to develop initial dependency so that the family can borrow confidence from the counselor and, at the same time, offer it to a child. This should be short-lived; long-term dependency should be discouraged.

Advice is generally given with caution, although this does not preclude informing the family about all relevant matters on which they are ignorant or misinformed. This will help the family direct their own energies to their own methods of problem solving.

Whenever possible, according to the age of the child, the interpretation that links feelings to behavior not previously connected by the child may be therapeutic. It may also assist the family in understanding the feelings and thoughts that signal the actual progression of crisis resolution. This will allow the family to make sense of feelings that are disturbing and, by putting those feelings in perspective, enhance their sense of mastery and control.

Emotions that are seen in the initial post-traumatic phases include sadness, fear, and anger. These are manifested in many forms and with a wide range of intensity. These emotions should be accepted as expressions of the pain the families have suffered and should be supported in the perspective of the event. Assistance to achieve resignation and acceptance of some of the reality situation in which they find themselves is an end point of grieving postdisaster.

Some families become cognitively and emotionally disorganized for a temporary period. The intervention needs to be acutely directed towards these functions, as they interfere with parenting tasks. Procedures must be implemented to increase competence and maintain their awareness that the situation generated by the disaster will demand increased individual mobilization of all parenting skills to help the child adapt to a traumatized environment. Support and encouragement is offered in strengthening parents' conscious awareness of the appropriateness of their social reactions in light of what is happening. This clarification is useful in reinforcing natural parental behavior. Continued cognitive disorganization will affect the parents' ability to deal with their problems and their children's problems.

One of the main considerations in this case is to help the parents diminish the effects of the disorganization and reinforce their cognitive mastery by offering psychological assistance that is useful according to their specific condition. By assisting the parents in diminishing their sense of helplessness, their indecisive or regressive behavior, and their disbelief that they lack coping skills, the therapist aids them in reconstituting themselves more rapidly and assuming responsibilities for child care. He assists them in the problem solving, dealing with the children directly when the children are showing expressions or the signs of emotional disturbance. As a result, the family members tend to pull together and continue to move forward in the crisis resolution pathway.

Strategies for intervention. The choice of priorities in intervention and selection of displaced families to assist in the first few days following the disaster is a difficult triage process. As soon as families are identified, they need help in regaining a sense of orientation, reinforcing reality, and developing support and trust. Ascertaining the needs of the family for the type of resources that can be obtained and provided by other agencies is the responsibility of the crisis worker.

A great array of resources in emergency programs that are available to the family must be organized to meet their specific needs. Many of these needs are material, but others are psychological. The crisis worker can mobilize appropriate help by observing the way staff from other agencies behave or approach the family. Required are special techniques that allow the worker to elicit directly and personally from the family, in their own communication style, what they perceive as immediate needs, to interpret these needs within the context of the shelter, and then to collaborate with other agencies in mobilizing the resources so that parents and children feel assisted, less helpless, less hopeless, and less destitute.

2. Direct Mental Health Intervention—Later Phase Postdisaster

As the families are relocated from emergency shelters to temporary lodgings or back to their own home, which may be damaged but safe, a new area of crisis work emerges which manifests itself through expressions of increased grieving and bereavement. The professional worker needs to develop a combination of activities which include outreach procedures to go out to the living site of relocated families and to follow the children's progression toward return of function. The family's level of adaptation is assessed and if the assessment does not reveal further decompensation, a message can be conveyed that the staff is available. If the family notices a psychological problem or is aware of further interest in using psychological resources, they can recontact the emergency assistance team.

It is during this sequential phase of postdisaster time frames that each level of development and previous experiences plays a role in the manifestation of coping mechanisms and level of adaptation in children. There appears to be a larger dependency on denial in the earlier years of development as a means of accommodating to the traumatic event. As the child develops a better command of expressing her ideas, she can talk more often about the frightening episodes, she is able to share experiences, she can reproduce in drawings some of the distressing visual experiences she lived through, and she can express through repetitive play her troubled conflicts. Older children appear to respond to explicit, directive, and encouraging discussion with the crisis counselors. The same objectives that were useful in the shelters—approaching daily activities through an accurate cognitive appraisal of the situation and enhancing the family's knowledge about its surroundings so that it can understand its own emotions and the external events—appear to aid during subsequent stages and increase adaptive mechanisms, diminishing the level of depression and anxiety.

If appropriate and feasible, group intervention with parents or teachers getting together with children to discuss how they are responding to stress and what is expected as natural, healthy crisis resolution behavior appears to enhance adaptation (Galante & Foa, 1986). The method of having parents and children in groups is helpful because the children's problems are often overlooked while family members are overwhelmed, not only by their own personal intrapsychic disorder and disorganized feelings but also because the enormous task of reconstructing their concrete world is a priority. The professional's function is to provide support, to offer himself as someone to whom the parents can come when in difficulties, to clarify the child's behavior, and to suggest methods of assisting it.

Often, too, other social agencies must be mobilized to help families which are having difficulty in adapting to their new setting and are disrupted or have difficulty in coping with the ordinary demands of family life. At times, working with the school may be essential to provide a child with additional assistance and contact with other adults who may be helpful to the family. To enable parents to use other community resources of social and practical support is part of educating them to the fact that they need assistance to carry out their task for a short time, but that does not mean that agencies should take over the parental role. Every decision must be the parents'; they must initiate every change in the sequence of life activities that will lead them to recuperate their family dynamic balance.

Indirect methods of assisting post-traumatized child populations. Two of the principal components of indirect intervention are: consultation and education. Through these activities directed at the problems of a child population, mental health professionals not only disseminate information and problem-solving skills, but also create a positive environment of support for the disaster relief program.

Mental health consultation is a cornerstone of all emergency intervention programs (Cohen, 1984). Consultation is the professional activity designed to promote the incorporation of psychological procedures in dealing with all the affected child population in an emergency situation. Specifically, its purpose is the early identification and use of psychological methodology to alleviate the disastrous effects of the traumatic experiences suffered by the child. As a method of problem solving, consultation generally addresses the issues of the case and program-centered problems in order to achieve this purpose.

Educational activities generally include education of the public and training and orientation of the disaster worker. Three groups have been selected to highlight the focus of these activities. The three groups are among the many involved in the care of children and are composed of 1) the family, 2) teachers, and 3) all professionals dealing with families in the disaster activities.

3. Consultation Objectives in a Postdisaster Program

Child victim-centered case consultation. This is a traditional type of consultation where the consultant is asked for his opinion, diagnosis, and assessment of adaptation problems in an individual victim.

In addition, the consultant might recommend a plan for effective approach to counseling the child. This is an appropriate method used with teachers when children return to their school settings. Teachers recognize age-appropriate cognitive and emotional behavior and can participate in the intervention program by adapting psychological knowledge of postdisaster reactions to problem solving in their classrooms.

Example: A teacher asked for help because he was unable to reach a six-year-old girl who appeared to have a change in her learning ability following a severe Hooding in her town. Analysis of the situation showed that the family was closely meshed, with an additional infant and toddler who remained at home. Parents appeared to have trouble expressing their emotional postdisaster reactions and became distant to the six-year-old who was "sent to school and was a relief to the daily work of the mother." This perceived rejection was causing difficulties between the student and her family. Specifically, when she returned home after school, she demanded increased attention. Advice and suggestions were given by the consultant to the teacher on how the needs of the child could be balanced in school and at home. The consultant suggested a meeting with the family and the teacher to assist them in balancing the needs of both the family and the child.

Consultee-centered case consultation. The consultant focuses his attention on trying to understand the nature of the work difficulties for a consulte'e with regard to a victim and on helping him to remedy these difficulties. The consultee's difficulties may be viewed as; 1) lack of knowledge about the problems presented by the child victims; 2) lack of skill in making use of such knowledge; 3) lack of self-confidence in utilizing his knowledge and skills; or 4) lack of professional objectivity due to subjective emotional complication.

An example of how to increase the consultee's professional objectivity and to review the distortion of her perception »^f the victim's condition was highlighted by a community nurse working with a family that presented the following problem;

Mary, a seven-year-old girl who had lived through a major earthquake, was brought to the community medical-nursing center for diagnosis of her inability to sleep and night terrors. The nurse who was examining her had herself suffered from a loss of home and hospital job in the same disaster and was now volunteering at the nursing center. She had a child a few years older than the victim and was having conflicts about leaving her child with a neighbor while she came to work at the center. She had difficulty in being objective about the child's symptoms and her own guilt feelings in leaving her child in a care-giving situation. She appealed to the consultant because of her inability to obtain a clear story of the family situation.

As she presented the case history, it became apparent that the distortion was a result of difficulties with her own child and worries that her child might also develop symptoms. By helping her to separate the two children, supporting her feelings, and complimenting her on her professionalism by volunteering to help her community, the consultant was able to strengthen her sense of competence and her ability to develop an appropriate psychosocial history.

Program-centered administrative consultation. The work problem in this type of consultation is in planning the administration of the intervention program. The concern is how to best develop a program that will meet the needs of the population of children affected by the disaster. The consultant helps by using her psychological knowledge, administrative systems knowledge of disaster programs, and experience with problem solution in other areas of human behavior postdisaster. The primary goal for the consultant is to prescribe an effective course of action in planning the programs for children. The following example will highlight some issues:

A consultant who was working with the leader of a city that had been partially destroyed by a tornado was asked to participate in a series of meetings to plan the care of a large number of children housed in two welfare centers. The activities to be planned included housing, feeding, child health care, and placement in school and recreational facilities. The consultant participated with all the human service systems involved with the child population. After acquiring firsthand knowledge of the problems faced by the service organization and the needs of the children, the consultant was able to introduce psychological concepts into the program service plan.

Another major area of program consultation emerges after a disaster when there are a large number of orphans who are congregated in a site where there might not be appropriate child care facilities. The issues raised by child care workers are whether to relocate these children out of their geographical setting, where they were bom and raised, and send them to distant cities where there is better schooling and health facilities. There is also a question of whether to send them in small groups or individually. The issue of foster care for these orphans and possible separation of siblings to suit the needs of the foster care system must be resolved. These are difficult and painful consultation issues that appear in almost all major catastrophic disaster events. The possibilities of assisting orphans are multiple, depending on the resources of the communities, but in general it is suggested that children should not be uprooted into unknown physical settings. If possible, they should be kept together in small groups that incorporate their own neighborhoods or family groupings for care in small homelike settings.

4. Education

An opportunity to implement educational activities promoting increased knowledge of the psychological reactions of children to disaster can be organized through a postdisaster mental health program. The primary educational need of a community which will include teachers, child care personnel, and disaster emergency personnel is the knowledge and understanding of how children react after an event. By reviewing the time phases of behavior reactions following a disaster, participants who work with children can examine the types of physical and emotional problems that can be expected at each phase of postdisaster time frames. Training is needed in the phenomena of psychic trauma, stress response, crisis resolution, loss and mourning in children, family disruption, and support systems, with recognition that the major objective is to enhance coping and adaptation in the children.

Teachers can be educated to assist children in their crisis resolution by;

1) allowing children free expression of feelings; 2) helping them correct misperception of the new situation; and 3) helping them to understand why they feel the way they do in order to increase mastery of emotions, Teachers should be aware that all children reenact in their play distressed memories that follow a postdisaster situation. This is a spontaneous process by which children master their experiences. For example, when a child is struggling to deal with problems of his parents' own confusing behavior and unpredictable expression of feelings, he may act this out in games and try to gain mastery of authority roles that have changed after the disaster.

At times, the teacher may feel that such games appear sadistic and callous and the impulse to intervene can be strong. It is not difficult, however, to educate the teacher to realize that this play has a therapeutic function and helps the child come to terms with the anxiety-arousing event she has recently lived through. The relief of anxiety through play has been observed after most traumatic events and it appears to help children gain control over their crisis feelings. The teacher may become aware of the child's reaction to the events and of the kind of reassurance and explanations appropriate for the specific expression of emotions.

Child care workers and teachers can be educated to allow the child to bring out in talk and in play his true thoughts and feelings about the event, even if these are aggressive, sadistic, and apparently callous. It is also helpful when the child reveals his misconceptions about what has happened that this be listened to. At the same time, the teacher with access to knowledge of the facts can offer this to the child for reality testing. Teachers can be encouraged to set up special opportunities for children to express their feelings and thus encourage the crisis resolution process that emerges after a disaster. In this way, the child is helped in the crisis through some form of activity (playing, drawing, story telling) and the problem is not just avoided.

Children at risk in postdisaster situations are those who have lost their parents and who not only have to work through the psychic trauma of the event, the mourning and loss of the important figure in their lives, but also have to work through bonding to a new individual who takes on the role of a foster parent. Childcare workers and teachers can be educated to understand not only the behavior of the child in their daily care, but their own responses. They should be aware of the complex phenomenology expressed by behavior, showing the processes that the child has to go through before he can have enough energy to bond again with the worker.

The complexity of the post disaster situation for a child increases when the predisaster situation includes special problems of learning, physical illness, or social deprivation. Such children present very special problems. They have difficulty forming relationships with others, their capacities to express themselves in words are limited, their ideas about the world in general are immature for their age, and they usually display marked behavior disorders that are aggravated by the traumatizing event that they have gone through in the disaster. Aggressive outbursts, bed-wetting, soiling, stealing, and running away are common among these children who, in the past, found their way toward maturity full of barriers for normal development, Even though the basic need of such children is for a stable home situation, distressing changes provoked by the fragmented planning in post disaster assistance programs often make them more reactive and unacceptable for permanent placement. It is important to teach the workers that the negativism that will prevent such children from coming close to their caretakers is an expression of traumatized trust.

It is helpful to educate the caretakers to recognize the regressive behavior, which is a stage of recapitulation of earlier stages of development that have been traumatized in the child and are going to emerge, post disaster, as part of the new effort to mature. Programming for these children has the following aims: 1) to provide them in the present with experiences that they have missed in the past; 2) to allow them to process the traumatic event and the crisis that they have experienced during the disaster; and 3) to allow them to correct their distrust of human relationships. With a stable, understanding environment, children can use the human resources available to fill the gap in their growth process.

Again, the healing and reparatory process necessary to assist a child in a post-traumatic situation will depend on level of development and life experience before the disaster. Education given to the families who are having difficulty with the child assists them in conceptualizing and understanding the behavior. This allows the family members to understand the crisis behavior and separate themselves from pathological interaction with the child. It also allows them to feel comfortable in expressing their own crisis feelings and thoughts, which they were not free to tell the others before because of fears that the child might get worse. Parents who are confused about their own emotions and behavior towards their children or each other feel relieved in recognizing that the difficulties were based on the experiences that they have gone through. This knowledge allows them to face the daily, realistic tasks.

Educating the caretakers in child post-traumatic behavior puts them in a unique position to prevent further deterioration of coping abilities. Secondary crisis situations can be averted by preventing further separation experiences from developing into deprivation.

An effective way of providing regular in-service training for teachers, childcare workers, and disaster workers is to develop post disaster professional training groups. This can be part of the educational activities of an institution where such workers assist with children brought from disaster areas. The mutual exploration of problems and situations not only helps the participants with their ongoing work but also provides a valuable extension to training in psychological child rearing methods. As the discussion focuses on the interaction between staff and children, it will highlight the fact that these children arouse feelings in the staff members such as anger, frustration, and anxiety, as well as affection and pleasure. Inevitably, too, irritations and frustration arise between staff members, often in relation to the organization of institutional life which is disrupted by the complicated post disaster situation of a community in which they themselves are often victims of the disaster.

In summary, a child disaster team can be educated to view themselves as providing three different kinds of services to foster care units after a disaster:

1. An individual diagnostic and treatment service for children and their families who identify themselves as in need of help and who are referred for psychological assistance.

2. Special consultation services for social agencies that work in the post disaster program. Direct links between the psychological teams and the agencies are cultivated. Special problem cases are referred for discussion and problem solving to assist the social agencies in obtaining resources for the family and the child.

3. A program of regular group discussions with professional groups helping children. The aim will be to help these professionals deal, with their current problems and increase their therapeutic/supportive, and healing skills. Because assisting children who are orphaned or separated from their parents following a disaster is such a new component of social welfare systems, professionals need regular help and support in their dealings with the children and in their contact with relatives.

During a training workshop, a child worker spoke of her inability to understand a seven-year-old boy who appeared to be having difficulty in learning some of the rules and regulations of the home where he was placed after he became separated from his mother during an avalanche that covered his town. The boy had been rescued by a helicopter that plucked him from a mud cover where he was caught for several hours. It was explained to the worker that young children have a way of thinking that is not logical, cannot process cause and effect relationships, and tends to be concrete, rigid, nonreversible, and relatively inflexible. To help this child understand the relationship between the changed conditions of his life, the disaster, and why he had to live in this house with different rules would be unproductive. After a child is seven or eight years old, he develops a more logical, abstract, and complex understanding of events. The worker corrected the educator by pointing out that this child was beyond seven years. It was at this point that the educator could explain the fact that all children who have been severely traumatized will suffer regressive impact on their newly acquired functions. This means that adults need to know expected child development behavior, but must be aware of a shift toward infantile expressions younger than the stated age. As the traumatic memories and the daily quality of life interact, and if the environment is therapeutic, the child will regain his functions.

SUMMARY

This chapter has addressed the unique needs for intervention with a post disaster traumatized child population.

Intervention activities are guided by a conceptualized body of knowledge based on the child as a biopsychosociocultural organism interacting with his environment (human and concrete). It is pointed out that a traumatized child will become dysfunctional for a specific length of time, but will recuperate his adaptive homeostatic balance if assisted by his family, environment, and community. The mental health professional who participates as a member of the disaster emergency team has the opportunity to help the child and his family through direct intervention, consultation, and education.