Hurricane Katrina: Creating a Trauma Plan for Children

Hurricane Katrina was a Category 5 hurricane that trampled the southeast corner of the United States on August 29, 2005 (Kronenberg, Osofsky, Ososfsky, Many, et al., 2008). A large-scale disaster of this size caused nearly 80% of New Orleans residents to evacuate (Jaycox, Tanielian, Sharma, Morse, et al., 2007). Houses were destroyed, towns were evacuated, lives were lost, and many thousands of children were traumatized by the natural disaster. Although some plans were implemented to rebuild houses and schools, and return lives to normal, it is widely supported that something must be done to help children cope with such a horrible catastrophe.

One of the ways that this lofty goal can be accomplished is to have a plan for such disasters. From a review by Bowers-Stephens (2006) of Ricky Greenwald's Child Trauma Handbook, "Specific guidance is given in taking a trauma history, developing a trauma-informed case formulation, and developing a treatment contract or plan. Particular attention is given to case management and working with parents, teachers, and other significant people in the child's life to help him or her feel safe and to promote recovery." It is also a main theme written about by Fendya (2006), when it is stated that differences in children's responses to disasters need to be taken into account when planning for triage and transport for the injured.

On the same note, children make up one-fourth of the population and have different needs physically, socially, and importantly, and sometimes forgotten, psychologically. Trauma nurses are urged to take into account that children and adolescents do not always fit into the adult-centered disaster plans, and to actively participate in planning for such situations. The physiological differences of children and responses to disaster are oftentimes heightened when an injury is added to the equation, and a child's reaction will differ greatly to that of an adult (Fendya, 2006).

Although children are extremely different physiologically, it is understood that the psychological and psychosocial differences apparent when caring for a pediatric patient are more complex and just as important as the physiological differences. Depending on the age of the child, there may be an inability to avoid danger and verbalize feelings or symptoms (Fendya, 2006). For example, infants who experience disasters typically exhibit anxiety reflective of their caretakers' stress level. Their levels of responsiveness decrease, they may have difficulty sleeping and eating, and often become apathetic (Murray & Kuntz, 2006).

Toddlers become much more stressed because of the disaster than infants, especially if separated from their parents. Children of this age tend to become withdrawn and even depressed in the wake of a natural disaster and also exhibit changes in sleeping and eating. Parents are urged to take note of night terrors, increased temper tantrums, recurring nightmares, and regression manifesting as helplessness. Children of preschool age exhibit the same symptoms as toddlers, but sometimes coupled with fear and guilt about the disaster. This age group also has the most psychosomatic symptoms such as stomachaches, headaches, and dizziness (Murray & Kuntz, 2006).

School-age children are more cognitively prepared to deal with the stress and changes that come with a disaster such as Hurricane Katrina, but they fear for their own safety and the safety of their loved ones. This results in difficulty sleeping which sometimes affects school performance. Children in this age group also show signs of sadness, listlessness, and decreased activity, as well as a preoccupation with events of the disaster (Murray & Kuntz, 2006). Murray and Kuntz also reported on the reactions of adolescents during disasters. They are particularly vulnerable, as they are already going through life changes, and may deal with the stress of the event by engaging in risk-taking behaviors. Acting out, delinquency, and poor school performance are all some of the risky behaviors seen in this age group.

Fendya (2006) reports that disaster situations such as Hurricane Katrina may leave a child appearing dazed, disoriented, or bewildered. Sometimes children hide their concerns from teachers, parents, or healthcare providers. Fendya also suggests that caregivers must be attentive to their children and look for unusual responses, seeking assistance from those in the mental health profession:

"The American Academy of Pediatrics suggests that parents...seek

professional assistance under the following circumstances:
o
-child becomes withdrawn or refuses to talk with parents
o
-child expresses thoughts of self-harm or harm to others
o
-difficulty eating/sleeping
o
-intense irritability or behavior outbursts"

Something that is of great concern after a large-scale disaster is the possibility of post-traumatic stress disorder. According to Lisa (2006), children's cognitive age was a factor in predicting the onset of PTSD symptoms after Hurricane Katrina. Also, the experience of loss was a large predictor in PTSD symptoms. Loss was also mentioned by Murray and Kuntz, explained that "if a family member, friend, teacher, and/or pet has been lost, seriously injured, or killed, or if the child' home, school, or neighborhood was severely damaged, there is a significantly greater chance that the child will experience adjustment difficulties."

Along with the post-traumatic stress disorder possibility and the adjustment difficulties following a natural disaster coupled with loss is the possibility of another psychiatric disorder. As stated by Dalton, Scheeringa, & Zeanah (2008), "Approximately eighty to ninety percent of individuals with PTSD have at least one comorbid psychiatric disorder. Not all of these comorbid disorders develop post-trauma, but...nearly all non-PTSD disorders that develop after disasters do so only in the presence of PTSD symptomology." Dalton and colleagues assessed 70 preschool children who experienced Hurricane Katrina. None of the children assessed developed a new non-PTSD disorder without new PTSD symptoms.

Some of the factors that help children cope with the stress of experiencing a disaster are close contact with family and a safe environment. Children are a part of a family and should not be separated from theirs. Fendya (2006) suggests that hospitals and trauma centers need to be child and family friendly, to create a warm environment for children. During disaster situations, the child's family members may not be available or even present, making the child feel more vulnerable. Murray and Kuntz (2006) go on to say that families and healthcare professionals should make sure that caretakers and other adults spend more time with children and allow them to be dependent on the adults for as long as needed after the disaster.

It is also very important that children feel safe after a disaster. According to Maslow's hierarchy of needs, basic physical needs like food, shelter, and safety must be met before psychological needs can be addressed (Kronenberg, Osofsky, Osofsky, Many, et al., 2008). Providing safety for children can be a tough goal to accomplish. As shown by Fendya (2006), threats to safe environments disrupt the achievement of normal growth and often adversely impact previously developed coping skills, rendering them completely ineffective.

It is also clearly stated by Hebert and Ballard (2007) that the goal of any intervention program set forth by professional counselors is to help children begin to recover from the trauma, which requires a safe and trusting environment.

At times, a safe and trusting environment is extremely difficult to come by, especially when a child's home and school are destroyed by the disaster. After Hurricane Katrina, more that 196,000 students between kindergarten and twelfth grade were displaced from Louisiana alone. Many of these students had to begin going to schools in other places while their school was rebuilt. Unfortunately, even though mental health professionals were coming in to talk to the students, many teachers and administrators wanted them to leave (Jaycox, Tanielian, Sharma, Morse, et al., 2007).

School officials wanted to help the students psychologically, but also felt the need to focus on academics instead. Administrators specifically asked mental health personnel to allow students to 'move on' from the topic of hurricanes. Teachers wanted to get back to normal and have counselors stop coming to class to talk about Katrina. School personnel discussed 'competing priorities' like rebuilding the school-not the mental of their students (Jaycox, Tanielian, Sharma, Morse, et al., 2007).

It is very important to have professional school counselors available for children to talk to, because the may need to refer the child to more time-intensive mental health counseling if the child's behavior changes significantly over a long period of time. "Children may become extremely withdrawn, suffer from significant anxiety, face serious school problems, and experience repeated aggressive emotional outbursts." All of these problems are larger than can be addressed by the professional school counselor (Hebert & Ballard, 2007).

Professional child psychologists have specific activities geared towards children in helping them communicate their feelings easily. One of the most well known of these activities is play therapy. This is especially helpful with children who do not possess the cognitive ability to express their thoughts and feelings. After Hurricane Katrina, for example, a child played with dolls in a dollhouse and recreated what happened to her and her family during the hurricane (Hebert & Ballard, 2007).

There are also activities that express feelings, such as drawing, commonly known as art therapy. In a group discussed by Hebert and Ballard (2007), some children who had experienced the disaster drew the hurricane with much emotion, showing their fear and the trauma they experienced. Another activity that was implemented after Hurricane Katrina helps children with stress relief. They were encouraged to write "Worry Cards" with a 'worry' on the front of the card, and a solution on the back. One child wrote, "I worry that my mother and I will get separated if there is another hurricane." On the back, the child wrote, "If there is another hurricane, I will hold my mother's hand so that we will not get separated" (Hebert & Ballard, 2007).

Murray and Kuntz (2006) also suggest the playing with puppets to express thoughts and feelings about the disaster. Another suggestion written about is finding another child of the same age to talk about their fear, anger, or concerns about the disaster or about the future.

All in all, any child's response to a disaster of any kind is dependent on psychological maturity, prior experiences, previously developed coping skills, the emotional well-being of the child's caretaker, and resources provided to the disaster victims (Fendya, 2006). More trauma plans should be implemented to care for these children before disaster strikes, and not after. It is important to treat the child's trauma as soon as possible after making sure that the are safe and taken care of. Parents also need to be educated and actively involved in helping their children through such a difficult and traumatic event.

References
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Dalton, R., Scheeringa, M.S., & Zeanah, C.H., (2008). Did the prevalence of PTSD
following Hurricane Katrina match a rapid needs assessment prediction? A template
for future public planning after large-scale disasters. Psychiatric Annals, 38(2), 134-
141.

Fendya, D.G. (2006). When disaster strikes-care considerations of pediatric patients.
Journal of Trauma Nursing, 13(4), 161-166.

Hebert, B.B., & Ballard, M.B., (2007). Children and trauma: A post-Katrina and Rita
response. Professional School Counseling, 11(2), 140-145.

Jaycox, L.H., Tanielian, T.L., Sharma, P., Morse, L., et al. (2007). Schools' mental health
responses after Hurricanes Katrina and Rita. Psychiatric Services, 58(10), 1339.

Kronenberg, M., Osofsky, H.J., Osofsky, J.D., Many, M., et al. (2008). First responder
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natural disaster. Psychiatric Annals, 38(2), 114-119.

Lisa, J. (2006). The effects of mass trauma on children of different developmental stages:
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Murray, J.S., & Kuntz, K.R., (2006). Addressing the psychosocial needs of children
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