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CHILD AND FAMILY

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University of Oklahoma Health Sciences Center. Northwest Center for. Public Health Practice ... University of Oklahoma Health Sciences Center. Alan M. Steinberg, PhD ... – PowerPoint PPT presentation

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Title: CHILD AND FAMILY


1
CHILD AND FAMILY DISASTER RESEARCH TRAINING AND
EDUCATION
2
Research on Childrens Disaster Mental
Health Gaps and Challenges
  • Randal Beaton, PhD, EMT
  • University of Washington
  • Adopted/adapted from
  • Gilbert Reyes, PhD
  • Terrorism and Disaster Center
  • University of Oklahoma Health Sciences Center

Northwest Center for Public Health Practice
3
Federal Sponsors
  • NIMH National Institute of Mental Health
  • NINR National Institute of Nursing Research
  • SAMHSA Substance Abuse and Mental Health
    Services Administration

4
Principal Investigators
  • Betty Pfefferbaum, MD, JD University of Oklahoma
    Health Sciences Center
  • Alan M. Steinberg, PhD University of California,
    Los Angeles
  • Robert S. Pynoos, MD, MPH University of
    California, Los Angeles
  • John Fairbank, PhD Duke University

5
Learning Objectives
  • Participants will learn to
  • Identify significant gaps in knowledge about
    harmful effects of disasters on childrens
    psychosocial functioning.
  • Identify significant gaps in knowledge about
    variables that influence the differential effects
    of disasters on childrens psychosocial
    functioning.

6
Learning Objectives (Continued)
  • Participants will learn to
  • Identify significant gaps in knowledge about the
    effectiveness of psychosocial services and
    interventions for children affected by disasters.
  • Identify significant challenges to extending and
    elaborating knowledge about the effects of
    disasters on childrens psychosocial functioning
    and the effectiveness of disaster mental health
    interventions.

7
General Research Questions
  • What are the psychosocial effects of disasters?
  • What factors influence those effects?
  • What can be done to alter those effects?

8
What are the psychosocial effects of disasters?
  • Where are the effects found (location)?
  • Who is affected (populations)?
  • How much are they affected (caseness)?
  • When are they affected (time course)?
  • Do the effects unfold in phases as conditions
    change?
  • How do the effects differ as a function of
    childrens development?

9
What are the psychosocial effects of disasters?
  • Pathogenesis
  • What are the pathogens?
  • Exposure to what?
  • Under what conditions?
  • At what levels?
  • Severity
  • Frequency
  • Chronicity
  • Duration

10
What are the psychosocial effects of disasters?
  • What pathologies are generated or exacerbated?
  • Trauma symptoms? PTSD?
  • Depression?
  • Anxiety?
  • Substance Abuse?
  • Social Disadvantages e.g. stigma
  • At what levels?
  • Among whom?
  • By what mechanisms?

11
What are the psychosocial effects of disasters?
  • Categories of studies found in the (adult)
    literature
  • Empirical Epidemiological
  • Study entire population
  • Define and describe psychopathology
  • Prevalence and incidence rates
  • Clinical Descriptive
  • Selected samples
  • Case study methods
  • Assess symptom levels
  • More descriptive than inferential

Rubonis Bickman, 1991
12
What are the psychosocial effects of disasters?
  • Findings from a meta-analysis of the empirical
    literature

Rubonis Bickman, 1991, p.391
13
What are the psychosocial effects of disasters?
  • Findings from an empirical review of the
    empirical literature
  • (a) specific psychological problems (disorders
    in the DSM-IV)
  • (b) nonspecific distress (i.e., subclinical
    elevation of symptoms associated with reactions
    to extreme stress),
  • (c) health problems and concerns (e.g., somatic
    complaints, substance abuse)

Norris, Friedman, Watson, Byrne, Diaz,
Kaniasty, 2002
14
What are the psychosocial effects of disasters?
  • Findings from an empirical review of the
    empirical literature (continued)
  • (d) chronic problems in living (e.g., increased
    daily hassles secondary to the disaster)
  • (e) psychosocial resource loss (e.g.,
    deterioration of personal hardiness and social
    support)
  • (f) problems specific to youth (e.g.,
    separation anxiety, developmental regression,
    and externalizing behavior problems)

Norris, Friedman, Watson, Byrne, Diaz,
Kaniasty, 2002
15
What are the psychosocial effects of disasters?
  • Findings from Norris, Friedman, Watson, Byrne,
    Diaz, Kaniasty, 2002
  • Levels of Impairment in studied samples
  • 51 (of 160) empirical studies reported moderate
    impairment among disaster survivors
  • 39 reported severe to very severe impairment
  • Suggests that a very substantial proportion of
    disaster survivors could benefit from
    psychosocial interventions
  • Comparable specification of effects on children
    is not evident in the literature

Norris, Friedman, Watson, Byrne, Diaz,
Kaniasty, 2002
16
  • What are the significant gaps in knowledge about
    the harmful effects of disasters on childrens
    psychosocial functioning?

17
Gap 1 Descriptive Epidemiology How are the
psychosocial effects of disasters distributed
among the exposed children?
  • Populations at risk (i.e., exposed) are
    inadequately defined.
  • Children are particularly overlooked.
  • Minority groups are underrepresented.
  • Exposure is inconsistently defined.
  • Case definitions are inconsistently defined.
  • Reporting (data) sources are inconsistently
    selected.
  • Biased sampling methods (representativeness)
    distort incidence and prevalence estimates
    (validity/reliability).
  • The instruments of measurement are not
    standardized.

18
Gap 1 Descriptive Epidemiology How are the
psychosocial effects of disasters distributed
among the exposed children?
  • Change over time is seldom studied
  • Lack of longitudinal investigations
  • Delayed onset latency is poorly studied.
  • Periodicity (e.g., phases, anniversaries) is
    poorly studied.
  • Natural attenuation (i.e., tincture of time)
    goes unmeasured.

19
Challenges To Accurately Assessing Of The
Psychosocial Effects Of Disasters On Children
  • Defining the populations at risk with sufficient
    breadth and specificity to ensure that children
    at all levels and types of exposure are properly
    screened.
  • Employing unbiased sampling methods that yield
    results representative of the populations at risk.

20
Challenges To Accurately Assessing Of The
Psychosocial Effects Of Disasters On Children
  • Adopting a standardized
  • set of instruments and protocols to be employed
    with consistency across studies.
  • set of adequately differentiated (not just
    trauma) and specified case definitions to be
    employed with consistency across studies.
  • protocol of data sources to be employed with
    consistency across studies.
  • Overcoming the lack of baseline information.
  • Difficulty distinguishing disaster effects from
    preexisting pathology.

21
Challenges To Accurately Assessing Of The
Psychosocial Effects Of Disasters On Children
  • Decreasing the time-lag between precipitating
    events and the initial point of measurement (time
    1).
  • Advanced preparation.
  • Funding.
  • Permissions and access.
  • Persuading and training researchers to adopt
    epidemiological standards.
  • Replacing static snapshot studies with
    longitudinal designs that account for change over
    time.

22
Which Factors Influence Those Effects?
  • Factors that increase risk (risk factors).
  • Factors that reduce risk (protective factors).
  • Factors that amplify or attenuate the translation
    of exposure into pathology (moderators)?
  • Affects the strength of the relationship.
  • Factors that are necessary for the translation of
    exposure into pathology (mediators)?
  • Explains a mechanism of the relationship.
  • These are the keys to resilience.

23
Which Factors Influence Those Effects?
  • Vulnerability (Mediators and Moderators)
  • What are the risk factors?
  • Female gender
  • Early or advanced age
  • Low SES
  • Pre-existing conditions
  • Degree of exposure
  • Unique event characteristics e.g. terrorism
    media
  • What are the protective factors?
  • Opposites of risk factors?
  • Training and experience?
  • Hardiness?
  • Self-efficacy?
  • Social support?

24
Which Factors Influence Those Effects?
  • Risk factors for more severe psychosocial
    impairment
  • Conditions of mass violence or massive
    casualties
  • Severity and level of exposure
  • Severity and pervasiveness of the financial
    social effects
  • Threat of or actual loss of life
  • Physical injuries
  • Pre-disaster psychosocial functioning
  • Post-disaster (secondary) stressors
  • Low Socioeconomic Status (SES)
  • Fewer social and economic resources (e.g., social
    support)
  • Higher risk among women, youth, disadvantaged
    minority groups, and residents of less
    developed countries

Norris, Friedman, Watson, Byrne, Diaz,
Kaniasty, 2002
25
  • What are the significant gaps in knowledge about
    variables that influence the psychosocial effects
    of disasters on children?

26
Gap 2 Differential Impact Factors Which
variables influence the psychosocial effects of
disasters children?
  • Risk and protective factors are poorly specified
    and inconsistently operationalized.
  • Personal attributes
  • Social/Cultural attributes
  • Environmental conditions and operators
  • Stressors buffers

27
Gap 2 Differential Impact Factors Which
variables influence the psychosocial effects of
disasters in children?
  • Utility of risk and protective factors for
    screening is insufficiently examined
  • sensitivity
  • specificity
  • Mediating and moderating relationships are
    insufficiently examined.

28
Challenges To Assessing Variables That Influence
The Psychosocial Effects Of Disasters On Children
  • Hastily prepared research designs lead to
  • Over reliance on small samples and convenience
    samples.
  • No power to examine complexity between variables
    (e.g., mediation and moderation)
  • Over reliance on categorical variables.
  • Inability to examine complexity within variables
    (e.g., threshold effects).
  • Over reliance on immutable variables e.g. gender
  • Poor utility for interventions.
  • Settling for descriptive results with poor
    explanatory power.
  • Inability to study change over time.

29
Challenges To Assessing Variables That Influence
The Psychosocial Effects Of Disasters On Children
  • Risk and protective factors need to be
    conceptualized in ways that better inform
    prevention, intervention, and public policy.
  • Examine relationships among risk and protective
    factors to distinguish between direct effects,
    mediators, and moderators.
  • Increase reliance on theory-driven models that
    move from mere description to explanatory
    mechanisms.
  • Examine the evolving influence of risk and
    protective factors over time.
  • Employ more sophisticated modeling techniques to
    clarify complex interactions of predictors and
    outcomes.

30
What can be done to alter those effects?
  • Which interventions will proactively reduce risk
    (prevention)?
  • Which interventions will reduce manifest
    pathology?
  • Which factors amplify or attenuate the
    translation of exposure into pathology
    (moderators)?
  • Affect the strength of the relationship.
  • Which factors are necessary for the translation
    of exposure into pathology (mediators)?
  • Explain a mechanism of relationship.

31
What can be done to alter those effects?
  • Conceptual and Design Issues
  • Targets of Intervention?
  • Scope of Intervention?
  • Modes of Intervention?
  • Timing of Intervention?
  • Levels of Intervention?
  • Method of Evaluation?
  • Timing of Evaluation?
  • Indices of Response to Intervention (outcomes)?

32
What can be done to alter those effects?
  • Needs Assessment
  • What is needed?
  • When is it needed?
  • Where is it needed?
  • Needed by whom?
  • What works?
  • What works with whom?
  • Individuals
  • Adults
  • Children
  • Families
  • Institutions (e.g., schools)
  • Communities

33
What can be done to alter those effects?
  • Modes of Service Delivery
  • Provided by whom?
  • In what amounts?
  • When?
  • For how long?
  • At what locations?

34
What can be done to alter those effects?
  • Barriers to Care What facilitates or discourages
  • the seeking of treatment?
  • Accessibility?
  • Financial concerns?
  • Logistical Concerns?
  • Competing priorities?
  • Acceptability?
  • Stigma?
  • Credibility?

35
What can be done to alter those effects?
  • Direct Psychosocial Interventions
  • Debriefing (prophylactic crisis intervention).
  • EMDR (Chemtob, Nakashima, Carlson, 2002).
  • Stress Management (coping skills).
  • Crisis Intervention (arousal reduction, problem
    solving).
  • Grief Counseling (loss and bereavement).
  • Psychotherapy (clinical disorders).

36
What can be done to alter those effects?
  • Indirect Interventions with Psychosocial Targets
  • Psychological First Aid
  • Reduction of unnecessary stressors
  • Respite care for caregivers
  • Advocacy to reduce bureaucratic frustration
  • Psycho-education to inform effective coping
  • Parenting education
  • Teacher education
  • Leadership training in the fire service
  • Community mobilization

37
  • What are the significant gaps in knowledge about
    the effectiveness of psychosocial interventions
    for children exposed to disasters?

38
Gap 3 Characteristics of Effective
Interventions Which characteristics influence the
effectiveness of psychosocial interventions for
children exposed to disasters?
  • Inadequate scientific evidence to support use of
    popularized interventions in the early
    post-disaster environment.
  • Treatment samples dont represent the population.
  • Therapists in studies differ from counterparts in
    field settings.
  • Tested interventions not employed in field
    settings
  • Commonly used disaster interventions with
    children go untested under field conditions.

39
Gap 3 Characteristics of Effective
Interventions Which characteristics influence the
effectiveness of psychosocial interventions for
children exposed to disasters?
  • Tested interventions are poorly disseminated and
    seldom adopted for field use, and field
    interventions are seldom tested.
  • Modes of service delivery differ substantially
    between clinical settings and field settings.
  • Barriers to care go unexamined

40
Challenges In Assessing the Effectiveness
Of Psychosocial Interventions for Disaster
Exposed Children
  • Competing priorities during the early phases of
    disasters.
  • Political and social concerns about unintended
    consequences and implications.
  • Community resistance.
  • Limitations on access.
  • Ethical concerns.
  • IRB approval barriers.
  • Funding barriers.

41
Conclusion
  • The existing research literature on disaster
    mental
  • health, while rich and useful in many ways, is
  • inadequate in the following ways
  • Inadequate basic epidemiology.
  • Unrepresentative samples.
  • Delay between precipitant and measurement (decay)
  • Neglect of time as a variable.
  • Unsubstantiated extrapolation and generalization
    of weak findings.
  • Inadequately systematic and precise examination
    of variables and relationships.
  • Untested effectiveness of interventions.

42
Impediments
  • Lack of Prediction and Preparation
  • Lack of Funding and Human Resources
  • Slow funding process
  • Lack of Access to Affected Populations
  • Proximity
  • Competing Agendas Priorities
  • Stigma and negative bias towards research
  • Ethical Objections

43
Proposed Solutions
  • Prepare for predictable events and aspects.
  • Alter funding mechanisms to promote rapid
    response protocols.
  • Integrate research designs into governmental and
    non-governmental relief efforts.
  • Form geographically distributed research networks
    to facilitate access and cut response times.
  • Integrate research with other agendas
    priorities.
  • Target stigma, ignorance and negative biases
    towards research with public education campaigns.
  • Promote policy reforms that raise the priority of
    childrens disaster mental health research.

44
Proposed Solutions
  • Adopt a public health approach to studying the
    psychosocial effects of disasters on children.
  • Adopt a developmental psychopathology approach
    that examines the the risk and protective factors
    related to the psychosocial effects of disasters
  • Promote the use of longitudinal designs that
    assess change over time.
  • Adhere to scientific standards of evidence.
  • Develop and test approaches to interventions that
    are congruent with local cultural values and
    expectations e.g. community action research
  • Confront pseudo-ethical objections We already
    know it works so…

45
Sustainability of Pacific NW LMRT Next Steps
  • Listserv- notify of future projects
  • Access to Regional Mentoring Consultants
  • All the DRT Newsletter
  • Invitation to describe and chronicle this
    technological training effort in an article
  • Specific Research Projects-brainstorm
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