The Psychosocial Impacts of Disasters,

Major Incidents & Warfare on Children &

Older People

Professor Richard Williams OBE TD

University of South Wales

Learning objectives

1. Reprise & revise some general matters, including psychosocial resilience, that apply to people of all ages

2. Introduce how children and older people people cope after disasters & summarise people’s psychosocial responses

3. Note the psychiatric disorders that some young and older people may develop

4. Introduce the risk factors for adverse impacts

5. Note the principles for prevention & intervening

Gaps in mental healthcare

• “Tremendous care gaps exist in access to mental health services globally, particularly in … armed conflict”

• Around 80% of people requiring mental health services in LIMICs do not receive the care they require

• Armed conflict is more common in LIMICs

• This results in more need, fewer services & fewer specialists &, as a result, mental healthcare for children & older people in conflict-affected settings is urgent but poorly addressed

The approach to psychosocial & mental

health care

• The approach recommended here espouses current professional opinion (Patel, 2014) that commends:

• Distinguishing people who are distressed from those who require biomedical interventions

• Providing assistance for the greater number of distressed people through lower intensity psychosocial interventions

• Basing the distinctions between the two sorts of conditions on symptom patterns and trajectories of people’s experiences observed in general populations

Defining psychosocial & mental health

care• Psychosocial refers to:

The emotional & cognitive (psychological), social, & physical experiences of people in the context of their particular social, cultural & physical environments. It describes psychological & social processes that occur within people, between people, & across groups of people.

• Psychosocial careThe numbers of people who require supporting interventions to assist them to cope with distress consequent on major incidents is very substantial despite the majority of distressed people not being likely to develop a mental disorder. Many of them may be psychosocially resilient despite their distress. But, intervening early can reduce the risks of their developing disorders later. These interventions are termed psychosocial care.

• Mental healthcareFormal biomedical and psychological interventions from which people who have disorders may benefit. Usually, they also require psychosocial care as a platform on which their mental healthcare is based.

People’s responses to single major

events

Direct effects of single event disasters on otherwise well people

1. Stress and, often, distress a. Resilient responses to immediate and short-term stress caused by, mainly,

primary stressors

b. Medium-termI. Persistent distress maintained by secondary stressorsII. Grief

2. Mental disordersa. Substance use disordersb. Adjustment disordersc. PTSDd. Anxiety disorderse. Depression

3. Longer-term impacts on personality

People’s responses to recurrent events

Direct effects of complex multi-event disasters on people who are at higher risk

1. Sustained distress that impacts on functioning

2. Exacerbation of previous mental disorders of many kinds

3. New onset of mental disorders including:a. Substance use disordersb. Adjustment disordersc. PTSDd. Anxiety disorderse. Depression

Indirect effects of disasters on people who are exposed

Conflict & disasters increase psychiatric & physical morbidity because they change the social conditions that shape mental health through:

1. Increased poverty

2. Domestic and community violence

3. Threats to human rights

4. Changed social & societal relations

Indicators of distress in the aftermath

Emotional reactions Cognitive reactionsShock and numbness Impaired memory

Fear and anxiety Impaired concentrationHelplessness and/or hopelessness Confusion or disorientation

Fear of recurrence Intrusive thoughts

Guilt Dissociation or denial

Anger Reduced confidence or self-esteem

Anhedonia Hypervigilance

Social reactions Physical reactionsRegression Insomnia

Withdrawal Hyperarousal

Irritability Headaches

Interpersonal conflict Somatic complaints

Avoidance Reduced appetite

Reduced energy

Trajectories of stress responses

1. Resilient ResponsesDepending on the nature of events, most people (70%) are psychosocially resilient. They suffer distress, usually mild to moderate, that reduces in severity if they receive support they perceive as adequate.

2. Slower Recovery Some people (10%) experience distress of moderate severity initially and then recover over time. The duration of their distress may be increased by secondary stressors.

3. Deteriorating Response/Prolonged Stress [*]Some people (10%) experience distress of moderate severity initially and these stress levels may later become prolonged or associated with significant dysfunction.

4. High Stress Responses [*]Some people (10%) may have high levels of stress after events (at above a level that is consistent with a psychiatric diagnosis). The symptoms, signs and dysfunction of about one half may be prolonged, while others improve.

[*] People who follow deteriorating or high stress trajectories tend to have had greater exposure to events, greater exposure to secondary stressors after the events & experience persisting adversity

Defining resilience

• Resilience is often said to be shown when something fails to happen (e.g. “lack of long-term pathology” in one paper)

• ‘Resilience is the capacity of a person to maintain stable psychological functioning throughout the course of adversity’After Bonanno GA. Loss, trauma, and human resilience: have we underestimated the

human capacity to thrive after extremely aversive events? American psychologist 2004;59:1:20.

• Psychosocial resilience is:

‘A process linking a set of adaptive capacities to a positive trajectory of functioning and adaptation after a disturbance’Norris FH, Tracy M, Galea S. Looking for resilience: understanding the

longitudinal trajectories of responses to stress. Soc Sci Med 2009;68:2190-8.

Features of psychosocial resilience

• Resilience is NOT the same as:

• Absence of mental or physical disorder

• Absence of distress

• Positive mental health

• Resistance to risk

• Absence of risk

Capacities that comprise resilience

First-generation resilience

• The ability to absorb stress & cope well with events & their immediate aftermath

Second-generation resilience

• The ability to adapt & recover from events

Third-generation resilience

• The ability of people to transform & mitigate future risks in the light of lessons learned from events

Williams, Kemp & Neal, 2016

Personal adaptive resources

• Personal skills

• Personal beliefs and attitudes

• Interactive skills, relationships and achievements

Collective & community adaptive

resources

Collective resources include:• Translational leadership

• Information & communication

• Social support

• The level and equitable distribution of economic resources

• A culture of care

Core features of resilience in disasters1. Social support

• The abilities to accept and use social support &

• The availability of support

are two of the key features of resilience that may have greater effects than exposure to events

2. Strong acceptance of reality

3. Is influenced by people’s experiences in childhood

4. Relates to people’s:• Attachment styles & capabilities

• Intelligence

• Temperament

• Belief in selves supported by strongly-held values

Children & conflict

• 1 in 10 children (nearly 250 million) live in areas affected by armed conflict (UNICEF, 2016)

• Impacts of conflict & war:

• Civilians comprise 80 to 90% of all who die or are injured in conflicts• In decade 1993- 2003:

• 2 million children killed • 6 million injured or permanently disabled in war zones• 1 million children orphaned• 20 million displaced

• Increasing intensity of killing, maiming, recruitment into armed forces & other grave violations of children

• Approx. 65.3 million people forcibly displaced in 2015 (highest on record) & approx. 51% of displaced people are under 18

• These figures reflect the changing nature of conflict and battlefields

Cultural sensitivity

• Diagnoses may be controversial

• Two ideologies

• Cross-cultural universality

• Cultural specificity

• Therefore, it can be more helpful to refer to impairment rather than symptoms

Children & conflict

• Children may be:

• Affected by direct impacts of violence

• Indirectly affected

• Perpetrators of violence

Quotes relating to continuing debates

• Events ‘scar the memory of the individuals and communities they touch, they have the capacity to forever change the character and life style of individuals and communities, and they confront one’s perceptions of the world and individual and collective vulnerability and strength’ Pfefferbaum 1988

• ‘It is widely believed that children are more resilient than adults. In reality, however, they are more vulnerable than adults due to the traumatic events, chaos and disruptions experienced and disasters’ and ‘Disasters threaten personal safety, overwhelm defence mechanisms, and disrupt the community and family structures’ Ursano & Norwood, 2003

More quotes

“This set of papers provides compelling cross-sectional and longitudinal evidence that early experiences of inadequate input (neglect / deprivation) and unwanted input (threat / trauma) –remembered or not – leads to long-term developmental and clinical abnormalities. They also add to a growing body of evidence about the neurodevelopmental pathways involved in psychopathology”.

“ … a number of papers demonstrates that the presence and behavior of caretakers moderate the effects of early adversity and response to interventions”.

Zeanah and Sonuga-Barke, 2016

Children & conflict

• Conflict shifts behavioural norms

• Conflict disrupts:

• Life trajectories of children & their families by limiting their basic opportunities for education or occupation into the post-conflict period

• Family, social & community support networks

• Access to services

• Intergenerational transmission of the impacts

• Impacts include:

• Functional impairments

• Social difficulties

• Risky behaviours

Impact

• The impacts are very variable and varies with:

• Within child• Age and level of development

• External locus of control

• Initial symptom severity

• Coping style

• Within the environment• Continuity of disruption

• Burden on carers

• Psychosocial milieu after the trauma

• Level of social support

Psychosocial impacts & psychiatric

disorders

• 22% to 94% - but underestimates are usual

• Conditions• Acute stress• Chronic stress

• Diagnoses• Conduct disorders• Anxiety disorders• Depression• Phobic disorders• PTSD• Somatic conditions

• Effects on psychological development• Affect control• Identity• Interpersonal skills

The Impacts

• Direct• Risk to life and limb• Abuse• Abusing and killing• Psychosocial impacts

• Acute stress reactions

• Chronic stress reactions

• Psychiatric disorders

• Indirect• Risks to physical health• Altered relationships• Death

• Separation

• Estrangement

• Other losses

• Family and community breakdown• Destruction of social and

education facilities

• Effects on views of the world and personal and family ideology

The Impacts on children’s emotional

development

• Indirect effects are through:• Failing to meet children’s needs

for dependency

• Loss and grief

• Effects of adults’ own distress

• Effects of adults’ changed views of the world

• Direct effects are due to:• Problems with reflecting on

and managing own feelings

• Intensely painful memories

• Regression that is a part of the stress reactions

• Fear

• Fantasies of retaliation

• Poor impulse control

• Preoccupation with/compulsive repetition of aggression

• Substance misuse

• Risk-taking

Recovery

• The principle is to assist communities to rebuild their children’s inner & outside worlds

• Three levels for intervention• Individual persons

• Families

• Communities

• Psychological healing can occur without formal psychiatric intervention, if the circumstances are right

• Some young people do need specific therapies - but which ones?

• Practical issues for service design & delivery

• Research

Factors that affect children’s responses

to being combatants

• Intensity, type & duration of the experience

• Degree of participation

• Victimisation by mutilation

• Witnessing killing of parents, family members and community members

• Increased risk of displacement

• Difficulty in returning to their communities

• Developmental phase

• Fantasy lives and interpretation of events

Research on Sichuan earthquake 2008

• Risk factors for general psychiatric morbidity include:

• Being elderly

• Family members or friends seriously injured

• Feeling guilt

• Risk factors for PTSD include:

• Being elderly

• Been in serious danger

• Loss of family members

• Feeling guilt

Indirect impacts on the psychiatric

morbidity of older people after disasters• Most older adults have at least one chronic disease or serious health

condition

• Many rely on critical services that are disrupted by disasters

• Impaired mobility and physical limitations limit evacuation & relocation in poor weather: disability and frailty impede access to recovery services

• Older adults may be more reluctant to seek help due to stigma and other barriers & self-report measures may underestimate their symptoms & functional impairment

• In cities, higher proportions of adults live alone

• Lower social connectedness & greater reluctance to seek help among older adults pose risks to post-disaster mental health & costs

• Social disconnection and perceived isolation are independently associated with lower levels of self-rated physical health

Hurricane Sandy (findings consistent with reports after H Katrina)

• 52 Sandy-related deaths: 48% in older adults

• Older New Yorkers continued to feel the impact 24 to 33 months later

• Depression (14.1% overall - 17% for English-speakers & 34% for Spanish-speakers) higher than general adult population

• Younger-old people (up to age 74): significantly higher rates of depression than older-old people (age 75+)

• Accumulation of stressors and specific traumas most strongly predict depression

• But, adults age 60+: least likely group to access mental healthcare (43% of sample but only 19% of visits)

Hurricane Sandy 2012

• Mental health outcomes differ by age group

• In younger-old people, depression is related to:• Chronic pain

• Limited morbidity

• Poor health

• Storm experiences 2-3 years earlier

• Losing access to medical care due to the storm was among the most stressful consequences & predicted depression in older-old people

The seven main components of the

strategic stepped model of care

1. Strategic planning

2. Prevention services intended to develop the collective psychosocial resilience of communities that are planned and delivered in advance of untoward events

3. Providing social support & other elements of psychosocial care based on the principles of psychological first aid delivered by families, colleagues & aid workers

4. Basic humanitarian, welfare & community development services that should be made available to everyone centred on families & communities

5. Providing monitoring, assessment & indicated intervention services for people who do not recover from immediate and short-term distress

6. Providing access to augmented primary care

7. Providing access to secondary mental healthcare services for people who need them

Core principles for preparing and

supporting people who are affected 1

1. Early intervention• “Early interventions in communities suffering mass trauma should consist of

general support and bolstering of the recovery environment rather than psychological treatment” Shalev, 2004

2. Approaches that are based on personal psychology • Helping people to normalise their experiences while being aware that some

people do develop a disorder

• Enabling people by providing social support

• Providing reflective listening and honest, accurate and timely information

• Helping people to restore their agency and perceptions of themselves as effective persons

• Enabling people to seek further help

• Peer support

• Training & supervision

Core principles for preparing and

supporting people who are affected 2

3. Practical interventions based on PIES• Proximity

• Immediacy

• Expectancy

• Simplicity of responses

4. Approaches that are based on supporting people’s memberships of families and social groups• Social support

• Leadership

• Teambuilding & training in groups that work together

• Creating & sustaining psychosocial safety in work cultures

• Psychosocial interventions based on the principles of psychological first aid & community development

• Access to employer-based or employer-arranged health surveillance & healthcare

Older people, disasters & psychiatric

morbidity• Mixed data relating to age differences in prevalence & persistence of

mental disorders

• Older adults sometimes described as less susceptible to psychopathology due to their experience with prior hardship, wisdom & reduced formal obligations

• Other studies found higher rates of PTSD & adjustment disorders for older adults cf younger survivors of disasters

• Low social support reinforces barriers to recovery among older adults

• After hurricanes in Florida in 2004:

• High levels of pre-disaster social support was best protective factor against health declines

• Older age associated with reduced social support & poorer self-rated health

Psychological first aid

Psychological first aid (PFA) is:

“providing a supportive and compassionate presence that is designed to enhance natural resilience and coping, while facilitating access to continuing care, if it is necessary”

modified after Everly & Flynn, 2006

Community re-development: general

interventions through the schools and educational curricula

• Based on• Developing optimism

• Developing self-confidence

• Support from families, friends, clubs etc

• Seeing possibilities for coping with problems

• Improving social relationships

• Work to develop attachments and attachment capacity

• Developing problem-solving skills

• Improving literacy and numeracy