The 2010 report of the National Commission on Children and Disasters recommended that the US Department of Health and Human Services (HHS) should “enhance the research agenda for children’s disaster mental and behavioral health, including psychological first aid, cognitive-behavioral interventions, social support interventions, bereavement counseling and support, and programs intended to enhance children’s resilience in the aftermath of a disaster” (NCCD, 2010). A virtual conference was subsequently convened to conduct an informal review of National Institutes of Health (NIH) grants in order to identify gaps in knowledge and recommend a national research agenda encompassing the full spectrum of disaster mental health for children and families. This review documented a paucity of funded research on interventions to promote coping and adjustment for children after disasters. Findings, as summarized in a report published in 2018 in American Psychologist, highlighted that although there has been progress in understanding the negative impacts of disasters on children, less is known about the effectiveness of interventions to promote behavioral health and coping after a disaster (Grolnick et al., 2018). The limited intervention studies have focused on treatment or prevention of mental illness, particularly trauma disorders.
There have been studies that have documented, not unexpectedly, that disasters are often life-threatening events for children causing traumatic stress that can persist for some and result in post-traumatic stress disorder (PTSD). What was critically lacking then, and still is now, is study of the effects of supportive interventions on distress associated with bereavement and other situations where a psychiatric disorder has not been diagnosed, as well as interventions to promote socio-emotional adjustment and the resumption of healthy child developmental processes. One barrier that was identified by Grolnick et al. is the absence of valid outcome measures for these supportive interventions and the difficulties associated with demonstrating their usefulness (and need) to research funders and policymakers. Evidence-based interventions have instead tended to focus on the treatment of psychiatric disorders, such as PTSD, for which there are already validated measures and evidence-based treatments. Researchers have focused more on demonstrating what is already known and can be more easily studied rather than addressing this important gap.
The conference participants concluded that developing evidence-based interventions for children experiencing distress following disasters is a national priority and that such research should be broadened to include the full spectrum of behavioral health needs, such as bereavement, nonclinical distress, adjustment, coping, and resilience—and the study of interventions in these domains. The recent COVID-19 pandemic showed how little (if any) progress was made to address this gap. This lack of progress left the United States unprepared to effectively mitigate many of the negative impacts of the pandemic, which are still manifesting today in behavioral dysregulation among children due to the numerous losses and distress experienced.
It is an understatement that the pandemic caused widespread distress among almost all children and adults. But not all this distress is readily identified by current taxonomies. Most children did not develop a diagnosable mental illness such as anxiety, depression, or PTSD—even though sadness and concerns about safety and well-being were widespread. The challenges facing many children, especially in the latter part of the pandemic, probably relate more to the numerous and varied losses suffered than the degree of fear or threat experienced. The interventions and means of support offered to children who are grieving are often quite different from the treatment provided to children recovering from exposure to threatening events. When addressing traumatic experiences, the primary focus is on children’s emotional and cognitive processing of a threat, which may or may not have resulted in harm to themselves and their family. Support for grief focuses instead on helping children cope with both direct and indirect losses—the persistent absence of something or someone of great importance.
Research that has been done in the aftermath of major disasters has also shown that distress among impacted children (and adults) is generally pervasive and long-lasting, but the vast majority will not obtain traditional mental health support. This reality should prompt a shift from exclusively relying on a medical model—characterized by screening, evaluation, diagnosis, referral, and treatment for individual children with mental illness—toward a system of universal support as the primary response during a major disaster, with a focus on building resilience rather than delivering treatment. This of course will need to be coupled with incorporating school and community-based mental health professionals for children requiring more assistance and treatment services. But the relative absence of research on the efficacy of supportive interventions that can be delivered at a population level makes mitigating the impacts of large-scale disasters and decreasing the later development of mental health disorders far less likely. It further burdens the already limited pre-disaster mental health treatment services. And it fails to take advantage of the wide range of caring adults, such as educators, parents and caregivers, and other sympathetic community members, who are well-positioned—but largely unprepared—to support children in distress.
One reason for this gap in the provision of mental health support relates to limitations in funding for supportive services that do not involve evidence-based treatment for a diagnosed mental illness. Because there are professionals funded to provide mental health treatment services, there is far more research conducted to collect evidence of the need for these treatments and the efficacy of treatment services.
The National Advisory Committee on Children and Disasters (NACCD) recently released a report that calls for efforts to improve pre-disaster preparedness and just-in-time training in pediatric disaster mental and behavioral health (HHS, 2023). The NACCD report highlighted that this training should include psychological first aid, bereavement support, and brief supportive interventions that would be used not only by mental health professionals but also by other professionals, such as educators, who are in a position to provide support to children on a daily basis. This training should also be provided to health care professionals, childcare and early education professionals, youth service providers, child welfare and juvenile justice professionals, faith-based professionals, parents and caregivers, and other community members—virtually all adults who can provide basic supportive services and brief interventions. The goal is to help these individuals acquire basic knowledge to recognize signs of distress (not just the early signs of mental illness that indicate the need for referral to treatment services) and practical strategies to promote coping and adjustment, as well as to learn how to identify children in need of clinical services.
The NACCD also called for more training for clinical and non-clinical health care staff in supporting children after a disaster, including their response to impacts such as traumatic stress, grief, and loss. This should involve broad training to support grieving children for a wide range of non-clinical professionals, including educators and other school staff. Training and resource materials that are freely available and widely endorsed already exist, such as those from the Coalition to Support Grieving Students, which comprises more than 125 professional organizations including major professional organizations in education, school mental health, and pediatrics (Coalition to Support Grieving Students, n.d.). The NACCD report recommended that comparable training and resource materials in psychological first aid should also be developed and widely distributed.
Beyond the limited research on the efficacy of population-level and individually delivered supportive services, there is even less research on how to effectively modify supportive services for sub-populations, individuals from historically underserved and marginalized groups, and groups with unique vulnerabilities such as children with neurodevelopmental disabilities. Children identifying with different racial, ethnic, and social groups may experience disasters and proposed interventions differently from other children. For example, increased school security staff may be supportive for some groups of children after incidents of school violence but may be distressing to students that are part of communities for which experiences with law enforcement may be viewed negatively.
Another glaring gap relates to the need for more study on effective methods of support and intervention for caregivers of children after a disaster, which includes parents and other family caregivers, educators and other school staff, and pediatric health care providers, to name just a few groups. Many individuals that enter child-serving fields, such as education, social services, child mental health, pediatric health care, and others, do so because they, or others they care about, experienced childhood trauma, loss, or other forms of adversity when they were young and either benefited from the help of others or recognized the impact of the lack of such assistance. Post-traumatic growth may prompt them to focus their career on ensuring that children receive such critical support. But when disasters do occur, this tends to uncover prior trauma and loss experiences, including among the professionals who are also impacted by the disaster. Those that devote their lives to helping children and care most deeply about them are most likely, in many ways, to be hurt personally by doing so. The striking lack of evidence-based professional self-care and supportive interventions in the context of disaster is therefore a critical gap that deserves more attention. Probably at no time in recent history has this become more glaringly obvious than during the COVID-19 pandemic.
It is imperative to expand beyond the knowledge that adverse childhood experiences and traumatic events have adverse impacts on children and to screen for these exposures, and instead invest in the development of approaches that promote coping and adjustment in children, families, and communities. It is time to focus research, training activities, and intervention efforts on remedying this persistent gap in meeting the behavioral health needs of children affected by disasters. Not all children impacted by a disaster will develop a mental illness, but nearly all will be distressed and can benefit from being surrounded by empathic and supportive adults that are able to help them cope with this distress. These are skills that all adults should know and could use virtually every day. And this becomes critically essential during and after a major disaster.
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A new #NAMPerspectives paper highlights gaps in research, policy, and practice for supporting children after disasters. What are the challenges and opportunities for better care? Read more: https://doi.org/10.31478/202409c #DisasterResponse #ChildMentalHealth
Supporting children after disasters goes beyond treating mental illness. A recent #NAMPerspectives paper explores the need for universal support to promote coping and resilience. Details here: https://doi.org/10.31478/202409c #PediatricCare #DisasterSupport
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References
- Coalition to Support Grieving Students. n.d. Coalition to Support Grieving Students. Available at: https://grievingstudents.org/ (accessed July 11, 2024).
- Grolnick, W., D. Schonfeld, M. Schreiber, J. Cohen, V. Cole, L. Jaycox, J. Lochman, B. Pfefferbaum, K. Ruggiero, K. Wells, M. Wong, and D. Zatzick. 2018. Improving adjustment and resilience in children following a disaster: addressing research challenges. American Psychologist 73(3):215-229. https://doi.org/10.1037/amp0000181.
- HHS (US Department of Health and Human Services). 2023. 2022-2023 Recommendations from the National Advisory Committee on Children and Disasters (NACCD): The mental health crisis in the aftermath of the COVID-19 pandemic and other lessons learned. Washington, DC: HHS Administration for Strategic Preparedness and Response. Available at: https://aspr.hhs.gov/AboutASPR/WorkingwithASPR/BoardsandCommittees/Documents/NACDD/NACCD-Recommendations-18Jan2023-PblcMtg.pdf (accessed September 21, 2024).
- NCCD (National Commission on Children and Disasters). 2010. 2010 Report to the President and Congress. Rockville, MD: Agency for Healthcare Research and Quality Publication No. 10-M037. Available at: https://www.acf.hhs.gov/sites/default/files/documents/ohsepr/nccdreport.pdf (accessed September 21, 2024).
Providing Effective Support to All Children in the Aftermath of Disasters: A Persistent Gap in Research, Policy, and Practice
The 2010 report of the National Commission on Children and Disasters recommended that the US Department of Health and Human Services (HHS) should “enhance the research agenda for children’s disaster mental and behavioral health, including psychological first aid, cognitive-behavioral interventions, social support interventions, bereavement counseling and support, and programs intended to enhance children’s resilience in the aftermath of a disaster” (NCCD, 2010). A virtual conference was subsequently convened to conduct an informal review of National Institutes of Health (NIH) grants in order to identify gaps in knowledge and recommend a national research agenda encompassing the full spectrum of disaster mental health for children and families. This review documented a paucity of funded research on interventions to promote coping and adjustment for children after disasters. Findings, as summarized in a report published in 2018 in American Psychologist, highlighted that although there has been progress in understanding the negative impacts of disasters on children, less is known about the effectiveness of interventions to promote behavioral health and coping after a disaster (Grolnick et al., 2018). The limited intervention studies have focused on treatment or prevention of mental illness, particularly trauma disorders.
There have been studies that have documented, not unexpectedly, that disasters are often life-threatening events for children causing traumatic stress that can persist for some and result in post-traumatic stress disorder (PTSD). What was critically lacking then, and still is now, is study of the effects of supportive interventions on distress associated with bereavement and other situations where a psychiatric disorder has not been diagnosed, as well as interventions to promote socio-emotional adjustment and the resumption of healthy child developmental processes. One barrier that was identified by Grolnick et al. is the absence of valid outcome measures for these supportive interventions and the difficulties associated with demonstrating their usefulness (and need) to research funders and policymakers. Evidence-based interventions have instead tended to focus on the treatment of psychiatric disorders, such as PTSD, for which there are already validated measures and evidence-based treatments. Researchers have focused more on demonstrating what is already known and can be more easily studied rather than addressing this important gap.
The conference participants concluded that developing evidence-based interventions for children experiencing distress following disasters is a national priority and that such research should be broadened to include the full spectrum of behavioral health needs, such as bereavement, nonclinical distress, adjustment, coping, and resilience—and the study of interventions in these domains. The recent COVID-19 pandemic showed how little (if any) progress was made to address this gap. This lack of progress left the United States unprepared to effectively mitigate many of the negative impacts of the pandemic, which are still manifesting today in behavioral dysregulation among children due to the numerous losses and distress experienced.
It is an understatement that the pandemic caused widespread distress among almost all children and adults. But not all this distress is readily identified by current taxonomies. Most children did not develop a diagnosable mental illness such as anxiety, depression, or PTSD—even though sadness and concerns about safety and well-being were widespread. The challenges facing many children, especially in the latter part of the pandemic, probably relate more to the numerous and varied losses suffered than the degree of fear or threat experienced. The interventions and means of support offered to children who are grieving are often quite different from the treatment provided to children recovering from exposure to threatening events. When addressing traumatic experiences, the primary focus is on children’s emotional and cognitive processing of a threat, which may or may not have resulted in harm to themselves and their family. Support for grief focuses instead on helping children cope with both direct and indirect losses—the persistent absence of something or someone of great importance.
Research that has been done in the aftermath of major disasters has also shown that distress among impacted children (and adults) is generally pervasive and long-lasting, but the vast majority will not obtain traditional mental health support. This reality should prompt a shift from exclusively relying on a medical model—characterized by screening, evaluation, diagnosis, referral, and treatment for individual children with mental illness—toward a system of universal support as the primary response during a major disaster, with a focus on building resilience rather than delivering treatment. This of course will need to be coupled with incorporating school and community-based mental health professionals for children requiring more assistance and treatment services. But the relative absence of research on the efficacy of supportive interventions that can be delivered at a population level makes mitigating the impacts of large-scale disasters and decreasing the later development of mental health disorders far less likely. It further burdens the already limited pre-disaster mental health treatment services. And it fails to take advantage of the wide range of caring adults, such as educators, parents and caregivers, and other sympathetic community members, who are well-positioned—but largely unprepared—to support children in distress.
One reason for this gap in the provision of mental health support relates to limitations in funding for supportive services that do not involve evidence-based treatment for a diagnosed mental illness. Because there are professionals funded to provide mental health treatment services, there is far more research conducted to collect evidence of the need for these treatments and the efficacy of treatment services.
The National Advisory Committee on Children and Disasters (NACCD) recently released a report that calls for efforts to improve pre-disaster preparedness and just-in-time training in pediatric disaster mental and behavioral health (HHS, 2023). The NACCD report highlighted that this training should include psychological first aid, bereavement support, and brief supportive interventions that would be used not only by mental health professionals but also by other professionals, such as educators, who are in a position to provide support to children on a daily basis. This training should also be provided to health care professionals, childcare and early education professionals, youth service providers, child welfare and juvenile justice professionals, faith-based professionals, parents and caregivers, and other community members—virtually all adults who can provide basic supportive services and brief interventions. The goal is to help these individuals acquire basic knowledge to recognize signs of distress (not just the early signs of mental illness that indicate the need for referral to treatment services) and practical strategies to promote coping and adjustment, as well as to learn how to identify children in need of clinical services.
The NACCD also called for more training for clinical and non-clinical health care staff in supporting children after a disaster, including their response to impacts such as traumatic stress, grief, and loss. This should involve broad training to support grieving children for a wide range of non-clinical professionals, including educators and other school staff. Training and resource materials that are freely available and widely endorsed already exist, such as those from the Coalition to Support Grieving Students, which comprises more than 125 professional organizations including major professional organizations in education, school mental health, and pediatrics (Coalition to Support Grieving Students, n.d.). The NACCD report recommended that comparable training and resource materials in psychological first aid should also be developed and widely distributed.
Beyond the limited research on the efficacy of population-level and individually delivered supportive services, there is even less research on how to effectively modify supportive services for sub-populations, individuals from historically underserved and marginalized groups, and groups with unique vulnerabilities such as children with neurodevelopmental disabilities. Children identifying with different racial, ethnic, and social groups may experience disasters and proposed interventions differently from other children. For example, increased school security staff may be supportive for some groups of children after incidents of school violence but may be distressing to students that are part of communities for which experiences with law enforcement may be viewed negatively.
Another glaring gap relates to the need for more study on effective methods of support and intervention for caregivers of children after a disaster, which includes parents and other family caregivers, educators and other school staff, and pediatric health care providers, to name just a few groups. Many individuals that enter child-serving fields, such as education, social services, child mental health, pediatric health care, and others, do so because they, or others they care about, experienced childhood trauma, loss, or other forms of adversity when they were young and either benefited from the help of others or recognized the impact of the lack of such assistance. Post-traumatic growth may prompt them to focus their career on ensuring that children receive such critical support. But when disasters do occur, this tends to uncover prior trauma and loss experiences, including among the professionals who are also impacted by the disaster. Those that devote their lives to helping children and care most deeply about them are most likely, in many ways, to be hurt personally by doing so. The striking lack of evidence-based professional self-care and supportive interventions in the context of disaster is therefore a critical gap that deserves more attention. Probably at no time in recent history has this become more glaringly obvious than during the COVID-19 pandemic.
It is imperative to expand beyond the knowledge that adverse childhood experiences and traumatic events have adverse impacts on children and to screen for these exposures, and instead invest in the development of approaches that promote coping and adjustment in children, families, and communities. It is time to focus research, training activities, and intervention efforts on remedying this persistent gap in meeting the behavioral health needs of children affected by disasters. Not all children impacted by a disaster will develop a mental illness, but nearly all will be distressed and can benefit from being surrounded by empathic and supportive adults that are able to help them cope with this distress. These are skills that all adults should know and could use virtually every day. And this becomes critically essential during and after a major disaster.
Join the conversation!
Download the graphics below and share on social media!
References
Schonfeld, D. J. 2024. Providing effective support to all children in the aftermath of disasters: A persistent gap in research, policy, and practice. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202409c.
https://doi.org/10.31478/202409c
David J. Schonfeld, MD, FAAP, is a developmental-behavioral pediatrician and Director of the National Center for School Crisis and Bereavement at Children’s Hospital Los Angeles.
None to disclose.
Other papers in this series can be found here.
DISCLAIMER
The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). This paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.
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