Australia has been hit with another turbulent summer of natural disasters. Severe bushfires continue to devastate communities across the nation. Drought conditions in eastern Australia are having catastrophic effects on the land and waterways, while storms in the northeast have caused widespread flooding. The annual economic cost of disasters in Australia is estimated to be $3.65 billion (Handmer, Ladds, & Magee, 2018). Natural disasters are an increasingly frequent occurrence in our nation, and accordingly, have become a significant contributor to trauma exposure for Australians.
Globally, the impacts of climatic and geological disasters are intensifying. In 2018, 60 million people were affected by natural hazards, with earthquakes and tsunamis accounting for the majority of disaster-related mortalities (CRED & UNISDR, 2019). Consistent with prior years, nations in the Asia-Pacific region were at highest risk. Disasters are single incidents or a series of events that threaten the health, safety and wellbeing of a community and overwhelm their ability to respond effectively. Survivors are thus at heightened threat of trauma exposure, bereavement, displacement, and experience the destruction of property and belongings, and sometimes, of entire communities.
For children and adolescents, disasters represent times of loss and change. Many changes are excruciatingly permanent: the death of parents, siblings and relatives, the onset of physical illness or disability, and the loss of homes and communities. In many cases, school closures mean a break in education or having to start school in another district. In low-income nations, the loss of schooling often means having to start paid work. Many young people are acutely aware of the impact these losses will have on their future health and livelihoods, and that they may never have a chance to return to school. The flow-on effects are substantial, and the acute and chronic stressors arising from disasters have significant potential for long-term psychological impacts.
Young people and the impact of trauma
There is wide variability in the psychological effects of disaster exposure. Psychological distress is a normal and adaptive response to trauma, which children often express through crying, social withdrawal, irritability, anxiety and heightened worry. Most will recover with access to family supports, safe housing and re-engagement in normal routines. However, a significant number of children and adolescents will develop psychological difficulties in the months following exposure. Current estimates suggest that 30–50 per cent of young people experience moderate to severe post-traumatic stress symptoms (PTSS) and 2–69 per cent report depression after a disaster (see Cobham & McDermott, 2014). Of those that report psychological distress, approximately half (44.8%) continue to report elevated symptoms at an 18 month follow-up (McDermott, Cobham, Berry, & Kim, 2014). It appears that gender has a complex role as a risk factor, in that girls and boys are likely to be exposed to different traumatic incidents during disasters, with varying effects on psychological health. However we know that a dose-response relationship exists, with greater severity of trauma often associated with more intense symptoms. Additional psychological effects include sleep disturbance, behavioural issues, developmental regressions, somatic complaints and suicidality; which like PTSS, vary with trauma severity, individual factors and environmental risks.
Even with intense exposure to trauma, many children and adolescents demonstrate tremendous resilience in the aftermath of disasters. Children who do well in the context of adversity are able to employ adaptive coping strategies, draw on individual and social resources, and re-engage with activities of daily living. Many young people demonstrate post-traumatic growth after disasters, sometimes in conjunction with the development of post-traumatic stress disorder (Jin, Xu, & Liu, 2014). Expressions of resilience are likely to vary with cultural norms and expectations, but indicators of psychological adjustment have been described in disaster-affected settings globally. Children are incredibly adaptive, even in severely adverse circumstances. However, high rates of resilience may also reveal the necessity of children to be self-reliant in settings where mental health services are often entirely lacking.
Lasting daily stressors
Low- and middle-income countries (LMIC) are disproportionately affected by disasters. The combination of increasing climate variability, urbanisation, population density and poor infrastructure has left millions vulnerable to emergencies. It is well established that poverty itself can have detrimental effects on child mental health and development. In particular, the stress associated with economic insecurity has potential to increase anxiety, depression, interpersonal difficulties, aggressive behaviours and physical health issues (Chaudry & Wimer, 2016). Daily stressors, the economic and interpersonal challenges that are caused or substantially worsened by disasters, are a key risk factor, and more so when a parent is absent or stressed. Recent studies have therefore questioned the hypothesis that psychological distress after disasters arises solely from exposure to trauma and bereavement. Rather, the field is expanding in focus to investigate the important role that daily stressors play in mediating psychological adjustment.
The risky environments that emerge after disasters have been a central focus of The Study on Adolescent Resilience after Disasters. Launched after a series of devastating earthquakes in Nepal and southern China, the study aims to determine the specific conditions for recovery for young people living in disaster-affected communities. Our partners include experts from Kunming Medical University in China, the Centre for Victims of Torture Nepal, the Chinese University of Hong Kong, Harvard Chan School of Public Health and Curtin University. Together, our focus has been investigating the interpersonal, environmental and psychological risk factors that affect adolescent mental health and resilience after disasters in Nepal and China. Nepal was hit by multiple earthquakes in 2015 that resulted in an estimated 8500 deaths, 22,000 injured, and hundreds of thousands displaced and living in temporary shelters. Infrastructure central to disaster response, including healthcare facilities, roads and electrical grids were destroyed. Similarly, Yunnan Province in China has been affected by frequent disasters in recent years, with large earthquakes occurring in Ludian in 2014 and Changning County in 2015.
Young people in both nations have told us that after the earthquakes, they experienced significant stress associated with housing insecurity, food deprivation, parental absence or unemployment, domestic violence (which is more likely to increase after disasters) and the dangers associated with unsafe camps and temporary shelters (Newnham et al., 2019). Girls were particularly at risk of sexual harassment while living in tents or accessing public toilets. In Nepal, some adolescents told us about young people being coerced into labour, early marriages or becoming victims of trafficking. These stressors had considerable impacts on adolescent mental health. As one Nepali participant explained, “Sexual violence, psychosocial problems, economic problems… these are daily life crises… the earthquake made these crises bigger”.
The mental health consequences reported by adolescents in the study reflected difficulties reported by children and adolescents globally. Descriptions of anxiety, stress, worry and hypervigilance were most common, followed by changes in mood, behavioural issues and somatic concerns (Newnham et al., In press). Nepali adolescents described a sense of existential stress: having to evaluate the substantial changes to their lives and whether they were at risk of harm in the near future. In response to the evident mental health gap in disaster-affected communities, we are currently designing a school-based intervention to be trialled in Nepal later this year, supported by the Australian Psychological Society.
Importantly, and despite the extensive range of stressors affecting each community, adolescents demonstrated remarkable resilience. In fact, many adults noted the extent to which young people had drawn on internal strengths to cope well and build closer ties with their families and neighbourhoods. Disasters sometimes present an opportunity for adolescents and youth to take on visible leadership roles within their community, and support family and peers. Participants in The Study on Adolescent Resilience after Disasters reported that adolescents often played a role in rescue efforts by delivering first aid, transporting building materials, conducting security patrols in temporary camps, caring for family members, distributing preparedness training messages, and assisting with health education (Newnham et al., 2019).
In a second phase of the study we surveyed more than 4200 adolescents across both countries. The results revealed high rates of PTSS, depression and anxiety. Daily hardships had a greater association with psychological outcomes than exposure to disasters, highlighting the critical importance of considering the post-disaster environment when addressing adolescent mental health. These results were consistent with our prior findings in West Africa. For youth affected by the civil war in Sierra Leone, the relationship between war exposure and psychological distress was largely mediated by daily stressors, indicating that these risks must be considered across all humanitarian contexts (Newnham, Pearson, Stein, & Betancourt, 2015). Yet despite their importance, these issues are less often prioritised in humanitarian response planning and psychological services. Addressing security risks, daily adversities, and economic insecurity for children, adolescents and their families has significant potential to improve psychological health in the months and years following disasters.
Interventions in disaster
It is clear that the psychological impacts of disasters require focused intervention. However many disaster prone nations do not have the mental health services and human resources necessary to support a population affected by severe trauma. Aid funding for disasters is primarily channelled into first tier needs – ensuring that people have access to food, water, safe housing and secure communities – and addressing these concerns will alleviate stress for most people. Mental health issues tend to arise in a second wave of humanitarian need – in the months and years that follow the crisis – which requires significant forward planning for human resources, health infrastructure and budget support.
Capacity to address the secondary surge of need is critical to address long-term psychological burden, but policy makers are often unaware of the nature of mental health conditions and the implications for future economic costs. Tackling the landscape of threats for young people in disaster-affected environments can be overwhelming, so which factors should be the focus for improving child and adolescent mental health?
A focus on family
The first priority is family. Parents and caregivers play a crucial role in creating a protective shield for child mental health during emergencies (Cobham & Newnham, 2019). Family cohesion provides a robust foundation for child and adolescent recovery, supporting children to adjust and acclimatise to new circumstances. In the aftermath of disasters, family reunification programs are implemented to ensure the safety of children and to foster family supports. It is vital that hospitals, clinics, schools and safe spaces also develop systems of child protection. Findings from research with bushfire-affected communities suggest that separation during disasters is significantly associated with PTSD in the years following the fire, and that depression outcomes were mediated by attachment type (Gallagher et al., 2016).
The relationship between parent-andchild mental health after disasters is dynamic and reciprocal. In most cases, parents will be dealing with their own experience of trauma and adversity, and as such, parenting often changes after disasters. Parents report becoming more protective, hypervigilant and paradoxically, less able to attend to a child’s distress following disasters (Cobham & Newnham, 2019). Family conflict has been associated with post-traumatic stress symptoms in children, and many parents report changes in patterns of discipline, with the use of more punitive and physical methods employed during times of stress. Parents who are dealing with significant levels of stress are less likely to allow their children to build autonomy. Thus reducing stress for parents in the post-disaster period and assisting them to navigate changes in their parenting approach will have important positive effects for child mental health. And yet, despite the significant potential for preventing child mental health difficulties through parenting support, few parenting interventions have been evaluated in disaster-affected settings.
Child-focused interventions
Current best practice guidelines promote the use of Psychological First Aid (PFA) in the immediate post-disaster period. PFA addresses acute stress by supporting the five essential elements identified by Hobfoll and colleagues as critical to recovery: safety, calming, connectedness, self-efficacy and hope. PFA is designed to be delivered by lay providers and non-specialist personnel, making it widely accessible and easily implemented. Although it is used as the first line of intervention by almost all agencies active in humanitarian response, the evidence base for its effectiveness is nascent. Endorsement of PFA is derived entirely from expert consensus, and the lack of rigorous assessment has led to criticism of its widespread use (Shultz & Forbes, 2014). However, the strategies underlying PFA are consistent with a common-sense, compassionate response to survivors, ensuring that they have access to reliable information, shelter and aid, connection to their own networks of social support and opportunities for self-agency. These elements are likely to support the majority of survivors, but for those that continue to experience significant distress, psychological interventions may be needed.
“The psychological consequences of humanitarian emergencies are complex and multifaceted. Accordingly, children and youth affected by disasters may require multiple stages of treatment, focused on important but differing aspects of their experience”
Emerging evidence supports the use of a number of trauma-focused interventions for children and adolescents in crisis-affected settings. Among these, trials of trauma-focused cognitive behavioural therapies (TF-CBT) and eye movement desensitization and reprocessing (EMDR) have had promising findings. TF-CBT engages cognitive reprocessing and behavioural techniques combined with skill building and parenting components to address the effects of single or multiple traumas. Randomised trials of TF-CBT have shown significant improvements in PTSD when implemented across a range of disaster-affected settings (Jaycox et al., 2010). In contrast, EMDR focuses on the symptoms arising from the experience of trauma, within a brief intervention approach. A number of trials have demonstrated the effectiveness of EMDR in reducing PTSS (Natha & Daiches, 2014) illustrating the potential for significant improvements in child and adolescent psychological outcomes with evidence-based treatments, even in very challenging settings.
The psychological consequences of humanitarian emergencies are complex and multifaceted. Accordingly, children and youth affected by disasters may require multiple stages of treatment, focused on important but differing aspects of their experience. In international settings, attention to the cultural specificity of psychological distress requires a carefully considered approach to assessing symptoms and implementing intervention. To do so, building meaningful local partnerships is critical.
The delivery of mental health interventions should always be conducted in conjunction with local providers, who are able to highlight community needs and expectations, identify deviations from behavioural and developmental norms, navigate the existing mental health service landscape, and advocate for mental health assistance that fits the specific needs of the population. Further, any work conducted in disaster-affected settings (whether in low, middle or high income nations) presents an important opportunity for capacity building. Training local psychologists and mental health workers improves the acceptability and sustainability of interventions, and supports the community’s ongoing capacity to respond in future emergencies.
Empowering young people
Psychologists have an important role to play in advocating for child and adolescent mental health, building capacity in psychological services, and supporting the delivery of evidence-based interventions. In addition, there is tremendous potential to support children and adolescents by involving them in disaster risk-reduction efforts. Many disaster-prone nations have large youth populations, and maximising their engagement in the recovery process can have flow-on effects for future community leadership.
Although it can be difficult for young people to speak up during times of crisis, their insights are important, and provide a perspective not always taken into account for policy and planning. Developing evidence-based practices and inclusive systems of engagement has great potential to improve child and adolescent mental health, and will foster sustainable change for disaster-affected communities.
The author can be contacted at [email protected]