Many Children Still Haven't Recovered from Katrina

Now, five years later, there's new evidence of the significant, negative impact of Hurricane Katrina on children's mental health. The study "Children as Bellwethers of Recovery" was conducted by researchers from the National Center for Disaster Preparedness at Columbia University's Mailman School of Public Health and was published online by the Journal of Disaster Medicine and Public Health Preparedness.

The results come from a longitudinal study of 1079 families in Louisiana and Mississippi that were displaced or greatly affected by Hurricane Katrina. Most of the data analysed in this study came from parent interviews conducted 4-1/2 years after Katrina.

The study's findings demonstrate the dramatic, long-term impact of Hurricane Katrina on the children:

• Over 37% of the children have been clinically diagnosed with at least one mental health problem—depression, anxiety, or behavioral disorders
• 45% of parents report that their children are experiencing emotional or psychological problems that they hadn’t experienced prior to Katrina
• Children in the study are nearly 5 times more likely to have serious emotional disturbance compared to children who were not affected by the disaster
• Less than 50% of the parents that sought mental health counseling for their children were able to access services

Co-author Irwin Redlener, M.D., director of the National Center for Disaster Preparedness, and president of the Children’s Health Fund, comments:

Nearly two out of three children affected by Katrina continue to experience serious mental and behavioral problems or the stress of unstable housing or both, with children living in poverty over two times as susceptible to serious emotional disorders. We believe that this represents at least 20,000 children affected by Katrina—and perhaps considerably more. Immediate action needs to be taken to increase mental health services in the region.

You can watch Dr. Redlener discuss the implications of this study with John Roberts on CNN:  Trauma After Katrina: Children Still Suffering Emotionally.

This study provides one more argument to improve access to mental health services for children. As I've written before, most of the children across the country who need mental health evaluation and treatment don't receive them. This is largely due to a combination of factors: the availability of mental health professionals who specialize in treating children, inadequate health insurance, reluctance to seek help because of stigma, and the failure to recognize mental health problems in children.

We must do better. The long-term effects and cost of mental illness on children, their families, and society are too great.


Abramson, D. M., Park, Y. S., Stehling-Ariza, T., & Redlener, I. (2010). Children as Bellwethers of Recovery Disaster Medicine and Public Health Preparedness : 10.1001/dmp.2010.7

Depression in Pre-Schoolers?

When researchers at the Washington University School of Medicine published the first longitudinal study of Major Depressive Disorder (MDD) in preschool children, it came as a surprise to many that young children even get depressed. Most people were unaware that MDD had already been found to be as common among preschoolers as among school-age children (approx. 2%).

The significance of the longitudinal study conducted by Dr. Luby and her colleagues is their evidence that depression in preschoolers is similar to that of school-age children. It's already known that an episode of severe depression in childhood often leads to more episodes as children get older. The researchers examined whether the same was true for preschoolers, that is, whether children depressed at the beginning of the study would be depressed two years later.

They also examined the risk factors that predicted depression both at baseline and at follow-up. Among school-age children, the strongest predictor of depression is a family history of depression. Both genetics and a depressed mother independently contribute to childhood depression. Stressful or traumatic events also predict depression, especially, in combination with a family history.

At the beginning of this study, depressed children were more likely to have mothers with a history of depression compared to children with other psychiatric disorders or no disorder. They also had experienced more traumatic events than the other groups. The types of events included "death of a parent, experience of physical or sexual abuse, and removal from one's home."

At follow-up, the strongest predictor of chronic depression was earlier depression. Children who were diagnosed with MDD at baseline were 4 times as likely to have MDD 2 years later. The second most powerful predictor was a family history of depression. Traumatic events contributed to a lesser degree.

Unfortunately, the popular press has reacted with the usual concerns about stigma and psychiatric medication. As Jennifer Gibson states in How Young is Too Young to Diagnose Depression? | Brain Blogger :

Experts are wary of labeling preschool-aged children with depression, since the diagnostic tools for this age group are not well established. However, early identification of depression may save a child from a lifetime of social and emotional consequences. Many adolescents and adults present to health care providers for mental health treatment, indicating that their symptoms started at an early age, and most adults with depression did, in fact, meet diagnostic criteria for depression in childhood. However, if children are labeled as “depressed” so early in life, are they set up for a lifetime of medications and treatments and stigmatization?

This ignores the opportunity for prevention by treating children who have experienced stressful or traumatic events. Most child clinicians are aware that the death of close relatives, prolonged separations from caretakers, separation and divorce of parents, and chronic abuse or neglect can lead to depression in children. I believe the results of this study provide further support for the early treatment of childhood trauma.

The treatment of choice for preschoolers should be psychotherapy. Given that research has found psychotherapy and medication equally effective at treating depression in adolescents and adults, there is no reason to assume it would be different for young children. For safety reasons, I believe anti-depressant medication should be considered only for children with severe or chronic depression that has not responded to psychotherapy.

Luby, J., Si, X., Belden, A., Tandon, M., & Spitznagel, E. (2009). Preschool Depression: Homotypic Continuity and Course Over 24 Months Archives of General Psychiatry, 66 (8), 897-905 DOI: 10.1001/archgenpsychiatry.2009.97

For those without access to the full article, see Dr. Nestor-Duran's review Depression in preschool children: not a temporary phase. - Child Psychology Research Blog.
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This post was featured in Grand Rounds, Vol. 6, No. 13

You Asked: What Are the Effects of Rape?

There are a wide range of short-term and long-term psychological effects that an individual victim may experience. The nature of the assault, use of a weapon, threats, violence, serious physical injuries, and relationship to the offender are some of the factors that can differentially affect the impact of rape on a particular victim. Those with a previous history of sexual abuse or other trauma are likely to be more severely affected by rape.

The immediate effects a victim may experience include shock, confusion, numbness, fear, anger, withdrawal, self-blame, guilt, shame, and denial. In the following weeks, victims often experience intense and unpredictable emotions, nightmares, flashbacks, difficulty sleeping, problems concentrating, feeling unsafe, and isolating from family and friends. Some victims may have great difficulty functioning in their daily life. Others cope by blocking their memories and feelings. Many cling to a semblance of normality as a way to deny the impact of their experience.

In the months following a rape, victims often have symptoms of depression or traumatic stress. They are more likely to abuse alcohol or drugs to control their symptoms. Nearly one-third have thoughts of suicide, and approximately 17% actually attempt suicide. Thirty-percent of victims will go on to develop Major Depressive or Post-traumatic Stress Disorders in their lifetime. Long-term negative effects on sexuality and the ability to form or maintain trusting relationships are common.

You may have noticed I have avoided gender pronouns. Although we most often think of females as rape victims, males are also victimized (estimates range from 10%- 20%). The effects on male victims are similar to those on female victims, but they are more likely to experience intense anger and aggression. They are also less likely to tell anyone about their experience or to seek help. Because the vast majority of offenders are men, it is not uncommon for male victims to question their own sexual orientation after the event.

It is essential for rape victims to seek help from mental health professionals with specialized training and experience. Rape crisis centers throughout the U.S. offer immediate support and counseling to help victims recover. You can search for a center in your community through RAINN (Rape, Abuse & Incest National Network). You can also call their hotline 1.800.656.HOPE, or speak to someone online for information and support. The following video explains how the hotlines work and the kind of help available at rape crisis centers.

Ten Common Causes of Child Trauma Due to Violence

I started this post several weeks ago to answer the question "What are the most common causes of child trauma?" It was much harder than I expected. The task of reviewing statistics wasn't just comparing apples to oranges. It was, instead, like comparing the ingredients of a fruit salad. The statistics varied greatly, in part, due to differences in research design:

• Some studies reported how many children experienced traumatic events in one year while others reported lifetime experience (incidence vs prevalence).
• Some included only children or adolescents while others asked adults to report on their entire childhood.
• Most focused on one type of trauma (for example child sexual abuse) rather than a wider range of traumatic experiences.
  
• Most weren't large enough or representative enough of the entire nation to draw firm conclusions. (Unfortunately, few researchers are able to obtain the funding needed to conduct large, representative studies.)
• Those that relied on victim reports to child welfare or law enforcement weren't able to estimate the number of victims who had not reported.
  

There are several ways to estimate how many children have experienced trauma. One way is to ask about a short period of time (incidence) rather than a person's entire childhood (prevalence). Some advantages of this approach is that it relies less on memory, and it is easier to compare different ages. Otherwise, when asked if an event has ever occurred, more teenagers are likely to report an experience than younger children simply because they've had more years for it to have happened.

A disadvantage is that the results do not reflect the full magnitude of a problem which is often better represented by an estimate of prevalence. For example, a familiar childhood statistic such as "one out of four girls experience sexual victimization before age 18" will be higher than the number of girls victimized in one year. Still, the advantages can outweigh the disadvantages when comparing rates across various traumatic experiences within different age groups, and a one-year snapshot of new cases can be more useful for current policy and service delivery.

My list is limited to child trauma caused by violence because there has been more research done for it than for other traumas (such as disaster or accidental injury). I selected a single study that included a wide range of violence-related victimizations by David Finkelhor and colleagues designed to address many of the issues listed above.

Finkelhor, D., Ormrod, R., Turner, H., & Hamby S. L. (2005). The Victimization of Children and Youth: A Comprehensive, National Survey Child Maltreatment, 10 (1), 5-25 DOI: 10.1177/1077559504271287


Their study included:

• a large, nationally representative sample of children ages 2 to 17
• younger children (through interviews with their parents)
  
• a comprehensive list of child abuse and other victimization experiences
• examined the number of victims for each trauma during one year
• relied on direct reports rather indirect statistics collected by reporting agencies
• reported how many children experienced multiple traumas

Of the 34 different direct and indirect victimizations included in the study, I've selected the top ten I believe best fit the criteria needed to diagnose PTSD. I converted population rates (number per 1000) to percentages more familiar to most readers. I've also included the definition of each trauma used in the study.

1. Bullying - 22% - A peer picked on child (for example, by chasing, grabbing hair or clothes, or making child do something he or she did not want to do).

2. Assault with injury - 10% - Someone hit or attacked child, and child was physically hurt when this happened. (Hurt means child felt pain the next day, or had a bruise, a cut that bled, or a broken bone.) No weapon was used.

3. Assault with a weapon - 8% - Someone hit or attacked child on purpose with something that would hurt (like a stick, rock, gun, knife or other thing).

4. Exposure to shooting, bombs, riots - 6%
Child was in a place (in real life) where child could see or hear random shootings, terror bombings, or riots.

5. Non-sexual genital assault - 5% - A peer tried to hurt child's private parts on purpose by hitting or kicking.

6. Robbery by nonsibling- 4% - A nonsibling (peer or adult) used force to take something away from child that child was carrying or wearing.

7. Physical abuse by caregiver - 4%
An adult in child's life hit, beat, kicked, or physically abused child in any way.

8. Witness domestic violence - 4% - Child saw one parent get hit (for example, slapped, hit, punched, or beat up) by another parent, or parent's boyfriend or girlfriend.

9. Sexual assault - 3% - Someone touched child's private parts when unwanted, make child touch their private parts, or forced child to have sex. Or attempted any of these acts.

10. Murder of someone close - 3% - Someone close to child (for example, family member, friend, or neighbor) was murdered.

There are some surprises here. Bullying was the most common. Significant numbers of children in the United States have been exposed to shootings, bombs, or riots. Many children have had someone close to them murdered though perhaps this shouldn't be surprising given the U.S.'s high murder rate.

In this article, I've focused on the number of children in the United States who experience trauma related to violence. In future articles, I will address other forms of child trauma such as disaster or serious accidents. I will also, from time to time, provide an in-depth look at items in the list including what is known about rates of PTSD and other negative consequences.
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This post was featured in Doc Gurley » Grand Rounds, Vol. 5, No. 44: Mystery!