(p. 272) Parenting Support in the Context of Natural Disaster
Introduction: The Significance of Natural Disasters for Children
With climate change has come an increase in the frequency of extreme weather events and natural disasters worldwide (Pall et al., 2011). In 2015, EM-DAT, the international disasters database, recorded 346 natural disasters, with 22,773 people killed, over 98 million affected, and an economic impact of roughly US$66.5 billion (Guha-Sapir, 2016). Importantly, natural disasters do not affect isolated individuals. Rather, they cause significant losses to, and disrupt the functioning of, entire communities.
Although the literature on child outcomes following a natural disaster is limited compared to the research on adult outcomes, it is well recognized that, following a natural disaster, children can develop significant mental health problems. A review of natural disaster studies reported that 30%–50% of affected children and adolescents demonstrated moderate-to-severe symptoms of post-traumatic stress disorder (PTSD), while 5%–10% meet criteria for a full PTSD diagnosis (La Greca & Prinstein, 2002). More recent studies confirmed that a significant proportion of children develop PTSD symptoms following exposure to a natural disaster (Bokszczanin, 2007; Hoven et al., 2005).
In a review of studies examining the prevalence of depressive symptoms in children postdisaster (both natural and human-made), prevalence rates were reported to range from 2% to 69% (Lai, Auslander, Fitzpatrick, & Podkowirow, 2014). Studies examining the persistence of PTSD symptoms among children affected by a natural disaster indicated that approximately one third of youth with early-onset PTSD continue to display significant symptoms up to 2 years following the weather event (Yule, Perrin, & Smith, 2001).
(p. 273) It is critical to note that, although the mental health outcomes for children exposed to natural disasters can be significant, most children do not develop lasting difficulties (Bonanno, Brewin, Kaniasty, & La Greca, 2010). For this reason, a stepped care approach to intervention has been advocated (McDermott & Cobham, 2014), with universal interventions offered to all individuals in a disaster-affected area (regardless of degree of exposure or any other risk factors) and targeted, more intensive, interventions offered only to the minority of people who go on to develop a mental health problem.
Postdisaster, children and adolescents are indeed recognized as a particularly vulnerable group (McMichael, Neira, & Heymann, 2008). Children and adolescents are less likely than adults to have the cognitive and emotional capacity to effectively respond to the challenges involved in coping with a natural disaster and thus must often rely on support from the significant adults in their lives. This is in keeping with the idea that parents play a vital role in children’s recovery from stressful life events (Scheeringa & Zeanah, 2001). From the child development literature in general, it is known that children look to important adults in their lives when assessing danger and attributing meaning to stressful events, as well as for protection (Feinman, Roberts, Hsieh, Sawyer, & Swanson, 1992; Pynoos, Goenjian, & Steinberg, 1995). However, in a postdisaster context, because the important adults (not only parents but also significant figures such as teachers and child care workers) in a child’s life will typically have been affected by the same disaster, their capacity to support children and adolescents—or indeed, to even be aware of their needs—may be compromised (Silverman & La Greca, 2002).
In attempting to understand why some children and youth and not others develop posttraumatic mental health problems following a natural disaster, integrated psychosocial models (e.g., La Greca, Silverman, Vernberg, & Prinstein, 1996) have suggested that a combination of predisaster child characteristics, disaster exposure, and aspects of the postdisaster environment may be influential risk factors. Of these sources of potential risk, only the postdisaster environment can be modified once a disaster has occurred. A recent meta-analysis of risk factors for the development of PTSD in children and adolescents identified two environmental factors: parental psychopathology and poor family functioning (Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012).
Increasingly, models of understanding children’s post-traumatic mental health problems have moved in the direction of focusing on not only risk but also resilience factors (Bonanno et al., 2010), where resilience is understood as a system’s capacity to withstand or recover from significant challenges (Masten, 2011; Masten & Narayan, 2012). Operating from a risk and resilience framework, efforts are focused not only on mitigating risk but also on developing resilience in children who have been exposed to potentially traumatic events (PTEs).
In the absence of clear intervention guidelines for working with children and families in a postdisaster environment, it is useful to consider the broad intervention principles proposed by Hobfoll et al. (2007) in working with individuals exposed to community-wide trauma. These principles recommend the promotion of a sense of safety, calm, self- and collective efficacy, connectedness, and hope. This move toward a risk and resilience framework parallels the importance of moving beyond the field’s traditional focus on the development of psychopathology in individual children to a more strengths-based, family-focused approach aimed at supporting adaptive coping in parents and children postdisaster (Cobham & McDermott, 2014).
(p. 274) The Importance of Parenting Support in a Natural Disaster Context
Parents have an important role to play in the way in which their children make sense of, and respond to, exposure to any kind of PTE. Because natural disasters almost always affect parents as well as children, they constitute PTEs in which parents may particularly benefit from support in taking on this role in their children’s recovery. It has been proposed that one of the most important ways in which children are affected by a natural disaster is via the impact of these events on their parents, with the consequent implications for parenting and the parent–child relationship (Masten & Osofsky, 2010).
A well-researched pathway by which this may occur is parental distress postdisaster. The interdependence of parents’ and children’s distress postdisaster has been well established (Bonanno et al., 2010; Conway, McDonough, MacKenzie, Follett, & Sameroff, 2013; Masten & Narayan, 2012; Morris, Gabert-Quillen, & Delahanty, 2012). A large number of studies have found that, consistent with the conclusion of Trickey et al. (2012), parental distress (over and above shared exposure to the PTE) predicts children’s post-traumatic stress symptoms (PTSSs; Kerns et al., 2014). A smaller body of work (focusing on terrorist attacks rather than natural disasters) has found that children’s distress affects parental post-traumatic stress (Koplewicz et al., 2002; Levine, Whalen, Henker, & Jamner, 2005).
A pattern of reciprocal influence makes intuitive sense; however, a recent study specifically examined this question of direction in parent–child dyads’ interdependent mental health following the 2006 Indonesian earthquake. These researchers found that, when trauma exposure was controlled for, parental post-traumatic stress predicted children’s distress but not vice versa (Juth, Silver, Seyle, Widyatmoko, & Tan, 2015). In the context of a postdisaster environment, parental post-traumatic stress in its own right appears to constitute a highly significant risk factor for children’s mental health outcomes.
It has been suggested that, in addition to parental PTSSs, changes in parenting behaviors (specifically, becoming more protective and less granting of autonomy and communicating a sense of current danger; Cobham & McDermott, 2014) and family environment factors may also put children at risk (Masten & Osofsky, 2010; McDermott & Cobham, 2012). Although many hypotheses have been advanced to explain how parent psychopathology and family functioning may be related to children’s postdisaster outcomes, comparatively few empirical studies have examined these possible mechanisms. Even fewer studies have examined parent- and family-related factors that might be associated with resilience. In a recent review, Cobham, McDermott, Haslam, and Sanders (2016) concluded that empirical evidence exists to support several parent- and family-related pathways by which children’s postdisaster vulnerability may be increased. These included “hostile” and “anxious” parenting styles, too much or too little conversation about the event, higher levels of conflict between parents and children or within the family, a perception by children and adolescents of lower family connectedness and greater worry about the family, family functioning that has become more dysfunctional in the wake of the disaster, and exposure to disaster-related media (see Box 24.1). In terms of factors associated with resilience, apart from an absence of the risk factors identified previously, there is some empirical support for parental encouragement of coping strategies that include acceptance, positive reframing, and emotional expression. In summary, the empirical research suggests that, in (p. 275) a postdisaster context, a parenting intervention has the potential to be useful in addressing both risk and resilience factors, and that a useful parenting intervention would provide parents with information about the “parenting traps” identified here and tips for avoiding them, as well as about the value of encouraging certain coping strategies in their children.
—An account provided by the first author
Disaster Recovery Triple P
Disaster Recovery Triple P (DRTP; Cobham, McDermott, & Sanders, 2011) was developed following the January 2011 floods in Queensland, Australia. This disaster resulted in 78% of the state of Queensland (an area of over 1.85 million km2 total) being declared a disaster zone. Thirty-three lives were lost; 2.5 million people were directly affected; 29,000 residences and businesses were destroyed or damaged; and $2.38 billion of damage was incurred (Queensland Floods Commission of Inquiry, 2012).
(p. 276) Disaster Recovery Triple P is a 2-hour universal parenting seminar that can be delivered to up to 100 people at a time. The seminar is psychoeducational in nature and involves a trained practitioner delivering a presentation, which combines didactic content, media footage relating to natural disasters, and video footage of interviews with parents and children who have been affected by a natural disaster. The presentation is followed by 30 minutes for questions from parents. Parents also receive a take-home tip sheet summarizing the content discussed.
The content covered includes common emotional and behavioral responses in children following a natural disaster; the natural course of these responses over time; predictable triggers for distress (e.g., media images, anniversaries); why some children are more affected than others; parent traps; managing children’s emotional and behavioral responses; other things that can help (e.g., self-care and having a dangerous weather plan); answering children’s questions; and referral pathways. The “parent traps” discussed include encouraging too much talk about the dangerous weather event, discouraging all talk about the event, being overly protective, and talking to children about your own fears and distress. Each of these parenting patterns is discussed in a nonjudgmental manner, with an emphasis on both the ease with which parents can fall into these traps and the potential importance of these traps in delaying children’s natural recovery. Real parents and children talking about their experience of these parenting traps postdisaster make this content particularly powerful.
When talking about strategies for managing children’s postdisaster emotional and behavioral responses, parents are encouraged to reassure their children that, in the short term, it is quite normal to be distressed; allow their children to be upset (while putting limits around this); make it clear that the danger is over now; show by example that they do not believe there to be any current danger; prompt children to use their existing coping skills; resume family routines to whatever extent is possible; give praise and attention for settled behaviors; stick to the facts of what happened; communicate confidence in their children’s ability to cope; and remind children that the entire community is working hard to get back to normal.
Throughout the seminar, a recurrent theme is the need to communicate to children that while the world is a place where dangerous things can happen, the world is not always a dangerous place. All content selected for inclusion in the program was based on the literature relating to the role of parents, parenting, and family environment in the development and maintenance of postdisaster mental health problems in children. Finally, in the development of DRTP, the possibility that too much early intervention may inadvertently communicate a lack of confidence in families’ and communities’ resilience (Bonanno et al., 2010) was always kept in mind. DRTP is a program of parenting support designed to empower parents.
Efficacy of Postdisaster Parenting Support Programs
Although the role of parent-related factors (including parental psychopathology, parenting, and the family environment) has increasingly come to attention in recent years, the literature on universal (or indeed, any type of) interventions for parents in the aftermath of a natural disaster is almost nonexistent. To the best of our knowledge, only one parent-focused intervention has published evaluation data (Powell & Leytham, 2014), with evaluation data for a second intervention—DRTP—reported here.
(p. 277) The Caregivers Journey of Hope (JoH) workshop is a 3-hour program that was delivered to 106 parents 3–8 months after an earthquake in Christchurch, New Zealand, in 2011 (Powell & Leytham, 2014). Developed by the Save the Children organization, this workshop had its origins in feedback from caregivers (parents, teachers, and child care workers) following Hurricane Katrina that they were concerned about the impact of their own distress on their ability to respond to children. The workshop consisted of five components: children’s common responses to trauma, types and sources of stress, how stress affects the body, coping strategies, and building community assets and supports. Parents were surveyed before and after the workshop about their knowledge relating to stress as it pertained to themselves (e.g., how stress affects their body); current stress levels; understanding of coping strategies for handling their own stress; ability to identify strengths in managing their stress; knowledge of community and social supports available to them; and likelihood of considering a positive future for their community. Improvements were demonstrated from pre- to postworkshop on all items, with the largest changes seen on knowledge about breathing exercises to reduce stress and knowledge of the different types of stress. While the authors acknowledge the limitations of this evaluation (lack of a control group, one follow-up point only, measurement of knowledge gained rather than outcomes such as enhanced coping skills), this study represents the first step in evaluating one of the only parent-focused postdisaster interventions described in the literature.
Disaster Recovery Triple P (Cobham et al., 2011) was rolled out across the state of Queensland, Australia, between March and July 2011 as part of the Queensland Health Child and Adolescent Disaster Response (led by the first and second authors). The aim of the program was to assist parents in supporting their children following the disaster. As described previously, DRTP focuses on helping parents to understand and mitigate potential parent- and family-related risk factors (such as too much or too little conversation about the disaster), while promoting resilience-enhancing strategies (such as allowing the contained expression of distress).
Thirty-nine free seminars were delivered by trained practitioners around the state, reaching 196 parents. The seminars were widely advertised in all media—including local radio stations, major newspapers, and TV news stations. Flyers advertising the seminars were distributed to general practitioners’ surgeries, pharmacies, local businesses, supermarkets, schools, and child care centers in disaster-affected areas (DAAs). A website was established and a Google advertisement link purchased. Google analytics indicated that 191,171 impressions were recorded throughout the campaign, with under a 6% Click Through Rate (the number of clicks an advertisement receives divided by the number of times it is shown).
Attendees and Satisfaction
Of the parents who attended a DRTP seminar, 161 completed a demographic survey and a satisfaction survey. Most attendees were mothers (85%), 30% had a university education, 64% were employed in either full- or part-time work, 80% resided in an intact biological family, and 21% indicated that there had been a time in the past 12 months when their family had been unable to meet essential expenses. In terms of flood-related characteristics, 76% had their homes damaged, and 53% had been displaced by this damage. Attending parents expressed a high level of satisfaction with the seminar—with the seminar content and helpfulness receiving mean ratings of 6.10 and 6.01 of 7, respectively. Attendees reported a mean of 6.22 of 7 in terms of their intention to implement the parenting advice they had received.
(p. 278) Given the constraints of the situation, a quasiexperimental design was employed to evaluate the impact of DRTP on both parent and child outcomes. Participant parents (N = 43) completed questionnaires before the seminar (Time 1), 2 weeks after attending the seminar (post–Time 2), and 6 months after attending the seminar (Time 3). Data for both follow-up points were collected for 40 participants. Questionnaires included the Depression Anxiety and Stress Scale (DASS; Lovibond & Lovibond, 1995), which parents completed about themselves; the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), which parents completed about their children’s emotional and behavioral problems; and the specially developed Parenting After a Disaster Checklist (PADC; Cobham, Sanders, & McDermott, 2011).
The PADC consists of two subscales: (a) children’s emotional and behavioral problems and (b) parental confidence in dealing with children’s problems. Parents rated the frequency of each item over the past 4 weeks from 0 (Not true of my child at all) to 3 (True of my child very much or most of the time), as well as their confidence in dealing with each item from 0 (Certain I can’t do it) to 10 (Certain I can do it). Sample items included “My child has nightmares about the flood” and “My child asks me lots of questions about the flood.” Higher scores on the problems subscale indicate more problems, while higher scores on the confidence subscale indicate more confidence. Both subscales had excellent internal consistency within the evaluation (α = .88 and .96, respectively).
Participant parents reported reductions from preseminar to each of the two follow-up assessments on the DASS total score, as well as on each of the DASS subscales. However, a one-way repeated measures analysis of variance (ANOVA) indicated that these differences were not significant. On the PADC, a one-way repeated measures ANOVA indicated that, over time, children’s emotional and behavioral problems decreased significantly as rated by their parents over time. Although parents’ mean scores on the confidence scale increased, these differences were not statistically significant. Finally, on the SDQ, a one-way repeated measures ANOVA indicated a significant reduction over time on the emotional symptoms subscale. Although means on the other subscales of the SDQ, as well as the total score, were reduced over time, these differences were not statistically significant.
This evaluation was limited by small sample size and the lack of a control group. The representativeness of the parents who attended DRTP seminars is also unclear. The challenges involved in conducting research in a postdisaster context have been well documented (Bonanno et al., 2010; Masten & Osofsky, 2010) and include many of the issues that limit the DRTP evaluation—for example, the lack of a wait-list control group, difficulties in recruiting research participants within the context of clinical service delivery, difficulties obtaining funding and training workers in a timely manner, and lack of predisaster data. However, to the best of our knowledge, this is the first evaluation of a parent-focused intervention that focused on parent and child postdisaster mental health symptoms, as well as parents’ confidence in dealing with their children’s postdisaster emotions and behaviors. Having follow-up data 6 months postintervention is a significant strength of the evaluation. DRTP appears to be highly acceptable to parents, and these preliminary data indicate that attendance at the seminar was associated with reductions in parents’ perceptions of their children’s general emotional problems (SDQ) and their children’s disaster-specific emotional and behavioral problems (PADC).
(p. 279) Making Triple P Work in a Natural Disaster Context: Implementation Issues to be Considered
The existing literature suggests that offering an empirically based program of parenting support (such as DRTP) in a postdisaster environment is worthwhile. The DRTP evaluation data reported here are promising. However, there are a number of challenges inherent in working in a postdisaster environment that must be considered.
The first challenge is getting parents to attend a universal parenting intervention such as DRTP in a postdisaster environment. Following a natural disaster, people’s time, energy, and thought tend to be directed toward practical tasks such as rebuilding. In line with Maslow’s (1943) hierarchy of needs, concerns around physiological needs (e.g., food, clothing, and shelter) and safety (e.g., personal and financial security) will, as they must, take precedence over all other concerns. Related to this, most people in a postdisaster environment do not see themselves as requiring mental health support and are unlikely to seek assistance (Young Landesman et al., 2003). Particularly in areas where disasters are common—or indeed, seasonal—there is typically not the clear sense of being exposed to something that has the potential to be emotionally harmful. While most people will not develop ongoing mental health problems, this lack of awareness of the potential psychological threat means that some people who would benefit from mental health support will not receive it.
In the context of DRTP, it is suggested that many parents did not view the seminar as relevant to them—despite the fact that it was advertised as being useful for all parents in DAAs. When put together, parents’ preoccupation with meeting their families’ physical and safety needs, and their tendency not to expect disasters to pose an emotional threat, may have contributed significantly to the difficulty we experienced in getting parents to attend a universal parenting intervention. Another contributory factor to the difficulty in getting parents to attend may have been lack of knowledge about the seminars.
How to address this challenge of parent attendance? Certainly, an outreach approach using social marketing techniques is necessary. One thing that should help in the future is having a media strategy and campaign plan ready to implement in the short-term aftermath of a disaster. In the DRTP rollout, developing a website, making contacts, and running a media campaign took valuable time. Another strategy that may help is psychoeducation about the potential threat to children’s psychological well-being for parents living in disaster-prone areas. In much the same way as Australian state governments launch public awareness-raising campaigns about keeping physically safe during storm/cyclone/bushfire seasons, a parallel campaign directed at parents and focused on helping children cope with natural disasters would be helpful in motivating parents to attend a universal program such as DRTP in a postdisaster environment.
Working with and through schools in the DAA (if they are intact and functioning) is another strategy that is likely to assist with attendance. Offering psychosocial support in schools has a number of advantages—including the capacity to reach a much larger number of parents in a normal and familiar context and the normalization of the support program being offered. Similarly, working with, and having the endorsement of, the local community support centers that spring up in a postdisaster environment is crucial. In a postdisaster context, many people and organizations (some with mandates and some without) are trying to help disaster-affected individuals and families. Sometimes, this can actually contribute to the sense of confusion and (p. 280) chaos that people experience after being affected by a disaster. The credibility that comes with being associated with the grassroots community support centers is crucial. When people move or change their phone number, it is their local community support center that they will inform. In line with this, it is certainly worth considering employing at least one local person to assume a leadership role in the rollout of a universal intervention such as DRTP. It should be noted that this is easier said than done.
A second important issue is timing. When is the right time to offer a universal parenting intervention such as DRTP? We would suggest that, for this particular program (with its preventive approach), delivery within 1–2 months postdisaster (when it is still early enough to help parents avoid parenting traps likely to increase their children’s risk) is optimal. However, there will certainly be individual variation in terms of the “right time” for different parents to be receptive to a program such as DRTP. The key is likely to be a degree of flexibility.
Finally, making delivery of the program as flexible as possible is critical. DRTP was originally developed for group delivery by trained practitioners. However, we quickly learned that this model was unnecessarily prescriptive. Key community members to whom parents may turn (e.g., general practitioners) needed to have a store of the DRTP tip sheets that they could give to and discuss with individual parents during consultations. This in turn means that careful thought needs to be given regarding who is seen as “qualified” to talk with parents about the principles and strategies within a program such as DRTP.
Implications and Future Directions
Although relatively sparse, the empirical literature does indicate that a postdisaster parenting intervention has value in terms of both mitigating parent- and family-related risk factors and helping parents to promote resiliency in their children. Although quite different in focus, both the JoH workshop and DRTP have obtained promising results, which require replication and extension. In the context of these programs, it is vital to provide parents with referral pathways through which they might receive additional parenting support (such as other variants of Triple P) around issues that either arise or persist in the months following a disaster.
Another important future direction for research focuses on disaster preparedness, which is of relevance in those countries (such as Australia) that have predictable disaster seasons. As an addition to DRTP, a preparedness tip sheet and video for parents (Approaching Bad Weather: Helping Children Feel Prepared Rather Than Scared; Cobham et al., 2011) were developed as a preparatory intervention resource. The tip sheet (with information about how to access the video) was freely distributed to all households in areas of Queensland at risk of dangerous weather during the 2011–2012 Australian disaster season (November to February). Undertaken as a public service initiative, no evaluation data were collected. However, anecdotally, parents reported the tip sheet was useful; funding to continue providing the preparedness tip sheet to parents in the lead up to the Australian disaster season is being sought.
Children represent a particularly vulnerable population in a postdisaster environment. Of the variables that contribute to children’s risk of developing postdisaster mental health problems, (p. 281) the only one that is modifiable is the postdisaster environment. The importance of parents (and thus parenting support) in the postdisaster environment is clear. Although limited empirical research exists, there is preliminary evidence for both the JoH workshop and DRTP. While the many challenges in conducting rigorous research in a postdisaster setting must not deter us from attempting this, there probably also needs to be an acknowledgment that, when it comes to postdisaster interventions such as DRTP, it is very difficult for the evidence base to ever be as robust as it could be in a more controlled (nondisaster) setting. Thus, while it is important to continue to evaluate such programs, equally it is important that an evidence-based program such as DRTP should be made available to parents in the aftermath of a disaster. A program of parent support such as DRTP should be a key ingredient of any disaster plan.
• Children and adolescents represent a particularly vulnerable group, with a significant minority likely to develop persistent mental health problems postdisaster. However, the majority of children and adolescents will return to their predisaster level of functioning with the passage of time.
• The impact of disasters on parents (in terms of their own distress, altered parenting, and altered family environment factors) is critical in influencing children’s outcomes. In a postdisaster environment, the limited existing research suggests that a parenting intervention that addresses both risk and resilience factors has the potential to be useful in supporting children and families.
• Despite the important role of parents in a postdisaster environment, to date only two postdisaster, parent-focused interventions (the Caregivers Journey of Hope workshop and Disaster Recovery Triple P) have been described and evaluated.
• Disaster Recovery Triple P (DRTP) is a 2-hour parenting seminar that was developed to specifically target empirically identified parent-/family-related risk and resilience factors (e.g., level of communication about the disaster, acceptance of children’s negative emotional responses).
• Following the 2011 floods in Queensland, Australia, DRTP was rolled out across the state. The intervention was evaluated, with outcomes indicating that, following attendance at DRTP, children’s emotional and behavioral problems (by their parents’ report) had reduced significantly over time.
• Research indicates that a universal parent-focused intervention such as DRTP is indicated in a postdisaster environment. The DRTP data reported here are promising. However, there are a number of implementation issues that must be considered. These include the many factors that may act as obstacles to parents’ attendance; the timing of such an intervention; and the need to be flexible in delivering a parent-focused intervention in a postdisaster environment.
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