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Vol.22, No.8, August 2006 - Into the eye of the hurricane: The kids are doing okay, but just wait...

Dr. Drell is the Head of LSU Infant, Child and Adolescent Psychiatry and Clinical Director of New Orleans Adolescent Hospital and community System of Care (NOAH). With his staff and 17 adolescent psychiatric patients, Dr. Drell evacuated New Orleans prior to Katrina and a second time after the storm knocked out all services to the second evacuation site. He and his staff have provided community mental health services to shelters, motels/hotels, schools, emergency rooms, FEMA trailer villages and clinics in southeastern Louisiana.

In my many years as a child psychiatrist in New Orleans, I have been through several tropical storms and hurricanes in which everyone (patients, staff, and the family of staff) either hunkered down at the hospital as the storms passed over (called "sheltering in place"), or evacuated to a safer hospital. Each time, I have been struck by the fact that most everybody predicts that the patients will do badly. I remember thinking the same during my first tropical storm. I also remember how well the patients actually did. Children of the staff were more of a problem than the patients.

Since then, I have always enjoyed telling new staff and residents about to experience their first tropical storm or hurricane that the kids will do OK. I enjoy their look of disbelief when I say this. I also enjoy the moment, days later, when they agree that the kids have done better than they expected.

The universality of dire predictions regarding patients' behavior is fascinating. Is this a projection? Is this a "hardwired catastrophizing about catastrophe" response? Is this partly our tendency to look for the worst in people? Or is this our need to diagnose? Or more specifically our propensity to diagnose when there are some, but not all the criteria needed?

Is it delayed response?
All I know is that at almost every point in the post-hurricane Katrina planning-process, months after the storm, people have continued to remark that the kids were, in general, doing better than expected. The fact that the kids were doing so well seemed to irritate many. Invariably, someone would say, "But wait. It's too early!" Some would remark on "delayed responses" or say, "They're still in shock," or, "They're still in the denial phase."

I figured that they were right. In doing so, I disregarded my own experiences in which the kids had done better than expected, and my own adage that one should never overestimate the skills of parents or underestimate the skills of children. After all, I had never been through a storm like Katrina. All my previous disasters of this type were counted in days, not weeks or months. I had never before encountered, "The Big One." The symptoms would surely come. And so I waited.

One month after the hurricane, people continued to say the kids were doing better than expected, and that the symptoms would come. My cognitive dissonance increased. I started creating hypotheses about why the kids weren't doing worse. I reminded myself that symptoms are often delayed. I even started theorizing that this was a chronic, type II trauma adjustment situation, a la Lenore Terr,1 in which the symptoms would be delayed. I reminded myself again that symptoms are often delayed. Perhaps, I thought, we were using the wrong risk scale or our cut-off scores were too high? And so I waited. At month two, everyone still said the same thing. "The kids are doing better than expected, but wait."

I noted that if the predictions in the early weeks had been true, my staff, who were working in shelters, walk-in clinics, and schools around the Greater Baton Rouge Area, would have been inundated. My staff members were finding kids with problems, just not in the numbers expected. The kids, it seemed, were doing better than expected! Perhaps we should be using a resiliency model that is a strength-based family therapy model that doesn't focus on pathology.

I remembered an e-mail I received after a key study on post-9/11 showed significant symptoms in the children of New York City. The e-mail asked why the authors had not focused on the fact that the vast majority of children in New York City had managed quite well. I also remembered a literature review I did several years ago on the history of the concept of PTSD, which showed what I thought to be a recurring tendency to overextend its diagnostic range (what I call the spectrumization of diagnoses) to a point where it "explained everything," and, therefore, lost its usefulness.

Avoiding over-diagnosing
I was not the only person having problems with this. One of the volunteers said, "Distress is common. Diagnosis is not. Treatment works." That seemed to echo my qualms. It wasn't that I didn't believe that some of the children were going to do badly and that the stress would trigger their diatheses, it was that I didn't think that kids would automatically do badly. Or that we need to better differentiate "normal" kids from those "at risk" and those with pre-existing conditions.

I worried that a philosophy that they would do badly would create a self-fulfilling, cognitive-behavioral prophecy that would mistake distress for diagnosis and trigger "false positives." In a similar vein, I wondered about the impact of multi-page risk assessments delivered by waves of well meaning, yet hastily trained, temporary workers? Does this have the same impact that first-year lectures have on medical students, who wonder if they have every disease in their textbooks? Does being asked over and over if you are feeling bad make you wonder if you are feeling bad?

What if the kids are just more resilient than we think? What if there were protective factors at work that we are unaware of or are disregarding, like the focus of the entire nation on the Gulf Coast? Perhaps there's something strengthening about being part of the greatest natural disaster to ever hit the United States? Didn't Camus say that everything that doesn't kill you strengthens you? Imagine all those who will proudly wear their "I survived Hurricane Katrina" T- shirt.

Not being absolutely sure what I truly believe and not wanting to commit for fear that next week the predicted onslaught of cases would flood-forth, I humorously began asking mental health types the following: "What happens when you send 100 lawyers to the scene of an airplane crash?" "Lawsuits" is the immediate answer. "And what happens when you send 100 mental health workers to the scene of an airplane crash?" They don't like to answer the second question. If they stick around after that, and most don't, then I generally tell them the story of Fred, a 15-year-old patient of mine with diabetes and depression, who I started seeing shortly before Katrina.

As I got to know Fred and his family it was as if a "black cloud" was hanging over them. Each session they'd show up with a new traumatic event that had befallen them. Dad lost his job. Then his sister was hospitalized. Then mom was diagnosed with cancer. Fred responded by becoming more depressed and even more enmeshed with his mother. He began to refuse school and to have the nurses send him home when his blood-sugar numbers went up.

As we were dealing with this, the dark cloud literally intensified as the hurricane struck. I was truly worried about Fred and his family. I could not contact them for weeks. When I finally reached the father, I asked anxiously how Fred was doing. The father answered with a smile: "He's doing great. We evacuated to my relative's house in Texas. There were 35 of us in a three-bedroom house. It drove me nuts, but Fred loved it. He was with his mom and family and didn't have school. He loved it. Now that we're home and he has school on Thursday, I suspect that he won't be so happy."

Fred's response to the hurricane reconfirms for me the tremendous individuality in responses to disasters. For some, it can even be a respite from pre-storm difficulties. As planning continues and my thoughts swirl I am pleased that the kids are doing better than expected. But just in case, I am waiting.

Reference:
1.Terr LC: Childhood traumas: An outline and overview. Am J Psychiatry 1991; 148:10-20.

A version of this article first appeared in the AACAP News, published by the American Academy of Child and Adolescent Psychiatry.


The Brown University Child and Adolescent Behavior Letter, August 2006
Reproduced with permission of John Wiley & Sons, Inc.
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