Disaster Psychosocial Intervention Programme:
A Home-based Disaster Psychosocial Intervention Programme:
Case Study of a School Fire Disaster Victim in India
This paper presents a case study of a 9-year-old girl who sustained 38% burn injuries on the face, back, hands, palms and shoulder and diagnosed with stress disorders three and half months after a school fire tragedy. The key objectives were to: identify harmful psychological reactions and associated behaviour in the child which could have long-term psychiatric implications; administer different play therapy activities to facilitate the ventilation of negative thoughts and emotions; apply and find out the suitability and appropriateness of a 10-days home-based psychosocial intervention program for children who encountered such traumatic life events; discuss the problems with the parents and to provide Psycho-education to them for a speedy recovery process of the child. The child was selected randomly for the pilot testing of the program. Trained disaster psychosocial care professionals applied different play therapy methods to facilitate the ventilation of thoughts and emotions in the child. The home-based intervention spanned for a period of 10 days. The comparison between the pre and post intervention psychological symptoms and behaviour were analysed on Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) validated by Dyregrov and Yule (1995) and Beck Anxiety Inventory (BAI). A significant reduction in psychosomatic symptoms, especially stress and anxiety symptoms was noted at post-intervention/treatment assessment. The mean scores on the IEC and BAI were also minimal. Psycho-education to the parents on the nature and course of stress disorder proved useful in the entire duration of intervention. Parents, neighbours and relatives corroborated the behavioural change in the child observed by the team. Reduced anxiety, apprehension, shyness also validated the intervention. The findings basically highlighted the significance of providing right kind of mental health care services/interventions to alleviate stress and other reactions associated with such traumatic life events encountered by children.
A Home-based Disaster Psychosocial Intervention Programme:
Case Study of a School Fire Disaster Victim in India
Reports of fire disasters in residential and non-residential structures across India remind everyone the horrific images of human sufferings in multifarious ways and more so the intense physical and psychological trauma associated with those incidents. Any fire disaster can spark an excessive fear for the families that suffered from burn injuries or lost family members. Fire disasters place the affected individuals under enormous pressure to cope and adjust effectively under psychologically adverse conditions, failure in which can result in a host of undesirable mental health consequences and impairment of socio-occupational and interpersonal functioning (Desai, et. al., 2000 & Desai, et.al., 2004).
Fire accidents in buildings across India have caused extensive loss of life, limbs and property in the last four decades. In fact, many of these tragic incidents have occurred in Tamil Nadu, a southern Indian state. Fire accident in a Higher Elementary School, Madurai (1964) killed 35 children; Touring cinema tragedy, Tuticorin (1979) witnessed 73 deaths; fire breakout in a Temple, Thanjavur (1997) killed 40 people; fire in a Mental Home, Erwadi (2001) resulted in 28 deaths; and fire in a Marriage Hall near Tiruchi (2004) charred 63 lives are some of the major incidents. Ironically, like in any other disaster, the worst affected in all these fire incidents were the children in terms of number of deaths, injuries and suffering.
Subsequent to the series of tragedies, fire safety measures were made compulsory in marriage and community halls in the state in 2004, with periodic inspection by fire service personnel and local administration. However, the arena was too narrow to include school safety measures in its purview. Consequently, within a couple of months a fire breakout at the Sri Krishna High School in Kumbakonam in Thanjavur district of Tamil Nadu state of India on 16th July 2004 was another incident added to the list. The school (15 feet wide and 115 feet long with a thatched roof) was located in a very congested residential area and did not have a playground for the children. The fire spread outside the hearth oven and further to the thatched roof of the school kitchen (In India there is nation wide programme of providing mid-day meal for children below 14 years of age in govt. and govt.-aided schools. This is part of the national movement in promoting Education For All 2000). The incident resulted in the death of 93 children. Twenty-one children sustained grievous burn injuries with similar pattern of burn areas, mainly affected the upper part of the body. A total of 14 children in the age of 7-10 had around 35-58% of burn injuries.
Review of Literature
The literature on the influence of psychological mechanism and consequences of natural as well as man-made disasters on disaster victims (Bachrach and Zautra, 1985; Gibbs, 1989; Green, 1993) is now corroborated by many others world over. However, while community characteristics and demographic vulnerability factors have received considerable attention (Paton, 1996), psychological vulnerability mechanisms and consequences, especially of fire disasters have been less extensively researched. Findings of a recent study on the impact of a fire on primary victims adolescents, (Broberg, et. al, 2005) reveals that the best psychosocial services for many secondary victims in fire disasters may not be suitable for the primary victims who are suffering from high levels of other types of psychological distress and PTSD. Systematic research studies on adults and children (Green, et. al., 1983 & Shore, et. al., 1986, Broberg, et. al, 2005), revealed proximity to traumatic event and degree of life threat remained as the primary predictors of post-traumatic stress reactions. The plethora of studies on natural disasters is particularly not very inclusive of the literature on the psychological consequences of fire disasters and providing mental health services to fire victims. Moreover, the Indian research on mental health consequences of disasters has primarily focused on natural disasters despite the fact that the worst scars in disasters are often psychological ones, more so in case of fire disasters, which leave the victims with tons of visible deformity and physical impairment. Although years of research have linked PTSD to life threatening (March et.al 1997), uncontrollable and unpredictable stressors (Basoglu, et. al., 2003), and adult victims in natural disasters (Yule, Williams, Joseph, 1999). A significant portion of people exposed to traumatic life events develop severe and prolonged psychological reactions (Canterbury and Yule, 1999), indicating the need and urgency for effective psychological intervention. The study of Yule in 1989 (Yule, 1989) revealed significant psychological impacts of disasters on children.
Therefore, designing and developing age-appropriate intervention models that accommodate all culture-specific factors along with special needs each child victim become the top priority of the mental health care service providers. The intervention program applied here was an attempt to design an age-appropriate and cost-effective home-based program keeping socio-cultural factors and family needs in view.
PARTICIPANT: X, is a 9 years old girl from a low middle class socio-economic background (Indian standard) with a monthly family income of $200-$300. She presented with symptoms of post traumatic stress reactions and other anxiety symptoms that involved reduced appetite, difficulty falling asleep, nightmares, weepiness, profuse sweating, reduced concentration, loneliness, shyness, and fear for social interaction. She described experiencing distressing dreams and anxiety symptoms like sweating on palms and feet, headaches, etc. The parents report revealed that the child keeps herself engrossed in touching the burnt area and shows lot of anxiety and crying regarding her newly acquired physical identity. It was observed that the childs strong feelings and emotions are generally related to the acceptance of her scarred face, disfigured upper limbs, patch of hair loss on her head, her concern about her newly acquired physical identity. The reported anxiety was more to do with her and society’s acceptance (especially friends in school and neighborhood) of this new physical identity.
She is considered as a very good student in fourth standard and is the only child of her parents. X sustained 38% burns on the face, back, hands, palms and shoulder. She was extremely social and very conscious of her physical identity and was popularly known as prettiest girl in the neighbourhood. Her social support network was moderately strong with parents, grandparents (same village) and helping neighbours. She expressed her insecurity, anxiety and apprehension in restarting her education.
MEASURES: The comparison between the pre and post intervention psychological symptoms (clinical as well as observed) and behaviour were analysed. To measure the post-traumatic stress symptoms, a subset of 8 items from the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) validated by Dyregrov and Yule (1995) was used. Seven more items were included later on, which made the total number of items 15 on the IEC scale for children. Both versions are psychometrically sound. Higher score implied more PTS symptoms. The Beck Anxiety Inventory (Beck and Steer, 1993) is a 21 item psychometric tool, focusing on the measurement of intensity of anxiety symptoms during one-week period. The pre and post scores were recorded and the level of anxiety was also assessed at subsequent follow-ups.
PROCEDURE: The intervention was undertaken three and half months after the incident took place. It was found out that no mental health intervention was done either with the child or with her family members. The selection of the child was made randomly from the list of injured children that was received from the District administration. Two trained disaster psychosocial care professionals along with a data recorder applied different play therapy methods to facilitate the ventilation of thoughts and emotions. Toy kits like, miniature animals, crayons, story cards, clay and family of dogs were used during different activities. The mediums and materials used to carryout the play therapy sessions are some of standard methods to facilitate ventilation in children and these methods were previously tested by National Institute of Mental Health and Neuro Sciences (the premier institute of mental health in India) during different natural and man-made disasters in India. However, the structure of the 10 days intensive home-based psychosocial intervention was designed in a totally different way to find out its suitability and appropriateness to deal with such kind traumatic personal life events encountered by children. The parents were also given 7 sessions of psycho-education on the nature of stress and its symptoms the child is undergoing and moreover, how they can facilitate substantially towards her speedy recovery. The role of father to bring back the happiness in his daughter was re-emphasized repeatedly during the session with the intention to reduce the consumption of alcohol during the daytime.
INTERVENTION: SYSTEMATIC COLLECTION OF DATA
Materials used: Set of animal/bird toys, story telling cards, clay dough, family of dogs, drawing set, snake & ladder, playing cards, painting-drawing, candles lighting, etc. Outdoor games (aimed to reduced the fear of social acceptance and to increase the self esteem and social adjustment) such as crocodile in the water, steppy, ring-a-rose, were also tried once each time. Data recording was done through taking down elaborate notes, psychometric tools, tape recording of the conversation and taking photographs.
Activity process and progress: As the child was very withdrawn, shy and less talkative, it took full two-days to establish rapport and be friendly with her. Efforts were made to develop a rapport with her by giving her chocolates, toys, crayons, etc. she likes the most and playing simple indoor games described above. Hint questions like describe about school, her teachers, school friends, (who among your friends likes this game, what are the games you used to play in your schools, who is the teacher encouraging play activities, where do you usually play in the school) etc helped her to start expressing her deep feelings associated with the tragedy. Supportive statement to explain her paintings also helped her to be conditioned with the feeling and to remain easy while describing. As on day-1, she avoided thoughts and feeling related to the trauma, these short of questions helped her to canalise her thoughts and its associated stress reactions. Since her parents were usually involved in the process slowly and steadily she started opening up and actively participated in the activities that were carried out by the team.
On subsequent six days the following activities were carried away with
In the first activity, she was asked to select her favourite animals/birds from a set of 17 animals. Then she was asked to describe and explain why she chose a particular animal/pair of animals, what is that she likes about that animal, and so on. In the second activity, she had to tell a story with the help of story telling cards (similar to TAT). In the third activity, she had to make something out of the colourful clay and explain about her activity. In the fourth activity, she used a set of soft plastic dogs (known as family of dogs). There she had to identify herself with one of the dogs and the others as other family members. Then she had to express their emotions and thoughts in terms a story. Similarly, all other activities were carried out smoothly and the child enjoyed all of them. Relevant and pertinent questions were asked during the activity, which helped her to ventilate her feelings and emotions. All these reactions, thoughts and emotions were immediately recorded then and there to maintain the accuracy and authenticity of information. During last two days of intervention, she was encouraged to play with the children staying nearby. The average duration of interaction and intervention was two and half-hours everyday including the psycho-educational session carried out for the parents. The parents were also actively participated in all activities.
Psycho-education to parents during the intervention regarding how to help and support the child to ventilate and accept the reality, how to boost her confidence by focusing on the strong skills in the child, how to encourage the outdoor games between child-friends in neighbourhood, and how to provide a better family environment was also important for the intervention as involvement of parents and with parents was essential for better results as well as a great help in recording the reported developments.
Clinical symptoms: IEC was again administered on the last day to check the accuracy of reduced clinical symptoms found with the victims towards the end of the intervention. The mean score was 23 as compared with 41, which again supported the observation of childs overall behavior and reactions over a period of ten days. She received a pre-intervention BAI anxiety score of 34 and a post-intervention score of 12.
The observations were recorded daily to study the pattern of change in
the thoughts, emotions and behaviour of the child.
Appetite was improved and as reported by parents, was near normal on the sixth day. Nightmares were stopped in last 5-days of intervention and the problem in difficulty in falling sleep was remarkably improved as reported by her parents. Anxiety towards social rejection and adjustment problems were reduced as reported by the child as well as her close family members. Parents reported that her concentration on touching the scarred parts of her body and weeping was reduced. The child showed keen interest in talking with the team members on day two and to her friends in her neighbourhood on day fifth, which meant reduction in shyness and fear of social rejection. Sweating (during the description of the incident) was stopped on day seventh. Earlier behaviour of social withdrawal was reduced significantly by day six. It was reported by the parents that she now has a strong desire to move around, sit outside the house, talk to the friends passing by and visit to her good friends in the neighbourhood. She appeared happier, cheerful and forthcoming, and showed lot of enthusiasm in the activities taken after day-seven and eight. She was comfortable in talking to her friends and was happy that she does not have any adjustment problems with her friends. She also viewed that none of her friends find any difficulty in playing with her. It was also observed that her overall state of happiness and activeness had increased. Parents also reported that she had started talking to other kids and some typical behaviour associated with the burn scars like, frequently looking at the mirror and body parts were also reduced, to a reasonable extent.
Her hesitance towards restarting the school was also reduced significantly.
The follow up after two months revealed the scores on IEC and BAI as 5 and 4. Her social network as well as general well being had reportedly increased.
This ten-days home-based psychosocial intervention package was received and responded well by the child as well as the family perhaps because of amount of time and privacy and independency provided to them to deal with negative thoughts and reactions. Psycho-educational sessions to the parents contributed towards childs overall emotional and behavioural change by canalizing her emotions and thoughts associated with the incident in a right way during the rest of hours in the family. As everyday some activities used to undertaken and parents were actively engaged, this checked the alcohol consumption of father during the daytime, as reported by childs mother and grand parents. This also facilitated in creating and promoting a healthy family environment. This finding also lends its support from the studies reporting a strong casual relationship between greater social support and lower psychological distress (Mc Farlane, 1987) and strong social support protects against development of physical and mental health problems (Yule et. al, 1999).
Analysis of the findings revealed that there was a remarkable reduction in the exhibition of psychosomatic symptoms, especially stress and anxiety symptoms in the post-intervention assessment both clinical and observational. The mean scores on the IEC and BAI scale were also minimal, which indicated reduction in PTSS. Parents, neighbours and relatives corroborated the behavioural change observed in the child. The design adopted for the intervention programme was found be very appropriate to deal with children encountering disasters like tragic fire incidents. However, this needs to be tested in similar cases to validate the results and its wider applicability.
The findings essentially highlighted the importance of mental health services
and specially designed home-based intervention programmes for children faced
with major fire incident. The suggestive measures from the case analysis included
planned psychosocial intervention to alleviate clinical symptoms of post-traumatic
stress symptoms, anxiety and co-morbid conditions. Conducting play therapy activities
for the child victim in socio-culturally sensitive manner and series of psycho-education
for the family members in the same intervention programme could restore normalcy
in the child to a maximum possible extent. This finding highlighted the importance
of treating disasters affected children in a need-based manner while planning
In an Indian context one needs to look at the following suggestions. Providing mental health services is still to be incorporated in the main primary health care system in India, though the National Health Policy, 2002 of Government of India stressed more on the integration physical and mental health at the district level (District Mental Health Scheme) the implementation needs to be pursued in a more vigorous manner.
Firstly, family counseling should be a compulsory part of the rural primary
health care services. These services should not only aim to alleviate the stress
of the injured child but also should target to foster and promote positive metal
health amongst these victims. Institutionalisation of the scheme would perhaps
check the long-term psychiatric complications of such tragic life events.
Secondly, introducing counselling in schools, where such children are relocated might help them to understand their emotions, canalise their emotions in the right direction, learn strategies to overcome the stressors, raise their physical self-esteem and self-efficacy and finally, to reshape their self-confidence and overall personality development.
Finally, including professional mental health care givers (not the psychiatrist only) in each emergency pre-hospital health care programme for the initial months could also be a feasible option. However, careful follow-ups with a regular and need-based approach need to be ensured, which is only possible through established primary health care facilities available to the communities during pre-disaster phase. Disaster-specific health management for children during response and rehabilitation phase must consider socio-cultural and psychological consequences and accommodate differences within communities. Qualitative results could be accentuated only if disaster mental health is integrated within the local primary health care services.
Children encountered such personalized traumatic life events need special psychosocial care and services on a regular basis. The ad hoc-approaches to deal with the issue need to be converted into a sustainable institutional mechanism to provide sustainable support to these victims, especially people from low/middle socio-economic status who may not be able to afford institutional service facilities.
The intervention model was found to be very effective given the need for speedy recovery to normalcy and highlighted the significance of such programmes to check the psychological morbidity that can go un-noticed after such small-scale incidents (unlike natural disasters where number of victims are in thousand) in developing countries, like India. Since, the study is based on isolated single case, the findings cannot be generalised. The present design of the intervention programme also needs to be replicated on similar types of disasters to generalise the findings and enhance its wider applicability. The future research could focus on the difference between the results of home-based vs. institutional (any set up out side the home of the victim) intervention package. Future studies can also look at the influence and impact of socio-economic status of family and impact of family environment on such intervention package.
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Massey University, New Zealand
November 14, 2007