February 2011 Prehospital and Disaster Medicine
Persistence of Mental Health Needs among
Children Affected by Hurricane Katrina
in New Orleans
Alina Olteanu MD, PhD;1,2 Ruth Arnberger, MSW, GSW;2 Roy Grant, MA;3
Caroline Davis, MPH;2 David Abramson, PhD;4 Jaya Asola, MD5
1. New Orleans Children’s Health Project,
New Orleans, Louisiana USA
2. Tulane School of Medicine, New
Orleans, Louisiana USA
3. Children’s Health Fund, New York,
New York USA
4. National Center for Disaster
Preparedness, Columbia University
Mailman School of Public Health,
New York, New York USA
5. Department of Global Health and Social
Medicine, Harvard Medical School,
Boston, Massachusetts USA
Roy Grant, MA
Children’s Health Fund
215 West 125th Street, Suite 301
New York, NY 10027 USA
Keywords: children; Hurricane Katrina;
mental health; New Orleans; post-disaster
ADHD = attention deficit hyperactivity
ODD = oppositional defiant disorder
Received: 01 June 2010
Accepted: 09 June 2010
Background: Hurricane Katrina made landfall in August 2005 and destroyed the infra-
structure of New Orleans. Mass evacuation ensued. The immediate and long-lasting impact
of these events on the mental health of children have been reported in survey research.
This study was done to describe the nature of mental health need of children during the
four years after Hurricane Katrina using clinical data from a comprehensive healthcare
program. Medical and mental health services were delivered on mobile clinics that traveled
to medically underserved communities on a regular schedule beginning immediately after
the hurricane. Patients were self-selected residents of New Orleans. Most had incomes
below the federal poverty level and were severely affected by the hurricane.
Methods: Paper charts of pediatric mental health patients were reviewed for visits begin-
ning with the establishment of the mental health program from 01 July 2007 through
30 June 2009 (n = 296). Demographics, referral sources, presenting problems, diagno-
ses, and qualitative data describing Katrina-related traumatic exposures were abstracted.
Psychosocial data were abstracted from medical charts. Data were coded and processed for
demographic, referral, and diagnostic trends.
Results: Mental health service needs continued unabated throughout this period (two to
nearly four years post-event). In 2008, 29% of pediatric primary care patients presented
with mental health or developmental/learning problems, including the need for inten-
sive case management. The typical presentation of pediatric mental health patients was
a disruptive behavior disorder with an underlying mood or anxiety disorder. Qualitative
descriptive data are presented to illustrate the traumatic post-disaster experience of many
children. School referrals for mental health evaluation and services were overwhelmingly
made for disruptive behavior disorders. Pediatric referrals were more nuanced, reflecting
underlying mood and anxiety disorders. Histories indicated that many missed opportuni-
ties for earlier identification and intervention.
Conclusions: Mental health and case management needs persisted four years after
Hurricane Katrina and showed no signs of abating. Many children who received mental
health services had shown signs of psychological distress prior to the hurricane, and no
causal inferences are drawn between disaster experience and psychiatric disorders. Post-
disaster mental health and case management services should remain available for years
post-event. To ensure timely identification and intervention of child mental health needs,
pediatricians and school officials may need additional training.
Olteanu A, Arnberger R, Grant R, Abramson D, Asola J: Persistence of mental health
needs among children in New Orleans affected by Hurricane Katrina four years later.
Prehosp Disaster Med 2011;26(1):3–6.
Hurricane Katrina made landfall along the US Gulf Coast on 29 August 2005, breaching
the levees that protected New Orleans and flooding 80% of the city with water up to
25 feet deep. Katrina was followed by Hurricane Rita, which hit the Gulf Coast on
23 September 2005. New Orleans’ infrastructure was disrupted, rendering parts of
the city virtually uninhabitable. Especially affected were lowest-lying areas that had
been home to the city’s poorest, predominantly African-American residents.1 The city’s
healthcare infrastructure was decimated. All but 19 of the 90 pre-hurricane primary care
safety net clinics in New Orleans closed,2 and the major provider of care to the city’s
poor and indigent, the Charity Hospital system, was destroyed.3
4 Persistence of Mental Health Needs
Prehospital and Disaster Medicine Vol. 26, No. 1
Mental health needs among children referred for evaluation and
intervention were presented at a similar prevalence and intensity
during the period covered by this study (from two years to nearly
four years post-event). Mental health problems could be char-
acterized as predominantly disruptive behavioral disorders with
underlying mood and anxiety disorders.
The demographics of the population changed significantly dur-
ing this period. The percentage of Hispanic patients increased and
the percentage of African-American and white patients decreased
(p <0.01). Age and gender distribution did not change signifi-
cantly. Patient demographic characteristics are detailed in Table 1.
In 2007, 37% of pediatric primary care patients had a psy-
chosocial (developmental, mental health, or family) problem that
required intervention. Housing was a major issue. Ninety-four
percent of the children and families receiving mental health ser-
vices reported having been dislocated by Hurricane Katrina, and
32% were unstably housed. Case management was essential to
help families navigate the often bewilderingly complex maze of
local, state, and federal assistance programs.12,13 Fifty-five per-
cent of pediatric patients receiving mental health services were
referred for psychiatric evaluation. Most met diagnostic criteria
for attention deficit hyperactivity disorder (ADHD) or opposi-
tional defiant disorder (ODD);14 however, most also had underly-
ing or co-morbid mood, stress, and/or anxiety disorders. In many
cases, their degree of agitation and disruptive behavior was such
that psychotropic medication, typically stimulants sometimes in
combination with adrenergic agonists, was required. Two chil-
dren were diagnosed with pervasive developmental disorder and
one with chronic tics. Several children referred for school behav-
ior problems were diagnosed with a learning disability.
The nature of traumatic exposures experienced by children
referred for mental health services is reflected in qualitative data
abstracted from the 2007 mental health charts. Selected case
vignettes are in Table 2.
In 2008, psychosocial issues in the primary care practice
remained high at 29%. Nearly one in four (24%) mental health
patients was in unstable housing, and 92% had been displaced from
their home. About half of these patients had been referred from
their school, predominantly for disruptive behavior problems.
During 2009, housing stability improved; however, present-
ing problems and diagnostic profiles of pediatric mental health
patients were similar to those in previous years. On the mental
health mobile clinic, the most prevalent primary diagnoses in
2009 were ADHD, ODD, and conduct disorders (71%); 29%
had primary mood or anxiety disorders including two cases of
post-traumatic stress disorder (PTSD). In 2009, a higher per-
centage of referrals related to family problems, including domes-
tic violence, separation, and divorce, was noted.
Aggregate data for 01 July 2007 through 30 June 2009 show
a significant difference emerged in the presenting problem based
on referral source. Referrals from school officials were 84% for
externalizing problems (disruptive behavior, short attention,
In April 2006, it was estimated that 110,000 children in New
Orleans, 85% of the population <18 years old, had left the city.4
Studies documented the immediate and ongoing health and
social needs of displaced and affected individuals in the Gulf
Coast post-event.5–7 A longitudinal, cohort study of randomly
sampled displaced and impacted households showed that one
year post-Katrina, 44% of Louisiana parents reported that at
least one child in their household was experiencing new-onset
behavioral or emotional problems.7,8
Days after Hurricanes Katrina and Rita, Children’s Health
Fund began a disaster-relief healthcare program using mobile
clinics to bring health care to children and families in the most
affected areas of New Orleans. A partnership was established
with the Tulane University School of Medicine, and the pro-
gram evolved into an integral part of the city’s safety net provid-
ing comprehensive health care in a medical home model9 using
mobile clinics. Medical services were supplemented by a mobile
mental health clinic beginning in July 2007 that was staffed by
an inter-disciplinary team of two clinical social workers, a clini-
cal counselor, and a part-time psychiatrist. Since few communi-
ty-based mental health services were available after Katrina,10
the mental health clinic almost immediately began to receive
school and community referrals, as well as referrals from the
primary care practice.
The clinical needs of pediatric patients of the mobile mental
health clinic from its inception in July 2007 through June
2009 are described. The study was conducted by a manual,
retrospective review of paper mental health charts for all
patients <22 years of age (n = 296). Data points included
date of birth, gender, race/ethnicity, insurance status, referral
source, presenting problem, and diagnoses. Age was calcu-
lated as of June 30 of the calendar year of first visit. Parent
reports of post-Katrina dislocation from the home and cur-
rent housing status were recorded. Housing was considered
“stable” if the family owned or rented an apartment or house,
and “unstable” if the family was domiciled in a homeless
shelter, trailer, or hotel, or was doubled up with relatives or
friends. Qualitative data descriptions of patient experiences
relative to Hurricane Katrina were recorded from histories
taken as part of mental health evaluations. Psychosocial
data also were abstracted from patient medical charts. Data
were entered in Excel spreadsheets then were coded into cat-
egorical and dichotomous variables as appropriate for analysis
in SPSS (Version 15.0, SPSS, Inc., Chicago, IL). Analyses
were primarily descriptive (frequencies, cross-tabs with
chi-square analysis). Pediatric patients who arrived with
their families into New Orleans after Hurricane Katrina11
Tulane University School of Medicine Institutional Review
Board Protocol 140664-1, “New Orleans Children’s Health
Project Retrospective Chart Review” applies to this study.
MaleMean AgeMedicaid or CHIPUninsuredAfrican-AmericanHispanicWhite
64%9.5 years 71%16%55%15% 27%
Olteanu © 2011 Prehospital and Disaster Medicine
Table 1—Patient characteristics (n = 296; CHIP = State Children Heatlh Insurance Program)
Olteanu, Arnberger, Grant, et al 5
February 2011 Prehospital and Disaster Medicine
hyperactivity) and 16% for internalizing (mood and anxiety)
problems. By comparison, referrals from pediatricians were more
nuanced; 38% were for externalizing and 62% for internalizing
problems (p <0.01). Externalizing presenting problems also were
significantly associated with referred males (81% vs. 59% female;
p <0.01), and with unstable housing (78% vs. 63%; p <0.05).
Sixty-nine percent of children referred from their schools were
male. Displaced status was not significantly associated with type
of presenting problem; it was ubiquitous in the population.
Relationship to Other Studies
The persistence of mental health problems among children and
youth in the years following Hurricane Katrina described in
this study is consistent with other findings.15 Data from pro-
grams providing federally funded disaster mental health services
(“crisis counseling”) up to 18 months post-Katrina indicated the
persistence of need and atypically slow rate of recovery from
disaster-related psychological distress after Hurricane Katrina.16
A study using the Strengths and Difficulties Questionnaire found
continuing symptoms consistent with psychiatric disorders in met-
ropolitan New Orleans two years post-Katrina. Most were con-
sidered hurricane-related.17 Survey data from children two years
after the hurricane show that the most prominent predictors of
the need for mental health services were displacement, separations
from caregivers, and adverse shelter experiences,18 all of which
were seen in the current study population. The trauma histories
described by these patients are consistent with those described in a
2009 study funded by the National Institute of Mental Health.19
Representativeness of the Sample
By design, the mobile clinic program served the high-risk and
medically underserved communities most affected by Hurricane
Katrina. Since Hurricane Katrina disproportionately impacted
populations already experiencing health disparities and inad-
equate access to care, this population is considered to be rep-
resentative of children most affected by Hurricane Katrina, but
not of all children in New Orleans, or more generally, children
affected by disasters in other locations.
While the population studied was limited to a single pedi-
atric practice, data suggest that the findings are consistent with
city-wide trends. After Hurricane Katrina, New Orleans school
officials reported being overwhelmed by new-onset behavioral
problems in their students.20–22 At Louisiana school-based
health centers during the 2007–2008 school year, mental health
was second only to general preventive medicine as the reason
care was sought.23
Implications for Practice
The data regarding referral trends are consistent with findings
in other studies, e.g., from a system of mental health care in
East Baltimore that found that school referrals predominantly
were male and presented with physical aggression and attention
deficits.24 The higher percentage of referrals of children with
mood and anxiety symptoms from health care rather than school
settings suggests that pediatric providers may be better equipped
to elicit these more difficult to detect symptoms or that parents
and children may be more likely to disclose these symptoms in
a primary care setting. However, studies of pediatrician knowl-
edge of mental health conditions after the terrorist attacks of
11 September 2001 showed that pediatricians may require addi-
tional training to identify internalizing disorders.25,26
Many children had serious signs of psychopathology, includ-
ing fire setting and animal cruelty, before becoming patients of
this mobile clinic program and being referred for mental health
services. In terms of post-event mental health planning, it is
important that pediatricians and other primary care providers
become better able to target children for referral and interven-
tions based on “red flag” indicators that differentiate those in
urgent need from children with typically occurring responses to
atypically stressful situations.27
A pre-disaster baseline for child mental health status was not avail-
able. As the program was created post-Katrina, there was no access
to the population to assess service needs prior to the hurricane. No
causal connection between specific traumatic exposures and diag-
nosed psychiatric disorders should be inferred from these data.
Another limitation is the nature of the data. The mental health
conditions and traumatic exposures described were derived from
chart review of a mental health-referred population. All data were
recorded in the context of clinical care delivery rather than a struc-
tured research protocol. Standardized diagnostic tests were not
used. Diagnoses were determined in the clinical setting by expe-
rienced clinicians according to DSM-IV-TR criteria. However, in
! An eight-year-old boy had been evacuated from floodwaters
where he witnessed dead bodies floating by. He had
persistent school problems while living in a Texas
homeless shelter. After resettling in New Orleans, he was
referred because of disruptive behavior in school.
! A four-year-old girl who had been evacuated from New
Orleans prior to the storm was separated from her parents
for several weeks, during which details of her situation were
unclear. She was referred from her preschool as an
alternative to expulsion after she was reunited with her
homeless family. It emerged that she recently had been
prevented from setting her doll on fire.
! Mental health referrals from pediatricians included a
five-year-old with sleep disorder and panic attacks whose
apartment and possessions were destroyed in the
hurricane, and a four year old whose mother had died the
year before the hurricane. Post-Katrina, she had nightmares
and regressed functioning, and was diagnosed with PTSD.
! A seven-year-old girl was rescued from the floodwaters by
boat and placed in a shelter apart from her family. She had
multiple cigarette burns when reunited with her family. In the
first two years after the storm, she attended five different
schools. Her symptoms included enuresis, hyperventilation,
and self-injurious behavior. She was diagnosed with PTSD.
! A seven-year-old previously diagnosed with PTSD following
an automobile accident had spent five days after the
hurricane in a hospital building without adequate food and
water. He was evacuated to two different states. When he
returned to New Orleans, he presented with nightmares
and a depressive disorder.
! Other features of this referred population included animal
cruelty, multiple school expulsions, and fighting that required
Olteanu © 2011 Prehospital and Disaster Medicine
Table 2—Case vignettes from 2007 mental health patients
(PTSD = post-traumatic stress disorder)
6 Persistence of Mental Health Needs
Prehospital and Disaster Medicine Vol. 26, No. 1
and families who were directly affected by the event. For this
high-risk population, psychosocial and psychiatric problems
persisted after living conditions stabilized and periods of home-
lessness and dislocation resolved. As a matter of public health
policy, mental health and case management services should con-
tinue to be made available to affected populations for years after
an event such as Hurricane Katrina.
most cases, diagnoses were confirmed by at least two differently
credentialed mental health professionals; e.g., a psychiatrist and a
licensed clinical counselor, thus minimizing possible bias.
Mental health needs persisted in New Orleans for at least four
years after Hurricane Katrina among the vulnerable children
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