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The American Journal of Family Therapy, 36:79–93, 2008
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926180601057598
Counseling Children After Natural Disasters:
Guidance for Family Therapists
JENNIFER BAGGERLY and HERBERT A. EXUM
University of South Florida, Tampa, Florida, USA
After natural disasters, most children exhibit typical symptoms,
which can be mitigated when parents and teachers provide emo-
tional support and facilitate adaptive coping strategies. However,
some children may experience clinical symptoms, which require
professional counseling. This article guides family therapists in (a)
identifying children’s typical and clinical symptoms after a natural
disaster, (b) training parents and teachers in basic interventions,
and (c) implementing developmentally appropriate clinical inter-
ventions that integrate play. A multimodal, three-phase approach of
Cognitive Behavior Therapy, Play Therapy, and Family Play Ther-
apy is described.
COUNSELING CHILDREN WHO HAVE SURVIVED
NATURAL DISASTERS
Natural disasters are a persistent threat to families in North America. In 2005,
the Federal Emergency Management Agency (FEMA, 2006) declared 48 fed-
eral disasters such as hurricanes, tornados, floods, and fires. The most promi-
nent natural disaster of 2005, Hurricane Katrina, was identified as the costliest
hurricane in United States history with over $81 billion in damage and the
deadliest in 77 years with approximately 1,833 fatalities (Knabb, Rhome, &
Brown, 2005). A 70% increase in U.S. major disasters has occurred in the
last decade from 319 disasters between 1986 and 1995 to 545 disasters be-
tween 1996 and 2005. Unfortunately, scientists are predicting high numbers
of storms in the next ten years (National Oceanic and Atmospheric Adminis-
tration [NOAA], 2006). These natural disasters will cause fear and disruption
in the lives of countless children and families.
Address correspondence to Jennifer Baggerly, University of South Florida, 4202 E. Fowler
Ave., EDU162, Tampa, FL 33620. E-mail: Baggerly@tempest.coedu.usf.edu
79
80 J. Baggerly & H. A. Exum
During natural disasters, children are one of the most vulnerable popu-
lations because their neuro-physiological systems are subject to permanent
changes and their coping skills are not developed enough to manage catas-
trophic events (Perry, Pollard, Blakely, Baker, & Vigilante, 1995; Speier, 2000).
Most children exhibit typical, temporary symptoms during and after disasters;
yet these symptoms can be mitigated when parents and teachers provide
emotional support and facilitate adaptive coping strategies. However, some
children may experience clinical symptoms, which require developmentally
appropriate counseling interventions that integrate play (Baggerly, 2004b,
2004c).
Family therapists must be prepared to provide developmentally appro-
priate interventions to children who experience distress after natural dis-
asters. However, the literature for family therapists on this topic is sparse.
Miller (1999) described treatment for Post-Traumatic Stress Disorder (PTSD)
for children and families but does not incorporate developmentally appro-
priate approaches of play. Wittenborn, Faber, Harvey, and Thomas (2006)
discussed integrating play therapy techniques into family therapy but did not
address natural disasters. The purpose of this article is to guide family thera-
pists in (a) identifying children’s typical and clinical symptoms after a natural
disaster, (b) training parents and teachers in basic interventions, and (c) im-
plementing developmentally appropriate clinical interventions that integrate
play. A multimodal, tri-phase approach of Cognitive Behavior Therapy, Play
Therapy, and Family Play Therapy is described.
TYPICAL SYMPTOMS OF CHILDREN AND ADOLESCENTS
Children’s typical symptoms after natural disasters include fear, depression,
self-blame, guilt, loss of interest in school and other activities, regressive be-
havior, sleep and appetite disturbance, night terrors, aggressiveness, poor
concentration, and separation anxiety (Speier, 2000). However, symptoms
vary from minimum to severe based on a child’s developmental level, per-
sonal experiences, emotional or physical health, and the responses of par-
ents to the incident (Vogel & Vernberg, 1993). For children 5 years old
and younger, typical symptoms include separation anxiety, excessive cling-
ing, crying, whimpering, screaming, and regressive behavior such as thumb
sucking and fear of the dark (National Institute for Mental Health, [NIMH],
2001). For children 6 to 11 years old, typical symptoms include extreme
withdrawal, increased fighting and aggression, hyperactivity and inattentive-
ness, irrational fears, irritability, sleep disruption, school refusal, complaints
of stomachaches, and emotional numbing (NIMH, 2001). For adolescents 12
to 17 years old, typical symptoms include flashbacks, nightmares, emotional
numbing, avoidance of reminders of the trauma, substance abuse, and de-
pression (NIMH, 2001). They may also experience headaches, stomachaches,
Counseling After Natural Disasters 81
risk-taking behaviors, lack of concentration, decline in responsible behavior,
apathy, and rebellion at home or school.
CLINICAL SYMPTOMS OF CHILDREN AND ADOLESCENTS
Although many children will recover from these typical symptoms with basic
family and school support after a natural disaster, some children experience
ongoing symptoms that disrupt their daily functioning. Vernberg, LaGreca,
Silverman, and Prinstein (1996) found 55% of elementary school children
in their study exhibited moderate to very severe symptoms three months
after Hurricane Andrew. In contrast, McDermott, Lee, and Judd (2005) found
22.6% of children in their study had abnormally high emotional symptoms
six months after exposure to a wildfire disaster.
Children’s clinical symptoms may result in a diagnosis of Acute Stress
Disorder (ASD), Post Traumatic Stress Disorder (PTSD), other anxiety disor-
ders, or depression disorders. Indicators of childhood PTSD include the fol-
lowing symptoms that persist longer than 30 days after the event: persistent
re-experiencing of the event through intrusive memories, frightening dreams
(with or without recognizable content), repetitive play in which themes or
aspect of the disaster are expressed, increased arousal such as irritability or
hypervigilance, and avoidance of things related to the disaster (American Psy-
chiatric Association, 2000). Rates of PTSD in children after natural disasters
vary. Evans and Oehler-Stinnett (2006) found 41% of children in their study
who experienced a severe tornado had PTSD symptoms that meet DSM-IV-
TR criteria. Vernberg et al. (1996) found 30% of children in their sample who
experienced Hurricane Andrew had severe symptoms of PTSD. Conversely,
Shannon, Lonigan, and Finch (1994) found 5% of 5,687 school-aged children
surveyed who experienced Hurricane Hugo met criteria for PTSD.
Children’s development of PTSD is influenced by the following five fac-
tors: (a) exposure to traumatic events during and after the disaster, (b) pre-
existing demographic characteristics, (c) occurrence of major life stressors,
(d) availability of social support, and (e) type of coping strategies used to
manage disaster-related stress (Vernberg et al., 1996). These researchers also
found that children’s symptoms persisted due to interactions between daily
life hassles and the severity of the disaster, stressful life events, e.g., parent’s
divorce or loss of employment, and loss of support from overburdened com-
munity systems and schools. In addition, McDermott, Lee, and Judd (2005)
found that younger children and children with higher levels of exposure and
threat had higher prevalence of PTSD than older children and children with
lower levels of exposure and threat.
When diagnosing children, counselors should ask parents, other rela-
tives, and teachers whether children’s behaviors would be considered “nor-
mal” for a given child prior to the disaster. To assess the impact of trauma
82 J. Baggerly & H. A. Exum
in children, Ohen, Myers, and Collett (2002) suggest several different assess-
ments. When a diagnosis of PTSD is the goal, they suggested the clinician-
administered scales of the Children’s PTSD Inventory [CPTSDI] (Saigh et al.,
2000) or the Clinician-Administered PTSD Scale for Children [CAPS-C] (Nader
et al., 1996). If clinician administered assessments are too time consuming,
then Ohen et al. (2002) recommended the self-reported Child PTSD Symp-
tom Scale [CPSS] (Foa, Johnson, Feeny, & Treadwell, 2001) for a quick first
screen or the culturally sensitive Children’s PTSD-Reaction Index [CPTS-RI]
(Frederick & Pynoos, 1998) or the Impact of Event Scale-Revised [IES-R] (Weiss
& Marmar, 1996). The Trauma Symptom Checklist for Children – Alternative
[TSCC-A] (Briere, 1996) assesses for trauma and more general psychopathol-
ogy, which provides for helpful follow along over time. For younger chil-
dren, the Angie/Andy Cartoon Trauma Scales [ACTS] (Praver, DiGiuseppe,
Pelcovitz, Mandel, & Gaines, 2000) for ages 6 to 12 or the Pediatric Emo-
tional Distress Scale [PEDS] (Saylor, Swenson, Reynolds, & Taylor, 1999) for
ages 2 to 10 were recommended. Since accurately diagnosing children with
PTSD is very difficult due to their limited cognitive and expressive skills
(Cohen, Berliner, & March, 2000), counselors are advised to provide treat-
ment even if symptoms do not meet a formal diagnosis of PTSD.
PARENT AND TEACHER INTERVENTIONS
Due to the large number of children that will experience typical symptoms
after a natural disaster, family therapists can maximize their efforts by train-
ing parents and teachers to provide supportive responses and basic inter-
ventions for their children (Harper, Harper, & Stills, 2003). In a study by
Wolmer, Laor, Dedeoglu, Siev, and Yazgan (2005), children exposed to the
1999 earthquake in Turkey who received teacher led interventions had sig-
nificantly higher functioning compared to a matched control group. These
researchers concluded that teachers may become efficient clinical mediators
due to the central role in the lives of children. Parents also play an important
role in their children’s recovery because children take their cues on how to
respond to the disaster from their parents (FEMA, 2004a). If parents are out of
control of their feelings and behavior, then children will feel more helpless
and scared. If parents are appropriately upset but maintain optimism and
control of their feelings and behavior, then children will feel more secure.
Therefore, it is important to teach parents and teachers how to maintain a
non-anxious presence by enacting self-soothing strategies such as relaxing
their body (Rank & Gentry, 2003).
Family therapists should help parents and teachers focus on maximiz-
ing children’s protective factors of good communication skills, strong self-
efficacy, and positive coping skills (Vernberg et al., 1996). To maximize
good communication skills, encourage parents and teachers to schedule
Counseling After Natural Disasters 83
regular times to talk with their children about their emotions, concerns,
and plans for the future. Since young children may not be able to verbal-
ize their feelings, other communicative modes, e.g., playing, drawing, or
singing, may be more effective (Webb, 2004). Coloring books and free flow
drawings are also useful ways for children to express themselves (Corder
and Haizlip, 1996). A hurricane coloring book that helps children express
their own story, feelings, thoughts, and behaviors is available on the web at
http://www.state.sc.us/dmh/schoolbased/hurricane.htm . A parent and child
coping workbook, entitled After the Storm (La Greca, Sevin, & Sevin, 2005),
also offers playful activities.
To maximize children’s sense of self-efficacy, parents and teachers
should reassure children that symptoms of nightmares, crying, etc. are typical
and usually temporary. Providing a handout of typical children’s cognitive,
emotional, physiological, behavioral, and spiritual symptoms will help par-
ents and teachers focus on the normalcy of children’s responses, rather than
seeing them as pathological. (Please see Figure 1). Children’s self-efficacy
can also be enhanced by quickly re-establishing a routine that is stable and
manageable (FEMA, 2004a). During the early phases of a natural disaster
the normal rules, expectations, and responsibilities at home and at school
are usually relaxed (Haizlip, 1999). However, parents and teachers should
remember that they do need to reestablish normal structure as much as
possible. For example, parents could re-establish routines of reading bed-
time stories or saying nightly prayers to comfort and reassure their children.
Teachers can resume regular classroom routines of readings, projects, and
limited homework. In addition, parents and teachers can promote children’s
self-efficacy by encouraging them to participate in social and school activities
as well as community rebuilding activities.
Parents and teachers should help children identify or learn positive cog-
nitive, emotional, physiological, behavioral, and spiritual coping strategies
that fit their unique coping style (Please see Figure 2). Felix, Bond, and
Shelby (2006) recommend playing a game of “Go Fishing for Coping Skills”
in which children discern adaptive from maladaptive coping skills by match-
ing categories of cards with adaptive coping skills and discarding maladap-
tive coping skills. For teenagers, positive coping strategies will include group
interventions that process emotions through expressive arts, drama, and rap-
ping/singing. Teens can also write letters to encourage survivors, first respon-
ders, and political leaders and participate in recovery efforts such as cleaning
apark or reading to younger children.
Disturbing Dreams
Counselors may need to train parents and teachers how to respond to their
children’s disturbing nightmares related to the natural disaster. Younger chil-
dren’s dreams related to the distressing event may change into generalized
84 J. Baggerly & H. A. Exum
FIGURE 1 Normal things that happen to normal kids after something scary.
nightmares of monsters or of rescuing others. Children in middle to late
childhood are more likely to experience sleep disturbances as they begin to
understand the finality of loss (NIMH, 2001).
To help children effectively process disturbing dreams, parents and
teachers can learn Dahlen’s (1999) Traumatic Dream Defusing Process
(TDDP) of creating a safe sleeping environment and giving voice to spe-
cific details, feelings, and thoughts from the dreams. Parents and teachers
help children defuse the strength of the dream and regain sense of control
by helping them record the dream in a journal. For younger children, par-
ents and teachers encourage children to draw or color their dreams and then
bury them in a structured ceremony. This symbolic burial gives children the
power to bring an end to the significance of the dreams. Another method is
Counseling After Natural Disasters 85
FIGURE 2 Things you can do to feel better.
to ask children to blow their fearful dreams into a balloon and then release
the inflated balloon. This activity helps children feel more in control as they
see their dreams disappear.
COUNSELING INTERVENTIONS
For children who experience typical symptoms after a natural disaster, fam-
ily counselors should provide parent and teacher consultation as described
above along with supportive counseling, crisis intervention, and resources
and referrals to meet basic needs (Harper et al., 2003). However, if children
continue to experience persistent symptoms that disrupt their functioning
weeks after the natural disaster is over, then more intensive counseling is war-
ranted. Herman (1997) recommends a three phase trauma recovery approach
of (a) establishing safety, (b) retelling the trauma story, and (c) reconnecting
86 J. Baggerly & H. A. Exum
with others. When working with children after natural disasters, we recom-
mend applying Herman’s approach via a multimodal three-phase approach as
follows: (a) establish safety and manage symptoms through Cognitive Behav-
ior Therapy, (b) facilitate the child’s retelling of their trauma story through
play therapy, and (c) reconnect the child with others through family play
therapy.
Cognitive Behavioral Therapy
Cognitive Behavior Therapy (CBT) has been proven to decrease children’s
symptoms related to ASD, PTSD, other anxiety disorders, and depression
(Cohen et al., 2000; Compton et al., 2004). When working with children after
natural disasters, CBT procedures that incorporate play therapy techniques
can be used to establish safety and manage symptoms (Knell, 2000; Shelby,
2000). To increase children’s sense of safety, family therapists should create a
child friendly environment by providing toys. In addition to inviting children
to play with the toys, family therapists can ask children to (a) play a game
of identifying indicators that they are safe at the present time, (b) draw a
picture of a safe place, and (c) develop a safety plan for future disasters.
To manage hyper-arousal symptoms, family therapists can teach children
self-soothing relaxation techniques to calm their bodies and deactivate their
“fight or flight response” (Perry et al., 1995). These procedures include (a)
taking deep breathes through playful activities such as blowing soap bubbles
or pinwheels; (b) progressive muscle relaxation by tensing muscle groups
like a toy soldier and relaxing like a rag doll; and (c) focusing on positive
images by drawing happy places, engaging in mutual story telling with a
positive ending, or meditating on peaceful places (Baggerly, in press).
Family therapists should teach children methods of managing intrusive
thoughts of disaster related events that are encoded in their implicit memory
(Perry et al., 1995). These procedures include (a) “changing the tape” by
replacing negative thoughts with a predetermined positive song, story, or
saying such as “I’m safe right now and I know it because I have . . .” and (b)
grounding activities such as rubbing stomach and hands together (Shelby,
Bond, Hall, & Hsu, 2004). Family therapists can also amend Baranowsky,
Gentry, and Schultz’s (2005) 5-4-3-2-1 sensory grounding and containment
procedure by asking children to play a 3-2-1 game. For this game, ask children
to identify three objects above eye level, three sounds everyone can hear,
and three things they can touch; then two things they see, hear, and touch;
followed by one thing they see, hear, and touch.
To help children manage avoidance of disaster related stimuli, family
therapists should implement systematic desensitization procedures of pairing
relaxation with a step-by-step hierarchy of exposure to the stimuli (Wolpe,
1969). For example, a child may be afraid to take a bath after a hurricane
because of the association that occurred when the family sought shelter in
Counseling After Natural Disasters 87
the bathtub during the hurricane. The family counselor should teach the
child to relax and then ask him to wipe his face with a wet wash clothe,
gradually progressing to washing in a sink, then near the tub, etc. (Baggerly,
Green, Thorn, & Steele, in press). Parents will need to be involved with these
procedures and provide positive reinforcements for each accomplished step.
Due to their egocentric and concrete cognitions, some children may
misattribute the cause of natural disasters to their bad dreams or someone’s
bad behavior. Family therapists should identify their misattributions and give
accurate information. Procedures to correct misattributions include (a) mak-
ing a Q-sort of possible reasons for the disaster and asking children to sort
them as true or untrue; (b) creating a blame box for younger children to
put in drawings of who or what they blame and then drawing the correct
reason together; (c) developing a puppet show in which puppets ask about
misattributions and another puppet gives accurate reasons; and (d) acting
out a radio show of people calling in with questions and an expert giving
correct information (Shelby et al., 2004). Many of the play-based procedures
described above are demonstrated in a video by Baggerly (2006) available at
http://www.emicrotraining.com/child.html#038
Play Therapy
After helping children establish a sense of safety and manage symptoms,
family therapists should help children retell their trauma story. Since chil-
dren ages two to ten years old are still in the cognitive developmental stage
of pre-operations or concrete operations, the most developmentally appro-
priate way for young children to communicate their trauma story is through
play (Kottman, 2001; Landreth, 2002). Landreth stated “Play is the child’s sym-
bolic language of self-expression. . . . Play is children’s way of working out
balance and control in their lives . . . that is essential to children’s emotional
development and positive mental health” (Landreth, 2002, p. 18).
Children often repeatedly reenact a specific traumatic event in their play
in an attempt to create a concrete narrative of traumatic events so they can
master frightening images (Baggerly, 2005c; Terr, 1990). For example, a 5-
year-old boy who experienced Hurricane Katrina named a toy dinosaur “the
sea monster.” He spun the sea monster in circles and repeatedly knocked
down the doll family and furniture in the doll house. Later, he used the army
men to kill the sea monster. Clearly, the boy was re-enacting his hurricane
experience in order to gain mastery of a scary situation.
Play therapy helps children process their trauma narrative, aids in resolv-
ing symptoms, builds resiliency, and resumes the process of normal devel-
opment (Gil, 1991; Shelby, 2000). During play therapy, the family counselor
should provide selected toys such as bendable doll families, zoo animals,
rescue vehicles, medical kits, etc., as recommended by Landreth (2002), so
children can express their trauma narrative through play. While children are
88 J. Baggerly & H. A. Exum
playing, family therapists should provide therapeutic responses of reflecting
content and feelings, facilitating decision making, encouraging, enlarging the
meaning, and facilitating accurate understanding (Baggerly, 2005c; Landreth,
2002). These play therapy procedures are demonstrated in a video by Bag-
gerly (2005a) available at http://www.emicrotraining.com/playtherapy.html.
After each play session, consult with parent and provide them helpful re-
sponses to their child’s concerns. If the child wants to play out their resolved
trauma story for their parents, instruct the parents to reflect their child’s feel-
ings and strengths and provide reassurance of their support.
There is a long history of using play therapy to treat traumatized chil-
dren, beginning with Anna Freud’s work with children after London was
bombed in World War II (Freud & Burlingham, 1943). The effectiveness of
play therapy was revealed in Bratton and Ray’s (2000) comprehensive liter-
ature review of 82 play therapy research studies and a meta-analysis of 94
play therapy outcome research studies, which showed a large positive effect
of .80 on treatment outcomes (Ray, Bratton, Rhine, & Jones, 2001). Recently,
Shen’s (2002) research with Chinese children who experienced earthquake
related trauma symptoms revealed that children who received 10 sessions of
child-centered play therapy had significantly lower anxiety and suicide risks
than did control group children. Given these positive results of play therapy
and its unique developmentally appropriate approach, family therapists are
encouraged to obtain play therapy training. Play therapy training information
is available at www.a4pt.org and www.cpt.coe.unt.edu.
Family Play Therapy
The final phase in trauma recovery is reconnecting children with others. To
accomplish this, family therapists can integrate play into family therapy so
that parents can enter their children’s world and develop emotional con-
nectedness (Gil, 1994; Wittenborn et al., 2006). “Play techniques can engage
parents and children in enhanced communication, understanding, and emo-
tional relatedness” (Gil, 1994, p. 42). Play in family therapy can also help
children and parents make sense of their lived traumatic experience, solve
problems, and build resilience as a family unit.
These goals can be facilitated through family play activities that utilize
avariety of mediums. If a sand tray and numerous miniatures are available,
ask the family to use these to create their world before the disaster, after the
disaster, and how they hope it will be in the future. Afterwards, the family
counselor should ask each family member to share their thoughts and con-
tributions to their sand tray world (Carey, 1999). If puppets are available, ask
each family member to choose and name two puppets. Then ask the family
to make up a story that has a beginning, middle, and an end. Afterwards, the
family counselor should interview each puppet to process feelings, percep-
tions, strengths, and problem solving strategies (Gil, 1994).
Counseling After Natural Disasters 89
Family art activities accomplish the above described goals in a medium
that is available to most family therapists (Gil, 1994). Provide three large,
poster-size pieces of paper, crayons, and markers and ask families to make
amural of their life before the natural disaster, afterwards, and in the future.
Family members can enhance the murals by pasting images from magazines,
if available. After the mural is complete, lead the family in processing feelings,
perceptions, strengths, and problem solving strategies. Another art activity is
to provide one large piece of paper and ask each family member to draw a
special place where they would like to live (DeTrude, 2003). Ask them not to
talk until everyone is finished. Then ask each family member to describe the
sights, sounds, and smells of their special place. Finally, ask family members
to make one positive comment about each person in the family. This activity
helps families focus on hopes and dreams, giving them a sense that there is
life after a disaster.
CONCLUSION
Recognizing children and adolescents’ typical and clinical traumatic stress
symptoms after natural disasters will guide family therapists in providing
needed therapeutic interventions. Since most of the recovery takes place at
home and at school, family therapists must teach parents and teachers to
understand symptoms and intervene with reassurance of normalcy, extra at-
tention and nurturance, re-establishing routine, open communication, and
facilitating adaptive coping strategies. If children experience clinical symp-
toms, family therapists are encouraged to follow the model of (a) establishing
safety and managing symptoms through Cognitive Behavior Therapy, (b) fa-
cilitating the child’s retelling of the trauma story through play therapy, and (c)
reconnecting the child with others through family play therapy. In doing so,
counselor will help children, families, and communities develop resilience
after natural disasters.
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