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| FIELD REPORT |
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| Year : 2020 | Volume
: 18
| Issue : 1 | Page : 85-91 |
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Psychoeducation for children in a psychiatric ward in the immediate aftermath of the 2011 earthquake and tsunami in Japan
Naru Fukuchi
Miyagi Disaster Mental Health Care Center, Miyagi; National Center of Neurology and Psychiatry, Tokyo, Japan
| Date of Submission | 20-Jun-2019 |
| Date of Decision | 11-Oct-2019 |
| Date of Acceptance | 28-Feb-2020 |
| Date of Web Publication | 29-May-2020 |
Correspondence Address:
PhD Naru Fukuchi
Takeda-Sendai building 3F, 2-18-21 Honcho, Aoba-Ku, Sendai, Miyagi 980-0014
Japan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/INTV.INTV_39_19
On 11 March 2011, Japan was struck by a massive earthquake and tsunami. There were a number of hospitals in the disaster-affected area, including some with psychiatric and children’s wards. Since all utilities were completely cut off for several days, children in the hospital had no access to information about the disaster. Therefore, they lacked a sense of the gravity of the situation and did not show any signs of panic. However, as several psychiatric hospitals located in the coastal area were severely devastated by the tsunami and therefore were unable to continue providing medical services, inpatients of these hospitals had to be accommodated in other hospitals that had children’s wards. The workers on these wards had to respond to minimise the negative psychological impact of this situation on the children in their care. On 18 March 2011, one week after the disaster, brief psychoeducation presentations were conducted with PowerPoint slides, teaching the children how to cope with the stress they were experiencing, using an original rating scale: a mood thermometer. Observations suggest that brief psychoeducation in the immediate phase after a disaster may effectively reduce the psychological trauma that children might otherwise experience.
Keywords: children, Great East Japan earthquake and tsunami, psychoeducation, psychological trauma
How to cite this article:
Fukuchi N. Psychoeducation for children in a psychiatric ward in the immediate aftermath of the 2011 earthquake and tsunami in Japan. Intervention 2020;18:85-91 |
| Introduction | |  |
State of Japan after the Great East Japan earthquake and tsunami in 2011
On 11 March 2011, an earthquake with a magnitude of 9.0 on the Richter scale, referred to as the Great East Japan earthquake (GEJE), struck the Pacific coast of north eastern Japan. The Japanese government reported 19,630 deaths, 2,569 missing and 6,230 injured. Approximately 400,000 people were evacuated to shelters and many suffered from long-term distress (Fire and Disaster Management Agency, 2018). Mental health care teams, which consisted of various professionals (including psychiatrists, nurses, social workers and others), performed outreach to the disaster-affected areas and supported survivors.
The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings includes a pyramid of four layers as a support approach: specialised services; non specialised supports; community and family support; and basic services and security (Inter-Agency Standing Committee (IASC), 2007). These guidelines emphasise the importance of collaboration with existing community support systems, the principle of ‘do no harm’ and the significance of cultural context. At the time of the disaster, there was no consensus among mental health professionals regarding emergency situations, and the IASC guidelines were not sufficiently understood, nor fully implemented (Kim, 2001). Therefore, professionals gave support to survivors, including children, in their own way, because there was a lack of common knowledge about what support should be provided in such situations.
Challenges for hospitalised children in emergencies
Children are considered a particularly vulnerable group in emergencies because it is difficult for them to cope alone, and there tends to be negative psychological impacts according to their individual situations, such as loss of loved ones (Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002). For example, following the massive earthquake in Nepal in 2015, posttraumatic stress disorder (PTSD) and depressive symptoms were found to be higher in children living in severely affected areas than in those living in less affected areas (Silwal, Dybdhal, Chudal, Sourander, & Lien, 2018). After the 2004 Indian Ocean earthquake and tsunami in Thailand, older children (aged seven to fourteen years) tended to have PTSD and depressive symptoms if they felt that their family members’ lives had been in danger (Thienkrua et al., 2006). Although these studies have also indicated that children separated from their caregivers and unable to procure information about the events they have experienced have a strong risk for PTSD and depression, it is unclear what impact this type of circumstance has on children who are already coping with depression.
As well as the IASC Guidelines, other strategies and treatments have been found to be effective in improving children’s psychological symptoms and promoting recovery in the aftermath of disasters, for example resources such as the website of the American Academy of Paediatrics. However, such strategies are often dependent on the engagement of an important person in the child’s life whom they trust, such as a parent or teacher. Places where children gather with reliable adults, such as schools, are ideal settings for providing psychological intervention because many students trust the adults and other students. Whaley, Cohen, and Cozza (2017), for example, indicate that universal programmes conducted by teachers or local professionals are effective in reducing PTSD symptoms within school settings. Akasaka and Kawashima (2019) also report on the use of psychological first aid in preventing children from developing psychological problems in emergency settings. Nevertheless, as there is a lack of research on psychological interventions for children who are already resident in psychiatric hospitals during emergency situations, the impact on children in such situations is unclear. Additionally, it is difficult to assess children’s mental health conditions because their verbal ability is limited, and they are often in a state of hyperarousal following emergency situations.
During and immediately after the emergency
The psychiatric hospital in which the author of this field report worked as a staff member and child psychiatrist was close to the disaster-affected area in Miyagi prefecture and was on a hill overlooking the city. This hospital has a children’s ward, and when the earthquake occurred, it had 15 inpatients under the age of 18. The children in the ward were not allowed to use mobile phones or leave the hospital freely. Because all utilities in the area were completely out of service, and the children could not watch television, they did not have any information about the earthquake. Since most children were unaware of what was happening, they did not show any signs of panic. However, some children were able to understand that something unusual must have happened by observing the view through the windows of the children’s ward, but they remained unnaturally calm. We believe this was due to the fact that some did not know what to do and others did not want to confuse or frighten their peers.
The children’s ward workers did not inform the children of the real gravity of the situation. Although the electricity returned after five days, they left the televisions off and, to prevent the children from seeing graphic images that they were too young to appropriately process, told them that there was no power. However, there were several other psychiatric hospitals in the coastal area, some of which were severely devastated by the tsunami. Many patients had died in the disaster, and since the hospitals were unable to continue their medical operations, the remaining patients had to be moved to hospitals where the damage was relatively minor. Thus, the children’s ward where the author worked had to accept patients who were over eighteen years old and who had experienced the disaster directly. As a result, we expected that the children would learn more about the situation along the coast and might be adversely affected. Zunih and Myers (2000) summarised psychological responses depending on each recovery phase; the early phase is defined as the time between one is defined as the time between one and seven days after a disaster, with survivors tending to have a variety of psychological symptoms during this phase, including hyperarousal, fear, anxiety and feeling ‘stunned’. Therefore, the workers needed to tell the children the truth and to provide support as soon as possible to minimise any negative psychological effects.
In understanding the potential consequences, it is important to highlight the cultural context here. Japanese people tend to think that being humble is a virtue and they should not express their thinking excessively, to keep their community stable. Even in such an emergency situation, it was possible that these children thought it would be rude if they became upset and sought help from others. If the children did not want to express their thoughts and feelings, this might have led to negative psychological impacts. Therefore, psychoeducation was attempted to prevent them from hiding their feelings.
The intervention
On 18 March 2011, one week after the GEJE and in the early phase, we conducted a two-hour psychoeducation session using a slide-show lecture, followed by a group discussion. Because almost all of the children had, before the disaster, had at least a two-hour daily programme for work, physical activity, learning and occupational therapy, we set our programme to be two hours long. The programme was created by several workers from the hospital through discussion, and a child psychiatrist and nurses conducted this psychoeducation [Table 1].
The psychoeducational materials were created with great attention to not exposing the children to any additionally traumatic events, following the principle of ‘do no harm’. The material consisted of three parts: (1) sharing accurate information about the disaster [Figure 1] , (2) explaining emotional reactions [Figure 2] and (3) learning relaxation techniques [Figure 3]. In the first part, we explained the magnitude of the earthquake, the size of the affected areas, the number of casualties and what would be required for recovery. In the second part, we explained how emotions are structured and what kinds of emotions the children might experience (our emotions have plasticity, may change in response to a situation and we can cope with the situation on some level). In the final part, we taught some relaxation techniques to help the children cope with any fear and anxiety they might experience, which included breathing, muscle relaxation and light massage (rubbing each other’s backs and stroking your temples softly and patting your chest gently). We posted all psychoeducational materials on a website where anyone could freely download them (National Center for Child Health and Development, 2011). | Figure 1 One of the slides from the first part of the presentation, titled ‘Sharing accurate information about the disaster’
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 | Figure 2 One of the slides from the second part of the presentation, titled ‘Explaining emotional reactions’
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 | Figure 3 One of the slides from the final part of the presentation, titled ‘Learning relaxation techniques’
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The aim of this intervention was to determine challenges in coping with children’s psychological responses in a resource limited situation. We also attempted to examine the ability of brief psychoeducation to relieve children’s acute psychological symptoms following a major disaster. Furthermore, we posted a report about our challenges on the Internet and confirmed whether our resource use had been effective.
Participants
The participants comprised children between the ages of 10 and 18 who were psychiatric inpatients with problems including ADHD, schizophrenia, obsessive compulsive disorder, anorexia nervosa and generalised anxiety disorder when the GEJE occurred. Children who returned home temporarily, or refused to participate in the psychoeducation session, were excluded from the intervention. The staff members and author conducted a single group intervention without a control group due to lack of resources and the need to respond quickly in an emergency situation.
Evaluating the intervention
In the clinical field, mental health professionals try to measure children’s mental health conditions through communication with their caregivers, rather than using standardised rating scales such as the Child Behaviour Checklist (Itani, Kanbayashi, Nakata, Kita, Fujii, & Kuramoto, 2001) and the Strength and Difficulties Questionnaire (Matsuishi et al., 2008). However, when it is difficult to contact caregivers in the early phases, as in our situation, it is necessary to use assessment tools with certain characteristics, such as ease of understanding the purpose of the assessment and answering questions through use of pictures and illustrations to simplify.
Due to the fact we were responding to an emergency situation, we created an original rating scale that children could easily utilise to self-assess their mental health condition. The scale consisted of two thermometers, a ‘happy thermometer’ and an ‘unhappy thermometer’, with scores ranging from 0 to 10, where 0 is weak and 10 is strong. Children could choose the temperature which suited their present feelings. Words representing happy (joyful, happy, feeling good and having fun) and unhappy feelings (sad, upset, irritated and in pain) were written next to the thermometers to help children assess their emotional condition [Figure 4]. We chose these thermometers because we had used such assessment tools (the Visual Analogue Scale (Aitken, 1969), the Face Rating Scale (Wong, Hockenberry-Eaton, Wilson, Winkelstein, Ahmann, & DiVito-Thomas, 1999), and others that use a thermometer or traffic signal before the disaster, and they made it easy for children to describe the gravity of their feelings. | Figure 4 An original rating scale we created for this study, ‘mood thermometer’
Click here to view |
Data analysis
We conducted a paired t-test to evaluate the effects of our intervention. The data were analysed using SPSS (version 21.0; IBM SPSS, Armonk, NY). Descriptive statistics were used to describe demographic characteristics and study variables. We set the significance level at 0.05.
| Results | | |
Although 15 children were in the hospital at the time, three went home temporarily immediately after the disaster and one declined to participate in the psychoeducational sessions. Thus, the participants included 11 children (seven boys and four girls) between the ages of 10 and 18 (mean = 14.1 years). The average length of time spent as inpatients was sixty days. Three (27.3%) of the children lived in the coastal area and had family members who had been evacuated.
[Table 2] shows the differences in children’s self-selected thermometer scores pre and post intervention. The results of the paired t-test were as follows: the pre intervention means of the ‘happy thermometer score’ was 3.56 (SD = 2.19), while the post intervention mean was 4.06 (SD = 2.40); the pre intervention means of the ‘unhappy thermometer score’ was 5.56 (SD = 3.72), while the post intervention mean was 5.19 (SD = 3.43). We found a slight statistical improvement in the ‘happy thermometer score’ (t (10) = 3.05, p < .05). No significant improvement was found in the ‘unhappy thermometer score’ (t (10) = 0.89, n.s.).
After the psychoeducation was conducted, we had the children write their answers down and we set up a group discussion. The children spoke and wrote down their feelings and thoughts as follows: ‘we felt heart-warmed and felt your (the workers) love’; ‘although I was worried about my family members, I found relief through this session’; ‘I could understand what happened’; and ‘you (the workers) don’t have to worry, we are OK’. After the intervention, they started spending time together and helping each other, and made efforts to keep the ward comfortable; some helped with serving and cleaning, some tried to decrease leftovers, and some tried to get up by the set time.
| Discussion | | |
Many previous studies have examined the psychological consequences of natural disasters, some of which were prospective cohort studies with control groups (Fergusson, Horwood, Boden, & Mulder, 2014; North & Pfefferbaum, 2013). Such studies have noted that exposure to massive natural disasters can lead to mental health issues for all ages.There have been several reports in which paediatricians and child psychiatrists have provided preventive intervention (Schonfeld, Demaria, Disaster Preparedness Advisory Council, & Committee on Psychosocial Aspects of Child and Family Health, 2015). Adams, Laraque, Chemtob, Jensen, and Boscarino (2013) reported that primary care paediatricians who attended a one-day training workshop could provide appropriate preventive intervention to disaster-affected children. Several preventive strategies and treatments have reportedly helped minimise negative psychological symptoms in children and promoted their recovery after natural disasters. Many of these prevention and intervention programmes have focused on the engagement of caregivers (Berkowitz, Smith Stover, & Marans, 2011) and teachers (Wolmer, Laor, & Yzgan, 2003). However, in our situation, we were unable to contact or collaborate with the children’s caregivers and teachers. We had to work with the limited information available to provide support for our young patients.
We found a slight statistical improvement between pre and post intervention on the original rating scales (mood thermometer scores). This result suggests that brief psychoeducation in the early phase after massive disasters may be effective for children. The children in our study could not access any information immediately after the earthquake, which might have caused them to feel anxious and fearful over time. Giving them accurate information and coping strategies through immediate psychoeducation seems to have had a positive impact on their responses.
After our intervention, we collaborated with the National Centre for Child Health and Development in Tokyo and posted all psychoeducational materials on their website, where anyone could download them for free (National Centre for Child Health and Development, 2011). Over 20,000 people visited this website from 2011 to 2019. One child welfare facility in the disaster-affected area, where children who could not live with their family stayed, used these materials through the website (Fukuchi et al., 2013). There were 24 children in the facility at that time, and the facility had no access to electricity, gas, or water. The children could not contact their loved ones and some felt anxious and experienced various psychological and physical symptoms, such as appetite loss, insomnia, constipation, irritation and interpersonal difficulties. Based on our advice, the workers (psychologists and life support staff) decided to provide psychoeducation for the children using our materials on the tenth day after the disaster. They provided counselling and interviews for all the children and confirmed their symptoms, provided psychoeducation through our materials, and established group sessions. Although they did not use a ‘happy thermometer’ or ‘unhappy thermometer’, they reported that the number of children with certain symptoms decreased. It is possible that the uploaded psychoeducational materials may be used in future disasters, and the summarised website with such collected information could be effective for disaster response.
In this emergency situation, we elected to conduct a two-hour psychoeducational session seven days after the earthquake (18 March 2011), which was a single group intervention without a control group. The optimal timing of post disaster intervention has remained a debatable topic. Litz and Maguen (2007) reviewed several reports that initiated delivery within the first month after a disaster, but asserted that there was insufficient evidence as to whether the early phase is an optimal time for intervention. Moreover, there are no reports of psychoeducational trials for children conducted within an early phase, that is, within only one week. Since during the early phase after an emergency, there are limited time and financial resources available to prepare a well organised intervention such as CBT, it was only possible to provide brief psychoeducation and relaxation strategies. The results of our challenge indicate that such provisions may relieve children’s psychological distress to some degree.
Limitations
Several limitations of the evaluation of the psychoeducation session must be addressed. First, the participants were not representative of the general population, because they suffered from psychological conditions, such as depression and PTSD prior to the disaster, and were already hospitalised for them. In addition, the number of participants was quite small; three of the children did not participate in the psychoeducation because they had temporarily returned home, and one child refused to participate. In addition, because this study was specifically looking at a very particular population (children who experienced a disaster after already being hospitalised for mental health symptoms), the possible population, even if every child had participated, was small. Second, we did not set up a control group to compare our data or confirm whether our intervention was better than other methods. Third, we used an original rating scale rather than scales that are already established in reliability and validity. Therefore, it was impossible to guarantee the scale’s reliability and validity. Finally, since we checked the children’s mental health condition only immediately after pre and post intervention, we could not confirm whether our intervention had lasting effectiveness.
| Conclusions | | |
This field report highlights that brief psychoeducational intervention in the early phase after a disaster may be helpful in addressing children’s psychological distress. Our findings have implications in understanding the effectiveness of psychoeducation on children to reduce negative psychological symptoms in emergency situations. Results indicated that brief psychoeducation may be enough, when a well organised intervention like CBT could not be provided. Future mental health research should examine the sustainability of the psychoeducational effect, as well as alternative effective methods. This might help to address child psychological distress after massive disasters, and aid supporters who work within limited resources.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
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