Sometimes it takes a hurricane to change your plans. At least, that was the force that shifted the career path of Annette La Greca, PhD.
In August 1992, La Greca was well into a productive career at the Univer- sity of Miami, conducting respected work on children's stress by examining the immediate surroundings of children's lives--how they coped with chronic diseases like diabetes, for example, and how peer rejection can fuel depression and anxiety.
Then disaster struck. Hurricane Andrew, one of the worst storms in recorded history, hit full force not four miles from La Greca's home and workplace, compelling the child clinical psychologist to expand her focus to include the effects on children of a major, all-encompassing trauma.
The field hasn't been the same since La Greca and child psychologists Eric Vernberg, PhD, and Wendy Silverman, PhD, stepped in immediately to train teachers to help youngsters cope with the emotional damage wreaked by the storm and conduct groundbreaking work on children's reactions to disasters in a field starved for empirical data.
"Annette's work on Hurricane Andrew is pioneering in terms of understanding how children respond to natural and man-made disasters, both in acute and long-term ways," says Larry Siegel, PhD, a pediatric psychologist and dean of Yeshiva University's Ferkauf School of Psychology. "She's given us a handle on what children and their families experience when they've undergone the trauma of disaster."
Applications to Sept. 11
That knowledge was critical in the wake of Sept. 11. Psychologists have already used the insights gleaned by La Greca to determine which children might need extra attention after the terrorist attacks and to shore up children's support systems, one of the factors shown by her research to help children cope.
Disaster expert Robin Gurwitch, PhD, of the University of Oklahoma Health Sciences Center, for instance, is incorporating La Greca's work on risk factors in projects on children she's developing in relation to the Sept. 11 attacks. Likewise, she used a manual La Greca developed for teachers and counselors following Hurricane Andrew to guide her own writing of a similar manual following the Oklahoma City bombing.
"Annette's Hurricane Andrew manual was incredibly helpful to me in developing my own treatment manual for young children who are experiencing trauma," says Gurwitch. "Several of the ideas and information in the manual draw from her insights in helping train professionals who work with children."
Relatedly, La Greca has developed a workbook for parents on helping children process the September terrorist attacks that's also being applauded by colleagues. Called "Helping America Cope," the empirically informed workbook, initially funded by the BellSouth Foundation, is being widely distributed in New York and Washington, D.C., and has been translated into Spanish. While about 125,000 copies have been printed with funds from charitable organizations, institutions around the country have requested more than 2 million copies, LaGreca says.
"It's an awesome piece of work in that there are different modules parents and children can do together depending on the child's emotional and developmental level," says La Greca's colleague Jan Faust, PhD, of Nova Southeastern University. "It's model-based, but it's written in a language children and parents can understand."
La Greca's disaster-related expertise has also led APA to support her as chief editor of an APA book to be released this spring, "Helping Children Cope with Disasters and Terrorism." The volume will synthesize the state of the art on the topic, covering what's known about children's reactions to specific disasters, including terrorism, and reviewing the quality of mental health interventions with an eye toward stimulating new research.
Gifts from a storm
In a basic sense, La Greca's research findings after Hurricane Andrew refuted the common assumption that children do not experience major emotional reactions to disaster. She and her colleagues found instead that more than half the children they studied had moderate to severe post-traumatic stress symptoms three months after the storm.
"Kids are afraid of upsetting their parents or teachers so they don't always tell them how they feel," La Greca says. "But what we learned from this project is that kids are much more affected than you would imagine."
One boy, she recalls, locked himself into the bathroom while the hurricane blew in windows, walls and doors. "He wasn't sure whether he'd live or not," she says. Scenarios like this were not uncommon, she adds.
Another new finding was that these effects can continue over time. Ten months after the hurricane, 12 percent of children still had severe or very severe levels of post-traumatic stress disorder (PTSD) symptoms. Recent research conducted by La Greca's former student Nicole Vincent, PhD, shows how persistent these effects can be. In a subsample of children interviewed three and a half years after the fact, 40 percent of children who'd reported high levels of PTSD at 10 months still had high levels of these symptoms.
"The disaster event is just the beginning of a sometimes cascading set of stressors children and their families have to cope with," La Greca says. "The hurricane may be over, but for many people, the aftermath and coping are just beginning." Many children affected by Hurricane Andrew lost their homes and possessions, including cherished pets and toys. And for poor families lacking adequate insurance, sometimes those losses were permanent, she notes.
The research also predicted and validated that certain types of children are more likely to have problems over time than others. Youngsters with more symptoms over time had:
Higher levels of perceived life threat during the hurricane.
Higher levels of life disruption after the storm.
Low levels of support from family and friends.
More intervening life stressors.
Negative coping mechanisms, such as blaming oneself and others.
Besides these findings, an unexpected turn of events allowed La Greca and colleagues to demonstrate that children who had high levels of anxiety and adjustment difficulties before the storm had greater PTSD symptoms afterward. By happenstance, she and Silverman had collected data on children's adjustment and anxiety levels 15 months before the hurricane struck.
On a more positive note, the research also showed that certain factors seemed to help youngsters cope better over time, La Greca notes. One was having a wide range of social support from family and friends. The other was getting back into normal roles and routines. Clinicians are using both of these elements in their work following Sept. 11, La Greca's colleagues say.
Overall, the research is unusual because it is prospective and it used a theoretical model to predict who might suffer the most. This methodology is considered a gold standard in research, because it tests variables already suspected to play a part in a given condition, rather than starting from scratch and guessing at what factors might cause problems.
"One of the key advantages of a prospective study is that it allows us to look at processes as they unfold over time, to examine which factors may precede certain outcomes," La Greca explains. "The research design showed that for most kids, things did improve over time. It also helped us figure out early on which factors predicted who would have more trouble coping."
Besides her work related to Sept. 11, La Greca is currently testing the conceptual model used in Hurricane Andrew in another kind of "disaster" situation: community violence in South Florida neighborhoods.
The contributions are new because they focus on risk and protective factors in children ages 8 to 12, whereas most community violence studies look at adolescents, she says.
"Many children report a variety of stressors related to community violence, such as seeing people using drugs and breaking into places," La Greca says. "All of these things are very disturbing when you're 8 to 12 years old."
The Hurricane Andrew model of risk and protective factors appears to hold up well in this externally dissimilar circumstance, accurately predicting which youngsters show more post-traumatic symptoms, she says.
As with Hurricane Andrew and Sept. 11, La Greca is developing a manual for teachers that helps children develop strategies for combating community violence. The workbook, "Keeping Children Safe," has utility both as an independent product and as a research aid, La Greca says: In fact, she'll compare coping among youngsters who have received training in the manual and those who have taken standard health classes.
An unexpected result of her disaster work is a new-found interest in child advocacy, La Greca comments.
"Sometimes adults don't realize how distressed children are, because children don't always have the capability of asking for help," she says. "Kids are left out of the mix a lot of the time."
By working with children, she's found, "they can really benefit from adults who open the door to a better understanding of their feelings. A lot of times when we interview children, they say they appreciate having the opportunity to talk to someone about these events."
That, she adds, is relevant for any kind of trauma a child may experience, whether it's chronic illness or a fear of future terrorist attacks.
Tori DeAngelis is a writer in Syracuse, N.Y.