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Logistic regressions, controlling for sociodemographic variables, were used to study the relation between disaster exposure and internalizing, externalizing, or any disorder. Results were similar across age ranges. Rates of specific internalizing disorders between exposed and unexposed children are provided. Research and clinical implications are discussed.

Disasters occur once a day on average in the world International Strategy for Disaster Reduction, n. As traumatic events, they are potentially strong stressors due to their disruptive nature, high extent of impact, production of terror and horrors scenes, undesirable and uncontrollable occurrences, and prolonged alterations in the social and material environment Davidson and Baum The scientific understanding of the impact of disasters on disterss and adolescent psychological functioning has greatly increased in recent times and various excellent recent reviews of the literature have been published e.

When children experience a sexouy disaster, they may show a wide range of psychological reactions, especially symptoms of post traumatic stress disorder PTSDdepression, generalized anxiety and pathological grief reactions La Greca et al. An important clinical issue regarding psychological responses to disasters is the persistence of these reactions. Existing evidence indicates that youth who are heavily exposed to a disaster may experience psychological distress that may last for years after the event Vogel and Vernberg For some children who experience catastrophic levels of trauma exposure in these events, initial posttraumatic sexout PTS symptoms common in PTSD and separation anxiety often develop over sexout into serious levels of depression Vernberg Generally, a decline in symptomatology is observed over the first years following natural disasters La Greca and Prinstein However, following Hurricane Katrina, studies on children and adults show an increase in PTS, anxiety, and distress symptoms over time, possibly due to prolonged stress in the distresss context Kessler et al.

Although these advancements in the scientific understanding of the impact of natural disasters on youth functioning are significant, research is still needed in some important areas, which this study can sexout.

However, reactions may include other internalizing disorders and the acting out, aggressive, and delinquent behaviors associated with externalizing reactions to stress. These reactions may persist for long periods of time for emotional children. In addition, how the types of trauma reactions may vary by the age of the child needs further exploration, but most studies of emotional survivors of disasters have had a limited distress range.

Thus, to better understand the range of traumatic reactions emotional children and youth, a wide range of emotional needs to be assessed across age ranges. Likewise, few studies have investigated if psychological post-disaster reactions meet criteria for a disorder, which our study can address.

Most studies examine symptoms only, and fail to assess for psychosocial impairment, although DSM-IV includes it as a criterion in the classification sexout disorders. The consideration of this criterion would make disaster studies more reflective of clinical reality, since the impairment that emotionxl from symptoms is what usually leads to a child being referred to services rather than the mere manifestation of symptoms Wmotional et al.

However, the persistence of distrezs disorders through time has not been studied distress the use of longitudinal designs involving multiple emotional post-disaster is sparse. Rather than merely documenting that exposure to disasters evokes symptoms and disorders, disaster studies need to identify factors that influence the development and maintenance of disaster-related reactions in children and adolescents.

To guide this research and organize its findings, a conceptual model e. Efforts to cope have a reciprocal relationship with PTS symptoms. Exposure to traumatic events influences aspects of the post-disaster recovery environment e.

The authors found empirical support for their model in predicting PTSD after Hurricane Andrew, but further research is needed in order to look at other psychiatric disorders emltional other populations. In support of the model, research shows that the more children perceive their lives, or distress lives of loved ones to smotional threatened, the closer proximity to the event, and greater loss, the higher the report of PTS symptoms Silverman and La Greca emotional This is likely true for other internalizing disorders, and may extend to externalizing problems as well.

Conversely, children who do not perceive their lives or loved ones lives to be at danger, or who do not experience significant loss, may not report PTS symptoms following a disaster. In contrast, Norris et al. They also report that poverty is a risk factor for worse post-disaster functioning, perhaps due to greater exposure or less resources to facilitate recovery.

In the present study we focus on aspects of the disaster experience and pre-existing child characteristics. Whether this holds after more than a year has passed has rarely been studied with youth.

But as recovery can be prolonged, mental health outcomes can persist e. We also explore the influence of gender, age, and poverty status for internalizing and externalizing disorders. Females may have been more at risk in past studies because PTS or other internalizing disorders were examined. A different result may emerge with the inclusion of externalizing problems. As prior findings have been equivocal Norris et al.

Financial strain, as a pre-existing demographic characteristic, is also explored. Poverty level is already high in this sample; however the perception of poverty can influence ability to recover.

Our study assesses the range of psychiatric disorders post-disaster sexoyt Puerto Rican children and youth. How our findings potentially generalize to other U. Thus, we briefly summarize relevant research that can guide the interpretation of our findings and lends some support to the ability to generalize the results. As the cross-ethnic research on youth mental health following a natural disaster is scant, we review many types of studies, including those on adults, studies following terrorism, and general cross-ethnic studies of youth mental health.

Distress adjusting for demographics, stressors, and stress moderators, they report little support for the idea that Latinos may suffer from worse mental health following a disaster than Whites. In contrast, Perilla et al.

Child disaster studies have also explored the role of ethnicity, exposure, and post-disaster mental health. Vernberg and associates did not find an effect for ethnicity on PTS symptoms. Overall, these findings support that the rates in a Latino population are likely similar sexout other populations if level of exposure is similar and demographic characteristics, for example socioeconomics, are controlled.

Issues of the influence of acculturation and cultural stress on mental health are also important to consider in terms of generalizability.

The hypothesis that Puerto Ricans living on the mainland US may distresss from those living in Puerto Rico PR on mental health due to differences in acculturation and cultural stress was explored by Duarte and colleagues diztress Using two samples of Puerto Rican youth one group living in South Bronx, the other in PRthe same measures distress methods, they emotionnal that the influence of acculturation and cultural stress on psychiatric symptoms was similar for mainland and island-bound Puerto Rican youth.

Consequently, this also lends some support to the generalizability of the findings of this current study to mainland populations. An unusual opportunity arose in in the Spanish-speaking Caribbean emotional of PR to study some of the issues previously mentioned, especially the persistence of disorders in the post-disaster period.

Emotional days after it struck PR, many communities reported property damage, government shelters were opened for approximately 28, persons,persons were without water and 1, distress no electricity for some time Center for Disease Control and Prevention The destruction left many families affected psychologically. For example, in the eastern part of the island, 2, individual cases were reported as receiving crisis counseling in a 3-week period, including approximately cases of children that were exhibiting acute reactions to stress Prewitt Although PR regularly experiences tropical storms, a hurricane hitting the island sexout a rarer event, compared to the frequency in which hurricanes inundate Florida, for example.

To date, a hurricane has not hit the island since Hurricane Georges. Prior to Hurricane Georges, the last hurricane to strike the island was Hurricane Hugo, which made landfall in September, Thus, the level of devastation experienced by the children and families in this study is beyond what they experience in a regular hurricane season. The present study, eemotional to its inception in a disstress, comprehensive two-wave study, overcomes some methodological limitations identified distresw the disaster literature Norris et al.

The availability of a large random sample of the population enables the comparison of exposed and unexposed groups and the use of control variables in the analysis to better study the disaster-disorder relationship; it also allows for the detection of interaction effects. We could not divide the age range further due to loss of statistical power. We explored the moderating effects of preexisting characteristics of the child i.

Finally, we provide frequencies for specific disorders if there was significant relation between exposure and the higher rank disorder categories. This sample and the methods of the study have been described in detail elsewhere Canino diistress al.

These units were classified according to economic level and size, grouped into block clusters and further classified as urban or rural. Three hundred block clusters were randomly selected and then divided into two random replicates.

A household was selected for inclusion in the study if it had children between the ages of 4 to One child was sexoit at random from each household using Kish Tables adjusted for age and sex.

The sample was weighted to represent the general population in the year The weights correct for differences in the sexout of selection because of the sampling design. The final sample of 1, children at T1 constituted a sampling fraction of approximately 2. We used a multi-stage method distress cross-cultural adaptation and translation of study measures derived from the medical, sociological and psychological literature Bullinger et al.

Our research team has used this method on multiple occasions to create measures that were both culturally and linguistically appropriate. The result was a translated version of the instrument that tackles the major dimensions of cross-cultural equivalence: content, semantic, technical, criterion and concept equivalence Canino and Bravo ; Bravo et al. Demographic Characteristics Interview emotional was obtained on demographic characteristics. Perception of poverty was used in the analyses because prior research with this sample showed that income was not related to prevalence of a mental disorder Canino et al.

Kappas for parent report in an outpatient sample in Puerto Rico range from 0. Procedures for Spanish translation and back translation are documented in the work of Bravo and colleagues Any disorder refers to meeting criteria during the last year for any of the DSM-IV diagnoses studied, evaluated on the basis of either parent or child reports.

Hurricane Exposure Questionnaire Questionnaires for caretakers and youth were adapted from an earlier study in PR about psychological consequences to a mud emotional disaster in Puerto Rico Bravo et al.

This measure was adapted for children using the La Greca and colleagues hurricane distress questionnaire as a guide. Items assessed direct exposure to sexout child and to the family as an organized unit. Parents provided information sexout their exposure to the hurricane feeling distress of dying or being hurt, becoming ill or injured during the hurricane or loss or damage to their home trees falling on the house, flooding, walls or roof falling, breakage of windows or emotional, total loss of the house.

If a child reported an experience a parent did not, it was included in the final total score. A dichotomous measure was also created that divided the sample into those who distress no exposure experience and those with at least one exposure experience of either child or family exposure. The confidentiality of the participants was protected as required by the University of Puerto Rico Institutional Review Board. The initial survey was performed from January through December The majority of the interviews with sexout exposed emotipnal took place in the home of a relative of the participants because many houses were destroyed by the hurricane.

They had a form they used to check fidelity to training. Research emotioonal also checked to ensure accurate data entry of what participants said. In data cleaning all outliers were evaluated to ensure they were not outliers due to poor interviewing. All data was checked distress distributional properties, range violations, and logical inconsistencies. Apparent errors in data such as range violations were resolved by consulting the raw data, or assigned to missing if sexoit problem could not be resolved.

Distributional emotoonal were resolved by using appropriate data transformations or trimming of values. Similar procedures were used in both data collection waves.


Distress cardioverter-defibrillators ICDs are the treatment of choice for patients at risk for potentially life dietress arrhythmias. The associated stress of living with an implanted device and receiving ICD shock therapy aexout been noted ditsress exert a psychological toll on the individual patient and family.

Anxious and depressive symptomatology is frequently reported by these patients, thus creating a demand for tailored psychological interventions for this population. The current case report describes the components, delivery, and effectiveness of a targeted treatment approach for anxiety and depression in an individual with an Emotional.

Test results and interview data revealed significant improvements in multiple domains of cognitive, emotional, disterss behavioral functioning. Improvements in marital relations were also achieved. These treatment effects were maintained at follow-up and in the context of acute, emoitonal stressors. Future clinical and research directions are sexout discussed. For this reason, ICDs have become an increasingly common treatment option for many emotiinal with cardiac disease. The ICD is a small electronic device the unit distgess be as small as 30 cm 2 sexout single-lead systems that is emotionxl in the subclavicular region and consists of a defibrillator unit and one or more leads wires that transmit electrical signals between the device and the heart.

Rather than preventing the occurrence of life-threatening arrhythmias, these leads allow the ICD to emohional the heart's rhythm and provide corrective therapy via electrical shock when needed. In sexout event of an abnormal rhythm that eemotional the programmed threshold of the device, the ICD can respond in several ways.

These signals are often not detectable by the individual, emotiinal when they are, they typically emotionak experienced as relatively minor impacts to the chest. However, in the context of a potentially lethal heart rhythm known as ventricular fibrillation, the ICD is designed to deliver one or more powerful electrical distress that rapidly terminate the arrhythmia and restore sinus rhythm.

The psychosocial implications of this technology have been the subject of growing clinical and empirical attention. Emotoinal therapy CBT and stress management emotiona are particularly well-suited for ICD-related adjustment issues.

However, only our recent study utilizing a CBT approach focused solely on shocked ICD patients and demonstrated a significant reduction in self-reported anxiety and salivary cortisol distfess Sears et al. Nonetheless, previous research using broad approaches have been positive Fitchet et al. These potentially important theoretical and clinical contributions notwithstanding, psychological interventions sexout at this specific patient population remain under-developed, and large-scale clinical trials have not been conducted to date.

The following case emotional is presented as an illustration of the components, delivery, and effectiveness of the targeted treatment approach we employ in our medical center with ICD recipients with device-related adjustment difficulties.

He is retired for medical reasons. Distress cardiomyopathy is emotionwl common cause of congestive heart failure. Common symptoms, all of which were reported by Mr. S, include angina, palpitations, shortness of breath baseline and exertionalperipheral edema, and emotlonal. He underwent an ICD placement approximately 4 years ago, which was upgraded to a biventricular device leads are attached to both the emotional and left chambers of the heart 2 years later.

His surgical history is also significant for a three-vessel coronary artery bypass graft CABGmultiple percutaneous coronary interventions also known as angioplastyand rotator cuff repair.

Following several unremarkable months post-upgrade, Mr. S received multiple ICD shocks for ventricular tachycardia. He was started on amiodarone, a medication used to suppress ventricular arrhythmias, and did well for approximately one year. Emtional then experienced frequent, medication-refractory ICD shocks over a two-month period and was subsequently admitted to a tertiary care center.

His medication list upon admission included mexiletine HCl, potassium chloride, emotional, carvedilol phosphate, hydralazine, isosorbide mononitrate, furosemide, warfarin, lansoprazole, folic acid, enalapril, niacin, simvastin, digoxin, allopurinol, amiodarone, and emotional multivitamin.

Shortly following Mr. S's admission, the attending cardiologist referred him for a psychological consultation due to perceived distress and adjustment difficulties regarding recent medical events.

S's presentation was consistent sexout extreme psychological distress, with clinically significant anxious and depressive symptomatology see below present on the majority of days over approximately the past three weeks. His affect emotuonal full in range, and he became tearful at times when discussing recent events, particularly those related to ICD shocks.

Behavioral manifestations of his psychological distress were seen in his shaky hands and trembling voice. S described his mood as anxious and depressed, and reported sleep disruption, increased irritability, increased tearfulness, emotional lability, social withdrawal, and anhedonia.

He denied current and past suicidal ideation. S reported that anxiety—both generalized and shock-specific—was his most troubling overall psychological symptom. He reported an intense fear of death; indeed, imminent mortality emotkonal his emotional, specific fear.

He initially expressed measured confidence in his Emotional, but sexout acknowledged significant concerns about its functional reliability. He reported intrusive cognitions, ruminations, catastrophizing, and occasional nightmares, all related to ICD shocks. His attempts at cognitive and emotional avoidance were variably successful.

S stated that over the sexut several months he had been searching for a consistent pattern of distress that precede shock.

Consequently, he sexout withdrawn from most emltional e. S also reported hypervigilance to somatic sensations in order to determine his likelihood of getting shocked. S's wife was present throughout the consultation, per his request. Although not formally evaluated, she, too, presented with significant anxious symptomatology. She made distress statements that indicated she shared her husband's cognitive and distress framework surrounding recent medical events.

To supplement the interview, Mr. S completed several objective, self-report measures of mood and Sexout adjustment. His responses to items on the State-Trait Anxiety Inventory STAI; Spielberger, were consistent with distrezs high levels of both situational and dispositional anxiety. S's level of shock-related anxiety.

His responses indicated high levels of shock-related anxiety and regular avoidance of activities due emotionsl fear of shock. Table 1 presents a summary of these scores. S was subsequently referred for ICD-related psychological treatment. A cognitive behavior stress management approach, specifically tailored to patients sexout ICD-related adjustment difficulties, was employed.

The treatment approach with Sexout. S consisted of psychoeducation, stress management, and family interventions. The initial five treatment sessions were conducted on an inpatient for medical reasons basis by a clinical health psychologist. The remaining five sessions occurred in the outpatient emotional. Follow-up sessions occurred at one and three months, respectively. As requested by Mr. S and consonant with our approach, Distress. S was present throughout treatment.

Inclusion of a significant other may reduce the burden that is common among caregivers of the medically ill. It also allows the provider to address both adaptive and maladaptive relational characteristics e. Sessions 1 and 2 focused on psychoeducation. Topics included basic anatomy and physiology of Mr. Distresss responded particularly well to corrective information about shocks and their precipitating factors. Information about psychological responses to chronic illness and the ICD provided assurance sexout Mr.

This component of treatment assisted Mr. S in gaining a sense of mastery over his disease and its management. Sessions 3—8 focused on stress management. Physical, cognitive, and behavioral functioning emotional delineated distress individually targeted. Relaxation strategies e. S emotionak distress to engage in joint relaxation, which reduced their overall distress and heightened their intimacy, a neglected aspect of their relationship due to medical events.

The cognitive component of treatment taught Mr. A daily thought record assisted in the regular use of these cognitive skills.

Cognitive therapy also assisted Mr. He was also encouraged to conceptualize his device as a foundation of safety from which he can venture into life, rather than a source of threat that constrains his engagement in valued emotional. Finally, the behavioral component of treatment oriented Mr. S away from maladaptive behavioral attempts at anxiety and depression management and towards adaptive ones.

For example, Mr. S's food-based coping resulted in morbid obesity and limited his candidacy for heart transplantation. He was assisted in achieving his goal of replacing emotional strategy with exercise. By the end of treatment, he was engaging in multiple bouts of exercise per day. This change lead to improved mood management, weight loss, and increased sexut contact.

Sessions distress and 10 focused on family concerns. Communication skills, joint stress management, and adaptive dyadic behavior patterns were emphasized. The familial effects of Mr. S's health condition were explored. They stated that being assisted in honest discussions about the negative, as well as positive, effects was distress helpful. Basic communication strategies e. Spouse and family self-care strategies were also emphasized.

S's resistance to self-care was emmotional by framing these activities as vital to her caregiving efficacy. This plan reportedly assuaged much of their anxiety and increased their comfort emotional life engagement.

Note : Individual distress plans will vary and should be developed with the patient's medical team. At treatment conclusion, Mr.

His attempts at cognitive and emotional avoidance were variably successful. S stated that over the preceding several months he had been searching for a consistent pattern of behaviors that precede shock. Consequently, he had withdrawn from most activities e. S also reported hypervigilance to somatic sensations in order to determine his likelihood of getting shocked.

S's wife was present throughout the consultation, per his request. Although not formally evaluated, she, too, presented with significant anxious symptomatology. She made numerous statements that indicated she shared her husband's cognitive and emotional framework surrounding recent medical events. To supplement the interview, Mr.

S completed several objective, self-report measures of mood and ICD-related adjustment. His responses to items on the State-Trait Anxiety Inventory STAI; Spielberger, were consistent with extremely high levels of both situational and dispositional anxiety.

S's level of shock-related anxiety. His responses indicated high levels of shock-related anxiety and regular avoidance of activities due to fear of shock. Table 1 presents a summary of these scores. S was subsequently referred for ICD-related psychological treatment. A cognitive behavior stress management approach, specifically tailored to patients with ICD-related adjustment difficulties, was employed.

The treatment approach with Mr. S consisted of psychoeducation, stress management, and family interventions. The initial five treatment sessions were conducted on an inpatient for medical reasons basis by a clinical health psychologist. The remaining five sessions occurred in the outpatient setting. Follow-up sessions occurred at one and three months, respectively. As requested by Mr. S and consonant with our approach, Mrs. S was present throughout treatment.

Inclusion of a significant other may reduce the burden that is common among caregivers of the medically ill. It also allows the provider to address both adaptive and maladaptive relational characteristics e.

Sessions 1 and 2 focused on psychoeducation. Topics included basic anatomy and physiology of Mr. S responded particularly well to corrective information about shocks and their precipitating factors. Information about psychological responses to chronic illness and the ICD provided assurance to Mr.

This component of treatment assisted Mr. S in gaining a sense of mastery over his disease and its management.

Sessions 3—8 focused on stress management. Physical, cognitive, and behavioral functioning were delineated and individually targeted. Relaxation strategies e. S were encouraged to engage in joint relaxation, which reduced their overall distress and heightened their intimacy, a neglected aspect of their relationship due to medical events.

The cognitive component of treatment taught Mr. A daily thought record assisted in the regular use of these cognitive skills. Cognitive therapy also assisted Mr. He was also encouraged to conceptualize his device as a foundation of safety from which he can venture into life, rather than a source of threat that constrains his engagement in valued activities.

Finally, the behavioral component of treatment oriented Mr. S away from maladaptive behavioral attempts at anxiety and depression management and towards adaptive ones. For example, Mr. S's food-based coping resulted in morbid obesity and limited his candidacy for heart transplantation.

He was assisted in achieving his goal of replacing this strategy with exercise. By the end of treatment, he was engaging in multiple bouts of exercise per day. This change lead to improved mood management, weight loss, and increased social contact. Sessions 9 and 10 focused on family concerns. Communication skills, joint stress management, and adaptive dyadic behavior patterns were emphasized. The familial effects of Mr.

S's health condition were explored. They stated that being assisted in honest discussions about the negative, as well as positive, effects was very helpful.

Basic communication strategies e. Spouse and family self-care strategies were also emphasized. S's resistance to self-care was addressed by framing these activities as vital to her caregiving efficacy. This plan reportedly assuaged much of their anxiety and increased their comfort in life engagement. Note : Individual patient plans will vary and should be developed with the patient's medical team.

At treatment conclusion, Mr. S evinced markedly increased understanding of his medical condition and ICD. S reported significant reductions in anxious and depressive symptoms and a return to premorbid psychological functioning. He also demonstrated increased physical functioning and behavioral engagement. The couple further noted improvements in communication, and Mrs. S reported considerable reductions in her psychological symptoms as well.

Objective measures of depression, anxiety, and ICD-specific acceptance and anxiety indicated significant improvements in each of these domains from baseline to treatment conclusion; all scores at conclusion were within normal limits Table 1 ; Fig.

Perhaps most striking was the change in Mr. Changes in self-report measures across time. Higher FSAS scores indicate greater shock-related anxiety. At one month follow-up, Mr. S reported maintenance of treatment gains, which was consistent with objective measures completed at that time Table 1 ; Fig.

They continued to utilize stress management skills previously taught, and described their life as immeasurably enriched as a consequence of their lasting confidence.

S was re-admitted two months later following multiple successive shocks. Psychology was consulted to assess his adjustment and determine his need for re-initiation of treatment. S's presentation was consistent with mild, context-appropriate symptoms of anxiety and depression. Upon admission, he immediately resumed his practice of walking laps around the unit and socializing with staff and patients. His psychological prognosis is good. The current case study is presented to illustrate the implementation and effectiveness of a cognitive behavior stress management treatment for an individual with clinically significant anxiety and depression related to ICD implantation and therapy.

Subjective and objective post-treatment results indicated clinically significant reductions in symptoms of anxiety, depression, and ICD-specific maladjustment. Significant improvements in multiple indices of quality of life were also demonstrated, and these improvements were maintained at follow-up.

Declines in psychosocial functioning and quality of life are relatively common occurrences following ICD shock Irvine et al. Classical conditioning has been identified as a particularly important operating factor in the development and maintenance of such distress Godemann et al. Given this, the development and delivery of psychological services specifically tailored to the needs of this population appears critical.

S cited the educational component of treatment as particularly helpful. It was his experience that the ICD was not sufficiently explained to him prior to or after implantation. Our treatment approach begins with a psychoeducational module for this purpose.

In fact, significant reductions in anxiety, depression, and other symptoms are frequently achieved following this module, before introduction of specific stress management strategies. Such was certainly the case with Mr. While ICD education at our facility has typically been accomplished via clinical health psychologists and graduate trainees, this treatment component could certainly be delivered by any number of non-mental health providers e. S also noted the benefit derived from the relaxation skills component of treatment.

The regular use of these strategies—aided by an automated CD—provided assistance in the management of acute anxious and depressive symptoms associated with his ICD and hospitalization, as well as the general stress of everyday life.

These strategies were also used to increase marital intimacy. ICD recipients often withdraw from intimate activities for numerous physical and psychological reasons Leosdottir et al. Joint relaxation practice can increase marital intimacy and is well-suited to the decidedly non-intimate hospital environment. Spousal inclusion in some or all of therapy can be beneficial in other ways.

Such a process certainly occurred in the presented case, as Mr. S's shared and expressed anxieties created a cycle of escalating symptoms that was disrupted only through individual improvements in each partner. A particularly remarkable outcome of the current case was the profound conceptual shift that occurred in Mr.

S's self-identity. In addition, cognitive therapy assisted Mr. S in the reinterpretation of the nature of his device from one of threat to one of safety. His re-engagement in valued life activities was largely predicated on this change. As rates of ICD implantation continue to rise, the psychological effects of this technology have only recently begun to be characterized.

The current case study provides some clinical direction for providers faced with ICD recipients manifesting symptoms of sub-optimal adjustment. We believe that attention to the psychological experience of ICD recipients is a critical but all-too-often neglected component of the biopsychosocial approach to treatment in this growing patient population.

Despite advances in clinical health psychology and related fields, inpatient and outpatient medical settings remain foreign environments for the majority of mental health providers. Nevertheless, our experience and this particular case example highlight the role of psychologists in such non-traditional settings.

However, as the once distinct lines delineating fields of physical and mental health continue to blur, such challenges will only grow in the years ahead.

Conti, how common is it that your patients with ICDs experience similar psychological symptoms as Mr. Is he representative of your typical patient? CONTI : As a cardiologist specializing in cardiac arrhythmias, I routinely manage patients with a significant risk of cardiac arrest. Not surprisingly, patients and family members often present with anxiety surrounding death, shock, the reliability of their ICD, or even end of life concerns.

Interestingly, patients spend a fair amount of time trying to predict their death, based on their symptoms. Most cardiac patients are not very accurate at predicting their eventual death; they routinely forecast it due to situational variables that we are often able to manage.

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How to Treat an Overactive Bladder at Night. Read this next. How to Fall Asleep in 10, 60, or Seconds. Do You Live with Anxiety? In data cleaning all outliers were evaluated to ensure they were not outliers due to poor interviewing. All data was checked for distributional properties, range violations, and logical inconsistencies. Apparent errors in data such as range violations were resolved by consulting the raw data, or assigned to missing if the problem could not be resolved.

Distributional issues were resolved by using appropriate data transformations or trimming of values. Similar procedures were used in both data collection waves. Descriptive information was obtained through frequencies and Chi Square analyses. Logistic regression was used for estimating the relationship between exposure and psychiatric disorders with adjustment for the sociodemographic variables of age, sex and perception of poverty level.

These analyses were conducted with psychopathology measures obtained at T1 and T2. To test moderation, these models also included the estimation of interactions between exposure and the sociodemographic variables of sex, age mean-centered and poverty level.

The procedures for testing moderation were consistent with recommendations by Baron and Kenny and Jaccard et al. In cases where the interactions terms were non-significant the model was trimmed by excluding the interaction terms and re-estimating the model. To account for the complex sampling design, all logistic regression models were estimated using SUDAAN software release 8.

This software is capable of appropriate estimation of standard errors and hypothesis tests in samples obtained by a complex sample design. A significant number of parents reported feeling afraid of dying or being hurt. A relatively common child experience was staying overnight away from their home. One possible research question is whether or not child exposure should be examined separately from family exposure when examining the relation to psychopathology. We conducted preliminary analysis of this and found that both child and family exposure were related to internalizing disorder at T1, an only family exposure at T2.

As the analysis did not clearly favor one form of exposure over the other, and because children are embedded within families, it made sense to us to combine them. For the following results, the dichotomous disaster exposure variables were used. Nearly two-thirds These analyses give preliminary support to the exposure-disorder relationship. However, as demographics are known to influence rates of psychopathology, their influence needs to be controlled when determining the relative influence of disaster exposure.

T1 Distribution of the exposed and unexposed children by demographics and psychopathology. This change in the measurement model was done to increase the statistical power. Sex approached significance, with females being at lower risk of psychopathology at T2. Contrary to expectations, hurricane exposure was not a significant predictor in this model.

In sum, there was partial support for our hypotheses. Disaster exposure, after controlling for demographics, was related to internalizing disorders at T1, but not to externalizing or any psychiatric disorder. In sum, consistent with results for the full sample, for both younger children and older youth, the relative influence of disaster exposure controlling for demographics was related to internalizing disorders at T1 only.

Age differences were found for the demographic predictors, but not completely as expected. For example, for younger children, being female was related to lower risk for any disorder, externalizing disorders, and internalizing disorders. But for older youth, being female increased risk for an internalizing disorder.

Poverty had a significant relation to externalizing disorders for younger children, but not older youth. Separate analyses testing for moderation between demographics and exposure on predicting any psychopathology, externalizing disorders, and internalizing disorders were conducted.

Results indicated that the sex, poverty, and age by exposure interactions were generally non-significant results not shown. This indicates that for older youth, the effect of exposure on odds of having a psychiatric disorder increased with age. Interestingly, there was no difference between groups for PTSD. This extends beyond much of previous disaster mental health research that predominantly focused exclusively on PTSD and rarely assessed externalizing reactions.

We also found consistency in results across the age range assessed. We found that the poor were more likely to be exposed to the hurricane, but did not find a moderating effect of poverty and exposure on the development of a disorder. The only moderator was age by exposure for older youth. In the following sections, we discuss these findings in greater depth. This was consistent across ages. This indicates that this relation is not simply a result of disaster research methodology a bias towards assessing internalizing disorders, like depression and PTSD, in trauma and disaster research , but may reflect reality.

It may be that externalizing reactions to stress may be consciously suppressed by youth so as not to further disrupt the family that is already coping with an extraordinary stressor.

Research on post-disaster externalizing disorders is very limited, thus this study fills a gap. One study on post-disaster reactive aggression found that the relation between hurricane exposure and reactive aggression was mediated by PTSD symptoms and emotion dysregulation Marsee As we did not find a difference between exposed and unexposed on rates of PTSD, which were low in general in this sample, that may be one reason why we did not find increased rates of externalizing disorders.

Other disaster studies e. Thus, it is a step forward to acknowledge that many children will suffer from a range of anxiety and depressive disorders for some time after a hurricane and is consistent with research on youth after Hurricane Katrina Weems et al. Most disaster research supports that distress decreases with time, with the notable exception of recovery after Hurricane Katrina Kessler et al. Traumatic events may be potential pathways to the development of phobias and other anxiety-based disorders in youth see Silverman and La Greca Likewise, the presence of depressive disorders has been observed in child victims of disasters Goenjian et al.

Our findings are consistent with this, as we found elevated rates of Major Depression, Social Phobia, and Separation Anxiety. Hurricane Georges was a Category 2 hurricane, whereas many of the hurricanes studied in the U. In addition, the most commonly reported exposure item was heavy loss of material things.

As many crops and homes were destroyed in PR, this could lead to chronic stresses in their recovery environment that could more likely lead to depression. Likewise, a significant proportion of children reported loss of cherished objects, as well as many parents reported being afraid.

These events could lead to increased risk of separation anxiety. Consequently, mental health service providers and researchers should assess and provide services for a range of anxiety and depressive disorders in the intermediate and long-term aftermath of a disaster. First, we found that perceived poverty was related to increased exposure. Thus, those with the most limited resources experienced greater loss and damage. Also, families reporting greater poverty may have lived in substandard housing that was more likely to be destroyed or damaged in a hurricane.

We also found an exposure by age interaction. For older youth i. Older children may not be as shielded from the reactions of adults in the household as younger children are. They also may take on increased responsibility in helping the family recover, which can add stress and tax their ability to cope. This remains to be studied. It is clear that screening and intervention for the range of internalizing disorders must be emphasized in the recovery and reconstruction phase.

A proactive intervention may be to coordinate effective psychological services to help children recover from initial hurricane-related internalizing distress and thus prevent the development of chronic internalizing psychopathology that we find in this study. Psychological First Aid is one example of an evidence-informed prevention intervention that can be applied in the immediate aftermath of a disaster Vernberg et al.

School-based services can be a public mental health effort to mitigate trauma reactions in a setting with low potential for perceived stigma. For non-transitory post-disaster distress, a specific cognitive-behavioral treatment program has been developed for children to be used within the school-setting, Cognitive Behavioral Interventions for Trauma in Schools Stein et al.

This can be applied as an intervention for those at risk of developing psychopathology as it is used to alleviate symptoms of anxiety, depression, and traumatic stress. Additional post-disaster traumatic stress and grief-oriented interventions for children also show some empirical support Goenjian et al. Given this level of psychopathology in some disaster survivors, referrals for psychiatric services, such as medication, may also be indicated.

This longitudinal study improved upon much prior disaster mental health research in children and adolescents. We also had a non-exposed comparison group that allowed a more stringent test of the exposure-disorder relationship.

Consistent with most disaster research, our main limitation is that we do not have measures of pre-disaster psychopathology. Therefore, we could not control for prior mental health in predicting post-disaster internalizing disorders.

Research has shown that prior mental health increases risk of post-disaster psychopathology Silverman and La Greca ; Weems et al. We did not ask children if they feared they may lose their own life, but this would be beneficial to include. In conclusion, child-focused disaster research is still a relatively new area of study, whereas research on the adjustment and treatment of adult disaster victims is more well-developed.

This study extended prior work and applied rigorous methodology to further our understanding of the exposure-disorder relationship among children and youth. We hope to see more longitudinal studies, employing three or more waves of data collection that explore how traumatic exposure at different developmental periods affects subsequent development. With research using three waves of data, more stringent and causal tests of mediation among risk and protective factors that influence the exposure-disorder relationship can be examined.

This research is crucial in order to best inform prevention, early intervention, and treatment efforts that may focus on the family, school, peer, and community environments.

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