The Opportunity for Occupational Therapy in Pediatric Disaster Recovery

Impact on Children

Although natural disasters also affect adults, children in disasters are an especially vulnerable population. Children who experience natural disasters may have to deal with the effects of grief; loss of safety and security; displacement from home and school; changes in their parents’ mental health; and loss of social support, typical routines, and roles (Kousky, 2016; Roberson, 2017). Younger children may have attachment issues or separation anxiety, exhibit regressive behaviors in their self-care, or demonstrate decreased social participation (Roberson, 2017).

Although younger children may present with behavioral problems or trauma-related fears, adolescents may have more symptoms of posttraumatic stress disorder (PTSD), depression, or substance abuse (Ruggiero et al., 2015). Adolescents may experience social isolation, depression, or maladaptive behaviors, leading to dysfunction in school, work, and leisure participation (Roberson, 2017).

The literature suggests that postdisaster trauma may differ not only according to the child’s developmental level but also in the level of disaster exposure. Many children are resilient, but children with great exposure to natural disasters are at risk for developing PTSD or other stress-related symptoms. For children with previous trauma, adverse childhood experiences, decreased social support, or ongoing racialized and environmental stress, disaster exposure exacerbates these factors.

Children and families of historically excluded populations, people with disabilities, immigrants and refugees, and those living in resource-poor areas may have increased vulnerability. These populations can have inequitable risk exposure and decreased access to social resources, leading to extensive displacements and increased negative consequences because of previous injustices in housing segregation and environmental systems (Gotham, 2017). In addition, children and families suffer when essential community services withdraw because of damage in a neighborhood, affecting those with existing health care needs, food insecurity, or decreased social support (Kousky, 2016).

Occupational Therapy in Disaster Recovery

Occupational therapy practitioners can help vulnerable populations affected by traumatic experiences because they are well prepared to help promote engagement in habits, rituals, routines, and occupations to foster mental health and occupational participation (AOTA, 2018). Because natural disaster exposure can have adverse effects on emotional, physical, and mental well-being, it is a traumatic experience with implications for occupational functioning (Fette et al., 2019). Given the knowledge of the mental health and developmental effects of disaster-related exposure, psychosocial and occupation-based interventions need to address recovery.

Occupational therapy practitioners understand the association between active engagement and positive mental health as well as the importance of activity and occupation-based interventions for mental health (Cahill et al., 2020). AOTA and the World Federation of Occupational Therapists (WFOT) have resources on disaster recovery, the impact of disasters on occupational performance, and the role of occupational therapy on a disaster relief team (see, e.g., Parente et al., 2017; Pizzi, 2015; Taylor et al., 2011). However, research is lacking on occupation-centered interventions that specifically address children affected by natural disasters.

According to AOTA’s (2018) Societal Statement on Stress, Trauma, and Posttraumatic Stress Disorder, with the knowledge that occupational therapy practitioners have of trauma-informed care, fostering occupational participation, and mental health, occupational therapy should have a more substantial presence in stress- and trauma-related interventions. Occupational therapy practitioners can analyze the fit among the environment, occupation, and the child; structure environments; and help develop social–emotional skills to regain routines and promote resilience (Petrenchik & Weiss, 2015). When occupational therapy is not an integral part of the disaster recovery team, children do not have a professional assessing their needs and concerns using a holistic, occupation-centered lens.

Treatment Approaches

When supporting children postdisaster, it is vital that they return to normal routines and activities (Mutch & Gawith, 2014). To help children cope and return to everyday routines, health professionals have used cognitive–behavioral approaches, play, art therapy, and psychosocial and child-led interventions that have shown promising results (Lai et al., 2014; Rolfsnes & Idsoe, 2011). Occupational therapy practitioners can engage in programs to foster improved mental health, resiliency, and occupational performance in interventions such as yoga, performing arts, social skills programs, stress management, mental health education, and playgroups (Arbesman et al., 2013).

Play Therapy

For young children who have experienced a disaster, studies have shown that play has a notable and effective role in recovery. Bondoc and Ching (2015) used a qualitative case study to assess an occupation-based intervention that involved creating a pediatric activity area that included opportunities for play and social interaction after a typhoon in the southern Philippines. More than 500 children participated in the community-based intervention, and clinical observations showed improved occupational routines (Bondoc & Ching, 2015). A child affected by trauma may struggle with play and learning; therefore, by targeting play skills, practitioners can rebuild safety and normalcy into routines and roles (Sanderson et al., 2016).

Activity and Child-Led Interventions

Children are a unique population because they process trauma differently than adults but also hold key roles in the recovery process within the community (Freeman et al., 2015). In a participatory research project, three schools affected by earthquakes chose collaborative projects (an illustrated book, mosaic panels, and a documentary) to help students actively engage in the recovery process (Mutch & Gawith, 2014). Students found that the project was an overall positive experience; created emotional distance from the impact of the natural disaster; and provided safe, child-involved opportunities for healing and emotional processing (Mutch & Gawith, 2014). Occupational therapy practitioners are well equipped to collaborate with youth to build emotional skills, resiliency, and a sense of connectedness through meaningful activities.

Psychosocial Interventions

Children exposed to trauma benefit from consistent, structured care and cognitive–behavioral approaches to improve psychological resilience (Chen et al., 2014). In a Critically Appraised Topic, Ladderud et al. (2018) found moderate evidence that cognitive–behavioral therapy interventions (including Cognitive Behavioral Intervention for Trauma in Schools, trauma-focused cognitive–behavioral therapy, and Bounce Back) reduced PTSD, depression, and anxiety symptoms among children and adolescents. Through psychosocial interventions, practitioners can also treat children in need of intervention because of a natural disaster in collaboration with other health care professionals. In an open feasibility trial by Stasiak et al. (2018), psychologists and an occupational therapy practitioner administered an online cognitive– behavioral therapy program for children and adolescents with anxiety symptoms related to earthquakes. Researchers found that 6 mo after completing the intervention, more than half of the participants had reduced anxiety symptoms and reported improvements in quality of life (Stasiak et al., 2018). This study is a notable example of the opportunity for practitioners to engage in psychosocial interventions and use cognitive–behavioral principles.

Implications for Occupational Therapy

Practitioners can assist in several ways to heal trauma and facilitate resiliency and hope among children with disaster exposure (Pizzi, 2015). As part of the intervention team, practitioners can help children develop coping skills and restore participation in their valued roles, habits, and routines (AOTA, 2011) by using the evidence-based interventions outlined in Table 1. It is essential that professionals recognize the distinct needs of children in disaster recovery and include them as active participants in their individual and community healing (Lopez et al., 2012). With their knowledge of occupational disruption and preexisting presence in their community, local, pretrained occupational therapy practitioners can support children through school and community programs. Practitioners can network and collaborate with community leaders and health care professionals on recovery programs and facilitate the use of support groups and occupation-based services for families during the disaster recovery period (AOTA, 2011; WFOT, 2014).

Future Steps

It is up to practitioners to take steps to learn about disaster recovery and trauma-informed interventions and to be trained in advance to volunteer resources and time. In addition to understanding disaster-related terminology, practitioners should also learn about the structure of local and national organizations involved in disaster recovery (AOTA, 2011). Because child care providers and school staff may be the first to encounter children after a disaster, occupational therapy practitioners in school and community settings should be aware of signs of trauma and changes in clients’ coping and regulation skills. Practitioners can create safe, predictable environments to support disaster-exposed families, but they should also recognize when to refer clients to those with advanced trauma-informed training (Fette et al., 2019).

The American Academy of Pediatrics (2022) has a plethora of resources, toolkits, and education opportunities for health care professionals’ use in considering children’s needs in disaster planning and response. The WFOT (2019) also has a training course, Disaster Management for Occupational Therapists, to help practitioners better understand their role in disaster management and to use occupations to restore health and well-being. In addition, practitioners can learn how to develop evidence-based programs from occupational therapy practitioners in other regions.

Disaster recovery intervention does not come without challenges. Disasters and their impact are specific to the area and the community. Devastation rarely comes with advance warning, and affected families may be difficult to reach postdisaster (Masten & Osofsky, 2010). Reflective practitioners should be aware of inequities in access to and equality of care for youth and families of color. Given environmental and racial stressors, parents of color may have difficulty with coregulation, lessening the protective barrier for children during disaster recovery (Fortuna et al., 2020). Local mental health professionals may also have increased distress from working with the intense needs of the community while also working through their own recovery process. Practitioners should educate themselves and partner with community leaders to provide a path of recovery that reflects the customs and history of affected communities and that intentionally creates safe and supportive environments.

Even with the previously noted barriers in the recovery process, the profession needs current qualitative and quantitative research that captures the experiences and needs of local communities. While continuing to focus on mental health roots and program planning, occupational therapy practitioners can assist in activity-based, psychosocial, and tiered intervention approaches in pediatric settings to deliver appropriate care to children affected by natural disasters, forced displacement, exposure to violence, and other manmade hazards. From advocacy for equitable community resources and disaster preparation to psychosocial interventions for families and occupation-focused research, practitioners have a unique opportunity to contribute to pediatric disaster services.