Clinical and Experimental Psychology

One day due to bad lightening in school while teaching was going on, school catch earth current, all children get out of sense, a child died on the spot and many more were injured and rest in a state of panic [1]. After few weeks, even after normal weather the children didn’t come to school and so also parent didn’t send their children to school. The team established a very good rapport with children by making friendship with them and by talking about the events which helps the child accept the facts and can cope with the losses. The team has observed that number of children attendance is less and some of the physical and emotional reaction found among the children after performed the four stations. The present study was designed to investigate the quality of life functioning and satisfaction of the affected children who received the Psychological Firs Aid (PFA) and psychosocial interventions. A small experiment was initiated after receiving the news regarding the lightning accident at Causally Primary School of Village-Chaupally, block-Khandrapara, Dist-Nayagrah. Immediately Disaster Mental Health team of Indian Red Cross, Odisha State Branch and Nayagarh district administrative emergency cell and Khadrapara hospital to know the actual fact and status of situation. American Red Cross in IRCS Delhi Head Office initiated the intervention with a team of professionals under the leadership of Dr. Joe Prewitte Diaz. Liaison was maintained District Red Cross branch of school, hospital, District Emergency Cell to ensure services according to need. The sample consisted of 162 subjects having the symptoms of fear and anxiety etc. due to the sudden lightening accident and death in the school.

The total number of children evaluated for the study is shown in Table 1. Among the samples evaluated School Strength 162, Teacher strength 4, Died 1, Injured 5 children / one teacher, Impact of the events was all children deny to go school (Table 1). A sense of fear, anxiety and insecurity prevalent among the children (Figures 1 and 2).

Table 1: Sample characteristics.

Figure 1: Sample distribution as on rapid assessment.

Figure 2: Stages of recovery.

Thunder storm and lightening is natural hazards which bring rains (which can cause flash flooding) strong wind, hail lightening and tornadoes. Lightening is major threat during a thunderstorm. In fact lightening will strike several times in the same place in the course of one discharge.

Lightening - Lightning is an electrical discharge that results from the buildup of positive and negative charges within a thunderstorm. When the buildup becomes strong enough, lightning appears as a “bolt”. This flash of light usually occurs within the clouds or between the clouds and the ground. A bolt of lightning reaches a temperature approaching 50,000 degrees Fahrenheit in a split second. The rapid heating and cooling of air near the lightning causes thunder.

There is quite a lot of energy in a lightning stroke, about 250 kilowatt-hours. The amount of energy, you could lift a 2000-pound car 62 miles high. Lightning doesn’t always travel from cloud to ground. If two parts of the cloud are charged highly (and oppositely), a lightning bolt can actually occur inside the cloud. Lightning can also arc from one cloud to another.

In the eastern part of Orissa, Village – Chaupally is situated in the foothill of the block-Khadarapara, district- Nayagarh is one of the thunder storm and lightening prone village, for the last ten years four people died by hitting of lightening. The village- Chaupally consist of 1000 population with heterogeneous communities. Depend on the making bidis for their livelihood, the whole family members involve in making bidis/home made cigars. The communication and transportation facilities are good in that village. There is a Chaupally upper primary school (I-V class) which is located at the top of the hill in one corner of the village. The traumatic incident took place, a thunderstorm lightening hit on the school which caused lot of panic and anxiety in the school as well as in the community. Parents ran to school to save their children. On that incident one teacher injured and one student died on the spot. A sense of fear, anxiety and insecurity are seen among the children. This event directly and indirectly put its impact to the children. IRCS-OSB/ARC decided to intervene in this situation on the following objectives:-

• To help the children to recover their sense of well-being.

• To help them overcome the trauma.

• To normalize their daily life routine and getting back to attend school.

• To enroll the school dropouts.

• To create awareness on Disaster Mental Health and Psychosocial Care with parents and teachers.

Duration of the Intervention – 2 weeks / till children resume to school (whichever is earlier). The intervention strategy was based and focused on the Psychological First Aid (PFA).

To offer a cure, one must know the ailment. Psychological First Aid is a common cure for people in distress. But first one must understand what kind of distress it is. Then the relevance of the psychological first aid can be understood.

Psychological first aid is as important as physical first aid. When someone is bleeding, you don’t immediately take the person to the Emergency room; you do something to stop the bleeding, and then take him/her to the Emergency Room. Likewise, you do not offer a person in need of immediate psychological assistance, trauma counseling, or take them for psychotherapy [2]. Firstly because in India, there are very few psychiatrists and psychologists to assist such a vast population and secondly, not all psychological problems require professional intervention. There are simple ways of assisting people in distress, which the fellow human beings can offer. These simple ways constitute Psychological first aid.

Almost every person faces difficult times in life. But some people face problems of greater magnitude and severity like disasters/ crises. Psychological first aid is a first order response, of short duration, to a person who is experiencing distress as a result of a disaster, an emergency or a crisis. The SPHERE 2004 manual defines psychological first aid saying the basic non-intrusive, pragmatic care with a focus on listening, but not forcing to talk; assessing needs and ensuring that basic needs are met, encouraging but not forcing company from significant others; and protecting from further harm”.

The conditions that will cause a reaction of distress are following conditions during the disaster, emergency or crisis will serve as an indication for psychological first aid.

• Physical proximity to the disaster.

• Emotional proximity to an event.

• Whether or not there are secondary events such as a disruption of daily routines through the loss of shelter, work place, or transportation.

• Whether or not a disaster has occurred by natural causes, such as hurricane or flood, or is caused by an act of another person known or unknown.

Based on the rapid assessment at the school the steps of intervention and list of activities and medium that can be used to identify the most affected children and their reaction which help the children overcome the impact of disaster (Table 2). The National Child Traumatic Stress Network and the National Center for PTSD [3] are pleased to make the Psychological First Aid for Schools Field Operations Guide and accompanying handouts available. Psychological First Aid for Schools is an evidence-informed approach for assisting children, adolescents, adults, and families in the aftermath of a school crisis, disaster, or terrorism event.

Table 2: The intervention should follow the four station of “carrousal of happiness”.

When a disaster, an emergency or a crisis occurs, the survivors depending on the level of exposure will require emotional support along with other relief material. By alleviating stress, psychological first aid will help the survivors to sustain mental/physical performance during routine activities, under extremely adverse conditions and in hostile environments [4].

Three main things need to be done when caring for these survivors.

• Provide information about normal behavioural responses to a disaster. Most people want to know they are not abnormal.

• Provide for the survivor’s basic needs. Some survivors will have no access to money, food or shelter.

• Refer the acute distress reactions to mental health professionals.

Implementation of Psychological First Aid was provided to the survivors who expressed stress reactions of the mind as well as to physical injuries of the body. You must know how to give psychological first aid to be able to, help yourself, your friends and family, and the community in times of a disaster or of a personal crisis.

Psychological first aid measures are simple and easy to understand. Improvisation is in order, just as it is in splinting a fracture. Your decision of what to do depend upon your ability to observe the survivor and understand his/her needs. Time is on your side, and so are the emotional resources of the survivor you are helping. Making the best use of resources requires ingenuity.

Before the follow the four station of carousal of happiness with children. The team established a very good rapport with children by making friendship with them and by talking about the events which helps the child accept the facts and can discuss the school teachers and parents of referral cases to help them to get over the trauma, in this cases identified two cases of trauma (Table 3).

Table 3: Present psychological morbidity status shown.

Before the follow the four station of carousal of happiness with children .The team established a very good rapport with children by making friendship with them and by talking about the events which helps the child accept the facts and can cope with the losses. The team has observed that number of children attendance is less and some of the physical and emotional reaction found among the children after performed the four stations (Table 4). The above events directly affected to the children of 4^th and 5^th standard class and indirectly affected to the 1^st, 2^nd and 3^rd standard class.

Table 4: Identified some of the referral case as follows.

Intervention strategies

i. Focused on special children - After the intervention, some groups of children especially from the 4^th and 5^th standard class were identified who need greater care and support. Identified 26 children deeply affected by the event.

ii. Identified some of the referral case; - Among this group of special children the team observed some children may require the help of a specialist. The team has noted their name to intimate them to specialist.

iii. Involvement of village volunteers and school teachers: - Efforts to activise and make the intervention sustainable, the team involve the member of youth club, ICDS staff, youth, and school teachers, who will give impetus to the programme. Initially very few volunteer approached to do volunteerism but slowly more volunteer join to the group.

The team briefed and discusses about the four station of “Carrousel of Happiness”, Red cross movement, Intervention of American red Cross, Stress Reaction with children Psychosocial care for children and help the children adopt healthy coping strategies.

The team interacted with parents and teachers of the school children, discussed about the need and importance of PFA with true experience. The team also suggested some tips like ensure that their children should have meal on time, sleep well, spend more time with them and encourage attending the school. This will help get over the trauma and start looking positively at their future. Especially for teachers, they should spend time with children to engage then to do creative things along with their studies.

Community approach

On the fifth day of the intervention, the community approached to the community to share tri fold - Share your feelings and Poster- Safe home. Before visit to community the team was briefed about the using and importance of the tri fold and Poster.

Fixation of the mural of safe school

Mural of safe school was painted on the wall of the school to convey the message in many people clearly and accurately.

Healing touch

The team took the child’s mother (Girl died by lightening) to the PHC for her health check – up. She was suffering from severe acidity and stomach ache. The team also interacted with group of women (Support group) and encouraged them to spend some time with child’s mother even few staff also alternately visited to her.

On the basis of the review of literature, the following hypotheses were formulated for the present study;

Strong community participatory approach for stakeholders throughout the process is essential for ownership of the reformation and sustainability of the psycho-social programming.

Play therapy and occupational therapy useful tool for the children and livelihood support providers psychological well-being of the survivors (Table 5).

Table 5: An overview of how play and other activities help children.

Sooner the psycho-social intervention reached to the survivor will create lesser chances of the psychological persistent morbidity among the survivors.

Both short-term and long-term plans were vital components of mental health reform and even in the midst of crises, it is important to make mental health services available at all levels, the involvement of service users is an extremely powerful component of reform (Table 6).

Table 6: Activities that can be used to help children feel good about themselves.

Investing in young, local mental health professionals (in terms of training different psycho social care technique, mentoring, and study visits) proved to be very helpful. They felt empowered as reformers, and often prioritized the ongoing mental health reform over potential personal benefits (such as better salaries or working conditions).

Play helps to gain mastery over issues and get a sense of power

Children have the power to create and protect and destroy during play without harming anyone and this gives them a sense of control, which in their lives they may not have. All their fears can be played out without any real danger. The child can talk about things that cause pain. The negative emotions associated with those events are brought out and the intensity of those emotions lessens through repeated expression. This enables the child to move beyond the issues and move forward in life.

Play helps to build self-esteem and self confidence

Being involved in activities like drawing or clay modelling helps the child tremendously. They are able to create and talk about their creations. If they get appreciation for their work or behaviour they tend to feel good about themselves. The process of creation is healing in itself and when they get recognition from others helps them get a sense of well-being. They are able to make new friends while interacting with the facilitator they develop a sense of belonging and feel accepted by the group. All this positively enhances their perceptions about themselves.

Play develop positivity and optimistic foundation for life. The activities given in Table 7 will help the children discover positive things about their life and themselves and all of these would add to their feeling of security and feeling good. Try and include these periodically in your work with children [5].

Table 7: Activities that can be used to help children gain mastery over the event.

Play helps in developing understanding

Stories on themes like not lying, how everyone feels sad and helpless. The child then has an opportunity to learn without feeling threatened by their own personal fears. They learn by listening to other children relate how they cope with particular situations. They can also modify their behaviors through observations of how other children are behaving (Table 8). All this helps in enhancing their own understanding of situations and issues and adopt more healthy ways of behaving and coping.

Table 8: Activities that can be used to help children develop understanding.

A story using a picture of bear who is awake lying on the bed and crying was told stating that the bear wakes up crying at night because it get bad dreams. There are activities that would facilitate the development of such understanding. They generally deal with the child’s feelings and thoughts and would enable the child to get some clarity about issues. These can be used with the children to help them deal with their personal issues.

Play facilitates skill development

Children interact with different kinds of medium ti interact with others. This improves many skills in the process (problem solving, communication, decision making and social skills). They learn simple things like waiting to have their turn to speak, listening to others. Appreciation helps as encouragement to do the work done by others. Learning to share was something they had to do as often they would have to wait for the particular crayon that they wanted.

Often just the experience of speaking in a group and having everyone listen was powerful enough for them to get some confidence. Being responsible in terms of having to return the caps of the pens, doing what they were asked to do and following the basic ground rules was a rich experience. They were at times required to think about situations presented through stories and see how it fitted into their personal life and then talk about it so even thinking skills were being enhanced. Some level of self-control was enforced since rowdy behavior was not tolerated. At one place the most aggressive child was given the responsibility to hand out the pencils and after everyone had finished to get them back that helped him not to behave badly.

Recognizing the ability of children and adolescents to deal with crisis

“Resilience is the capacity to transform oneself in positive way after a difficult event. Just as the way the bamboo springs back after pressure, the resilient individuals recover after a difficult time or a crisis. “The ability to spring back from and successfully adapt to adversity is Resiliency”.

Children and adolescents have tremendous capacity to bounce back after a crisis event if they are provided with a supportive environment (Table 9). The ways in which children and adolescents behave and respond to adults after a crisis situation are indications of their ability to deal with what has happened.

Table 9: Coping mechanisms by boys and girls.

Recognizing resilience in children

A child’s resilience is built by the coping skills s/he adapts, his/her behaviour with friends and family, his/her performance at school and the way that s/he follows his/her daily routines.

(a) If a child is coping well, s/he is:

• Happy and interested in his/her surroundings.

• Will make friends and enjoy playing with them.

• Offer and accept affection.

• Will want to learn, be happy at school.

(b) If a child is not coping well, then s/he would show the following signs at school:

• Very quiet and unresponsive to questions asked.

• Does not participate in the class or play with friends.

• Is irritable and fights with other children.

• Cries and shows regressive behaviour such as thumb sucking or clinging to the teacher.

• Gets scared easily. Always feels fearful and nervous.

• Physical problems. For example, headaches and backaches.

• No visual contact. The child does not look into the eyes of the other person.

• Very low achievement in school. The child does not understand what the teacher explains.

Recognizing resilience in adolescents

In case of adolescents, adults need to realize that it is a time when s/he is growing from a child to an adult and can no longer be treated as small children. Adolescents usually have an innate capacity to deal with crisis in a positive way although at times they might adopt negative ways. Because of the crucial time that they are in, they have to constantly adjust and recreate the way they deal with crisis and can sometimes be confused or misled. It is important for adults to provide them the support and encouragement that will help them to become resilient.

Coping power of adolescent boys and girls: In India, adolescent girls and boys are brought up with different roles. Expectations from boys and girls are very different. Most of the time boys are not expected to carry out household activities, as are girls. In rural India schooling activities are also discontinued for girls as soon as they attain puberty while there are expectations from boys to finish education and start earning for the family. Such differences influence their coping mechanisms. Gender discrimination prevails in the major villages.

Interest to serve others, altruism, patience, good communication skill, ability to accept a person uncritically, good social behaviour, ability to empathies and sympathies are most frequently quoted facilitating personal factors that helped psychosocial intervention. Individual level continuous positive feedback and encouragement from the beneficiary helped most. Willingness to accept the help offered, cooperation, ability to express the feelings easily.

Encouragement, felicitation, acceptability, cooperation, support were facilitating factors. Other factors were encouragement from one’s own family members, suggestions from village elders, support from school teachers, women self-help groups and support from social workers.

The impact of psychosocial counselling was quite visible. Most of the victims were rehabilitated in the community. There has been a change from ‘hopelessness’ to motivation to live a better life. People have understood the value of psychosocial counselling. The dawning of the attitude of self-survival, self-sufficiency and looking forward optimistically has occurred. Community as a whole was feeling more secure. There was more understanding and cooperation and less fear and anxiety. Victims were confident that they could continue towards leading life against all odds. They were able to see meaning in life and had ‘reasons to live’. Some said that they were alive because of the timely psychological help they received.

1. All children are very happy.

2. On the 14^th day of intervention all the children resumed to their normal studies.

3. Children actively participated in resilient activities along with studies.

4. All the classes started with full occupancy.

5. Enrollment of dropouts.

6. Teachers have also developed resilient capacity and coping system.

7. Teachers are involved in children resilient activities.

8. Village volunteers are involved in resilient activities.

9. 14 more children have taken admission in school.

10. Awareness was established on Psychological First Aid and play and creative activities among teachers, parents and community.

Acceptance of the emotionally disturbed persons had perceptibly increased in the community. Emotionally disturbed persons were no more being called as “mad”. There were increased awareness on women rights, children’s’ rights and an increased ability to fight injustice. Assertiveness of the women had increased. Standard of care of children and ladies in the community had increased.

Hence, timely provisioning with better and early intervention through Psychological First Aid and Psycho-social programming after any emergency, disaster or crisis event helps building resiliency with more empowered preparedness with Quality of life and courage to bounce back to the normalcy. Help the child adopt healthy coping strategies [6].

The child will often be confused about what can help him or her. You need to facilitate the recovery process. For this the first task is to normalize their life routines. Help them get involved in routine tasks like helping you with household work, getting back to school etc. Also you need to be available for play or ‘talk time’ where the child may want to talk or play out their experiences. Both these will help the child regain their original level of functioning. The diagram below captures the recovery process after a disaster and what you can do to hasten the recovery [7].

As an adult caregiver you need to take the child to a specialist. Follow up on the advice given both at school and at home. Discuss the progress periodically with the specialists. The table given below describes some of the symptoms that may require referral. As Dr Ajit Ku Mohanty’s study on The Weaning Syndrome: Acquired Dependence among Super Cyclone Victims in Orissa.

Benefits were mostly given to them as passive recipients. But, the villagers were not fully satisfied with the obtained relief; over 65% had either a negative view or were unsure of the benefits. One can interpret such response as showing that relief was accepted as a due. It is as if, they have come to deserve the relief because they have suffered a disaster [8-10].

The need for professionals was also felt when guidance on the difficult cases seen in community was required. There was need for medicinal treatment and psychotherapy. However a few CLVs also felt that there was no need for medication for these patients as their reactions were understandable considering the magnitude of the trauma. Thus, change of attitude of the community and for motivation for life style changes professional help was required. Social problems like begging, abuse of elderly and children, indiscriminant sexual activity by many were other problems which required help from specific professionals. Triangle of care was required more than 11% of DMH affected population even today for 1) drug therapy example needed medication to continue, 2) Psychotherapy means to be treated within the family because recovery is better and 3) Occupational therapy means continue to work and earn livelihood, feeling productive and positively react psycho-pathologically to drugs being active.

Some skills that can be developed through these activities are Speaking skills, Listening skills, concentration, Waiting for turns, appreciating others, being positive, Developing understanding and being sensitive to others, creative skills, finding solutions, cooperation, competitions to some extent maybe, learning to have fun and sharing things [11,12].

Trauma-informed approaches within any system aim to adhere to the “4 Rs” i) Realizing the widespread impact of trauma and pathways to recovery ii) Recognizing traumas signs and symptoms iii) Responding by integrating knowledge about trauma into all facets of the system iv) Resisting re-traumatization of trauma-impacted individuals.

In some instances a child may require the help of specialist and each caregiver needs to be aware of when such help is required. Referral is required if no indication of the reactions becoming less, Increase in severity, Is distressing to the family or the child, Interferes with the daily routine of the child, Interferes with interaction with others like friends, relatives, Interrupts work or school.

The author thanks the psychosocial care provider Madhusmita Panda and Sabyasachi Rout and whole team for their cooperation in this project.