Puerto Rico after Maria: Trauma team returns

 

Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.

Leaves are appearing on defoliated trees; the devastated rain forest is slowly improving. Wildlife is returning. Homeless dogs are reappearing on the streets. But how are residents faring in the wake of Maria’s devastation?

Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
 

Week-long training gets underway

A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.

Courtesy Dr. Judith R. Milner

Upon our arrival in late May, we heard anecdotal reports of children manifesting ongoing and escalating symptoms of PTSD. In 2014, the U.S. Census Bureau reported that 58% of the children in Puerto Rico lived below the federal poverty level, and there is reason to believe that this percentage is even higher after Maria. The reasons are many, including transportation challenges, impassable roads, gasoline shortages, and the difficulty of tracking appointments without cell phone service. Other explanations include a shortage of clinicians, and challenges of parents who are preoccupied with the daily struggle of mere survival. Another deterrent is the stigma of mental illness.

Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.

Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
 

 

Regressive behaviors cited

Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.

Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
 

Compassion fatigue

Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.

Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.

Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.

Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.

Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.

Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.

 

UMICPT curriculum

When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing. Interventions focus on efforts to build resiliency in children, and the model is collaborative, interactive, and experiential.

Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
 

Future plans

UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
 

Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.

 

Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.

Leaves are appearing on defoliated trees; the devastated rain forest is slowly improving. Wildlife is returning. Homeless dogs are reappearing on the streets. But how are residents faring in the wake of Maria’s devastation?

Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
 

Week-long training gets underway

A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.

Courtesy Dr. Judith R. Milner

Upon our arrival in late May, we heard anecdotal reports of children manifesting ongoing and escalating symptoms of PTSD. In 2014, the U.S. Census Bureau reported that 58% of the children in Puerto Rico lived below the federal poverty level, and there is reason to believe that this percentage is even higher after Maria. The reasons are many, including transportation challenges, impassable roads, gasoline shortages, and the difficulty of tracking appointments without cell phone service. Other explanations include a shortage of clinicians, and challenges of parents who are preoccupied with the daily struggle of mere survival. Another deterrent is the stigma of mental illness.

Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.

Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
 

 

Regressive behaviors cited

Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.

Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
 

Compassion fatigue

Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.

Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.

Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.

Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.

Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.

Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.

 

UMICPT curriculum

When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing. Interventions focus on efforts to build resiliency in children, and the model is collaborative, interactive, and experiential.

Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
 

Future plans

UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
 

Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.

 

Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.

Leaves are appearing on defoliated trees; the devastated rain forest is slowly improving. Wildlife is returning. Homeless dogs are reappearing on the streets. But how are residents faring in the wake of Maria’s devastation?

Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
 

Week-long training gets underway

A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.

Courtesy Dr. Judith R. Milner

Upon our arrival in late May, we heard anecdotal reports of children manifesting ongoing and escalating symptoms of PTSD. In 2014, the U.S. Census Bureau reported that 58% of the children in Puerto Rico lived below the federal poverty level, and there is reason to believe that this percentage is even higher after Maria. The reasons are many, including transportation challenges, impassable roads, gasoline shortages, and the difficulty of tracking appointments without cell phone service. Other explanations include a shortage of clinicians, and challenges of parents who are preoccupied with the daily struggle of mere survival. Another deterrent is the stigma of mental illness.

Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.

Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
 

 

Regressive behaviors cited

Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.

Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
 

Compassion fatigue

Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.

Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.

Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.

Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.

Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.

Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.

 

UMICPT curriculum

When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing. Interventions focus on efforts to build resiliency in children, and the model is collaborative, interactive, and experiential.

Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
 

Future plans

UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
 

Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.