G

The Science and Practice of Resilience Interventions for Children Exposed to Disasters

David Abramson, Ph.D., Columbia University
Kallin Brooks, J.D., Columbia University
Lori Peek, Ph.D., Colorado State University

A white paper prepared for the June 10-11, 2013, workshop on Disaster Preparedness, Response, and Recovery Considerations for Children and Families, hosted by the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events. The authors are responsible for the content of this article, which does not necessarily represent the views of the IOM.

PROLOGUE

The post-Katrina trailer park where we met “M” was markedly different from the many others that had sprung up in the weeks and months following the devastating 2005 hurricane. Rather than being situated in a dusty field, surrounded by chain-link fencing, this trailer park was in a forested glen. The houses were well-kept, single-wide mobile homes, arranged in a horseshoe shape around a grassy field, rather than the smaller travel trailers arranged in endless rows common to other trailer parks. Our research team of interviewers pulled up to this trailer park mid-afternoon just as the school bus arrived. Twenty to 30 schoolchildren emptied from the bus and went running across the field to their



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G The Science and Practice of Resilience Interventions for Children Exposed to Disasters David Abramson, Ph.D., Columbia University Kallin Brooks, J.D., Columbia University Lori Peek, Ph.D., Colorado State University A white paper prepared for the June 10-11, 2013, work- shop on Disaster Preparedness, Response, and Recovery Considerations for Children and Families, hosted by the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events. The authors are responsible for the content of this arti- cle, which does not necessarily represent the views of the IOM. PROLOGUE The post-Katrina trailer park where we met “M” was markedly dif- ferent from the many others that had sprung up in the weeks and months following the devastating 2005 hurricane. Rather than being situated in a dusty field, surrounded by chain-link fencing, this trailer park was in a forested glen. The houses were well-kept, single-wide mobile homes, ar- ranged in a horseshoe shape around a grassy field, rather than the smaller travel trailers arranged in endless rows common to other trailer parks. Our research team of interviewers pulled up to this trailer park mid-afternoon just as the school bus arrived. Twenty to 30 school- children emptied from the bus and went running across the field to their 177

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178 APPENDIX G homes. Many knew each other from their old New Orleans neighborhood in the Lower Ninth Ward. The residents were mainly working-class and working-poor residents who had been displaced from their homes, and represented a mix of homeowners and renters living in this Federal Emergency Management Agency (FEMA)-subsidized emergency housing. Our team of 15 researchers fanned out across the trailer park to re- cruit the mobile home residents to our Gulf Coast Child and Family Health Study. This was the baseline survey for what would ultimately be a 5-year longitudinal cohort study of 1,079 randomly sampled house- holds in Louisiana and Mississippi. The interviews generally took about 45 minutes. One of the interviewers emerged from a home after 2 hours with the resident. She was visibly moved as she recounted the woman’s story. “M” was in her late 40s, a mother of 2 children, 1 high-school-aged, the other an adult. During the hurricane, “M” was separated from her husband and daughters, because she had been required to report to the health care facility where she worked and ended up evacuating with the patients. For almost a week, the family did not know of one another’s fate, or even whether they had survived the storm. They ended up reunit- ed at a Texas shelter, and during the succeeding 6 months leading up to our interview, they moved 7 times, across multiple states. As “M” de- scribed her journey to our interviewer, she pulled out a scrapbook. It was filled with pictures—of her destroyed home in New Orleans, and then of every place where she and the family had stayed since the hurri- cane. They had moved from shelter to shelter, to hotels and motels, to crowded homes where they doubled up with friends, and ultimately to this trailer park. Her husband drove their teenaged daughter back and forth to her old New Orleans high school daily, commuting up to 4 hours in an effort to maintain this stability in their daughter’s life. The snap- shots in the scrapbook chronicled this story. “Whenever my girls face something difficult in their lives, I want them to be able to pull this scrapbook out,” “M” told our interviewer. “I want them to see where they’ve been, the challenges they’ve faced. This is their strength. There isn’t anything they can’t handle.” Our research team re-interviewed “M” three more times in the sub- sequent 5 years. Two years after the hurricane, the team found her living in a travel trailer in the front yard of her New Orleans home as she su- pervised its reconstruction. By the last round of interviewing, she and her family had moved back in to their home, and her daughter had grad- uated from high school and was attending college. It appeared that the

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APPENDIX G 179 family had regained its pre-hurricane stability despite almost 5 years of enormously difficult economic and social hardships. As a tale of resilience, “M”’s story reflects so many of the character- istics and attributes identified by researchers. Despite exposure to ex- treme adversity, “M”’s daughter maintained critical academic routines, was encouraged by her parents to develop her cognitive skills, was living in a supportive and nurturing household with a mother who actively promoted her daughter’s sense of self-efficacy and hope for the future (embodied by a tangible tool—the scrapbook—to reinforce the message). “M” herself was a woman who personified “hardiness” and whose per- sonal outlook was dominated by her faith, good humor, and unshakable optimism. At a larger level, her daughter’s resilience was further bol- stered by the sense of community offered by the mobile home park, by the stability of her mother’s workplace, and even by the policies that brought her family back to the Lower Ninth Ward to become actively engaged in the community’s redevelopment. All of this leads to a central question: Is it possible to design poli- cies, programs, and interventions to replicate such resilience? Is it feasi- ble to identify the factors that promote such “resilient” outcomes among children and youth, either directly or indirectly, and then target interven- tions to enhance, activate, or facilitate these factors? Resilience is com- plex, operating at multiple intersecting levels that encompass individual biology, cognition, and psychology; family dynamics; communal and institutional support systems; and policy environments. This puzzle re- flects a fundamental question that has been posed by Yehuda and col- leagues (2006): “Are resilient people born, or made?” INTRODUCTION In this white paper, we consider the current science and practice of resilience interventions for children and youth1 who are susceptible to disasters or who have been exposed to disasters. Starting from the central question introduced in the prologue above—is it possible to design evidence-based resilience interventions for children?—this paper reviews the ways in which resilience research has influenced resilience interven- tions, considers specific illustrations of these resilience practices, and examines the evidentiary base for these activities. Furthermore, we will place these disaster-related resilience interventions within a public health framework of primary, secondary, and tertiary prevention. Public 1 In the interest of editorial brevity, throughout this white paper, we will mainly refer to children and youth, across the age spectrum of toddler to adolescent, as “children”

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180 APPENDIX G health may have entered the field of resilience interventions rather late in the game, but its community-based practice orientation and methods for assessing programmatic effectiveness and theoretical construct fidelity can offer powerful tools to this burgeoning field of “interventional resili- ence.” Lastly, we will explore the inherent challenges of developing evidence-based resilience practices within the context of disasters. The field of resilience research has evolved in the 50 years since de- velopmental psychologists first began examining what factors contribut- ed to the positive social, emotional, and intellectual growth of children growing up in the face of highly adverse conditions, such as being reared by a schizophrenic parent (Garmezy, 1985; Garmezy et al., 1984) or liv- ing in environments of extreme poverty (Masten, 2001). Researchers noted that deficit models that focused on correlations among a child’s personality, environment, and subsequent psychopathology were inade- quate frameworks for providing robust explanations of how children de- veloped. The goal was not merely to avoid psychopathology in children, but also to understand how children achieved their cognitive, social, and emotional potential. By contrasting children who were more successful at reaching key developmental milestones despite their adverse circum- stances with those who were less successful, effectively illuminating what made them resilient, researchers hypothesized that they could artic- ulate adaptation mechanisms. After these adaptation pathways were un- derstood, the subsequent step would involve developing interventions that stimulated or facilitated these growth processes to encourage better outcomes for more children, regardless of their circumstances. As a number of scholars have noted, this field of “positive psycholo- gy” spawned a short list of factors that were persistently associated with children’s ability to adapt and achieve developmental milestones despite being exposed to chronic and acute adverse conditions (Luthar and Cicchetti, 2000; Luthar et al., 2006; Masten, 2001, 2008; Masten and Obradovic, 2008; Wright et al., 2013). These factors included child- specific characteristics such as good cognitive abilities; positive con- structs of self (including self-efficacy and self-control); attitudinal and belief systems that encompassed hopefulness, faith, and a positive worldview; and the ability to form and sustain relationships with parents, peers, and siblings. Studies of American soldiers who were held captive in Vietnamese prisoner-of-war camps for extended periods revealed many of the same characteristics of resilience among adults (Yehuda et al., 2006). Scholars have long noted that children do not grow up in a vacuum, but are embedded in a number of concentric social systems that support and nourish them—notably, their parents, their households, their peers,

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APPENDIX G 181 the institutions with which they interact, their communities, and society as a whole (Bronfenbrenner, 1986)—all of which exert an influence on children’s ability to adapt to adverse conditions. Factors across all of these domains are often divided into two categories: those that “promote” adaptive competencies in children, and those that “protect” them from the negative consequences of exposure to adverse events leading to psy- chopathologies or stunted development. Wright and colleagues (2013) have referred to this phase of inquiry in the scientific evolution as the first two of four waves of resilience research: the first wave identified resilience factors, and the second wave explored resilience processes within individuals and across these multiple social systems. With each succeeding wave, the resilience research field expanded beyond the original boundaries of developmental psychology. Wright et al. (2013) referred to the third wave as the examination of interventions that might enhance or facilitate resilience, and the still-emerging fourth wave is focused on a consideration of multiple system effects, notably within the fields of epigenetics and neurobiology. In the second and third waves, social scientists, education researchers, and social epidemiolo- gists applied their disciplinary perspectives, particularly as the research explored the intersection of multiple levels (e.g., How does one measure a family or community’s social capital and its relationship to a child’s ability to adapt?); the relationship of resilience to health outcomes (in- cluding the biological mechanisms of action of adverse events triggering stress responses, which, in turn, lead to biochemical and genetic chang- es); and the institutional settings most conducive to resilience interven- tions for children (e.g., schools and day care centers). These succeeding waves of resilience research have resulted in sig- nificant analytical shifts in the field as well. What began in the first wave as qualitative case-based research and quantitative variable-based re- search that generally relied on correlational analyses such as regression modeling, analysis of covariance, and categorical data analyses has evolved to include hierarchical modeling; latent growth curve analyses (particularly when looking at the relationship of resilience factors com- pared to recovery over time) (Bonanno et al., 2011); structural equation and propensity score modeling (Abramson et al., 2010b, Stehling-Ariza et al., 2012); and complex system science approaches (Sherrieb et al., 2010). The benefit of such sophisticated analyses is that they permit far more nuanced tests of frameworks and models that can incorporate mul- tiple social levels, as well as dimensions of time. The cost to such com- plexity is that it may be regarded as out of reach for a practice communi- ty eager to translate such findings in to programs and interventions.

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182 APPENDIX G As different scientific communities struggled with finding common ground in defining, operationalizing, and analyzing resilience, the con- cept of population resilience emerged in political discourse as well, par- ticularly during the past decade. In 2005, the United Nations secretariat of the International Strategy for Disaster Reduction convened 168 coun- tries in Japan, culminating in the Hyogo Framework for Action. This in- ternational blueprint for risk reduction urged countries to develop nation- al resilience programs and strategies to reduce the impacts of natural dis- asters. In response, political leaders in a number of countries, including the United States and Canada, called for national resilience efforts. For example, the 2009 U.S. National Health Security Strategy has two goals, the first of which is to “build community resilience” and the second of which is to strengthen health and emergency response systems. This foundational policy document goes on to elaborate that Communities help build resilience by implementing policies and prac- tices to ensure the conditions under which people can be healthy, by assuring access to medical care, building social cohesion, supporting healthy behaviors, and creating a culture of preparedness in which bystander response to emergencies is not the exception but the norm. In Presidential Policy Directive 8, issued in 2011, resilience is defined as “the ability to adapt to changing conditions and withstand and rapidly recover from disruption due to emergencies” [emphasis added] (Brown, 2011). This political rhetoric has translated to administrative action as well. Among the notable mandates are the Centers for Disease Control and Prevention’s (CDC’s) Public Health Emergency Preparedness Capabili- ties: National Standards for State and Local Planning (2011), which lists community preparedness and community recovery as the two capabilities that every public health department should plan for as part of their “community resilience” domain. State and public health agencies, in turn, are tasked with identifying processes and outcome measures that can demonstrate to their satisfaction, and that of their federal funders, that they are engaging in and achieving “community resilience.” Al- though these appear to be entirely different constructs from individual resilience, as Norris and colleagues (2008) pointed out in their seminal article on community resilience, (a) the concept of resilience is often viewed metaphorically rather than operationally (in that it represents a return to a prior steady state after being shocked or deformed, and thus may be viewed as either an outcome or a dynamic process), and (b) community resilience is often measured as the capacity to sustain indi- vidual physical and mental health and well-being within a community

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APPENDIX G 183 (Norris et al., 2008). The combination of the definitional ambiguity and the potential interpretation of community resilience as the aggregation of individually resilient residents suggests considerable measurement challenges. In addition to scientific and governmental interest in cultivating “re- silience interventions,” there has been increasing awareness and attention to the specific risks associated with children who have been exposed to natural, technological, and manmade disasters (NCCD, 2010; Peek, 2008). Despite the apparent rarity of a disaster happening in any one in- dividual’s life, in recent years the number of domestic disasters and complex emergencies affecting children and youth has increased— including several high-profile events such as the World Trade Center attacks (Hoven et al., 2003); Hurricane Katrina (Abramson et al., 2008; McLaughlin et al., 2009); the BP oil spill (Abramson et al., 2010a); the Joplin, Missouri, tornado; the Newtown, Connecticut, school shooting; and, most recently, the Moore, Oklahoma, tornado. In addition to these major events, children are exposed to any number of “smaller” commu- nal disasters, including flooding, wildfires, and mass traumas. The acute phases of a disaster inevitably lead to secondary stresses on children and youth: displacement, academic interruptions and disruptions, social net- work cleavages, and economic and mobility constraints. These initial and secondary stresses lead to many consequences, some of them invisible for years. Among these are physical health effects and increased rates of chronic health conditions that emerge across the lifespan; immediate and enduring mental health effects, including self-limiting posttraumatic stress disorder, behavioral and emotional disturbance, and complicated grief; educational disadvantages, including missed grade promotions; and social role effects. Alongside this increased awareness and understanding of the many complex effects of disasters on children has been a growing emphasis by governmental, philanthropic, and voluntary sectors on iden- tifying and intervening to promote positive development among children and avert long-term morbidity and pathology. Cumulatively, these various interests, the evolving science, and the pressing demands to address children’s needs post-disaster have led to an increasing appreciation of the need to develop evidence-based resilience interventions.

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184 APPENDIX G THE LANDSCAPE OF DISASTER-RELATED RESILIENCE INTERVENTIONS FOR CHILDREN We employed several search strategies to identify programs and in- terventions whose expressed goals and objectives were to enhance chil- dren’s resiliency and to identify evidence of the effectiveness of resili- ence interventions. The initial Internet search for programs was conduct- ed using the following search terms: “youth empowerment program,” “youth leadership programs,” “disaster preparedness [or] recovery,” “youth [or] child resilience,” and “disaster education.” Based on these search criteria, a limited number of programs were identified. A second search was conducted in which we added identifiers for specific disas- ters: “Hurricane Katrina,” “Hurricane Rita,” “Joplin tornado,” “April 2011 tornados,” “2010 Midwest floods,” “2010 Arkansas floods,” “2007 California wildfires,” and “9/11 terror attacks.” Lastly, programs were further identified and researched as they arose throughout the literature search. For instance, programs referenced by articles uncovered during the literature search were included in the list of programs. Each program or intervention was reviewed to determine if it intentionally addressed any of the “short list” of resilience factors identified in the literature (Wright et al., 2013). A total of 17 programs were identified; these are listed in Tables G-1 and G-2. This is not intended to be an exhaustive list of all resilience programs or interventions, but rather an illustrative list. As depicted in Table G-1, we have characterized resilience interven- tions according to moderating and mediating factors that correspond to the most commonly cited predictors of child resilience. The interventions may be intended directly for the children and youth or for the parents or household, or be targeted to larger social spheres such as child-oriented institutions or the community at large. For each mediating or moderating factor, we have further distinguished the programmatic objectives of the interventions. For example, there are resilience interventions that focus on promoting “self-identity,” and within that domain there are distinct programmatic objectives of enhancing self-efficacy and others for en- hancing self-esteem. We have also characterized each of the interven- tion’s objectives by where it would fit in a public health prevention mod- el. Given that these disaster resilience programs are often similar in size and scale to community-based health promotion and disease prevention programs, and that there may be advantages to aligning the resilience programs with similar programs that target risk reduction or skill en- hancement among children and youth, we have categorized the interven- tions as fitting within primary, secondary, or tertiary prevention models:

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APPENDIX G 185  Primary prevention programs target populations who are po- tentially exposed to disaster, and their objective is to prevent ex- posure to, or consequences of, adverse or toxic agents. This is consistent with the definition of resilience as “withstanding” or resisting the disaster exposure. Much of the programmatic activi- ty in these programs occurs before the disaster.  Secondary prevention programs target populations who were exposed to disaster but for whom it is unknown whether or to what extent they were affected. The objective of these programs is to “treat” populations to minimize the debilitating effects of disaster exposure. This is consistent with the definition of resili- ence as “adapting,” and generally occurs after the disaster and the exposure.  Tertiary prevention programs target populations who were exposed and affected; their objective is to facilitate rapid and complete recovery and prevent “spread” to others or deteriora- tion of the health of the population. This is consistent with the definition of resilience as “rapid recovery,” and exclusively oc- curs after the disaster exposure. Table G-2 describes the specific programs that illustrate the resilience objectives in Table G-1. Overall, it is noteworthy how few programs were identified using these search criteria, and it suggests that the field of “interventional resil- ience” programming for children and youth is still evolving. It is likely that a number of programs have been developed in response to disasters, but are implemented locally with little documentation or evaluation of their effectiveness. Furthermore, we are aware of a number of programs in development whose express purpose is to enhance child and youth resilience through targeted interventions, but they are in the early stages of design and implementation. It is also important to note that we have purposefully excluded the many non-disaster resilience programs that exist (Head Start and 4-H programs, for example), because disaster con- text is often quite distinct from chronic adversities or more routine envi- ronments. We also elected to exclude programs or interventions that were narrowly focused on mental health treatment only, even in post- disaster settings. Many of the programs and interventions we identified were built on preparedness education models, in which children and youth were taught the basics of emergency preparedness, given risk-specific instructions (such as seeking shelter in tornado-susceptible areas or bomb shelters in war zones), and taught specific survival and recovery skills. These inter-

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186 APPENDIX G ventions were often classroom-based (e.g., Minnesota’s Disaster Readi- ness Actions for Teens, Wisconsin’s READY program, American Red Cross’ Masters of Disaster, Israel’s Urban Resilience Program), but a number were also community-based (such as the Boy Scouts, Girl Scouts, or Teen Community Emergency Response Team [CERT]). Many of these programs are explicitly intended to enhance self-efficacy and provide opportunities for helping others, although we have attempted to characterize these programs by their presumed or implicit objectives, notwithstanding their stated programmatic goals. Virtually all of these education-based interventions occur in the pre-disaster stage and are generally intended to promote moderating traits among children and youth. In addition, they develop facets within youth that may be “mobi- lized” during a disaster and that can serve as risk-activated moderators. Several of the programs and interventions promote very specific so- cial and emotional skills, including stress-reduction techniques (e.g., Is- rael’s Urban Resilience Program), communication and relationship- building techniques (e.g., Journey of Hope), or political advocacy skills (e.g., the Vietnamese American Young Leaders Association [VAYLA] and the Rethinkers, both in New Orleans). These skill-oriented programs are a combination of pre- and post-disaster activities and appear to be most effective as primary prevention models when they are tied to spe- cific risks or hazards. Three programs in particular—Save the Children’s Resilient and Ready Community Initiatives, the Communities Advancing Resilience Toolkit, and the Joplin Child Care Task Force—focus on community- wide policies, infrastructure, governance and response entities, and child- oriented institutions rather than directly on the children or youth. Their objectives fit more properly into larger ecological models of resilience, in which children’s well-being is contingent on the stability and compe- tency of multiple institutions affecting their lives. We have included these broader community-oriented programs in the program matrix be- cause they explicitly reference children’s well-being and resilience as a programmatic objective. A number of the resilience interventions seek to broaden children and youth’s worldviews, offering historical, political, and social context to disaster events and their consequences. These include the New York City–based 9/12 project that emerged after the September 11 attacks, Israel’s Urban Resilience Program, VAYLA and the Rethinkers pro- grams in New Orleans, and FEMA’s Youth Advisory Council. Although these programs differ in their perspectives, all offer youth explanatory frameworks for disaster risk and consequence that promote hopefulness and agency for the children. These programs are a mix of pre- and post-

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APPENDIX G 187 disaster interventions, and thus serve both primary and secondary pre- vention goals. Across all these resilience interventions, however, there is very lim- ited evaluation of their effectiveness or representation of a clear evidence base that reflects interventions mapped to theoretical constructs that had been measured and analyzed. Although the research literature offers sub- stantial evidence on the relationship of child, parental, and communal characteristics to child development, the evidence for programmatic effectiveness is extraordinarily shallow. The next section considers some of the challenges in developing such an evidence base for resilience interventions.

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Institutional Stability Increase stability and  Resilient and Ready  Resilient and 192 support of schools, Communities Initiative Ready youth sports and  The 9/12 Generation Project Communities programs, and day Initiative care, as well as  Child Friendly primary and specialty Spaces care Program***  Journey of Hope***  Rethinkers*  VAYLA*  Joplin Child Care Task Force Resumption of Social Provide environment  Urban Resilience Program**  Child Friendly Routines for or facilitate return  The 9/12 Generation Project Spaces to pre-disaster routines Program***  Journey of Hope*** Social Address community-  Rethinkers* Order/Stability wide issues of social  VAYLA* disruptions, inequality, and stability of social institutions such as schools, health care facilities, and criminal justice systems *Process or program evaluation (accomplishes program objectives). **Intermediate impact (intervention achieved intermediate objectives). ***Outcome impact (intervention either promotes recovery, decreases pathology, increases educational attainment/objective).

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TABLE G-2 Youth-Oriented Program Descriptions Program Target Setting Objectives Audience 9/12 Generation Youth, Community Activate students in service-learning projects focused on community Project (New middle, and revitalization, disaster relief, and the arts; empower students to engage in York Says Thank high school positive impacts beyond their immediate communities and economic You Foundation) students means; encourage solidarity among students and youth nationwide; provide positive lessons arising from disaster Child Friendly Children, Post- Provide stable space for children to play, socialize, and begin to recover Spaces Program youth, disaster, post-disaster with the goal of protecting children from harm and providing (Save the caregivers, shelters, a sense of normalcy and community; educate leaders to meet needs of Children) disaster- places of children affected congregation communities post- emergency Communities Communities Community Community intervention process for community action planning; Advancing encourage community relationships and resilience, prompt community Resilience members to assess needs, generate community profiles, develop strategic Toolkit plans, and implement these plans (Terrorism and Disaster Center of the National Child Traumatic Stress Network) Disaster Youth Community Provide emergency preparedness training for teens by engaging, educating, Readiness and empowering youth to respond safely during critical incidents; utilizes a Actions for “train-the-trainer” concept to educate teens to come together to teach others Teens about preparedness (Minnesota 193

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Department of 194 Health) Emergency Youth, boys Community Educate and empower young men to respond when disaster strikes; provide Preparedness opportunity to help others during emergency Award (Boy Scouts of America) Emergency Youth, girls Community Motivate and empower young women to become leaders in emergency Preparedness management and response; provide opportunity to help others during Patch (Girl emergency Scouts Council of the Nation’s Capital) Joplin Child Youth Community Community-based collaboration to respond to children’s and providers’ Care Task Force mental health needs; provide stable space for children to play, socialize, and begin to recover post-disaster with the goal of protecting children from harm and providing a sense of normalcy and community; educate leaders to meet needs of children Journey of Hope Youth Community Provide caregivers and youth with the support, education, training, and (Save the resources necessary to understand and normalize emotions associated with Children) hardships; support children and caregivers in developing positive coping strategies to deal with their emotions; build on the inner strengths of children, families, schools, and communities to further develop positive coping strategies; develop a person’s sense of hope and future by empowering him or her to feel more in control Masters of Youth School, Ready-to-go kit designed to integrate lessons of disaster into regular school Disaster community lesson plans; provide disaster safety instruction to students and families; (American Red help students and families understand and prepare for disasters; educate Cross) youth on how to stay safe and help others during and after a disaster Mobile Medical Youth Community, Provide primary medical and mental health care to children in individual and Community school settings and provide group activities to facilitate communication; utilize

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Resilience “coping boxes” and play therapy with younger children; promote healthy Support Units development and emotional well-being (Children’s Health Fund) Resilient and Youth, Community Community-based approach to help local communities address the needs of Ready children, children in disasters; reduce impact of disasters and emergencies on Communities caregivers, children through effective preparedness, response, recovery, and advocacy; Initiative communities help at-risk regions meet national standards and integrate best practices to support children’s safety and well-being through preparedness planning and programs Rethinkers Youth New Orleans Empower youth to identify needs in their post-disaster community and (New Orleans public advocate effectively for reform; provide youth with the skills necessary to public schools) schools take action to improve their educational experience STEP Program, Youth, Community, Educate and prepare youth and teachers to respond and recover from READY Camp teachers school serious, unexpected situations; empower youth to take control of their and Class (Wisconsin) safety by developing emergency plans for themselves and their families; (Wisconsin train youth to help themselves and others during emergencies Center for School, Youth, and Citizen Preparedness) Teen Youth Community, Educate youth about disaster preparedness for hazards specific to their Community school community to ensure they have the skills needed to protect themselves and Emergency assist others; prepare and address response capabilities in high schools; Response train students in school security and emergency response procedures; Training involve youth in the country’s overall emergency preparedness and basic (CERT) (Federal response plans Emergency Management Agency) 195

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Urban Youth School Prepare youth and the population to cope with the consequences of 196 Resilience (Israel) disasters and reinforce citizen resilience; aid communities in developing Program function, social flexibility, and a means of coping through community (Cohen-Harris capital, resilience and education Center) Vietnamese Youth Community Promote youth development and community empowerment through American (New cultural awareness, education, and engagement; empower youth through Young Leaders Orleans) supportive services and organizing for cultural enrichment and positive Association of social change New Orleans Youth Youth National Promote youth empowerment, preparedness, and resiliency through the Preparedness experience of peer discussion and learning; educate and promote youth to Council serve on a national council and bring their experiences back to their communities to help develop and advance local preparedness and resilience

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APPENDIX G 197 EVALUATING THE EVIDENCE BASE FOR RESILIENCE INTERVENTIONS At a minimum, there appear to be at least three types of challenges to the development of an evidence base for resilience interventions: defini- tional, operational, and political. These are above and beyond the simpler explanation that this is still a young field, particularly in the context of disasters, and that it will take time for the programs to be sufficiently developed to allow for robust evaluations and accumulation of evidence.  Definitional challenges: o Resilience outcomes are not universal or standardized. Even distinguishing between the ability to withstand, adapt, or re- cover quickly reflects vastly different outcomes, and there is still a vigorous debate about whether resilience is a process, a latent construct, or a specific outcome. Furthermore, resili- ence can only be measured in the presence of (or in response to) an adverse or potentially traumatic event, thus complicat- ing pre-disaster baseline measurement. o There is still considerable debate about whether resilience is defined as the absence of mental health pathology, the achievement of a specific developmental milestone, or the representation of a specific constellation of positive attrib- utes (e.g., self-efficacy, positive worldview, etc.). The latter also raises the question of whether resilience may be subjec- tively or objectively measured. o Because of the recent interest in resilience across many dis- ciplines and sectors, there are numerous methodologies and disciplinary lexicons that do not necessarily align.  Operational challenges: o The processes and factors underlying resilience are extraor- dinarily complex, operating at multiple levels that include biological, psychological, social, and cultural domains. Ana- lytical techniques such as systems science and structural equation modeling are being employed to handle these com- plex designs, although the value of such approaches will re- quire many replicated studies. The statistical complexity also limits its accessibility to researchers and stakeholders. Be- yond that, the multidisciplinary nature of these complex re- search questions and designs requires scientists and scholars who can understand and apply theory and methods from areas of expertise far beyond their own.

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198 APPENDIX G o The nature of much resilience research is that it relies on ob- servational data, which is daunting for a number of reasons. The events themselves are rare and unpredictable; it is diffi- cult to get into the field quickly enough to collect critical time-series data; there are rarely accessible pre-disaster data available; and it is particularly difficult to control for com- peting explanations in such quasi-experimental research. o It has also been difficult to operationalize the effects of for- mal help mechanisms in observational studies because they are so varied, are not universally defined, and have no com- mon data systems. The problems inherent in such resilience research are common to public health research’s efforts to evaluate community health interventions, and solutions in that field may find traction in resilience research. o Exposure itself may be related to social vulnerability factors, which limit researchers’ ability to develop case-control strat- egies contingent on exposure.  Political challenges: o Domestically, the federal government does not generally provide or fund disaster-related child resilience services, strategies, or programs, and therefore has little institutional interest in funding evaluation research (Abramson et al., 2007; Garrett et al., 2007). o Most of the extant programming has emerged from the non- profit, philanthropic, and humanitarian aid sectors, which have limited funding for rigorous evaluation methods, and which favor programmatic dollars over research dollars. o “Root-cause” theories and frameworks suggest the need for interventions that are (a) complex, (b) socially progressive, (c) structural, and (d) not the responsibility of any one sector or domain (meaning that there is little accountability or demand for an evidentiary base). As such, there is a limited political advocacy coalition that can advocate for federal research funding, particularly in times of constrained and shrinking science budgets. MOVING FORWARD WITH “INTERVENTIONAL RESILIENCE” Despite the challenges noted above, there are several noteworthy trends or opportunities in resilience research. The first is the notion of

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APPENDIX G 199 expanding existing youth programs that have the capacity to “reach for- ward” into disaster settings. The Boy Scouts and Girl Scouts are exam- ples of such programs, but it is easy to imagine that other well- established youth-empowerment and youth-development programs (such as 4-H) could be expanded in to disaster realms. This would provide con- trol groups of children who have not been exposed to disaster. Just as there is possibility for reaching forward, there is evidence of “reaching back,” when disaster-inspired programs, such as VAYLA and Rethink- ers, establish themselves in communities as progressive (but non- disaster) youth-empowerment programs. This extends the utility of such programs and also affords the research community the ability to test the effect of disaster context on resilience outcomes (as do the reaching- forward programs). As mentioned earlier in this white paper, there are also public health research strategies that can be employed in resilience research. There is a long history in public health of community-based research; the Healthy Communities movement, social medicine, and social determinants of health models align both theoretically and programmatically with a num- ber of resilience interventions. There are well-developed evaluation and meta-review strategies, such as the Cochrane Collaborative and CDC’s Community Preventive Services Guide, which can serve as models for programmatic evaluations. The field of social epidemiology in particular has embraced complex systems sciences, which can be applied to many multilevel resilience research strategies. This brings us back to “M,” the hardy Katrina survivor and her daughter who were profiled briefly in the prologue. In thinking about bottling the resilience factors in their lives and designing interventions that can be applied to others, a number of possibilities emerge. First, to the extent possible, create programs and policies that allow children to remain within their educational environments, assuming that these were positive and high-quality environments. Develop family-based programs that bring parents and children together to create and employ coping skills (like the scrapbook “M” created) that can further enhance familial closeness and communication. Create community-focused emergency housing environments for populations that may be displaced for long periods of time to allow for collective self-efficacy and communal soli- darity. Finally, develop programs that empower children and families to be actively involved in rebuilding their own communities, as a means of affirming their self-efficacy and countering the social role of “victim.” That said, we do not know with any certainty that these strategies are effective or, rather, which parts of these strategies exert what effect, and to what end? Of course, in the absence of hard evidence, we can certainly

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200 APPENDIX G follow the five principles offered by Hobfoll and colleagues (2007) in the design of any resilience intervention: (1) promote safety, (2) promote calming, (3) promote self- and collective efficacy, (4) promote connect- edness, and (5) instill hope. REFERENCES Abramson, D. M., S. S. Morse, A. L. Garrett, and I. Redlener. 2007. Public health disaster research: Surveying the field, defining its future. Disaster Medicine and Public Health Preparedness 1(1):57-62. Abramson, D., T. Stehling-Ariza, R. Garfield, and I. Redlener. 2008. Prevalence and predictors of mental health distress post-Katrina: Findings from the Gulf Coast Child and Family Health Study. Disaster Medicine and Public Health Preparedness 2(2):77-86. Abramson, D., I. Redlener, T. Stehling-Ariza, J. Sury, A. Banister, and Y. S. Park. 2010a. Impact on Children and Families of the Deepwater Horizon Oil Spill: Preliminary Findings of the Coastal Population Impact Study. New York: National Center for Disaster Preparedness, Columbia University. Abramson, D. M., T. Stehling-Ariza, Y. S. Park, L. Walsh, and D. Culp. 2010b. Measuring individual disaster recovery: A socioecological framework. Disaster Medicine and Public Health Preparedness 4(Suppl 1):S46-S54. Bonanno, G. A., M. Westphal, and A. D. Mancini. 2011. Resilience to loss and potential trauma. Annual Review of Clinical Psychology 7:511-535. Bronfenbrenner, U. 1986. Ecology of the family as a context for human development: Research perspectives. Developmental Psychology 22(6):723- 742. Brown, J. T. 2011. Presidential Policy Directive 8 and the National Preparedness System: Background and Issues for Congress. Washington, DC: Congressional Research Service, R42073. CDC (Centers for Disease Control and Prevention). 2011. Public Health Preparedness Capababilities: National Standards for State and Local Planning. http://www.cdc.gov/phpr/capabilities/Capabilities_March_2011. pdf (accessed April 4, 2011). Garmezy, N. 1985. Stress resistant children: The search for protective factors. In Recent Research in Developmental Psychology, Journal of Child Psychology and Psychiatry (Book Supplement No. 4). Oxford: Pergamon Press. Pp. 213-233. Garmezy, N., A. S. Masten, and A. Tellegen. 1984. The study of stress and competence in children: A building block for developmental psychopathology. Child Development 55(1):97-111. Garrett, A. L., R. Grant, P. Madrid, A. Brito, D. Abramson, and I. Redlener. 2007. Children and megadisasters: Lessons learned in the new millennium. Advances in Pediatrics 54:189-214.

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APPENDIX G 201 Hobfoll, S., P. J. Watson, C. W. Bell, R. A. Bryant, M. J. Brymer, M. J. Friedman, M. Friedman, B. P. R. Gersons, J. T. V. M. de Jong, C. M. Layne, S. Maguen, Y. Neria, A. E. Norwood, R. Pynoos, D. Reissman, J. I. Ruzek, A. Y. Shalev, Z. Solomon, A. M. Steinberg, and R. J. Ursano. 2007. Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry 70(4):283-315. Hoven, C. W., C. S. Duarte, and D. J. Mandell. 2003. Children’s mental health after disasters: The impact of the World Trade Center attack. Current Psychiatry Reports 5(2):101-107. Luthar, S., and D. Cicchetti. 2000. The construct of resilience: Implications for interventions and social policies. Development and Psychopathology 12(04):857-885. Luthar, S., D. J. Cohen, and D. Cicchetti. 2006. Resilience in development: A synthesis of research across five decades. Developmental Psychopathology 3. Masten, A. S. 2001. Ordinary magic: Resilience processes in development. American Psychologist 56(3):227-238. Masten, A. S. 2008. Resilience in developing systems: Progress and promise as the fourth wave rises. Developmental Psychopathology 19(3):921-930. Masten, A. S., and J. Obradovic. 2008. Disaster preparation and recovery: Lessons from research on resilience in human development. Ecology and Society 13(1). McLaughlin, K., J. A. Fairbank, M. J. Gruber, R. T. Jones, M. D. Lakoma, B. Pfefferbaum, N. A. Sampson, and R. C. Kessler. 2009. Serious emotional disturbance among youths exposed to Hurricane Katrina 2 years postdisaster. Journal of the American Academy of Child and Adolescent Psychiatry 48(11):1069-1078. NCCD (National Commission on Children and Disasters). 2010. 2010 Report to the President and Congress. Rockville, MD: Agency for Healthcare Research and Quality. Norris, F., S. Stevens, B. Pfefferbaum, K. Wyche, and R. Pfefferbaum. 2008. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology 41(1):127-150. Peek, L. 2008. Children and disasters: Understanding vulnerability, developing capacities, and promoting resilience—an introduction. Children, Youth and Environments 18(1):1-29. Sherrieb, K., F. Norris, and S. Galea. 2010. Measuring capacities for community resilience. Social Indicators Research 99(2):227-247. Stehling-Ariza, T., Y. S. Park, J. J. Sury, and D. Abramson. 2012. Measuring the impact of Hurricane Katrina on access to a personal healthcare provider: The use of the National Survey of Children’s Health for an external comparison group. Maternal and Child Health Journal 16(Suppl 1):S170- S177.

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202 APPENDIX G Wright, M. O. D., A. S. Masten, and A. J. Narayan. 2013. Resilience processes in development: Four waves of research on positive adaptation in the context of adversity. In Handbook of Resilience in Children, edited by R. B. Brooks, and S. Goldstein. New York: Spinger Science Business Media. Pp. 15-37. Yehuda, R., J. D. Flory, S. Southwick, and D. Charney. 2006. Developing an agenda for translational studies of resilience and vulnerability following trauma exposure. Annals of the New York Academy of Sciences 1071.