Storm Alex: acute stress responses in the pediatric population.

Introduction: On 2 October 2020, a violent storm (Alex) reached the French Riviera and caused significant damage in three inhabited valleys in the hinterland of the city of Nice. Entire populations were exposed to prolonged stress (no means of communication, electricity nor water) and were particularly at risk of suffering from psychological consequences. We first hypothesized that a majority of children would experience an acute stress reaction. However, we also hypothesized that their clinical expression would differ depending on their developmental age. Thus, we aimed to evaluate, according to the child's level of development, the presence of acute stress symptoms.
Methods: Consecutive interviews with the child/adolescent and his/her parents were conducted by child and adolescent psychologists and psychiatrists to assess symptomatology following storm Alex (from day 1 to day 3). Each interview assessed nine classes of symptoms that have been compared according to age-groups.
Results: 116 children have been evaluated (0.2-17.6 years, mean 9.1). The 0-5-years-old showed more agitation as well as developmental regression than children aged 6-11 (p = .011, p = .045) and 12-18 years (p < .001, p < .001). Anxiety was reported more frequently among the 6-11 years old than the 0-5 years children (p = .018). Overall, the interviewed children presented at least one manifestation of acute stress after the storm (94% for the 0-5 years; 83% for the 6-11 years and 74% for the 12-18 years). Discussion: The results highlight the high rate of acute stress symptoms in a natural disaster context, their specificity depending on children's age. Therefore; it emphasizes the need to develop, improve and validate specific assessment tools. Scheduled follow-up evaluations will help to understand, after a natural disaster, the long-term stress response in children, paving the way for targeting early, intensive, specific and multidisciplinary symptomatic treatment approaches.Trial registration: ClinicalTrials.gov identifier: NCT04850924. HIGHLIGHTS: Acute stress symptoms in children and adolescents are very frequent in the context of exposure to a natural disaster with specifications depending on the developmental age.

Introduction

On October 2nd 2020, a violent storm (Alex) reached the French Riviera and caused significant damage in three inhabited valleys in the hinterland of the city of Nice (Storm Alex (2021)). During this event, nine people died. Many families found themselves in severe precariousness (house collapsed or unsafe). Entire populations were exposed to prolonged stress (no means of communication, electricity nor water) and thus were particularly at risk of suffering from psychological consequences (Cryder, Kilmer, Tedeschi, & Calhoun, 2006). Emergency measures were rapidly established in order to evacuate towards Nice via helicopter in secured facilities. After arriving in a dedicated area of Nice airport, the local Psychological Emergency Care Unit (CUMP Chauvelin et al., 2019) evaluated each individual in order to assess early stress symptoms via the national psychological emergency call scheme: ‘Patient Emergency Checklist’ (PEC). PEC allows rating of major symptomatic signs observed during the interview based on Acute Stress Reaction described in international classifications such as DSM-5. For the assessment of children and adolescents, the specific ‘Patient Emergency Checklist for Children and Adolescent’ (PEC-C) based on PEC has been used. The tool takes the form of an index card in which the CUMP professionals record the basic information about the patient and his family as well as the presence or absence of nine classes of clinical manifestations frequently observed during emergency stress situations in children of various ages. In fact, items are observable and thus easily identifiable manifestations of the child by the field’s professionals on site (e.g. agitation, passiveness or regression). They are inspired from and in line with the more theoretical criteria of international classifications such as DSM-5 and DC:0–5™ (Zero to Three: National Center for Infants, Toddlers, and Families, 2016).

PEC and PEC-C are therefore largely used to complete quick psychological assessment by CUMP teams, enabling early triage of patients and transmission of these informations for later use (e.g. to plan follow-up psychosocial care).

We hypothesize that after storm Alex, a majority of children will present symptoms of acute stress reaction but that their clinical expression will differ according to their developmental age. Thus, we aimed to assess the presence of acute stress symptoms according to the child’s level of development.

Methods

Following storm Alex, CUMP teams were deployed at the dedicated area at the local airport (from day 1 after the storm to day 3) and consecutive interviews with the child/adolescent and his/her parents were realized by a pair of specifically trained professionals, from the CUMP teams. The interviews consisted of a systematic family time for all age groups where the evaluation was based on the parents’ answers and observation of their child. This stage was reproducible for all age groups except for 2 adolescents whose parents were left behind. Then, an individual time with the child was proposed for the 6-11 and 12-18 age groups to perfect the clinical observation made during the previous time. Games or drawings were systematically proposed, but only to mediate the interview, especially for children aged 3 to 11. Symptoms of acute stress reaction were assessed using the PEC-C and were classified in 9 overall classes and evaluated for the three age groups (0-5, 6-11 and 12-18 years). Comparisons between age groups for the nine classes of symptoms were tested using ANOVA with post-hoc comparison using Bonferroni correction (Jamovi software). This study was registered on Clinical Trials (NCT04850924) and informed consents were given by all participants and parents.

Results

A total of 116 children (mean age = 9 years 1 month, SD = 4 years 5 months; age range: 2 months – 17 years 7 months) were evaluated (sex ratio male/female 1.23) which represents the total number of children evacuated from this site during the first three days after the disaster.

Analysis revealed several differences in clinical responses of acute stress according to age group (see Table 1). There is an effect of age group on the agitation response (p < .001), verbalization of fear (p = .03), developmental regression behaviours (p < .001) and anxiety (p = .013). The 0-5 years-old children showed more agitation as well as developmental regression than the 6-11 (p = .011, p = .045) and 12-18 years-old (p < .001, p < .001). Anxiety was reported more frequently among the 6-11 than the 0-5 years children (p = .018). Intergroup differences failed to reach significance for the verbalization of fear. Overall, the interviewed children presented at least one manifestation of acute stress after the storm (94% for the 0-5; 83% for the 6-11 and 74% for the 12-18 years-old). Nevertheless, adolescents (12-18 years) were significantly (p = .019) less often reporting symptoms than young children (0-5 years).

Table 1.

Participant demographic characteristics and core results from Patient Emergency Checklist for Children and Adolescents (PEC-C).

Characteristics	Participant, No. (%)
	Age Groups
	0-5 years	6-11 years	12-18 years	Total
Overall	38 (32.8)	47 (40.5)	31 (26.7)	116 (100.0)
Sex
Male	22 (57.9)	24 (51.1)	18 (58.1)	64 (55.2)
Female	16 (42.1)	23 (49.9)	13 (41.9)	51 (44.8)
Clinical screening
Anxiety	9a (23.7)	25a (53.2)	16a (51.6)	50 (43.1)
Sadness / Cries	10 (26.3)	16 (34.0)	9 (29.0)	35 (30.2)
Mutism / Apartness	9 (23.7)	7 (14.9)	6 (19.3)	22 (18.9)
Passiveness	9 (23.7)	9 (19.1)	8 (25.8)	26 (22.4)
Agitation / Panic / Desorganization	16b (42.1)	8b (17.0)	1b (3.2)	25 (21.6)
Somatization	2 (5.3)	5 (10.6)	2 (6.4)	9 (7.8)
Developmental regression / Excessive attachment to caregiver	13b (34.2)	7b (14.9)	0b (0.0)	20 (17.2)
Verbalization of fear	12a (31.6)	21a (44.7)	5a (16.1)	38 (32.8)
Sleep disorders	7 (18.4)	5 (10.6)	4 (12.9)	16 (13.8)
No symptoms	2a (5.3)	8(17.0)	8a (25.8)	18(15.5)

ANOVA p < .05.

ANOVA p < .01.

Significant results (a, b) are highlighted in Bold.

Discussion

The majority of the interviewed children, especially the younger ones, presented at least one manifestation of acute stress after being exposed to storm Alex. The clinical profiles differ according to developmental stage, with developmental regression and restlessness in young children. These external symptoms (such as fits of anger, agitation or oppositional behaviour) might be explained in young children by a level of emotional control that is too low in a context of anxiety and fear or by the children’s perception of the parental distress and their own manifestation of stress. Thus, social and cognitive capacities in the context of stress could then be undermined and prevent the child to express his/hers own suffering other than by external symptoms (Côté et al., 2017).

The results highlight the high rate of acute stress symptoms in the pediatric population in a natural disaster context, and their specificity depending on the child’s age and therefore the need to develop, improve and validate specific assessment tools. Authors also want to emphasize the necessity for emergency team members to have access to knowledge and tools that reflect the current state of scientific data on pediatric psychological trauma and acute stress, also taking into account the developmental level of the children.

The main limitations of these preliminary results are the use of a non-validated but frequently used national French questionnaire collecting acute stress symptoms corresponding to international classifications such like DSM-5 and DC:0–5™, and the lack of consideration of pre-event mental health status. The present results of the acute phase do not include follow-up data. Nevertheless, the study will be completed by follow-up evaluations including lifetime medical and psychiatric history. Thus, considering previous mental health status in line with acute stress evaluation and follow-up evaluations will help to understand the specificity of stress reactions after a natural disaster in children depending on their age, paving the way for targeting early, intensive, specific and multidisciplinary symptomatic treatment approaches.