Mental Health Care for Children
Appropriate to the Stage of Recovery in the Areas Affected（Model of Needs Required for Survivors of the Disaster））
Created by Prof. Yoshiki Tominaga (Hyogo University of Teacher Education, Japan)
Summarized by Kyoko Morinaga, Ph.D. & Riichiro Miwa, Psy.D.
Translated by Riichiro Miwa, Psy.D.
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 This model focuses on the different stages of needs that child should be progressed through during
recovery from trauma
 Stages: Safety  Social and Emotional Support  Psychoeducation  Self-Expression
Exposureo Order of the stages is criticalo Avoid self-expression and exposure before acquiring a sufficient sense of physical safety
since doing otherwise could cause secondary harm to the children Physical-safety and comfort are usually established within 2 weeks, but it is difficult to do so withinthat timeline in this disaster. For each separate area of devastation, assess at which stage of recovery
the particular area is. The stages of recovery will differ for each area affected by the disaster.
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Stage 1: Safety and Comfort*The most basic requirement that needs to be provided throughout all the stages under discussion
Physical & Psychological responsesa) Fatigue, insomnia, “Economy class syndrome” (*deep-vein thrombosis), etc.
b) Fright reactions, anxiety, despair, acute stress reactions, etc.
Interventions• Provide for basic physical needs, social support, and coping resourcesa) Basic physical needsa. Food / Water / Warmth / Ablution facilities (Baths / Foot Baths etc.) / Portable toilets /Privacy / Drills in preparation for aftershocksb) Social support
a. Re-establish the reassurance gained from human connections and support
b. Stay with the those who are informed of bad news concerning the safety of their friends andfamilyc) Coping resources
a. Provide physical exercise to prevent deep-vein thrombosis
b. Provide hope for the recovery of lifelines
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Stage 2: Awareness of physical and psychological responses*After assuring physical safety.
• There will be emerging physical and psychological responses once physical safety has been
provided for• Encourage self-awareness and self-monitoring of one’s own responses• [Warning] Avoid debriefing!
Physical & Psychological responsesa) Insomnia, lassitude, apathy, hopelessness, etc.
b) Flashbacks caused by activated traumatic memories (recurrent and intrusive recollections causing
distress)a. e.g., Nightmares, make-believe play (focused on the tsunami and earthquake)i. *Young children may exhibit repetitive play focused on themes or aspects of theirtraumatic experienceb. Painful experience through all five senses, by which children may re-live the pastc) Regression and over-dependence
a. e.g., Clinging to a reliable person. Unable to perform tasks that s/he used to be able toperform
Interventions• Careful and thoughtful interventions are essential• Appropriate interventions should be provided toward recurring recollections, because they
could result in post traumatic responses• Relaxation exercises are helpfulo Massage, dosa-ho, progressive muscle relaxation, deep-breathing, etc.
a) Intervening with make-believe playa. Do not scold. (e.g., “Stop it! That’s not right!)
b. Join in with the play and empathize with the children’s feelings, including anger, fear,
anxiety, etc.
c. Prevent dangerous behaviors and listen to their underlying feelingsb) Intervening with regression and over-dependence
a. Stay with the child until the child feels safe
b. Regression and over-dependence are signs of recovery after such a massive shockc) Coping with flashbacks
a. Distract
i. Teach thought-stopping and distraction techniques
1. e.g., Stretching and self-talk, “Focus on my work!”b. Over time and only when appropriate, encourage the child to face and stay with the painful
memories
2i. Encourage intentional and repetitive effort to stay with emerged feelings
1. *Flashbacks become less-frequent and less-strong eventually
ii. Avoidance will only prolong traumatic responses
c. Utilize “Play Groups”
i. Form groups with volunteers in the affected areas and shelters
ii. Play with the children until they feel enjoyment and a sense of wellbeingiii. Be aware of anger and aggressiveness1. Once the children get used to the volunteers, they may try to physicallyassault them because of their anger and depression
2. Sublimate children’s aggressiveness with sports, etc.
iv. Provide for the volunteers to meet with professional therapists daily forsupervision, advice, support, etc

Stage 3: Psychoeducation*After Stage 1. In parallel with Stage 2• Learning about:o Self-monitoring regarding one’s own post-traumatic responses
o Effective coping strategies• Reopening schoolo *Collaboration with school system is important in Japan
 School structures are organized and homeroom teachers are greatly involved inchildren’s daily activities in Japan
Physical & Psychological responsesa) Insomnia, avoidance behaviors (avoiding beaches, water-related places, news about the disaster, etc.),
truancy, social withdrawal, etc.
b) Guilt feelings, anxiety, suicidal ideation, etc
Interventions• Provide knowledge about post-traumatic responses and effective coping strategieso Post-traumatic responses are inaccurately learned responses and behaviorso Facilitating self-monitoring, self-expression, understanding of the responses, gradualexposure, etc. will prevent children from developing stress-related disorders and otherinterferencesa) Learn about post-traumatic responses and exposurea. Excessive avoidance behaviors from stimuli that cause post-traumatic responsesi. One factor of maintaining stress-related disorderii. Exposure needs to be provided graduallyb. Post-traumatic responses
i. Difficulty distinguishing safe stimuli from dangerous ones
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ii. Inaccurately perceiving safe stimuli as being dangerous and actively
avoiding these stimuli
c. Need to practice own coping strategies to rollback inaccurate learning as much as
possiblei. By gradually being exposed to the stimuli
1. New learninga. The stimuli is safe and neutral
b. One’s fear responses are unnecessary and excessive
d. Sense of safety is essential when providing exposure to the stimulib) Utilize questionnaires to facilitate self-awareness, while understanding children’s actual
condition• e.g., Health Questionnaire, PTSRED-TRAUMA25
a. Questionnaires are helpful because of the frequently covert responses
b. Helpful for the children to understand their post-traumatic responses
c. Helpful in providing effective coping strategies to the specific issues
d. In order to avoid negative reactions to the questionnaires, conduct them in a safe
environmenti. Assess and screen severe cases and provide further care (e.g., individualcounseling)ii. Relaxation exercises can be provided before or after the questionnairee. Warning:i. Questionnaires should always be provided along with psychoeducation,
stress-management experience, preparation for follow up care, etc.
ii. Need continuous care and support system
iii. Do not exploit the victims for research purposes

Stage 4: Expressing life experience*After Stage 1 & 2Interventions• Refer to the psychoeducation guidelines in the first step
• Facilitate implementing effective coping strategies• School-based approacha) Exercise, games, relaxation activities (Stretching, deep breathing, etc.)
a. After these activities, create a sober atmosphere and facilitate talk and self-expressionb) Self-expression through speech and/or writinga. Sharing one’s own experience about the current experience
i. e.g., “The things I did well in the shelter,” “Creative ideas in my everyday life,”“Enjoyable time with my friends,” etc.
ii. Avoid expressions of direct experience of the actual disaster event (e.g., “How I4

ran away from the tsunami”)
iii. Provide safe environment for expressing oneself
iv. Empathize and accept their expression as it isc) Special class about psychological carea. Education in stress-management, social skills, peer support, etc.

Stage 5: Expressing traumatic experience*After completing Stage 1-4
Physical & Psychological responsesa) Stress-related disorders (e.g., PTSD)b) Various feelings related to traumatic experience
Interventions• Refer to the psychoeducation second step
• Facilitate children to express their traumatic experience and to face it• Do not coerce them and take things only at their own pace
• Separate facing fears and sadness from the fun activities of daily life

Stage 6: In vivo exposure*After completing Stage 1-4, after some experience of Step 5
Physical & Psychological responses• Avoidance behaviors (Unable to go to beaches, unwilling to swim, etc.)
Interventions• Refer to the psychoeducation second stepa) Psychoeducation (understanding the reason why exposure to stimuli that causes post-traumatic
responses is essential)b) Gradual exposure to less painful/fearful stimuli
a. Start from the level of 50-60/100 (Moderate anxiety)b. Help children experience that the stimuli are safe and neutral
i. In case of severe post-traumatic responses, provide individual counselingStage 7: Mourning process
Physical & Psychological responses• Anniversary reactions
Interventions
5a) Help children cope with the traumatic responses toward the memorial ceremonyb) Separate coping time from playtimec) Have the children have an internal dialogue with the deceased person(s)6