Psychologist Paula Madrid says that the experience of one of her young patients from New Orleans is all too common. The 13-year-old girl has entertained thoughts of suicide since Hurricane Katrina sent rapidly rising floodwaters through St. Bernard Parish, forcing her family of six onto the roof of a neighbor's home where for two days they waited hand-in-hand in the heat for rescue. Before a helicopter took the three kids to safety, they watched their uncle drown in the floodwaters.
The girl was bussed to Dallas, while her brothers, ages 8 and 12, were sent to the Astrodome in Houston. It was two weeks before they saw their parents again. The family then spent the next few weeks crammed in a hotel room with eight strangers, sometimes camping out in a tent and sharing a small pizza for dinner. After the father started abusing alcohol, the mother took the kids to live in a two-bedroom house in Baton Rouge, La., with seven other family members.
It was five months before the girl (whose name remains confidential under doctor-client privilege) received professional help to deal with her anguish. According to Madrid, who is director of the Resiliency Program at the National Center for Disaster Preparedness in New York, the girl's story is emblematic of what mental health professionals are seeing with children across the Gulf region, leaving them deeply concerned for "Katrina's kids" a year after the disaster.
Mental health experts agree that the scope of the damage, a lethargic rescue effort, and a still tentative recovery process have combined to make Hurricane Katrina uniquely damaging to children. After the trauma of the initial deluge, many spent days amid the terrifying pandemonium of the overstuffed Superdome, endured months of suitcase living, moved between family members' homes, FEMA trailers and hotels, and missed out on long periods of school. In essence, many of them remained in a suspended state of crisis that lasted months.
Even child psychologists who have extensive experience working with kids after natural disasters like hurricanes, floods and wildfires say Katrina's toll was unnerving. "I've never experienced being on the ground and seeing and hearing that degree of devastation and human despair," said Russell Jones, a psychology professor at Virginia Tech University and consultant for the National Child Traumatic Stress Network. In his eight visits to the Gulf region since Katrina, Jones said he encountered kids who had trouble eating and sleeping, exhibited hyper-vigilance, and seemed constantly in anticipation of an imminent disaster.
Recent studies have made clear that Katrina's emotional toll on kids has been severe. In July, Louisiana State University researchers presented findings from a screening of 4,000 children in the region: One-third showed signs of depression, while a third showed signs of full-blown post-traumatic stress disorder. A survey of 665 households released in April by Columbia University and the Children's Health Fund, a not-for-profit organization focused on medically underserved children, found that almost half of parents living in FEMA-subsidized housing reported a child who developed emotional or behavioral problems after the storm.
And estimates of the long-term toll are even more bleak. According to four child psychologists who spoke with Salon, based on standard models for forecasting the development of PTSD after exposure to trauma, at least 8 percent of the more than 1.2 million children under the age of 15 living in FEMA-declared disaster zones could be stricken. That's as many as 100,000 or more kids across the Gulf region.
In New Orleans, mental-health workers fear that in a city where mental health services were already poor at best before the storm, children will be cheated of critical mental health care. Before Katrina, Louisiana ranked lowest in the nation for state health based on a high number of uninsured citizens, meager public health funds, and a high child poverty rate, according to the United Health Foundation.
The hurricane ravaged New Orleans' hospitals, including Charity Hospital, the city's largest public hospital and principal source for acute psychiatric care. Today, there are 44 operational hospitals in the city, while 17 remain closed, according to the Louisiana Hospital Association. The Jefferson Parish Human Services Authority has closed one of its three facilities, but continues to offer the same level of services that it did pre-Katrina; the Metropolitan New Orleans Human Services District has reopened two of its five facilities, and has three temporary sites with limited services. More troubling is the lack of personnel. According to a report published in early August in the Journal of the American Medical Association, of the 196 psychiatrists practicing in the city before the storm, there are now only 22.
On Aug. 17, FEMA announced that $34 million has been set aside for mental-health counseling in Louisiana. That's in addition to the collaborative effort between FEMA and the Substance Abuse and Mental Health Services Administration, a division of the U.S. Department of Health and Human Services, to mobilize out-of-state assistance to help deal with the crisis. According to Kathryn Power, director of SAMHSA's Center for Mental Health Services, "over $12 million in personnel mission assignments, involving over 1,000 behavioral health professionals, have focused on direct support while the mental health systems in Louisiana, Mississippi and Alabama rebuild their infrastructure."
But some mental-health workers are skeptical of the actual impact of these mission assignments, which ended in March in Mississippi, and in June in Louisiana and Alabama. "It's a nice thing that a lot of people want to come down and help for a couple days or weeks," said Dr. Maurice Sholas, director of LSU's Pediatric Rehabilitation Program. "But that's like putting a bunch of band-aids on a big wound. The problems we have here are not going to be solved that way. You can throw a lot of money around and make a lot of sound but there's a need to rebuild the city's medical and psychiatric infrastructure."
Sholas said that New Orleans is in such "dire straits" that he wouldn't even begin to know where to send a child who needed to be hospitalized for a psychiatric illness. The psychiatry departments at LSU and Tulane University need to be strengthened for starters, he suggested, so that they can serve as a foundation for a new local infrastructure.
Complicating things is the fact that the extent of the crisis is not yet fully understood. "As we know, PTSD and depression are sometimes slow to emerge," said Dr. Raymond Crowel, vice president for mental health services at the National Mental Health Association. "For children, these symptoms might not make themselves known until this hurricane season."
"States certainly need to be as quick as possible in their role of coordinating and identifying where the help is most needed," Crowel said. But overwhelmed as they are, he argued, the Gulf states need support from the federal government in the form of Medicaid funds that allow disaster survivors to automatically be eligible. "As the [state and local] governments get themselves back on the ground, those federal emergency efforts can step down," Crowel said.
Crowel points to another serious problem: the exodus of skilled mental-health professionals at a time when the need is acute. "You've had providers who have moved out of the area, and those remaining in the area have been inundated with requests."
"What we're seeing now in the city is the extent of the devastation and the slowness of recovery," said Dr. Joy Osofsky, a professor of pediatrics, psychiatry and public health at LSU. "I'm optimistic that we have made some progress, but there will be an enormous need for mental health interventions. But I would prioritize trying to rebuild the local services as opposed to people coming from other communities to provide services for a few weeks and then leaving."
Nearly universal among child psychologists is one point of optimism -- that in general children are incredibly resilient. But crucially, this is most true when they are provided with a supportive and stable environment, both at home and at school.
With the latter, New Orleans still faces serious problems. Even including charter and state-run recovery schools, which the state Legislature introduced as an emergency measure, fewer than half of the city's public schools that were open before Katrina have reopened a year later. There were 117 public schools to accommodate 65,000 kids in New Orleans before the storm; there are now only four public schools, 18 recovery schools and 35 charter schools. The Columbia study found that "20 percent of school-aged children are either not enrolled in school or miss more than 10 school days each month."
"Even as a psychologist I will tell you that post-Katrina, the most important thing -- take away the psychologists and social workers -- is a sense of stability and a sense of connectedness," Madrid said. "Schools provide a sense of structure and continuity."
According to Osofsky of LSU, all of the operating schools in New Orleans now have an on-site social worker, and there are plans to contract with LSU to have psychologists working across the schools. In Louisiana, the Children's Health Fund has mobile units that serve neighborhoods most ravaged by the storm, providing children and families with access to mental-health professionals who specialize in trauma and children's issues. They also provide training for teachers and school clinicians.
Madrid worries that some school clinicians are unprepared to deal with the scope of this disaster. "These are clinicians who are, perhaps, not well trained. They do a good job, but are overworking themselves with stress," said Madrid, who has had workers break down in tears when telling her about their emotional exhaustion. She said that many of New Orleans' mental-health workers are experiencing "compassion fatigue" or "vicarious trauma." Compounding the struggle is that many of these workers have lived through the very trauma experienced by their patients.
Misdiagnosed or untreated PTSD in Katrina's kids is only magnified by a city still deeply submerged in the struggle to recover, and could lead to problems as far as 10 to 15 years down the line, Madrid said. "Having experienced so much trauma and disconnection from others, it's scary," she said. "These are their formative years. This is when they should be learning about safety, appropriate care for themselves and others. If they're not picking up on that now, how will they end up as parents?"