KATHMANDU: A teacher shows a hole in the ground, everyone surrounds it discussing what could have caused it. Then suddenly one of the teachers interrupts, “All students are back at school, they don’t want to talk about this (earthquake). Everything is fine, we are fine.” Surprised everyone keeps mum. Later the reason is revealed — this teacher lost his infant on April 25. Since then his elder son has been clinging to him wherever he goes.

Seems strange? In such a situation, there is always more than what meets the eye.

This situation was one among many observed by Dr Sophia Banu, a child psychiatrist from Houston, USA, in a school in Melamchi during a visit for need assessment on teachers’ training. Dr Banu bears many designations, one among others is Director at Clinic for International Trauma Survivors.

She reached the Capital on May 29. Her family was safe, but that was not enough. She had to help.

“I felt helpless sitting in Houston not being able to do anything. I knew my family and my sister were fine but I felt — ‘I know the language, I know the culture, I am psychiatrist, I should be helping’. So, I decided to come and spend three weeks here.”

Dr Banu has been volunteering in the Disaster Psychiatry Outreach based in the US and through that she came to Nepal to help during her vacation. Here “we are working with Psychiatrists Association of Nepal (PAN), Child Reach Nepal, and Rato Bangla Foundation”.

After reaching here, she visited various schools in Melamchi and Gorkha for need assessment to train teachers. Why teachers? Even in the remotest areas more than the physician, teachers are present, so this was a practical decision. The training is to educate teachers to identify children with trauma symptoms, emotional issues, and to make sure that they (affected children) get help.

In the training

On June 17, she left for Melamchi to start the pilot training based on Dr Arshad Hussain’s module. Dr Hussain is a psychiatrist who has done teachers training in different parts of the world where disaster has struck. The module has been altered keeping in mind the needs in Nepal. The best part about the training is that it is not over after a week or so, it continues with supervision. “Once I leave, we will give them a form — if there are cases of domestic violence, how many came for counselling, child attending school or not et cetera. A month later, we send the same form and see if there is a difference. If we notice a huge difference, then we will ask Dr Hussain to come and train the teachers here.”

First the training will consist of psycho education about trauma and what it does to not just an individual but the community as a whole. Then psychological first aid will also be talked about. Besides that Dr Banu will talk about art and expressive therapies — a child who may not talk about anything, may express through other medium. “We will talk about relaxation exercises. We want to teach them how it affects the brain. When they see all this, they can explain to the child or parents of the child. So if the child is behaving in a certain way, they know the reason and can help the child instead of punishing.”

Understanding what kids go through

Trauma depends on the children’s age group. Their development stage is divided into age groups of zero to two and half, then three and half to six, six to 12 and 12 to 18. To help a child, it is essential to know these development stages. “For instance, in case of an infant, the mother or caregiver needs to be consistent like holding the child. You have to be calm for your child to be calm. If it’s a breastfeeding mother, the child will sense the fear while s/he is being breastfed. Take care of yourself to provide support to your baby.”

Two and a half to about 4/5 years old: They don’t understand the concept of death, they don’t realise if someone dies it’s permanent. “So don’t scold the child. It is important you know the age of the child while you are talking to him/her. If somebody is potty-trained by the age of two to three, they can start regressing when they are five. They start peeing in bed, they become more cranky, clingy.”

Like an adult, a child gets scared but they just have different ways of showing it. They get very irritable, angry and it is very important that parents maintain normalcy. The longer the child takes time to return to normalcy, the more difficult it is for the child. “What I would really stress for parents is to maintain sleep hygiene. Don’t let the child be on any electronics at least before two hours they go to bed. The tablets and all have been made very bright, that brightness sends a wrong message to the brain saying it is still day though it is night and the child is concentrating so much that it will be more difficult for the child to sleep if s/he is already traumatised. This then will lead to a vicious cycle.”

Six to 12 years old: They will regress, they will become clingier, more dependent on the parents, they understand the concept of death and “one thing we always tell parents and teachers — this is not the time to discipline them. Give them love, hug them, talk to them about school, homework, and increase the interaction”. At home or in school, try not to talk about earthquake and aftershocks all the time that the child only hears about this.

Twelve to 18 years old: All the fears are like an adult in this age group. Symptoms will be like an adult — nightmares or having flashbacks, being always alert like a loud noise will startle them, and some children may feel that this is the end and there is no future in Nepal. “So, it is important to talk to your child and give them reassurance but never lie to the child like — ‘this will never happen again’, because no one can predict earthquake. Tell them it may happen again and have a safety plan ready. This can also be done with an adult.”

A safety plan becomes essential if the child is really anxious. Put all the basic necessities in a bag and come up with a plan of who can leave from this door and that “just for the child to know you are in control, because if you are anxious, the child’s anxiety will increase. We are also telling in school to have safety drills as much as possible in case of anything.”

When to seek help?

Usually after a trauma, symptoms develop four weeks later. Then some people get better, while some

worse. But here there was first earthquake then the second one hit and then the aftershocks kept coming, which is continuing — so it is one trauma after another. Every aftershock is also like trauma. “You really can’t say in Nepal that after so and so duration you should be feeling better. As long as people can feel the aftershocks, the trauma is sort of ongoing. But it is minimising as the frequency and strength of aftershocks are decreasing.”

In such a case, one needs help when trauma interferes with your daily functioning — if you are unable to go to work, unable to talk for weeks, unable to go to your house or the first floor of your house, if it is interfering in your relationship with your loved ones. All this has to be continuous though. “To seek help, there needs to be impairment of functioning but it should be compared to how the child was before and after the earthquake.”

Teachers need to notice change in behaviour, academics, interaction between peer/teacher/parents of the child. “But sometimes we also noticed that the child is coming to school and doing relatively well, but s/he is fighting at home and is always angry. The reason — parents were very anxious and the child was picking up on that causing him/her to have imbalance between reactions. This is an unconscious reaction the child shows.” So, the teacher needs to be aware of the child or interact with parents often.

However, it is not necessary everyone will go through Post Traumatic Stress Disorder (PTSD). Some people go through worse experience than earthquake, some people lose more and some less. It depends on the individual and how they perceive the trauma. “Some people may not have lost anything but the threat of losing your life can result in PTSD. And if you have a history of depression, it is not necessary the person will suffer from PTSD. You can’t determine it as black and white, there is always a grey area, which determines how you react to the trauma.” If a child is going through PTSD, the severity can vary from child to child.

It is also imperative to understand that if someone is going through PTSD, it doesn’t mean s/he is

becoming crazy. “Post disaster is not equal to PTSD. You may be traumatised but it doesn’t mean you have a disorder.”