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expert reaction to Thai school children in cave

Twelve boys and their football coach have been trapped in a waterlogged cave in Thailand for almost two weeks.

 

Dr Andrea Danese, Head of the Stress & Development Lab the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, and Consultant Child & Adolescent Psychiatrist at the South London & Maudsley NHS Foundation Trust, said: 

How might the children have reacted once they discovered they were trapped?

“The children likely have initially tried to look for escape routes out of the cave. Once it became clear that there was no escape route, the children likely experienced frustration and agitation. Some of them might have eventually become hopeless and despaired in the days before the rescuers reached them.

“In addition to the direct psychological toll, the children have spent days in the darkness, possibly wondering about threats in their surroundings, like spiders or insect. This has likely raised their perception of threat and also impacted on their circadian rhythms. They have spent weeks without food and in poor hygienic conditions. This has likely made the children weak and possibly caused infections. Overall their physical restrictions are likely to have caused tiredness, fatigue, irritability, and low mood in at least some of them.

How might the children have reacted once they were discovered by the rescuers?

“Children were likely elated when the rescuers made contact, giving them hope to be brought to safety. In addition to hope, the rescuers brought nutrition and lighting, helping the children re-establish some level of normality.

“Some children might have become upset in discovering that they could not be brought outside the cave immediately.

How will the children react during the rescue operation?

“It is quite likely that the children will become anxious or possibly panic during the rescue operation, while hopefully taken out of the cave. This is because their survival will be at stake, the procedure will be unknown to them, and the rescuers are unfamiliar to them.

“To reduce the risk of anxiety during the rescue operation, it may be helpful to prepare the children with clear information about the procedure, using terms that they can understand, and asking them to repeat the instruction to ensure that they have understood. Similarly, it may be helpful for the rescuers directly involved in the operation to spend time with the children and build some rapport with them, so that the children could trust them at the time of need.

What will be the challenges for the children outside the cave?

“After this ordeal, children should be given time to get back to their families and claim back their routines and daily activities. This is likely to help them recover.

“Intense media scrutiny might act as a reminder of their traumatic experience and prevent them from settling back to normal life. Therefore, the children should not be involved in interviews or asked to take part in pictures for some time after the rescue

What are the expected mental health consequences for the children?

“In the longer term, within months, most children will recover from the initial emotional symptoms. A sizeable minority (10-30%) will however experience enduring mental health problems, such as depression, anxiety disorders, post-traumatic stress disorder, conduct disorder, and substance abuse.

“These children may be more vulnerable to develop mental health problems than adults who might have been exposed to similar experiences (e.g., Chilean miners) for several reasons. The children were not expecting any risk from their exploration and clearly were not trained in emergency rescue operations. The children have accumulated less lived experiences and therefore have fewer skills in coping with strong emotions. Biological factors also play a role. Children still have not fully develop inhibitory areas of the brain, such as the prefrontal cortex, that enable adult to contain emotional responses. In addition, exposure to such traumatic experiences may influence the way their brain is developing and affect the way their brain will process threats in the future. For these reasons, children might be at greater risk than adults to develop psychopathology.

How should the children be assessed and treated?

“Because there are many types of psychopathology that could be triggered by trauma, the assessment of the children needs to be broad, considering all types of psychopathology rather than only focus on specific types of symptoms, such as post-traumatic stress disorder (PTSD). In addition because of trauma-related psychopathology, young people often struggle to cope with their intense emotions, engage in self-injurious behaviour, and find maladaptive ways of coping with distress, such as substance abuse. Therefore, the children’s assessment should include a careful assessment of their risk for self-harm and substance use. Finally, some of the children may have had pre-existing vulnerability to psychopathology, which should be considered in the assessment.

“With regard to treatment, it is important that the boys who develop psychopathology receive evidence-based treatments personalised to their clinical presentation rather than general counselling advice on copying strategies or interventions with poor evidence base. The best evidence-based intervention for children who develop post-traumatic stress disorder is a type of psychotherapy called Trauma-Focused Cognitive-Behavioural Therapy, which has been endorsed by key institutions in the UK, US, and elsewhere.”

 

David Trickey, Consultant Psychologist and Co-Director of National Trauma Centre and Professor Eamon McCory, Professor of Developmental Neuroscience and Psychopathology and Co-Director of the National Trauma Centre, said:

“One of the biggest predictors of a traumatic reaction is the meaning individuals give to events they have experienced. A young person who sees an event as life-threatening and uncontrollable is much more likely to experience chronic psychological difficulties. By contrast, a young person who sees the same event as frightening but retains a sense of agency and control is more likely to see themselves as strong and is less likely to have future problems.

“The meaning that young people make of events is crucially shaped by those around them – their peers, the adults (including carers) and the media.

“The potential negative psychological impact could be reduced at this stage in a number of ways:

  • Shaping the current sense of threat that the young people feel by focusing on the positive and hopeful aspects of what is being done to rescue them. At the same time, overly minimising the actual danger would be counter-productive. In other words, the boys should be helped to see the current situation through an optimistic but also realistic lens.
  • Increasing a sense of calm. For example, developing a predictable routine of activities (including sleep) and possibly teaching them strategies and techniques to regulate their arousal levels.
  • Increasing the boys’ sense of social support and connectedness within the group, but also with others to whom they feel attached such as family members. For example, by planning joint tasks that build teamwork, communication and trust that are also fun and provide an opportunity for laughter and humour.
  • Promoting a sense of agency and control by involving the boys in even minor decisions, for example, about their daily routine or what they are eating.
  • Effectively supporting the teacher with the group. He is a central person who is likely to play a key role in shaping the appraisals of the young people at present. It would be important to ensure that he also receives support from individuals with leadership experience of risk situations as well as emotional support from friends and family.”

“When the ordeal is over, we would expect many of the young people to experience a range of psychological symptoms including:

  • Nightmares
  • Memories or pictures of the event unexpectedly popping into the mind
  • Feeling as if it is actually happening again
  • Repeatedly playing or drawing about the event
  • Not wanting to think or talk about it
  • Avoiding anything that might remind them of the event
  • Getting angry or upset more easily
  • Not being able to concentrate
  • Not being able to sleep
  • Being more jumpy and on the look-out for danger
  • Being more clingy with parents, carers or other known adults
  • Physical complaints, such as stomach aches or headaches
  • Temporarily losing abilities (e.g. feeding and toileting)
  • Problems at school”

“However for many, these symptoms will only be temporary. Furthermore, knowing that such reactions are entirely normal in the short-term helps them not to worry about them.

“Returning to their friends and families is often extremely helpful, as is returning to normal and routine activities such as school. This may help to reduce the chance of the event being interpreted as having ‘changed everything’. The opportunity to talk through what happened, if they wish, may help them to make sense of the event in a helpful and realistic way. The adults around them will be key in this spontaneous meaning making. Some adults are so worried about making things worse that they say nothing and avoid any discussions about the event or how the young people are coping. The adults may therefore benefit from help and support to ensure that they are able to communicate with the young people so that they in turn feel supported and able to process events if they wish to. In other words, each young person needs to be supported by the trusted adults around them to create, in their own time, a coherent story of what happened to them rather than be encouraged to dismiss the event or pretend it did not happen.

“Following up and checking how they are doing as time goes on (referred to as “active monitoring” in the current draft of the revision of the NICE Guidelines for PTSD) will help to identify those young people who may benefit from further help and support.” 

 

Prof Peter Styles, Professor of Applied and Environmental Geophysics, Keele University, said:

“The difficulty is that these are not single caves but a series of linked caverns which are caused by water laced with CO2 which forms a weak acid and dissolves the limestone. The cave system (which may run many many miles) tends to be liked by narrow connections which can easily flood which is clearly what has happened here as the storms occur. The fact that a diver has dies indicates how hazardous the journey through these is. It may be worth trying to see whether there is access into the cave where they are from the surface or whether it is feasible to make one if there isn’t a natural access. If it is already partly connected it would be feasible but tricky. To drill a shaft big enough to get folks through in virgin rock is difficult but not impossible as the other alternative may be to wait for the waters to fall which as they have said may be months!”

 

Dr Andrea Danese, Head of the Stress & Development Lab the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, and Consultant Child & Adolescent Psychiatrist at the South London & Maudsley NHS Foundation Trust, said:

“Many of the young people trapped in the cave in Thailand are likely to develop new psychological symptoms in the short-term. They may become fearful, clingy, or jumpy; they may be fear for their safety; they may become very moody or easily upset (or, in contrast, they may become detached or numb); or they may develop headache and stomach-ache related to the intense distress.

“Most of these young people will recover from these symptoms in a few weeks at most. However, we can expect that a sizeable proportion of the young people involved (10-20%) will develop more enduring mental health problems related to the trauma, such as post-traumatic stress disorder (PTSD), depression, or conduct problems. These young people will benefit from psychological assessment and treatment.”

 

Prof Neil Greenberg, Professor of Defence Mental Health, Academic Centre for Defence Mental Health, King’s College London, said:

“In the days prior to being found, it is likely that the boys and the coach would have experienced a range of emotions including denial, anger, despair, acceptance and bargaining. These are common reactions in people who are trying to come to terms with a hugely stressful event. When the two divers arrived in their cavern, it is likely that, after a moment of disbelief, they would have experienced elation at least in the short term. Now the uncertainty of when and how they might be rescued will be beginning to set in.

“However, there are a wide range of factors which might influence how they cope prior to them being ultimately rescued including team spirit, their health and the approach that the rescuers take to getting them to safety. It is also likely, given their age, that the nature of their communication with their families will also affect the children; anxiety expressed by their families could easily erode a child’s resilience. On the other hand a positive, “it’ll be just fine” approach may be an effective way of allaying their fears. The coach may of course be concerned about how he will be judged when the situation is finally over. In the longer term, it may well be that many of the group will find it challenging to ‘return to normal’ when they are initially freed, however chances are most will be fine, perhaps even psychologically stronger in the longer term. We have to hope that if any of them do stay distressed for an extended period when released that they will be able to access good support and professional care to ensure that they are returned to a good state of health.”

 

Declared interests

None received.

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