New paradigms for therapeutic recreation and recreation and leisure service delivery: The Pattillo A+ Elementary School: Disaster Relief Project.

In a 1999 P&R article, Shelia Franklin described some of the beneficial services that recreation professionals could bring to bear in the aftermath of natural disasters. In the article, Franklin justifies the need for recreational professionals to team up and form rescue operations in the tumultuous times following a disaster. According to Franklin, Operation Recreation Relief's mission should be threefold:

* Facilitate a donation program for equipment as well as service-donation program

* Establish a training program for park and recreation professionals

* Create teams of professionals to restore damaged parks and facilities and provide recreation programming and leadership.

The Pattillo A+ Elementary School Disaster Relief Project illustrates Franklin's three-pronged mission of Operation Recreation Relief in an applied setting through an on-going flood relief project coordinated by the Department of Recreation and Leisure Studies and the School of Health and Human Performance at East Carolina University. This project was initiated in October of 1999 immediately following the flooding from Hurricane Floyd, which decimated much of Eastern North Carolina.

In addition to Franklin's three-pronged approach, the Pattillo Project employed a fourth process through which therapeutic recreation professionals (and pre-professionals) can specifically contribute to any given disaster relief mission: the prescription of recreational activity to ameliorate negative symptoms resulting from the trauma (recreational therapy). This fourth service delivery area broadens the paradigm of therapeutic recreation from traditional hospital-based RT services and community-based recreation services for persons with disabilities, to one that includes disaster relief assistance. These services as illustrated by Franklin also encompass recreation and leisure service delivery systems.

Prescribed activities and other psycho-social programs play a valuable role in the healing process and should be included as part of any disaster relief effort. The provision of recreational therapy services, including specific and comprehensive treatment-oriented programs are critical to disaster relief efforts. The Pattillo A+ Elementary School Relief Project demonstrates the successful application of these treatment services and illustrates a broader scope of service for therapeutic recreation professionals.

HURRICANE FLOYD AND THE SUBSEQUENT FLOOD

"We need recreational therapy", stated Dana Alexander, social worker at Pattillo A+ Elementary School, during the initial telephone conversation seeking help for 450 fourth and fifth grade students who had been displaced because of flooding after Hurricane Floyd.

On September 15, 1999 Hurricane Floyd came ashore in Eastern North Carolina and subsequently dumped an estimated 20 to 25 inches of rain. Within 36 hours, the Tar River rose to 43 feet, breaking the 500-year flood plain and overwhelming scenic Tarboro. Located within one of the poorest counties (Edgecombe County) in North Carolina, Tarboro was hit exceptionally hard by this disaster. In the days, weeks and even months following the flood, Tarboro, an historic agricultural tobacco and cotton town, would experience conditions reminiscent of war, with large sections of town needing to be evacuated (Eastern North Carolina experienced the largest organized disaster-related evacuation in U.S. history). Helicopters would be in and out of Tarboro seemingly every 15 minutes for the first four days. Fifty-one people would die as a result of the hurricane and flooding which wrecked havoc throughout Eastern North Carolina (Ground Zero). The Governor eventually proclaimed that Floyd's indelible impact was the greatest the state ever endured. It was immediately evident that recovery would take many years.

The waters rose quickly and enveloped entire buildings and their surroundings. Pattillo A+ Elementary School was in the direct path of rising floodwater and as a result, the students, teachers and administrators lost everything. None could predict they would never be able to return to their school.

There were many losses as a result of Hurricane Floyd including Pattillo A+ Elementary School. The ultimate effects were the impact on the stability and security of the fourth and fifth grade students. In a matter of days, the familiar places where the children sat, learned, stored their belongings, and played were gone. Many children were relocated in Federal Emergency Management Agency housing or began staying with relatives and friends.

When students did return to school, approximately three weeks after the hurricane, it was to modular classrooms set up adjacent to the Tarboro Armory. The 32 makeshift modular classrooms, albeit inadequate and comfortable, have the feel of a military compound. Tightly grouped together and connected by sidewalks made from pallets, the modular classrooms have only a few windows that look directly at other modular classroom walls or the armory parking lot. The "campus" grounds located next to the Tarboro Armory, with a tank in sight, are crude and inadequate for the growth and developmental needs of fourth and fifth grade children. There was no playground on which the children could interact and practice critical physical and social development skills.

The grounds presented unique challenges, as there is little outdoor space for running, playing ball, and other physical activities. The inability of these children to participate in regular activities, coupled by the devastation, contributed to dramatic increases in behavioral problems noted by teachers and administrators. In addition, due to the inaccessibility of the modular classrooms, two exceptional children's classrooms were separated from the main group of children. All faced hardships because of the multitude of barriers created by the flood.

THE INTERVENTION

Approximately one month after the crisis, a team consisting of Eastern Carolina Universtiy, ECU students and faculty was briefed on the situation at Pattillo Elementary School. Using their own transportation, this team of concerned faculty and students began driving the 27 miles each way, every Monday, Wednesday, and Friday afternoon, to respond to the impact of the disaster on the children of Pattillo Elementary School. (It is noteworthy to point out that some of the ECU students involved in the relief project had lost their homes and belongings to the flood. The actions of this volunteer effort epitomize the spirit of altruism.)

The ECU intervention team immediately began to systematically work with one classroom at a time until every child had an opportunity to begin the healing process. The initial goal was to help the children become stress-hardy by teaching and practicing coping skills and facilitating the process of healing through a series of recreational and other biopsychosocial activities.

"Nothing you do for children is ever wasted." -- Garrison Keillor; Leaving Home, "Easter"

Shortly after this initial effort began, the ECU Department of Recreation and Leisure Studies and the School of Health and Human Performance suggested that Pattillo A+ be adopted. A committee consisting of faculty from the Departments of Recreation and Leisure Studies, Health Education and Promotion, and Exercise and Sport Science met to discuss a multifaceted approach to address the needs of Pattillo's children and teachers. The disaster relief project would soon be granted the use of a van to transport students to and from Pattillo and a graduate assistant to help coordinate the project. These two additions would directly contribute to expansion of the project and more effectively deliver the services.

To complement the efforts, a number of individuals and volunteer organizations assisted in the acquisition of recreational equipment, sportswear and school supplies. These groups included the Recreation and Leisure Studies Student Society, and other campus societies and volunteer associations. One student group raised donations for 500 tickets for the children to enjoy a professional presentation of Charlotte's Web. Another group spontaneously delivered flowers, while others provided prizes for students excelling in school despite the flood. Other activities included the delivery of a stress management seminar for teachers and stress management training sessions for student volunteers.

A NEW PARADIGM FOR THERAPEUTIC RECREATION SERVICE DELIVERY

As with the disaster relief model proposed by Franklin (1999), the Pattillo Project includes a formal four-tier disaster relief volunteer service project. Each tier plays a critical role in disaster relief.

Tier One includes the acquisition of recreation supplies and materials to facilitate growth and development. Broad-based community support was generated in the effort to secure replacement recreation and sports equipment and supplies for the school. Donations were solicited via radio, television, and through a community disaster relief arts festival sponsored by ECU's Department of Recreation and Parks and the Greenvilee Parks and Recreation Department.

The second tier (recreation facilities) is on-going and includes the planning and construction of a new playground for the children of Pattillo. Too often, recreation professionals take for granted the critical role sound playground facilities play in the development of the child.

Tier Three includes the provision of hands-on training to utilize the concept of learn and serve. Through supervised direct service delivery, recreation pre-professionals are introduced to the multitude of roles and responsibilities their profession plays in disaster relief. These responsibilities include the prior two tiers and are expanded to include direct services.

The fourth tier, the provision of systematic intervention to address the effects of natural disasters on the lives and functional performance of school-aged children, represents a new paradigm for the therapeutic recreation and recreation service provider. Encompassing three levels of services delivery (i.e., 1:1, small group, and large group activities), this fourth tier integrates both therapeutic recreation and recreation service delivery as a comprehensive model of service for delivery.

The therapeutic recreation pre-professional students were introduced to a new fact of service delivery in the form of systematic coping skills development as a medium for recreation therapy services. This component involved the delivery of a comprehensive program of physical and psycho-social activities designed to promote cognitive, social, emotional, and physical development and to enhance coping strategies for stress. The program, "I'm in Charge of Me" (I-C Me) employs a bio-psychosocial program strategy and includes a cognitive\behavioral stress control component found to be effective in increasing the use of appropriate coping strategies and increasing self-concept of school-aged children (Henderson & Kelbey, 1992). Therapeutic recreation pre-professionals led classroom groups to help students identify and cope with stress (cognitive behavioral). In addition, bio-psycho-social recreational activities were integrated into the strategy in order to promote normalization. High-risk students, identified by a teacher-rating scale are placed with undergraduate and graduate students for one-on-one and small group treatment and recreation activities.

I'M IN CHARGE OF ME

The "I'm in Charge of Me" program is a five-week program that helps children identify the symptoms of stress and teaches them coping skills to ameliorate these symptoms. Across the five-week program, students are introduced to sessions covering a range of topics designed to promote and facilitate positive coping strategies.

* Week One: What is Kid Stress?

* Week Two: The Power of Positive Thinking

* Week Three: Breathing for Health

* Week Four: Dealing With Stress: Coping Activities

* Week Five: Expressing Emotions

This program has been well received by the children, who now eagerly anticipate ECU student arrival, as do the teachers of Pattillo A+ Elementary. School administrative personnel have also noted numerous positive behavioral changes in the children, including increases in attentiveness, positive assertiveness, improved attention span, and a decrease in hyperactive behavior following the sessions. It should be noted that end of grade testing for Pattillo A+ Elementary School students reflected greater growth than all other county elementary schools.

The Pattillo A+ Project has become a successful learn-serve project that demonstrates, through action, a shift in the traditional therapeutic recreation paradigm. The Pattillo A+ Project illustrates the importance of recreation therapy involvement after a disaster and perhaps as a component of the traditional education process.

Perhaps among the real benefits for the future are the outcomes of learning and practicing the recreational therapy process while reaping the benefits of altruism. In addition, the children of Pattillo A+ continue to benefit by learning how to effectively cope with the aftermath of a disaster and life in general. The project demonstrates that in spite of a natural disaster, many positive experiences can be facilitated for those served as well as for those who are serving.

In the last ten years, due to a variety of factors not the least of which is need, the charge that guides therapeutic recreation professionals and the recreation profession continues to shift. The role of recreational professionals is changing accordingly. One area, which requires the attention of all recreation and leisure professionals, is disaster relief. As this area becomes more defined, it is becoming increasingly evident that recreation and leisure services can and should play an integral role in disaster recovery. Moreover, recreational therapy intervention can play a critical role in helping individuals cope with the aftermath of a disaster and, therefore, be included as in integral component of extended disaster relief.

POST-TRAUMATIC EVENT EFFECTS

Approximately 50% of the children of Pattillo A+ lost their homes. Other children lost play areas and personal belongings. The children not directly affected at home lost their "home away from home" and some would express survivor's guilt and empathy for their classmates who were affected. Pictures drawn during a processing exercise immediately after return to classes poignantly depict the sorrow and sadness of the children's losses. While many of these losses were material and can be replaced, others, like innocence and the sense of safety and security, will be difficult, if not impossible, to recapture. Given the vulnerable age of these children, the impact of Hurrican Floyd and its flooding will be life lasting.

Elementary school children experience specific reactions to trauma associated with disaster (posttraumatic stress disorder, PTSD)including: withdrawal; apathy; anxiety; depression; somatization; hostility towards peers, parents and others; decreased interest in activities, and insomnia (National Institute of Mental Health, 1999). In addition, posttraumatic stress results in dysfunctional behaviors and decreased performance in school. These effects are measurable well beyond the event. Children show difficulty in concentrating, remembering and controlling emotions. The cumulative effect can be seen as they do poorly on assignments and tests (American Academy of Pediatrics, 1999; Sleek, 1998; National Association for Social Workers, 1999). Notably, children with preexisting risk factors such as physical and psychological problems are particularly vulnerable to disaster and should be sought out through outreach for specific intervention (American Academy of Pediatrics, 1999).

Incredibly, children in elementary school often still believe that death and loss are forms of punishment. How cruel to think that a child might feel-that they had any responsibility for this disaster. Left unattended, the symptoms of PTSD continue to negatively affect a child's health and performance for an indefinite period of time. One of the best-recorded examples is the landmark study conducted after Hurricane Andrew. PTSD was reported in 40% of the most affected children four years after the traumatic event (Sleek, 1998). The implications for recreation and therapeutic recreation professionals are far-reaching.

RELATED PROJECTS AND OUTCOMES

As a result of the tremendous amount of work, numerous projects have been developed as a result of the initiative. These projects include the development of an intervention manual for developing stress hardiness, coping strategies, and post-traumatic stress symptom reduction.

A symptom rating scale was also created to assist school officials in identifying those children most affected by natural disasters. This manual and rating scale may also be applicable for use with a range of at-risk youth confronted with symptoms of stress. Furthermore, a web site accessed through ECU's School of Health and Human Performance has been created (http://www.ecu.edu/rcls/pattillo/pattillo.htm). The page includes disaster relief resources for children and adults, links to other disaster relief sites, on-going projects and a section where children share their experiences.

Recreational therapy faculty and students will continue to offer the "I'm in Charge of Me" program and other intervention services at Pattillo for the foreseeable future. Data on the impact of the program will soon be analyzed to determine the program's effectiveness and modifications if needed. The Pattillo A+ Project, the first of its kind in disaster relief, demonstrates the effectiveness of a planned bio-psycho-social intervention and provides a point of reference for future disaster relief efforts.

Dr. Carmen Russoniello has over 15 years experience as a recreational therapist, counselor, biofeedback therapist, and educator. He is a past president of the American Therapeutic Recreation Association and currently serves as team leader for the Association's Healthy People 2010 initiative. His research is focused on understanding the underlying psychophysiological processes evoked by recreation participation and the relationship of these processes to health. Dr. Russoniello currently teaches recreational therapy and biofeedback courses at East Carolina University. Thomas Skalko, Ph.D., TRS/CTRS is professor and chair of the Department of Recreation and Leisure Studies at East Carolina University. Jennifer Beatley is an employee in the Department of Recreational Therapy at Pitt Memorial Hospital. Dana Bingham Alexander is the social worker at Pattillo A + Elementary School. Together they have combined to produce the article beginning on page 74 titled "The Patillo A + Elementary School Disaster Relief Project."