TEAM RESPONSIBILITIES: School Mental Health Crisis Intervention Teams

TEAM RESPONSIBILITIES:School Mental Health Crisis Intervention Teams Eric M. Vernberg, Ph.D. University of Kansas Clinical Child Psychology Program Terrorism and Disaster Branch, NCTSN

The Educator’s Mantra There cannot be a crisis next week… My schedule is already full. -Henry Kissinger

Managing the Crisis • Crisis Levels: • Level I - Has a significant school-wide impact • Managed under the direction of the Principal or Site Incident Commander • Additional personnel may be requested by administrator through local district Operations Coordinator • School site team and other personnel work under the direction of school administrator • Level II – Does not have school-wide impact and would not be a significant threat to the survival of the students or school personnel • School administrator continues to have authority and responsibility • However, team leader and crisis team members typically will manage this level crisis • Administrator needs to be kept informed and briefed

Four Phases of Disasters Mitigation Recovery Preparedness Disaster Response

Mitigation The First Purpose Outlined in the EOP: “Prevent avoidable disasters [prevention] and reduce the vulnerability [mitigation] of students, faculty, administration, and school property to any disaster that may strike” Pre-emergency mitigation involves the on-going efforts to reduce hazards, the likelihood of their occurrence, and/or the severity of their impact if experienced.

Current Mitigation Measures - Examples Bomb Threat • Minimizing the presence of hazardous flammable/explosive materials in the buildings/schools Bus Accident • Buses are well maintained Earthquake • Reinforcing the connection of light fixtures to the ceiling

Mitigation Measures - Mental Health • Build community at school • Identify, monitor, and support at-risk students and staff • Develop ties with mental health resources • Work to develop resilient students and staff • Obtain parental consent prior to traumatic event for screening students

From the Field of Brain Research In order for children to learn… • Eliminate Threat from the Environment • Enrich the Learning Environment

Rationale for Screening Children • Exposure can affect children’s behavior, emotions, & learning • Trauma-related symptoms often go unnoticed & untreated • Symptoms do not necessarily go away on their own • School-based screenings can effectively identify children who may benefit from treatment • Effective, relatively brief treatment produce positive results that last • School- & community-based mental health clinicians can provide these treatments

Important Aspects of Good Screenings • Confidentiality assured (how will data be used?) • Tied to organizations that provide for basic needs after disasters • Assessment linked to low-or no-fee services • Clear rationale for screening provided • Endorsed by a well-known, trusted organization

Resilience Adapting in a positive manner or thriving in the face of great stress or adversity Helping students bend - not break

Resilience Remember: Most students will recover well with the support of family, friends, and community organizations “What began as a quest to understand the extraordinary has revealed the power of the ordinary.” - Masten, 2001

Resilient Characteristics • Optimistic - enduring hope • Self-efficacy -belief they have needed skills • Sense of mastery - problem solving, achieving goals • Personal competencies - academic or social skills • Cohesive families - includes connectedness to school • Coping skills - modeled by adults in their environment • Hardiness - active, see change as a challenge • Resilience info from: www.apahelpcenter.org

Actions to Promote Resilience - Examples Preparedness Assess and address social isolation and bullying Classroom projects that promote teamwork, respect, and bonding to the school During Response Keep students grouped with familiar peers Have distraught students comforted by familiar adults Reunification plan Goal: Increasing connectedness to others

Actions to Promote Resilience - Examples Preparedness Practice safety plans Find ways to help others as a class (e.g., raising $, writing letters) During Response Ask students to help you w/ a manageable task Give students age-appropriate duties (handing out water, comforting younger students) Goal: Increasing feelings of empowerment (active coping)

Actions to Promote Resilience - Examples Preparedness Keep a daily routine Encourage family members to provide structure for students During Response Remind students about safety plan Keep students informed using easy-to-understand language Goal: Maintaining consistency and predictability

Actions to Promote Resilience - Examples Preparedness Help students focus on positive images in the media Brainstorm healthy activities that are not associated with anxious feelings During Response Limit graphic talk or media exposure of the trauma Shield students from further exposure to traumatic stimuli/scenes Goal: Take a break

Actions to Promote Resilience - Examples Preparedness Teach basic relaxation skills (e.g., test preparation) Encourage healthy habits: exercise, eating, and sleeping During Response Shield students from further exposure to traumatic stimuli/scenes Prompt students to use positive coping skills (relaxation, verbalizing feelings, social support) Goal: Teach self-care skills

Promoting Resilience -What Doesn’t Work • Forcing students to talk about feelings • Avoiding all discussion about traumatic event • Being a poor model • Allowing your personal resources to be drained • Using negative coping • Showing uncontrolled emotions in front of students

Risk Factors • Greater exposure to traumatic event or graphic media coverage • Lack of family cohesion or parental distress • Financial or marital problems in family • Socially-isolated or bullied students • Exposure to previous traumas • Previous mental health or behavioral pxs • Recent life stressors or major changes • Community disruption

Types of Exposure • Bereavement • Injury to self or family member • Panicking, feelings of dissociation during disaster • Horror/ gruesome scenes • Property damage or financial loss • Relocation • Entrapment • Separation from family

Exposure Screening • Adults tend to minimize or underestimate students’ responses to trauma • Prevents traumatized students with internalizing symptoms from being overlooked • Helps tailor intervention to students’ needs • Shields low-exposure students from being exposed to graphic discussions of high-exposure students in group discussions/interventions

Threat Assessment - Overview Step One: Receipt of information by the school’s multidisciplinary threat assessment team and notification of the district office Step Two: Assess the threat itself Step Three: Conduct a 4-pronged assessment if the ID of the threatener is known Step Four: Involve law enforcement in conducting a threat investigation and in deciding on the threat level and appropriate response

Threat Assessment – Step 1 Multidisciplinary Team: • School administrator • Faculty member • School resource officer (where available) • Counselor • Mental health professional

Threat Assessment – Step 1 Information will be organized into 4 categories: • Information about the individual suspected • Information about “attack-related” behavior (planning, weapons acquisition/ practice, casing out possible sites, rehearsing, etc.) • Motives • Target selection

Threat Assessment – Step 2 Low Level: the threat is vague/lacks detail; contains inconsistent information; not plausible Medium Level: threatener has given thought to how the act will be carried out; general info about place & time, but no strong indication of preparatory steps having been taken High Level: wording is direct, specific and plausible; suggests that concrete steps have been taken toward carrying out the act

Threat Assessment – Step 3 4-pronged Assessment Model (FBI): • Assess the personality of the threatener (how s/he copes with conflict, expresses anger, responds to rules, etc.) • Assess the family dynamics • Assess the school dynamics • Assess the social dynamics

Threat Assessment – Step 3 Assess the personality of the threatener: • Frustration tolerance • Coping skills/resiliency • Relationships with others (romantic & platonic), alienation • Response to rules, authority figures • Desire for control, attn., respect, admiration, confrontation • Expression of empathy • General attitude toward others • Leakage

Threat Assessment – Step 3 Assess the family dynamics: • Traditions, roles, customs, values • Relationships between family members, who is in charge? • Any disruptions to family system • How does family handle conflict or stressors • Access to weapons or violent media

Threat Assessment – Step 3 Assess school dynamics & role in those dynamics: • Beliefs, traditions, roles, customs, values • To what clique does student belong? • Relationships with peers • Relationships with teachers • Bullying - perpetrator or victim

Threat Assessment – Step 3 Assess social dynamics: • Beliefs, traditions, roles, customs, values of larger community • What is neighborhood like? Are neighbors close to one another? • Safety of neighborhood • Choice of friends, activities, attitudes • Drug/alcohol use • Media (TV, computer games, internet, books, etc.) • Role models

Threat Assessment – Step 4 Involve law enforcement: • conducting a threat investigation as appropriate • deciding on the threat level and appropriate response

TEAM RESPONSIBILITIES:During the Disaster Eric M. Vernberg, Ph.D. University of Kansas Terrorism and Disaster Branch, NCTSN

Four Phases of Disasters Mitigation Recovery Preparedness Disaster Response

TriageFrench: “to sort” • Victims are sorted/tagged into four categories: • Immediate (Red) - life-threatening injuries requiring rapid tx • Delayed (Yellow) - injuries do not jeopardize the victim’s life if treatment is delayed • Non-emergent (Green) - no need to be transported by ambulance, the walking wounded • Dead (Black) - no respiration after 2 attempts to open the airway

First Aid Team Duties • Establish triage location • Establish four treatment areas: • Red area for victims with life-threatening • Yellow area for victims without immediate life-threatening injuries • Green area (away from other areas) for victims with minor injuries • Black area (away from other areas) for the dead or mortally wounded • Assign a triage team leader if Nurse is not available

Triage Status # Students Injured/Sick # Staff Injured/Sick # Others (specify) # On Site # Evacuated Dead Immediate Delayed Triage PERSONNEL STATUS Injured/Sick as of time/date:___________ Location:________________ Number of personnel in attendance this date: Students_____ Staff_____

Date Name / Triage Tag # Destination Time Arrived in Triage Triage Color Time Transported Transporting Agency and Unit # Triage Triage Accountability Form

The First Few Hours: On Your Own • Schools will be highly prioritized by emergency responders • Should be prepared to manage on their own for 3 or more hours when involved in an area-wide disaster • You could find yourself on the front lines of a mental health response to a disaster

Mental Health Objectives in School Settings • Restore the Learning Environment • Re-establish Calm Routine • Assist with Coping and Understanding of Reactions to Danger and Traumatic Stress • Re-unite Students with Caregivers ASAP • Support the Emotional Stabilization of Teachers and Parents

Teacher Interventions • Provide structure • Stay calm • Reinforce safety and security • Be patient • Reduce class workload as needed • Be an active listener • Be sensitive to language and cultural needs • Set realistic perspectives • Be nonjudgemental • Defuse anger • Do not tolerate negative or cruel behavior • Reduce immediate reminders

The First Few Hours: What Students Will Need to Know • Adults are in control and will help keep them safe • What happened and the order of events (keep it simple, no graphic details) • What will happen, especially how they will be reunited with caregivers • That what they are feeling in response to the disaster is normal • Words to help them organize their thoughts about the events and their feelings

The First Few Hours: What to Do • In the event of an evacuation, keep each classroom grouped together • Keep students near familiar peers and adults • Keep students grouped with their classroom rather than putting them into a larger group of students or letting them detach themselves from the classroom • Shield students from seeing damage or severe injuries if possible

The First Few Hours: What to Do -2 • Use distraction techniques (snacks, songs, games) to help reduce focus on traumatic scenes or events • If a student becomes distraught, have an adult who knows the student provide comfort • Model good coping. Use the buddy system to take time away from the student if needed to cope with your own stress/emotional response • Meet students’ physical needs (bathroom breaks, snacks) - helps reassure them that adults will take care of them

The First Few Hours: What to Say • Provide clear, simple explanations for what happened and what will happen • Acknowledge students’ feelings and help them label them • If you do not know the answers to the students’ questions, admit it and tell them how you can find out the answers

The First Few Hours: What to Say - 2 • Reflect students’ feelings, but redirect them from talking excessively about gruesome or terrifying details • Praise students for their bravery, helping peers, following your directions, etc. • Before students are released to caregivers, summarize the disaster and its resolution to the class.

Goals at Disaster Site • PROTECT - shield children from: • Bodily harm • Exposure to traumatic stimuli (sights, sounds, smells) • Media exposure • DIRECT - ambulatory students in shock, dissociative • Use kind and firm instruction • Move away from danger, destruction, severely injured • CONNECT • To you - be a supportive presence • To caregivers • To accurate information • (Young, Ford, Ruzek, Friedman & Gusman, National Center for PTSD)

Crisis Response • Triage for signs of stress that jeopardize safety • Segregate survivors based on exposure level • Control flow of information and limit unnecessary re-exposure • As appropriate, activate the Regional Homeland Security Mental Health Response System • Begin psychological first aid (reestablish the perception of security and sense of power) • The majority of children will display normal stress reaction

Immediate Crisis Intervention • To help manage intense feelings of panic or grief: • Signs of panic - trembling, agitation, rambling speech, • becoming mute, or erratic behavior • Signs of intense grief - loud crying, rage, or catatonia • Attempt to quickly establish rapport • Ensure the student’s safety and offer empathy • Remain with the student in acute distress or find someone to remain with him or her until initial stabilization • (Young, Ford, Ruzek, Friedman & Gusman • National Center for PTSD)

Psychological First Aid Psychosocial interventions • Facilitate reunion with loved ones • Identify distressed survivors for early attention and support • Provide information for action

TEAM RESPONSIBILITIES: School Mental Health Crisis Intervention Teams