CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION

1. CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION CHILD & FAMILY DISASTER MENTAL HEALTH RESEARCH TRAINING & EDUCATION

2. Federal Sponsors NIMH National Institute of Mental Health NINR National Institute of Nursing Research SAMHSA Substance Abuse and Mental Health Services Administration

3. Principal Investigators Betty Pfefferbaum, MD, JDUniversity of Oklahoma Health Sciences Center Alan M. Steinberg, PhD University of California, Los Angeles Robert S. Pynoos, MD, MPHUniversity of California, Los Angeles John Fairbank, PhDDuke University

4. Children’s Psychosocial Services in Disasters Gil Reyes, PhD Associate Dean for Clinical Training at Fielding Graduate University

5. Learning Objectives Upon completion of this Module, participants will be able to: • Recognize the current status and limitations of child • disaster mental health services and interventions • Describe the goals and elements of psychological first aid and other early interventions • Identify the reasons screening is needed after disasters • Describe the rationale for providing child disaster • mental health interventions in schools

6. Services

7. Types of Services • Educational Interventions • Pre-disaster preparedness • Red Cross Masters of Disaster • Injury prevention • Coping self-efficacy • Stress-inoculation • Post-disaster coping education • Mastery of reactions • Verbal group processing of reactions and coping • Class-room projects • Coloring books Reyes et al. 2005

8. Types of Services • Crisis Intervention • Psychological First Aid (e.g., Pynoos & Nader, 1988) • Establishing rapport and comforting presence • Protecting and reassuring • Mobilizing support • Connecting with significant others • Crisis Hotlines (e.g., Ponton & Bryant, 1991) • Suicide prevention • Substance abuse intervention • Coping assistance • Often operate indirectly through parenting assistance Reyes et al. 2005

9. Types of Services • Crisis Intervention (continued) • Psychological debriefing (e.g., Stallard & Law, 1993) • Adapted from adult format (e.g., CISD) • Verbal group processing of reactions and coping • 1 or 2 lengthy (e.g., 3 hr.) group sessions • Share perceptions, thoughts, and feelings about the event • Reflect on treatment they’d received • Explore psychological effects of traumatic experiences • Discuss problems and methods of coping • Normalize response similarities Reyes et al. 2005

10. Types of Services • Crisis Intervention (continued) • Caregiver Support • Parenting support • Informational support • Coping support • Respite care • Disaster Childcare • Critical Response Childcare (aviation events and terrorism) Reyes et al. 2005

11. Types of Services • Community Outreach • Mobilization, Consultation, and Capacity-Building • Political and Social Leaders • Primary Healthcare Systems • Pediatric facilities and providers • Mental Health Systems • Community mental health centers • Public and private provider networks • Childcare facilities and providers • Schools • Teacher and other personnel education • Screening • Direct education of students Reyes et al. 2005

12. Types of Services • Group Interventions • General emphasis groups • Addressing fears and concerns • Stress management education • Coping education and modeling • Issue oriented groups • Grief groups (Saltzman et al. 2001) Reyes et al. 2005

13. Recommendations • National Initiatives modeled after the National Child Traumatic Stress Network • Raise the profile and priority of children’s psychosocial needs following potentially traumatic events. • Improve dissemination of accurate and useful information and training. • Developing a National Public Health Model for disaster mental health • Address and redress the existing inadequacies (surge capacity). • Emphasize population level preventive efforts. • De-emphasize immediate direct “clinical” intervention. • Define and incorporate key roles for pediatricians, schools, and other systems of care for children (not mental health specific). • Coordinate efforts across multiple disaster systems of care. Reyes et al. 2005

14. Recommendations • Develop culturally sensitive and appropriate approaches for serving a diverse range of communities • Recognize “subtle” cultural differences and how they inform differential responsiveness to a generalized model of care. • Adapt generalized models of care in collaboration with key cultural informants. • Don’t assume that proximity or similarity confer equivalency. • Living nearby • Looking alike • Migrating from the same country, region, or continent • Sharing a salient demographic characteristic • Age • Gender • Sexual orientation Reyes et al. 2005

15. Public Mental Health Approach Pynoos, Goenjian, & Steinberg, 1998

16. Organization • Sources of population-based mental health interventions for children involve three levels of organization: • Governmental and Social Institutions • Mobilization of public, private, and volunteer resources • Educational Systems • Healthcare Systems • Mental Health Systems • School-based services • Community-based intervention teams Pynoos et al. 1998

17. Components • Screening • Triage and assessment • Traumatic exposure (objective and subjective) • Loss exposure • Acute difficulties • Ongoing adversities • Traumatic reminders • Recent traumatic exposure or loss (one year) • Current levels of distress • Mental health interventions Pynoos et al. 1998

18. Guidelines • Augment children’s self-report with other sources: • Parent reports • Teacher reports • Conduct periodic screening to track the course of recovery • Surveillance for more than trauma • Depression • Adverse circumstantial stressors • Choose continuous scales over categorical decisions • Use results to promote effective dedication of mental health resources where most needed • Example of school-based services Pynoos et al. 1998

19. Disaster Mental Health Services for Children Covell et al. 2006 Hoven et al. 2002 Stuber et al. 2002 Fairbrother et al. 2004 Pfefferbaum et al. 2003

20. September 11 Project Liberty Services • 753,015 service logs (inception through 2003) • Group education • Individual (including family) counseling • Agencies • Large and small mental health agencies • Consumer-run organizations • Faith-based social service agencies • Agencies serving particular ethnic, cultural, or racial groups Covell et al. 2006

21. Project Liberty Services for Children – 1 • 15% of service logs for first and follow-up visits were for children either individually or in family counseling • 9% of first visits were for children • Significantly fewer than represented in census data • 69% of first visits for children were for those aged 12 to 17 years • 41% of first visits for children were provided in schools • Children were more likely than adults to receive follow-up visits Covell et al. 2006

22. Project Liberty Services for Children - 2 • Elementary school children were more likely than older (12-17 yr) children to exhibit • Isolation and withdrawal • Anxious and fearful reactions • Concentration difficulties • Older children more similar to adults and more likely than younger children to exhibit • Avoidance and numbing reactions • Abuse of substances • Possible major depressive disorder and PTSD appeared to increase with age Covell et al. 2006

23. September 11 School-based Study ~ 2/3 of children with PTSD and impaired functioning had not sought treatment 6 months after the attacks Representative sample of > 8000 students in grades 4-12 6 months after the attacks Hoven et al. 2002

24. September 11 Counseling 22% received counseling 58% of those receiving counseling received them at school Telephone survey of 112 parents in lower Manhattan 5-8 weeks after incident Stuber et al. 2002 10

25. September 11 Counseling 10% received counseling 44% in schools Of those receiving counseling 47% had severe or very severe posttraumatic stress 50% had moderate posttraumatic stress 3% had mild posttraumatic stress1/3 had received counseling before 9/11 NYC parents 4-5 months after incident Fairbrother et al. 2004

26. Early Psychological Interventions NIMH 2002 APA 1954 Everly and Flynn 2006 NCTSN and NCPTSD 2006 ARC IFRC

27. Early Psychological Interventions Recommendations from Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices (NIMH 2002)

28. Hierarchy of Needs • Early assessment and intervention should focus on a hierarchy of needs • Survival • Safety • Security • Food • Shelter • Health (physical and mental) • Triage • Orientation (to immediate service needs) • Communicate with family, friends, and community • Other forms of psychological first aid NIMH 2002

29. Assumptions and Principles • In the immediate post-event phase, expect normal recovery • Presuming clinically significant disorder in the early post-event phase is inappropriate except in those with a pre-existing condition NIMH 2002

30. Key Aspects of Early Intervention • Psychological first aid • Needs assessment • Monitoring the recovery environment • Outreach and information dissemination • Technical assistance, consultation, and training • Fostering resilience, coping, and recovery • Triage • Treatment NIMH 2002

31. Technical Assistance, Consultation, and Training • Improve capacity of organizations and caregivers to provide what is needed to • Reestablish community structure • Foster family recovery and resilience • Safeguard the community • Provide assistance, consultation, and training to relevant organizations, other caregivers and responders, and leaders NIMH 2002

32. Monitor Rescue and Recovery Environment • Observe and listen to those most affected • Monitor the environment for toxins and stressors • Monitor past and ongoing threats • Monitor services that are being provided • Monitor media coverage and rumors NIMH 2002

33. Outreach and Information Dissemination • Offer information/education and “therapy by walking around” • Use established community structures • Distribute flyers • Host websites • Conduct media interviews and programs and distribute media releases NIMH 2002

34. Fostering Resilience and Recovery • Foster but do not force social interactions • Provide coping skills training • Provide risk assessment skills training • Provide education on • Stress responses • Traumatic reminders • Coping • Normal versus abnormal functioning • Risk factors • Services • Offer group and family interventions • Foster natural social supports • Care for the bereaved • Repair organizational fabric NIMH 2002

35. Needs Assessment • Assess current status of • Individuals • Groups • Populations • Institutions/systems • Ask • How well needs are being addressed • What the recovery environment offers • What additional interventions are needed NIMH 2002

36. Triage • Conduct clinical assessments using valid and reliable methods • Refer when indicated • Identify vulnerable, high-risk individuals and groups • Provide for emergency hospitalization NIMH 2002

37. Treatment • Reduce or ameliorate symptoms or improve functioning through • Individual, family, and group psychotherapy • Pharmacotherapy • Short- or long-term hospitalization NIMH 2002

38. Follow-up • Follow-up should be offered to those at risk of developing adjustment difficulties including those • Who have ASD or clinically significant symptoms • Who are bereaved • Who have preexisting psychiatric disorder • Who have required medical or surgical attention • Whose exposure was intense and of long duration • Who request it NIMH 2002

39. Expertise, Skills and Training for Providers of Early Intervention • Providers must • Practice within the scope of their expertise and education • Practice within the structure responsible for coordinating the response • Make referrals when appropriate • Avail themselves of training NIMH 2002

40. Research and Evaluation • The scientific community has an obligation to examine the relative effectiveness of early interventions • A national strategy should be developed to ensure that adequate resources are available for research • A standard taxonomy and terminology are needed for program evaluation to identify • The most significant variables to monitor • Post-event physical and psychosocial environment • Subgroups of the affected population including responders • Mental health interventions that are provided • Characteristics of those deemed the most appropriate providers • The broader research community should be informed of need for research NIMH 2002

41. Key Research Questions • What ethical issues are introduced by widespread use of unproven interventions? • How acceptable is research to potential subjects? • What is the best process for seeking informed consent; what information should be given in the consent process? • Can a standard taxonomy and terminology be developed? • How effective is public education? • Is screening in itself an effective intervention? • Can screening cause harm; if so, what is the nature of the harm and is the risk offset by risk of failing to screen? • Is it acceptable to screen if care is not provided or accessible? • How feasible are studies of early interventions ? • How can clinical demand be balanced with inadequacies in the empirical evidence-base? NIMH 2002

42. Psychological First Aid • Goals: • Should be concerned only with the immediate situation. • Restore people to reasonably good functioning. • Make people as comfortable as possible until more complete care can be arranged. • Five types of reactions: • Normal reactions to stress (transient states, not to be confused with abnormal adjustment). • Panic (a rare, but contagious risk). • Immobility or numb detachment. • Hyperactivity and over confidence (hypomanic). • Somatic complaints. • Four principles of care • Accept people’s right to their own feelings • Accept a person’s limitations as real. • Size up a casualty’s potentialities as accurately and quickly as possible. • Accept your own limitations in a relief role. American Psychiatric Association 1954

43. Psychological First Aid • Protect survivors from further harm • Reduce physiological arousal • Mobilize support for those who are most distressed • Keep families together and facilitate reunions of loved ones • Provide information and foster communication and education • Use effective risk communication techniques NIMH 2002

44. Physical First Aid Stabilize physiological functioning Mitigate physiological distress and dysfunction Achieve return to acute adaptive physiological functioning Facilitate access to next level of care Psychological First Aid Stabilize psychological and behavioral functioning by meeting physical needs and then addressing psychological needs Mitigate psychological distress and dysfunction Achieve return to acute adaptive psychological and behavioral functioning Facilitate access to continued care Principles and practical procedures for acute psychological first aid training for personnel without mental health experience. Everly & Flynn 2006

45. Psychological First Aid • Several organizations have developed manuals to guide the delivery of psychological first aid • International Federation of Red Cross and Red Crescent Societies • American Red Cross • National Child Traumatic Stress Network and National Center for PTSD

46. International Federation of Red Cross and Red Crescent Societies (IFRC) PFA - Modules • Community-based Psychological Support (PFA) • Stress Responses and Coping Skills • Developing Supportive Communication • Promoting Community Self-help • Caring for Populations with Special Needs • Helping the Helper IFRC, 2003

47. American Red Cross (ARC) PFA - Actions • Psychological first aid actions • Make a connection • Help people be safe • Be kind, calm, and compassionate • Meet people’s basic needs • Listen • Give realistic reassurance • Encourage good coping ARC, 2006

48. NCTSN and NCPTSD PFA Core Actions and Goals - 1 • Contact and engagement • To respond to contacts initiated by survivors, or initiate contacts in a non-intrusive, compassionate, and helpful manner • Safety and comfort • To enhance immediate and ongoing safety and provide physical and emotional comfort • Stabilization • To calm and orient emotionally overwhelmed or disoriented survivors • Information gathering: current needs and concerns • To identify immediate needs and concerns, gather additional information, and tailor PFA interventions NCTSN & NCPTSD 2006

49. NCTSN and NCPTSD PFACore Actions and Goals - 2 • Practical assistance • To offer practical help to survivors in addressing immediate needs and concerns • Connection with social supports • To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources • Information on coping • To provide information about stress reactions and coping to reduce distress and promote adaptive functioning • Linkage with collaborative services • To link survivors with available services needed at the time or in the future NCTSN & NCPTSD, 2006

50. Screening Limitations and Rationale for Child Screening