Anita Chandra, Dr.P.H .

1. Emergency Preparedness: New Opportunities for Strengthening Community Resilience and Helping Children and Youth Anita Chandra, Dr.P.H. Presentation to the Missouri Department of Mental Health Spring Training Institute May 20, 2011

2. Roadmap for Presentation • New national focus on community resilience • Key components related to children and families; behavioral health • Implications for emergency response and recovery, particularly for child behavioral health • Across disaster cycle • School and community settings

3. Community Resilience Is a Priority Topic in National Strategies • National Health Security Strategy (NHSS) • National Security Strategy • National Disaster Recovery Framework We have engaged communities across the United States to develop the NHSS, including identifying strategies needed for community resilience.

4. Community Resilience is Key to Reducing Negative Consequences of Disaster • Definition Developed with Communities (2008-2010): • The ongoing and developing capacity of the community to account for its vulnerabilities and develop capabilities that aid in: • preventing, withstanding, and mitigating the stress of an incident; • recovering in a way that restores the community to a state of self-sufficiency and at least the same level of health and social functioning after an incident; and • using knowledge from a past response to strengthen the community's ability to withstand the next incident

5. Resilience is Especially Important in Communities With Multiple and Overlapping Disasters Progress toward recovery can be slowed by multiple incidents • competing priorities • limited resources Human recovery is as critical as infrastructure recovery Chandra & Acosta. (2009). The role of nongovernmental organizations in long-term human recovery after disaster. Santa Monica, CA: RAND Corporation.

6. Involvement of Community Based Organizations (CBOs) and Faith Based Organizations (FBOs) Enhance Both Response and Long-Term Recovery • Provide manpower and other resources • Information and referral • Direct services (e.g., case management, behavioral health) • Financial support • Examples from across the United States: • Using promotoras to disseminate disaster information in San Antonio • Connecting residents to social and mental health services after Hurricane Katrina in New Orleans • National strategies recognize need for greater CBO/FBO participation in disaster planning, response and recovery

7. Challenges Exist in Connections Between Government and CBOs/ FBOs in Building Resilience • Few formal partnerships between government and CBOs/FBOs in disaster preparedness, response, and recovery • Little community engagement among government entities for greater disaster resilience • Limited capacity building opportunities to enhance roles and responsibilities of CBOs/FBOs in resilience

8. We Note Eight “Levers” Or Means of Achieving Community Resilience Levers of Community Resilience Core Components of Community Resilience Social and economic well-being Physical and psychological health Wellness Access Community context Education Effective risk communication Ongoing Development of Community Resilience Engagement Self Sufficiency Social connectedness Ongoing disaster experience Integration and involvement of organizations Partnership Quality Efficiency From: Chandra et al. (2011). Building Community Resilience. RAND TR-915.

9. Address Physical and Psychological Health Needs • Bolster coping skills and psychological wellness by developing public health campaigns focused on these messages • Train workforce on culturally competent and linguistically appropriate psychological and behavioral health care • Provide “psychological first aid” or other early psychological or behavioral health interventions after a disaster

10. Promote Social and Economic Well-Being • Work with other agencies (housing, social services) to improve socioeconomic conditions before an event • Coordinate efforts to plan for human recovery after an event (e.g., intersection points of ESF-8 (health) and ESF-14 (health-related))

11. Communicate Risk Information Effectively • Develop programs and policies to increase population health literacy • Use technology and social media to communicate information before, during, and after an event • Promote and incentivize individual preparedness and connections between individual and community preparedness, including the notion of self-reliance

12. Increase Social Integration Among Community Organizations and Government Agencies • Enhance coordination regarding roles and responsibilities and strengthen relationships across levels of government and with non-governmental organizations • Thread preparedness activities through other topics in health/wellness/safety addressed at the local level

13. Build Social Connectedness • Strengthen existing networks pre-event to accelerate recovery post-event • Engage social institutions in increasing outreach to community residents • Employ networks to “push” resources (e.g., supplies) and innovation (e.g., psychological first aid)

14. Creating Community Resilience is A Set of Capacities and Capabilities • As such, what are current capacities and capabilities for: • Distributing resources and minimizing vulnerabilities before an event • Engaging citizens in the planning for an event • Strengthening social support • Ensuring that communication is clear • Schools, CBOs, and FBOs play a key role in all of these.

15. Implications for Schools and Communities

16. Schools and CBOs Boost Community Resilience Along Preparedness Continuum • Prevent—How do we make sure that we have systems in place to prevent unnecessary negative impact on a community? • Response—How do we attend to the needs of the community during an event? • Recovery—How do we address community needs in the immediate event aftermath and in the long-term?

17. Prior Disasters Raise Questions for At-Risk Populations, Too • PREVENT • What kinds of supports need to be in place prior to the disaster to mitigate its impact? • How should we think about strengthening communities (schools and families), particularly to address child behavioral health needs? • RESPONSE/RECOVERY • How should CBOs be used more strategically in the immediate response and ongoing recovery, particularly for at-risk individuals?

18. Children in Particular are at Greatest Risk During and After Disasters • Katrina example: • Of 12,000 children in the Gulf States region screened for mental health issues, 43% reported depressive and posttraumatic stress symptoms • Strengthening school, family, community relationship is important, part of community resilience

19. PREVENTAt-Risk Individuals, Including Children

20. New Focus on Children in National Efforts • RAND analyses show some progress in the following preparedness efforts for children, but more work needed: • Risk communication materials, particularly in recovery • Training for child care facilities • School action plans • Psychological services for children

21. National Health Security Strategy Developed; At-Risk Pops Key • Attention is being paid to incorporating the needs of children and families, but community input is necessary • Community resilience and mitigation strategies are a core element of the strategy, but questions remain: • What are the most effective approaches to strengthening community supports before, during, and after an event, particularly for hard to reach or underrepresented populations?

22. PREVENTDeveloping Mentally Healthy Schools

23. Youth-Family-School: A Key Aspect of Community Resilience • The youth-family-school system is a network to use before, during, and after a disaster (Ronan, 2004) • To diminish impact of disasters, school-based prevention can help families and communities better manage response and recover activities

24. Recent Events Highlight New Avenues for Mental Health Promotion • Efforts to rebuild and improve services after disaster represents a dual-use opportunity • To respond to disasters more effectively in the future: • Incorporate lessons learned from the past three years • Build on existing assets • Build the components of a “mentally healthy” school during non-emergent times

25. Unmet Behavioral Health Need for Children Continues to be a Challenge • Despite the prevalence of behavioral health issues for children, we often fall short in meeting their needs • Many of our efforts do not include primary prevention or health promotion strategies--many are deficit-based models • Initiatives that focus on building skills for better behavioral health can be effective and cost efficient

26. Unique Models in Other Regions Can Be Adapted for Use in United States • MindMatters is model school program from Australia • Key tenets: • Importance of mental health emphasized • Positive mental health modeled by staff and students • Help-seeking behavior encouraged via accessible and culturally supportive services

27. MindMatters Positions Schools as a Core Support for Community Resilience • MindMatters helps schools audit, plan and implement mental health promotion structures, policies and activities • School audit focuses on the areas of a health promoting school (WHO): • Curriculum--teaching and learning • School organization, ethos and environment • Partnerships and services

28. These Types of Programs Not Only Address Prevention, But Hopefully Reduce the Need for Resources in Response Crisis intervention Indicated MH promotion Universal programs Primary prevention • Early intervention • Targeted

29. RESPONSE Lessons Learned from the State and Local Public Health Response to Prior Disasters

30. Public Health, Mental/Behavioral Health and CBOs Need Stronger Partnership • Many family and CBOs have been left out of the planning equation, but needed in the scramble to respond • Jurisdictions that had engaged in partnerships pre-storm tend to be in a better position for response It’s important to train, respond, and plan with our community partners. Knowing community partners was a big help; we didn’t need to introduce anyone-we all knew each other. • --Louisiana Official

31. Volunteers from CBOs Critical to Response • Volunteers important but no method of: • Credential verification particularly for health care providers • Resource and skill typing • Staffing triage sites, mass care shelters, and special needs shelters a major problem • Workforce can experience short- and long-term behavioral health problems • We didn’t think enough about mental health. We underestimated the stress and strain on our own workforce…that is the invisible thing that has to be addressed. • --Mississippi official

32. The Plan For Special Needs or At-Risk Populations Has Been Incomplete • States and local jurisdictions need help in defining their special needs populations • Historically, there has been relatively less focus on children • Challenges in locating these populations and determining plans of pre-identification, supply distribution

33. Behavioral Health Care Has Been A Major Stumbling Block • Little anticipation of behavioral health care need in shelters • Behavioral health agencies not at planning table • Staff and bed capacity extremely limited • Need for conducting behavioral health needs assessment has been critical in response

34. Key Roles for CBOs in Response Planning • Participate in tabletop drills and field exercises to ensure that CBO role is articulated in response plan • Assist in crafting plans for homebound and shelter-based population in immediate response • Link with traditional response organizations to ensure representation in communication plans

35. Key Roles for CBOs in Response Planning (2) • 4. Engage in defining and locating special needs or vulnerable populations • Import client data into special needs registries, GIS efforts • 5. Consider role to provide complementary behavioral health support

36. RECOVERYPlanning for Mental Health Needs

37. Lessons Learned from Prior Disasters • Implications for Providers • Many children do not experience natural recovery after disasters • Disaster exposure is only part of the picture: essential to screen for lifetime trauma history and treat “worst” • Implications for Advocacy/Policy • Funding is needed to support trauma-informed services, within a public health framework

38. Barriers to Obtaining Behavioral Health Services • Difficulties communicating with parents • Inadequate resources • Insufficient staff training • Burnout among staff or personnel implementing programs

39. Key Roles for CBOs in Recovery Operations (Child Behavioral Health) • In aiding children experiencing effects of the disaster: • Offer children the opportunity to express feelings • Help families to return to routines as much as possible • Help children to regain a sense of power and security—get involved in helping • Approaches need to be age-appropriate (see table)

41. Consider ways to enhance family resilience Make sense of what happened Affirm strengths Key Roles for CBOs in Recovery Operations (Child Mental Health) (2)

42. Next Steps and Discussion Questions

43. Several Questions Require Further Investigation • What are the promising strategies for supporting children before, during, and after disaster? • How should we integrate resilience planning into emergency preparedness? What are we already doing that is resilience-building? • What are the roles and responsibilities of DMH/Behavioral Health in supporting community resilience?