Behavioral Health Disaster Response in School-Based Health Clinics

Chikira Barker, MATimothy Craft, MSWLouisiana State University Health Sciences Center- New OrleansSchool of MedicineDepartment of Psychiatry

Terrorism and Disaster Coalition of Child and Family Resilience

Funding and partnership with the National Child Traumatic Stress Network

Formation of coalitions of local, state, community agencies united to develop resources for and respond to instances of disasters, terrorism, or other types of critical incidences.

Types of Disasters: Terrorism, Violence, Humanitarian, or Complex

Terrorism or Violence Humanitarian and Complex Emergencies

• Arson• Intentional Explosions• Mass/Multiple Shootings• Release of chemical/biological

agents• Riots

• Droughts• Famine• Genocidal Acts• Displaced Populations• War/Political Conflict

American Academy of Pediatrics (2019)

Types of Disasters: Natural and Technological

Natural Disasters Technological Disasters

• Hurricanes• Tornadoes• Floods• Other extreme weather events

• Oil Spills• Industrial Fires• Hazardous Materials Accidents• Nuclear Materials Accidents

Images from apr.org and The Daily Advertiser

Disaster Comparison

Natural Disasters

Immediate loss of human life

Usually community preplanning is possible

Pattern: Warning, threat, impact, rescue, inventory, remedy, rehabilitation

Technological Disasters

Longer-term event

Greater anxiety because of the rarity of the event.

Rare to have community pre-planning

Unknown long-term impact

Palinkas, 2012

Disaster Comparison

Natural Disasters

“Therapeutic Community” Pulling together

Social connectedness

Coordinated effort to return community to pre-disaster state

Technological Disasters

“Corrosive community” Pervasive exposure of

trauma after the event

Increased social conflict and competition for resources

Increase in litigation

Distrust of public officials in preventing future disasters

Palinkas, 2012

Phases of a Disaster

Mitigation

• Steps taken to reduce the potential impact of a disaster by fostering more resilient communities.

Preparedness

• Pre-Disaster Strategic planning

Response

• Addressingimmediate needs and threats following a disaster.

Recovery

• Restoration following a disaster. Long-term efforts.

Phases of a Disaster Recovery

Adapted from Zunin & Myers as cited in DeWolfe, D.J. (2000). Training manual for mental health and human service workers in major disasters, 2nd ed.). Rockville, MD: U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Disaster Behavioral Health

Mental health services, including stress management reactions and substance abuse, to survivors and responders to disasters.

Disasters can have long lasting physical and mental health impacts for individuals, families, and communities.

Traumatic events can disrupt normal development

Recalling Hurricanes Katrina and Rita

Katrina and Rita hit the Gulf Coast less than a month a part

Estimated that 196,000 public school students were displaced. 61,000 of those students attended other schools in the state.

81% from Orleans, Jefferson, and Calcasieu

19% from St. Tammany, St. Bernard, Plaquemines, Vermilion, and Cameron

Schools reopened in October for students in Jefferson and Calcasieu

Pane, McCaffrey, Tharp-Taylor, Asmus, & Stokes, 2006

Louisiana Child & Family

Health Study

Nearly half of parents reported new emotional or behavioral problems in at least one of their children following these storms.

50% of female caregivers scored in the clinical range on screeners for depression or anxiety.

Children of these parents were twice as likely to have emotional/behavioral problems following the hurricane based on parent report.

Abramson & Garfield, 2006

Louisiana Child & Family

Health Study

Abramson & Garfield, 2006

Why School-Based Health Clinics?

1. Schools typically become the primary locations of response outreach, as well as support to communities, following disasters.

2. Children often have a desire to return to schools immediately following disasters.

Highlights need for trauma/disaster informed staff.

3. Physical and mental health symptoms are common following incidents… and SBHC’s may be treating both.

4. Mental health symptoms impair school functioning.

5. Trauma has long-term impacts without some intervention.

6. Schools typically do not have enough staff to address immediate behavioral health needs.

7. Teachers and school administration also may be impacted by the disaster

Why School-Based health Clinics

Stressors impacting the school and its environment Despite principals endorsing the need for more professional development for

teachers, they noted difficulty in finding time and resources.

Limited school staff- teacher absenteeism, teacher turn over

Smaller numbers of substitute teachers

Lack of funding to meet student needs

Pane, McCaffrey, Tharp-Taylor, Asmus, & Stokes, 2006

SBHC Census (2013-2014)

67% of SBHC’s have a behavioral health provider

• Depression/Sadness (76%)

• Anxiety/Nervousness/phobias (71%)

• Social skills/Relationship issues/Conflicts (71%)

• Attention/Concentration/ADHD (68%)

Screenings for:

• Substance Use (80%)

• Violence Prevention (76%)

• Dating Violence (76%)

• Suicide Prevention (76%)

• Positive Youth Development (71%)

Individual counseling in adolescent clinics

SBHC’s With vs Without Mental Health Providers

Mental Health Provider No Mental Health Provider

Crisis Intervention 92% 40%

Comprehensive evalsand treatment

90% 30%

Classroom behavior/learning supports

74% 33%

Substance abuse and counseling

64% 25%

Individual assessment of learning problems

59% 26%

Peer mediation 53% 17%

Survey of Mental Health Providers in SBHCs following Katrina and Rita

53% of SBHCs reported that there was a significant increase in patient volume following the hurricanes.

Greatest symptoms noted: Anxiety and adjustment problems Depression reportedly increased

Substance abuse and suicidal ideation remained stable or increased over time.

Madrid, Garfield, Jaberi, Daly, Richard, & Grant, 2008

Survey of Mental Health Providers in SBHCs following Katrina and RitaMadrid, Garfield, Jaberi, Daly, Richard, & Grant, 2008

Common Reactions to

Disasters

Fear, anxiety, easily startled

Sleep difficulties, trouble relaxing

Numbness and/or feeling disconnected; Desire to isolate

Pronounced sadness

Anger or irritability

Physical symptoms: headaches, stomachaches

Trouble concentrating

Avoidance of reminders of the event

Forgetfulness

Guilt

Use of substances to cope

SAMHSA, 2013

Child and Adolescent

Reactions to Disasters

Widely varies depending on certain factors: Type, extent, and duration of the event

Extent of exposure to the event (including media coverage)

Support received before, during, and after the disaster

Perception of life-threat or injury to self or family/friend network

Personal loss experienced

Disruption in daily living

Child or adolescent’s developmental stage

Caregiver coping; separation from caregivers

Familial resources

Previous trauma history

Mental and physical health history pre-disaster

Child’s coping ability (resilience)

Cultural differences

Community response

American Academy of Pediatrics (2009)

Re-Experiencing

• Intrusive, pervasive thoughts

• Repetitive dreams/nightmares

• Physiological triggers

Avoidance and Numbing

• Avoidance of potential triggers

• Loss of interest in previously enjoyable activities

• Restrictiveness in emotions or range of affect

• Emotional detachment

Increased Arousal

• Sleep disturbance

• Difficulties concentrating

• Hypervigilance

• Exaggerated startle

• Irritability

Common Symptoms of Posttraumatic Stress Disorder

Mental Health Symptoms Post-Disaster: Post-Traumatic Stress Disorder

Preschool age School-Age Adolescents• Difficult to communicate

symptoms• Wide range: Withdrawn,

indifferent, fearful• Regressive behaviors• Re-enact trauma through

repetitive or traumatic play• Regressive behaviors

• Full expanse of PTSD symptoms• Irritability• Somatic complaints• Pervasive worries about disaster• Re-enact trauma through play

and/or drawings of event• Regressive behaviors

• Expanse of adult PTSD• Risks for anxiety, depression• Suicidal ideation• Illicit substance use• Antisocial behaviors

Developmental Differences in Posttraumatic Stress Disorder

Role of Clinics and Mental Health Providers in Disaster Response

Challenge for Mental Health Providers

Integration into two different systems Health care clinic

Schools

Finding balance in the various roles you could have in response

Sticking with your level of expertise and not feeling pressured to know all of the answers.

Role of Mental Health Professionals in Disasters

Pre-Disaster/Preparedness

• Community education on disaster behavioral health and trauma symptoms• Developing community response network• Providing (or taking) courses in disaster response and resiliency trainings• Strengthening community education

Immediately after the disaster (Heroic and Honeymoon Phases)

• Mental Health surveillance/Rapid assessment• Providing health care• Targeted interventions• Outreach teams• Collaboration with administrative teams and funding agencies• Collaborating with community agencies for capacity building• Providing behavioral health education to response teams/volunteers• Outreach messages via social media• Collaborating with partners in doing research

During Disillusionment Phase

• Long-term treatments• Continued outreach and capacity building• Collaboration with community health workers• Training resourceful community members

Math et al., 2011

Role of Mental Health Professionals from SBHC in Disasters

Developing response plan for your SBHC

(and e-mail it to your group)

• Emergency contact information, e-mail addresses for staff and school administration• Mobilizing for mental and physical health response; Assigning tasks• Clinic operations if electricity is out/building is destroyed• How do parents contact you if needed? Do you have emergency contact numbers,

emails for parents? How can prescriptions be filled? Getting out information to parents and students.

• Can you access your electronic health records? Use of cloud-based medical records?

• WRITE OUT YOUR PROTOCOL

Developing community response network

• Basic question that you should know- What is the emergency response plan for your area?

• Emergency contact numbers and emails for referral sources and other community organizations. Ways of accessing this information when communication abilities are limited.

• Connections to state agencies and other SBHCs• Are other connections needed?• Contacts for other MH professionals

Pre-Disaster Preparedness and Mitigation

Role of Mental Health Professionals from SBHC in Disasters

Disaster response and resiliency training for staff

members

• Psychological First-Aid (National Child Traumatic Stress Network)• Trauma and Resiliency• The process of disaster recovery

Integrating disaster education and

preparedness for students and parents

• Emergency/disaster handout as part of the informed consent process• Emergency response checklists, trauma symptoms as handouts available in waiting

area• Provide local emergency response and planning materials.

Speak with school officials on collaborative

efforts/roles in the event of a disaster

• What is your school’s emergency response plan? How does your SBHC fit into that plan?

• Provide trainings during teacher in-service meetings- topics on trauma, development, disaster recovery, self-care, etc.

• Does your school have a health advisory board? How can they be included in preparedness?

Pre-Disaster Preparedness and Mitigation

Addressing Student Needs

Role of Mental Health Professionals from SBHC in Disasters

Capacity-building by collaborating with administrative

teams, funding agencies, and community organizations

• Administrative teams• Funding agencies• Community organizations• Partners in research

Outreach messaging

• Messaging on what to expect post-disaster. There is typically a substantial drop in elevated mood post heroic/honeymoon phases. Tips for coping and expectations.

• How can you get messages out to the students, families, and school administrative staff:

• E-mails? Social media? News? Automated messaging blasts?

Providing behavioral health education

• Staff members• Teachers• Volunteers

Immediately After the Disaster: Heroic and Honeymoon Phases

Training Needs for staff members working with students

Trauma and its impact on classroom behaviors

• Typical trauma reactions, expectations post-disaster

• Behaviors or signs that require referral to mental health professional.

Responding to student and family needs post-disaster

• Tailored depending on the situation. It may need to focus on responding to needs of students who have been displaced.

The school’s role in disaster recovery for children and families

• Re-establishing a sense of normalcy and routine

Teacher self-care following disasters

• Reaching out for school and community support

Usually school districts will have outside experts come in to do trainings. Your role:• See if you can attend the training• Reinforce the message(s) to teachers and administrators.

Determining Risk: Screening for Student Problems

School-wide screener being administrated?

What screeners are you using in

the clinic?

School-wide screeners

Typically selected by the school district/administration May be tailored based on the event

Screeners should be brief

Purpose: Identify the experiences of the students

Determine needs for children and communities in recovery

Connect students with resources

Justification for grants

How will students be referred for services? Where will they be referred?

If they will be primarily referred to the clinic, what is your capacity to deal with the potential influx of students and families?

Clinic Screeners

Standard clinic assessments PHQ-2/PHQ-9

Pediatric Symptom Checklist

Trauma-specific assessments The Child PTSD Symptom Scale (ages 8-18)- Public Domain

Young Child PTSD Checklist (ages 1-6 yrs)- Public Domain

Trauma-Exposure Checklists- Public Domain

Trauma-Symptom Checklist for Children (8-16 yrs)/Trauma Symptom Checklist for Young Children (3-12 yrs)

Multi-tiered response: Moving into long-term response

Intensive Services:

Children demonstrating significant mental health problems

Targeted Interventions:

For students at risk of developing significant problems

Universal Services:

Promotion of skill-building/healthy coping strategies for all children

Evidence-Informed Interventions

Psychological First Aid/PFA-Schools (PFA/ PFA-S)

Skills for Psychological Recovery (SPR)

Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Childhood Traumatic Grief Cognitive Behavioral Therapy (CTG)

Evidence-Informed Interventions

Psychological First Aid (National Child Traumatic Stress Network) Intervention focused on reducing the initial distress immediately following disasters or

other traumatic events.

Days to weeks following the event.

Focus on short and long-term adaptive functioning/coping.

Survivors have a wide range of early reactions post-traumatic event. Provides guidance to disaster responders on reducing how these responses interfere with their ability to cope.

6 hour interactive course online

Operations manual and other handouts available

Psychological First-Aid: 8 Core Actions

Contact and engagement

Safety and comfort

Stabilization (if needed)

Information gathering on current needs and concerns

Practical assistance

Connection with social supports

Information on coping

Linkage with collaborative services

National Child Traumatic Stress Network: https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological-recovery/about-pfa

Evidence-Informed Interventions

Skills for Psychological Recovery (SPR) Developed by the National Child Traumatic Stress Network and the National Center

for PTSD

Prevention modality for building skills in weeks to months following the traumatic event.

Skills for Psychological Recovery

• Identifying primary issues; planning on skill to be a focus.Gathering Information and

Prioritizing Assistance

• Breaking down complex tasks into manageable tasks; creating plans of action.

Building Problem-Solving Skills

• Scheduling pleasurable and/or mastery activitiesPromoting Positive

Activities

• Manage physical and emotional reactions through controlled breathing, journaling, and strategic planning for trauma reminders.Managing Reactions

• Thought-Monitoring; challenging thoughtsPromoting Helpful

Thinking

• Guidance on accessing social/community support systemsRebuilding Healthy Social

Connections

Evidence-Informed Interventions

Cognitive Behavioral Intervention for Trauma in School (CBITS) Group or individual intervention

5th grade – 12th grade

Main goals:

Decrease symptoms related to the trauma

Building skills to handle stress and anxiety

Building social support through caregivers and peers

https://cbitsprogram.org/

Cognitive Behavioral Interventions for Trauma in Schools

Uses CBT techniques

Psychoeducation

Relaxation training

Problem-solving

Cognitive Restructuring

Exposure therapy techniques (creating trauma narrative)

Other Evidence-Informed Interventions

Trauma-Focused CBT: https://tfcbt2.musc.edu/ Dyadic with caregiver

Modules appropriate for younger children

Childhood-Traumatic Grief: http://ctg.musc.edu/

SBHC Response: St. Martin Parish

SBHC Response: St. Martin

Parish

Staff at SBHC offered case management assistance to help families find temporary housing.

The SBHC helped to get donations from the community for uniforms, book bags, school supplies, and hygiene kits.

Expanded clinic hours (provided an after-hours clinic)- the SBHCs received additional funding to provide this clinic.

Volunteers from other clinics also helped to staff the SBHCs

Families preferred early morning or late evening appointments over Saturday appointments.

Children and their family members were able to receive the services at no cost.

SBHC provided transportation from other schools to the clinics

Dolch, Meyer, & Huval, 2008

SBHC Response: St. Martin

Parish

Experts provided training to the SBHC staff on responding to the long-term needs of children and families evacuating due to storms.

Trauma and grief counseling.

Adjustment issues

The SBHC used risk assessments from the school district’s homeless program to identify physical and mental health needs for children who had to evacuate to St. Martin after the storms.

Based on this information, they developed new medical charts/records for each child.

Provided services onsite or referred children to community resources based on need.

MHP noted an increase in visits due to adjustment difficulties.

Kids were referred for MH services either by teacher or self-referrals.

Prescriptions filled for antidepressants (those who had evacuated and did not have their medication).

Dolch, Meyer, & Huval, 2008

SELF-CARE…A gentle reminder

Signs of Compassion Fatigue

Feeling Burnout

Tired, exhausted, and overwhelmed

Depressed- Feeling disconnected, indifferent

Needing alcohol or other substances to cope

Feeling like a failure and/or as if you are not doing your job

Feeling frustrated or cynical

Traumatic Stress

Sense of impending doom, expecting the worse

Excessive worrying about safety of self or others

Feeling jumpy, easily startled

Heart pounding/racing

Tension headaches

Taking on the traumas of others as your own

SAMHSA, 2014

Self-Care

Responders often forget about taking care of themselves, so do those things that you preach to others.

4 Components of Resilience Adequate sleep

Adequate nutrition

Physical activity

Relaxation

Other basic tips Basic hygienic tasks can make you feel better

Take time to get away from work!

Connect with friends and family

Find things that make you feel a sense of mastery, but more importantly pleasure!

Resources

Ordering Handouts for Clinic (Emergency Preparedness)

• Substance Abuse and Mental Health Services Administration (SAMHSA publications)

• Ready.gov (publications)

Ordering Handouts for Clinic: General Mental Health

• Substance Abuse and Mental Health Services Administration (SAMHSA publications)

• National Institute of Mental Health (Brochures and Fact Sheets)

Additional Resources

• National Child Traumatic Stress Network (NCTSN)

• SAMHSA Disaster Technical Assistance Center (DTAC)

• Terrorism and Disaster Coalition for Child and Family Resilience (TDC4)

Speaker Contact

Chikira Barker

LSU Health Sciences Center-New Orleans

School of Medicine, Dept. of Psychiatry

(504) 903-9212

cbark1@lsuhsc.edu

References

Abramson, D., & Garfield, R. (2006). On the edge: children and families displaced by Hurricanes Katrina and Rita face a looming medical and mental health crisis. New York: National Center for Disaster Preparedness & Operation Assist. Retrieved April 5, 2018 from https://academiccommons.columbia.edu/doi/10.7916/D88S4Z4B

American Academy of Pediatrics. Children & disasters: Disaster preparedness to meet children’s needs. Retrieved March 3, 2019 from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Disaster-Phases.aspx

American Academy of Pediatrics (2009). Pediatrics in disasters (PEDS): A course of the program helping the children. Stephen Berman (Ed.). Retrieved March 6, 2019 from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Pediatric-Education-in-Disasters-Manual.aspx

Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Macy, R., Osofsky, H., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., Watson, P., National Child Center for PTSD and National Child traumatic Stress Network. (2012). Skills for Psychological Reocvery: Field Operations Guide. Retrieved April 5, 2018 from https://www.nctsn.org/resources/skills-psychological-recovery-spr-online

Brymer, M., Taylor, M., Escudero, P., Jacobs, A., Kronenberg, M., Macy, R., Mock, L., Payne, L., Pynoos, R., & Vogel, J. (2012). Psychological first aid for schools: Field operations guide, 2nd edition. Los Angeles: National Child Traumatic Stress Network.

DeWolfe, D.J. (2000). Training manual for mental health and human service workers in major disasters, 2nd ed.). Rockville, MD: U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Dolch, N.A., Meyer, D.L., & Huval, A.V. (2008). Hurricane disaster response by school-based health centers. Children, Youth and Environments, 18, 422-434.

Madrid, P.A., Garfield, R., Jaberi, P., Daly, M., Richard, G., & Grant, R. (2008). Mental health services in Louisiana school-based health centers post-Hurricanes Katrina and Rita. Professional Psychology: Research and Practice, 39, 45-51. DOI: 10.1037/0735-7028.39.1.45.

Math, S.B., Kumar, C.N., Nirmala, M.C. (2011). Commentary: Disaster mental health and public health: An integrative approach to recovery. In Dan Stein, Matthew J. Friedman, and Carlos Blanco (Eds.). Post-traumatic stress disorder (pgs 266-271). Hoboken: Wiley-Blackwell (as cited in Math et. Al., 2015).

Pane, J.F., McCaffrey, D.F., Tharp-Taylor, S., Asmus, G.J., & Stokes, B.R. (2006). Student displacement in Louisiana after the hurricanes of 2005. Retrieved April 3, 2019 from https://www.rand.org/content/dam/rand/pubs/technical_reports/2006/RAND_TR430.pdf

Palinkas, L.A. (2012). A conceptual framework for understanding the mental health impacts of oil spills: Lessons from the Exxon Valdez oil spill. Psychiatry, 75, 203-222. DOI: 10.1521/psyc.2012.75.3.203.

School-Based Health Alliance. 2013-14 Census of school-based health centers: Methodology, key report data details, and acknowledgements. Retrieved March 13, 2019 from https://www.sbh4all.org/school-health-care/national-census-of-school-based-health-centers/

Substance Abuse and Mental Health Administration (2013). Tips for survivors of a disaster or other traumatic event: Managing stress. Retrieved March 29, 2019 from https://store.samhsa.gov/system/files/sma13-4776.pdf

Substance Abuse and Mental Health Administration (2014). Tips for disaster responders: Understanding compassion fatigue. Retrieve March 29, 2019 from https://store.samhsa.gov/system/files/sma14-4869.pdf