Disaster Mental Health Response for Children

Disaster Mental Health Response for Children
An Independent Study Education Program Third edition December 2017 Welcome to the Disaster Mental Health Response for Children web education seminar! Thank you for joining us today. We hope you enjoy this informational program.

Illinois Emergency Medical Services (EMS) for Children
Illinois EMS for Children is a collaborative program within the Illinois Department of Public Health, aimed at improving pediatric emergency care within our state. Since 1994, Illinois EMS for Children has worked to enhance and integrate pediatrics into emergency care system through: Education Practice standards Injury prevention Data initiatives Disaster preparedness Illinois Emergency Medical Services for Children is a collaborative program within the Illinois Department of Public Health aimed at improving pediatric emergency care within our state. Since 1994, Illinois EMS for Children has worked to enhance and integrate pediatric education, practice standards, injury prevention, data initiatives and disaster preparedness into our state emergency care system. This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters. This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters.

Illinois EMS for Children Pediatric Preparedness Workgroup
Acknowledgements Illinois EMS for Children Pediatric Preparedness Workgroup Susan Fuchs, MD, FAAP, FACEP Ann & Robert H. Lurie Children’s Hospital of Chicago Chair, EMSC Pediatric Preparedness Workgroup Mary Connelly, BSN, RN Illinois Medical Emergency Response Team Tina Johnston, BSN, RN American Red Cross Michele McKee, MD University of Chicago Medicine Comer Children’s Hospital Laura Prestidge, MPH, RN Illinois EMS for Children Elisabeth K. Weber, MA, RN, CEN Chicago Department of Public Health Rita George, MS, RN, IPEM NorthShore University HealthSystem-Skokie Hospital Tina Hatzopoulos, Pharm D Chuck Nozicka, DO Advocate Condell Medical Center Michael Robbins, PharmD Keneatha Johnson Illinois Hospital and Healthcare Association Jeanne Grady, BSN, RN Division of Specialized Care for Children Moses Lee, MD Cassandra O’Brien, MSN, RN University of Chicago Medicine Comer Children’s Hospital Christina Swain, RN, CEN Lake County Health Department Susan Gregory, RN, MSN, PEL-CSN, NCSN Cathy Grossi Illinois Hospital Association Evelyn Lyons, MPH, RN Illinois Department of Public Health Mary Otting, BSN, RN, TNS Michael Wahl, MD Illinois Poison Center Judy Courter Franklin Hospital This educational module was developed by the Illinois EMS for Children Pediatric Preparedness Workgroup and Megan Peace, a project consultant. If you wish to cite any of the materials contained in this module, citation information is listed on this slide. Any information presented in this module may be used freely provided appropriate acknowledgement is cited. Finally, nothing in the module should be considered a replacement of prudent and cautious judgment of the health care provider treating a child. Every situation is unique and requires individualized care and independent treatment options. Special thanks to: American Red Cross Permission granted to use their photos in this presentation Melissa Brymer Permission granted to use PFA in this presentation Illinois EMS for Children Advisory Board Margaret L. (Peg) Maher, LCSW, ACSW St. Clair County Mental Health Board Mark Popenhagen, PsyD Dreyer Medical Clinic Nikoleta Boukydis Chicago Department of Public Health Diane Cuddeback Heartlink Grief Center Kat Hindmand, LCSW ARC Disaster Mental Health Team Megan Peace, PsyD, LPC Project consultant Merritt Schreiber,Ph.D. Permission granted to use PsySTART in this presentation Suggested Citation: Illinois Emergency Medical Services for Children, Disaster Mental Health Response for Children, December 2017

Table of Contents Introduction Reactions to Disaster Interventions
Common Reactions to Disasters Childhood Grief and Childhood Grief in Disasters Severe Reactions to Disasters: Stress, Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD) Risk Factors for Developing PTSD When to Seek Help Interventions Helping Children Psychological First Aid Additional intervention: PsySTART Conclusion Resources References/Works Cited This educational program will begin with a brief introduction to the project and the topic of disaster mental health response for children. We will then discuss children’s reactions to disasters including both normal and abnormal responses and the risk factors that make a child more vulnerable to experiencing lasting trauma symptoms. The third section discusses interventions with children in a post-disaster setting including a brief discussion on how to talk to children about disasters. This training activity concludes with a list of resources and handouts that responders may utilize and give to survivors in a post-disaster environment.

Objectives Define common and abnormal reactions that children may experience following a disaster Describe methods for providing support to address the post-disaster needs of children Review the current mental health response technique of Psychological First Aid and PsySTART List existing available mental health disaster resources for caregivers The purpose of this training is to provide education and resources that can be used as just in time training to prepare providers to identify the needs of pediatric survivors so that they may provide support in a way that helps these children return to pre-disaster levels of functioning.

Introduction In a post-disaster setting, providers are faced with the challenge of meeting a vast variety of needs for many survivors. For this module, the term provider is used to include: pre-hospital and hospital professionals, primary healthcare providers, public health department personnel, nonmedical volunteers, and mental health professionals. It is the duty of a provider to simultaneously attend to the medical and mental health needs of survivors while providing the safest possible environment. This educational activity will help providers understand the mental health needs of child and adolescent survivors so that they may provide emotional support and protect from further harm. (Photo Credit: Bob Carey; Talia Frankel/Red Cross)

“For children, the ‘costs’ of disaster extend far beyond those of rebuilding. Disasters take a toll in terms of children’s personal growth and development, missed school, reduced academic functioning, missed social opportunities and increased exposure to life stressors such as family illness, divorce, family violence and substance use.” To begin, let us review the vast potential impact of a disaster. When children experience a disaster, their entire life can be impacted. Their home and school may be damaged or destroyed, disrupting their daily routines and access to social supports. They may lose a family member or friend or economic hardship may place stress on those around them, increasing the incidence of substance abuse and violence in their home. One of the jobs of a provider is to help recognize a child’s needs and prevent further injury or harm in any way that they can. (La Greca, Silverman, Vernberg & Roberts, 2002)

Types of Disasters Impacting Children Around the World
Tornados Earthquakes Flooding Hurricanes Tsunamis Wildfires Ice storms Natural Disaster Acts of violence Terrorism War Toxic waste spills Residential fires Dam/levee breaks Disasters Caused by Humans and Technology Millions of children around the world are impacted by disasters every year. In recent years, many parts of the world have been significantly affected by natural disasters, such as hurricanes, earthquakes and tsunamis as well as man made disasters such as industrial accidents, war violence and shootings. Many times, these events result in total devastation, completely changing the lives of children in their paths. The examples of disasters that are included on this slide will be referred to in this training.

Reactions to Disasters
Common Reactions to Disasters Childhood Grief and Childhood Grief in Disasters Severe Reactions to Disasters: Stress, Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD) Risk Factors for Developing PTSD When to Seek Help A child’s reaction to traumatic stress is largely dependent on their age and developmental level. A toddler’s understanding of a traumatic event is much different than a school aged child’s understanding, impacting the way in which these children respond to the threats they feel during and after the event. The next few slides will discuss typical physical, emotional and behavioral responses for infants and toddlers, pre-school aged children, school aged children and adolescents. Knowing what to expect from children after a trauma will help providers identify, understand and respond to children’s needs.

Reactions to Disasters
In a post-disaster setting, parents and children need to remember that they are having a NORMAL reaction to an ABNORMAL situation! Disaster survivors often feel as though they have lost complete control of their environment and their abilities to control their emotional responses. It is important for providers to help survivors understand that they are experiencing a transient reaction that is usually normal and temporary. This being said, a minority of disaster survivors do go on to experience lasting symptoms of anxiety, depression and posttraumatic stress. Some survivors will eventually meet the criteria for Post Traumatic Stress Disorder, or PTSD, and other clinically relevant disorders. This is dependent on many risk factors, including the magnitude of the event and direct exposure to the event. (Mitchell, 2006)

Common Reactions to Disasters: Infants & Toddlers (Birth to Age 2)
Physical Exaggerated startle reflex Emotional Separation fears Worries Sad Missing people and/ or things Behavioral Fussiness/ tantrums Feeding and sleeping problems Regression Aggression Hyperactivity We will begin by discussing common reactions to disasters for infants and toddlers. Many assume that a child this young is not able to understand the impact of a traumatic experience and, therefore, are minimally impacted by these events. On the contrary, infants and toddlers are very perceptive. Their level of distress will typically reflect that of their caregiver’s distress. Caregiver coping skills are very important for children this age, as they will gather information regarding distress and threats in their environment from their caregivers’ cues. Typically, infants and toddlers have not developed the ability to understand and verbalize their emotions related to a disaster. Because it is difficult for them to articulate their feelings, they often express their emotions through their behavior. A distressed infant or toddler may demonstrate physical reactions such as exaggerated startle responses. Toddlers may throw temper tantrums more frequently. Young children often regress in response to stress, losing developmental abilities that they had previously acquired. They may become aggressive when they are feeling angry or scared. This may be because they are trying to show adults what they experienced or they may be trying to communicate the internal turmoil they are feeling. Separation fears are very common because young children depend on their caregivers to provide for their basic needs and protect them from danger. A toddler may worry excessively that something bad might happen to their caregiver. This is a very reasonable response considering that they may have just observed actual or threatened harm to themselves or others. Toddlers depend on both caregivers and objects for security. If important people or objects are lost, a child will likely demonstrate a more severe reaction to the disaster. (Brymer et al., 2006)

Common Reactions to Disasters: Preschoolers (Ages 3-6)
Physical Confusion Sensitive to noise Emotional Fear of separation Fear of being alone Helplessness Passive behaviors Behavioral Regressive behaviors Excessive clinging Eating/ sleeping problems Crying Not talking Magical thinking and misunderstandings about the event mark preschool aged children’s reactions. They may not understand everything that happened, and their attention is often narrowly focused. A preschool-aged child may have many false perceptions related to the event. It is important to observe a child’s play and to listen to them to gather an understanding of what they think has happened. It is also common for a preschooler to think that the event is in some way their fault and that it would not have happened if they had behaved better. A preschool-aged child may be confused and not understand that the danger is over. They also may overhear adult conversations or view media replays of the event and not understand how far away from home the event happened, or that the event is not actually recurring. Like a toddler, pre-school aged children may develop many fears and they often want to be around adults that can protect them at all times. At this age, children are still dependent on caregivers to provide nurturance and protection and they may feel particularly vulnerable after a disaster or traumatic experience. Pre-school children may also demonstrate clinging behaviors or eating and sleeping problems. They may unintentionally regress, losing the ability to perform previously learned tasks. They may also demonstrate regressive behaviors to elicit nurturance and comforting from adults. Crying and not talking is also common. They may present with helplessness and passivity as well. (Brymer et al., 2006)

Common Reactions to Disasters: School-Aged (Ages 7-12)
Physical Aches & pains Confusion Poor concentration Emotional Withdrawal Fearfulness Sadness Irritability Feels responsible Safety concerns Behavioral Appetite & sleep changes Competition for attention Regressive behaviors School avoidance Aggression Stuck on event School-aged children are not yet capable of abstract reasoning. However, they are capable of understanding concrete explanations of events. In the aftermath of a disaster, they may not be able to fully comprehend the circumstances leading up to the event and this often results in children feeling fearful and anxious. They will look to trusted adults for an explanation of what happened and why it happened. Caregivers should remain open and honest while discussing the matter in an age appropriate manner. It is common for children this age to present with multiple somatic complaints. Headaches, stomach aches and other aches and pains are often a sign that the child is internalizing some anxiety and worry. School-aged children may also demonstrate emotional reactions such as withdrawal, fearfulness, sadness and irritability. They may feel responsible for what has happened or feel that they could have done something to stop or prevent the incident. Continued questions regarding their safety are a typical reaction as children are trying to gain an understanding of the event so that they may be prepared for any further threats. Changes in a school-aged child’s behavior are typical for children who have experienced a disaster. They may refuse to go to school because they doubt their ability to independently care for themselves or are afraid of being away from their parents or caregivers. They may regress back to needing external reassurance from caregivers and they may behave in a competitive manner in order to try to show themselves and others that they are capable of caring for themselves. When a child appears stuck on the event, it is likely because they are trying to make sense of what has happened and regain a sense of emotional control. (Brymer et al., 2006)

Common Reactions to Disasters: Teens (Ages 13-18)
Physical Aches & pains Poor concentration Emotional Withdrawal Fearfulness Sadness Irritability Hopelessness Detached Shame/guilt Change in attitude Behavioral Sleep changes Acting out Substance abuse Avoidance Isolation Abrupt social change Risk taking Adolescents are capable of abstract thought and they are able to understand things from another’s point of view. Their ability to completely understand the events and impact of a disaster resemble that of an adult. A teen’s reaction is typically marked by a desire to be independent. They often may keep things to themselves and demonstrate angry or isolative behaviors, but they are also capable of coping very well and demonstrating helpful and supportive behavior during relief efforts. Aches and pains may be a sign that a teen is internalizing some of their feelings related to the incident. Although teens typically have the language abilities to express most of their feelings and concerns related to the disaster, they may choose to isolate themselves from family or friends. They may act out their feelings of anger and sadness instead of talking about them appropriately. Sharp changes in their attitudes and relationships are typical but responsible adults should continue to be aware of a teen’s whereabouts at all times to monitor them for possible risk taking behaviors. (Brymer et al., 2006)

* Helping Children Cope with Grief tip sheet
Childhood Grief Children often: Respond differently than adults Have inaccurate beliefs about death/loss React to death based on cognitive developmental level Grief is the emotional reaction to loss. Children often respond differently to grief than adults due to differences in their ability to understand death. Younger children may not understand the finality of death and they may ask many questions over and over or believe that death is reversible. An adolescent’s understanding of death resembles that of an adult’s understanding. Adolescents are capable of expressing grief, but may also appear to be coping well when they are not. Adolescents that have experienced loss should be monitored for impulsive, risk taking behaviors. The link on this page is to a tip sheet that provides information on: childhood grief; age appropriate ways to talk with children about death; and ways to help children deal with grief. * Helping Children Cope with Grief tip sheet

Childhood Grief in Disasters
May occur following the death of someone important to a child Common after mass casualty disasters Trauma symptoms interfere with child’s ability to go through bereavement process Children in a post-disaster setting may be dealing with disaster and grief reactions simultaneously. Grief reactions can sometimes resemble reactions to a disaster. Some symptoms of grief that overlap with reactions following a disaster include sleep and appetite disturbances, difficulties concentrating, detachment, agitation, separation anxiety, regressive behavior, aggression, drug and alcohol use or risk taking behavior. A basic understanding of childhood grief will be helpful in responding to children that have lost a loved one. A child may experience severe reactions when they have lost a loved one. Any thought or reminder of that person, even a happy memory, can cause the child to experience frightening thoughts or memories of how the loved one died. (NCTSN, n.d.)

Severe Reactions to Disasters: Stress
Cognitive symptoms Emotional symptoms Physical symptoms Behavioral symptoms An acute stress response is the emotional, dissociative and physical reaction one has during and immediately after a disaster or traumatic event. Acute stress responses to a disaster are very common and often resolve with proper education, self-care and treatment. Symptoms of stress can impact a child’s cognitive, emotional and physical well being. Though younger children have not developed the language skills to be able to articulate their feelings related to traumatic events, signs of stress can be observed through their behavior. Cognitively, a child experiencing stress may demonstrate confusion, difficulty concentrating, preoccupation with the event, difficulty understanding the consequences of their own behavior and even suicidal or homicidal thoughts or psychosis. Emotionally, a child may experience anxiety, panic, phobias, anger, irritability, depression and grief. Some of these symptoms of stress may be apparent while others may be less obvious. The physical consequences of stress such as headaches, hyperventilation, sweating, chest pain, fatigue and indigestion are often the result of a child internalizing their stress. If a child does not find appropriate ways of expressing stress and coping, the physical consequences can be very damaging. Lastly, a child often responds to stress by acting out behaviorally. Impulsiveness, risk-taking behavior, excessive eating, crying spells, aggression and sleep disturbances may present in children of all ages. Adolescents may be particularly vulnerable to using alcohol and drugs and engaging in risk taking behaviors. (Mitchell, 2006; Photo Credit: Talia Frenkel Red Cross)

Severe Reactions to Disasters: Acute Stress Disorder & Post Traumatic Stress Disorder
ASD Early reaction to trauma Symptoms present 2 days to 4 weeks Symptoms similar to PTSD PTSD Pathological variant of normal trauma response Symptoms persist beyond one month Symptoms interfere with daily functioning As we move forward in our discussion about reactions children may experience post-disaster, we will briefly review pathological variants of the normal and transient stress reactions. These abnormal variants include Acute Stress Disorder and Post Traumatic Stress Disorder. The minority of children will be diagnosed with these disorders. However, an awareness of the signs and symptoms for each of these disorders is an important part of training for providers. Providing accurate information to caregivers so that they may seek further help for their children, if necessary, is imperative. This information should be presented in a sensitive way that does not scare caregivers, but rather provides information to help them know when to seek professional assistance for their children. There is specific criteria for diagnosing both Acute Stress Disorder and Post Traumatic Stress Disorder. A child must have experienced an event that involved the actual or perceived threat of death or serious injury and the child’s response to the event must have included fear, helplessness and/or horror. In addition to this, a child must be demonstrating signs of re-experiencing the event, avoidance of related stimuli, symptoms of anxiety or increased arousal and these symptoms must meet certain length and severity requirements. Acute Stress Disorder, or ASD, is diagnosed when a disaster survivor presents with symptoms of dissociation, altered perceptions of the external world so it seems unreal, intrusive thoughts, avoidant behaviors and hyperarousal from 2 days to 4 weeks post disaster. This diagnosis is often considered when a child presents with severe anxiety and symptoms of dissociation that are more serious than a typical stress reaction. Three symptoms of dissociation must be present in order to diagnose Acute Stress Disorder. Symptoms of dissociation include a sense of numbing or detachment from their environment or decreased emotional reactions. Children may appear to be less aware of their surroundings and they may feel as if the world has been changed or lost. A child’s perceptions of themselves or their environment may change and they may be unable to recall important details related to the traumatic disaster event. A child may re-experience the event through recurrent, unexpected images, regular intrusive thoughts, and recurrent dreams in which the child may not be able to identify the content. A child may show an extreme fear of bedtime or they may demonstrate play reflective of the events. A child may also demonstrate fear in the presence of reminders of the event such as sights, sounds or smells that the child associates with the event. Avoidance of stimuli that reminds the child of the event is another symptom indicative of a problematic posttraumatic stress reaction. A child may show that they are avoiding thoughts, feelings, activities, people or places that remind him or her of the event. A child may develop new, specific fears. For example, a child may develop a fear of things such as wind or clouds if they experienced a natural disaster like a tornado. Symptoms of anxiety or increased arousal may appear through disturbances in a child’s sleep habits. Children may fear falling asleep or may wake up and have trouble getting back to sleep. Exaggerated startle responses, disturbances in concentration, and trouble focusing at school may all be signs of anxiety or increased arousal. Post Traumatic Stress Disorder, or PTSD, is diagnosed when a child presents with symptoms similar to ASD for at least one month and their ability to function normally is being impacted.

Risk Factors for Developing PTSD
Event Risk Factors Personal Characteristics Pre-event Risk Factors When talking with children and their families after a disaster, it will be important for providers to be familiar with factors that may place a child at an increased risk of developing a lasting and severe response such as Post Traumatic Stress Disorder. A few factors may place a child at a higher risk for developing problematic reactions. Direct exposure to the disaster event is largely correlated with more severe posttraumatic reactions. If a child witnesses a large amount of destruction or he or she was exposed to the grotesque, a provider should take note that the child may be at a higher risk than other children. Loss of a family member or loved one, especially if the child witnessed that loss also places the child at a greater risk. Personal characteristics such as a previous mental health diagnosis or a history of a traumatic experience, may place a child at greater risk. If a child has limited coping skills, there is a family history of mental illness or there is chronic family dysfunction, a child may need to be monitored for symptom development. Limited social support, poverty and limited access to resources can also place a child at greater risk. If a provider notes any of these risk factors, it will be important to ensure the child and his or her family is offered continuing care for the weeks and months following a disaster.

When to Seek Help Risk factors present Reaction appears severe
Reaction is concerning Symptoms persist beyond one month Symptoms of Acute Stress/PTSD or prolonged grief present Child appears “stuck” on the trauma When responding to children’s mental health needs after a disaster, providers should educate parents or caregivers on when to seek professional assistance. A child presenting with any of the risk factors that were discussed on the previous slide, such as a previous mental health diagnosis, would benefit from being referred to additional services. If a parent or caregiver notices that a child’s reaction appears more severe than other children’s reactions or changes in their behaviors are concerning, additional assistance may be necessary. An overwhelmed parent may require gentle encouragement to identify problematic reactions and seek additional assistance. If symptoms persist or any symptoms of Acute Stress Disorder or Post Traumatic Stress Disorder are observed, seeking additional help is advised.

Interventions Helping Children Psychological First Aid PsySTART
This next section will discuss current intervention techniques that will answer the question, “What can I do to help after a disaster?”

Helping Children: Ages Birth-5
Time with adults Physical contact Physical activity Limit media exposure Reassurance Infants and young children are very perceptive and they will be impacted by disaster events. One of the most important things adults can do to help young children is spend time with them and provide a lot of physical contact. Time with parents or caregivers is preferable. Limiting exposure to media is also important since young children are not able to understand that the events are not actually recurring when they observe repeat video footage of the event. Providing lots of reassurance that they are safe now will be very helpful in providing a sense of security for young children. Click on the link on this slide to access tip sheets for helping children of this age range. Tips for helping Infants & toddlers and preschoolers after disasters (Brymer et al., 2006; CDC, n.d.; Photo credit: Bob Carey/Red Cross)

Helping Children: Ages 6-12
Time with adults Physical contact Opportunities to talk Reassurance Physical activity Spending time with adults is also important for school-age children. At these ages, children continue to seek security in their parents or caregivers and physical contact provides children with a sense of safety. Providing opportunities to talk will also be helpful. Though children should never be forced to talk, adults should make sure that school-aged children understand that it is okay to talk about the event and their feelings. Children will sometimes fear that talking about their feelings will be upsetting to adults so they internalize their reactions, causing further stress and somatic complaints. It is important to provide reassurance that they are going to be okay and they will be cared for. Opportunities for physical activity provide an outlet for stress and help children cope with stressful events better. As often as possible, social outlets should be provided as well. Click on the link on this slide to access tip sheets for helping children of this age range. Tips for helping school-aged children after a disaster (Brymer et al., 2006; CDC, n.d.; Photo credit: Talia Frankel/Red Cross)

Helping Children: Ages 13-18
Time with peers Opportunities to contribute Encourage self-care Discuss healthy coping Listen A large part of an adolescent’s social development includes seeking independence from their parent or caregiver and depending more on peer support. After a traumatic event, providing time for adolescents to be with their peers will be important. Adults need to talk to teens about healthy ways of coping and discourage negative responses such as drug and alcohol use and other risk taking behaviors. Remind them that it is important to continue to eat well, sleep regularly and be active. Allow teens to contribute during disaster response activities, if applicable. This will help them feel that they have some ability to control the chaotic world they are living in and feel like they are able to help right the wrong that they are experiencing. Click on the link on this slide to access tip sheets for helping children of this age range. Tips for helping adolescents after a disaster (Brymer et al., 2006; CDC, n.d.; Photo credit: Chuck Haupt /Red Cross)

Helping Children: Children Separated from their Caregivers
Separation from caregivers during a disaster increases a child’s vulnerability to: Abuse Neglect Trafficking Malnutrition Psycho-social trauma Disease Separation from a child’s primary caregiver can affect how a child responds to and recovers after a disaster. Being separated from their primary caregiver during and after a disaster increases their risk of abuse, maltreatment, and psychological trauma. (Photo Credit: Patrick Fuller/Red Cross)

Unaccompanied minors are a priority Provide for their safety and security first Assign a provider to each unaccompanied child and have the provider stay with the child at all times Provider should: Comfort child if he/she becomes distraught Model good coping Address child’s physical needs As a provider, there are many things that should be done in order to protect children who have become separated from their caregiver during a disaster. It is vital to identify any unaccompanied children early and ensure their immediate safety needs are met. An appropriate provider should be assigned to each unaccompanied child and this provider should stay with the child at all times. This provider should be the primary person responsible for ensuring the safety, security and physical needs of the child are met. It is important that this provider is calm and displays good coping skills as these characteristics can help make the child feel secure and safe.

Keep child in safe area Prevent further exposure of event Control flow of people in safe area Report suspicious people/activity Begin Psychological First Aid Work with community services to reunify child with caregiver A safe area should be established for children who are unaccompanied by their caregivers. This area should be: separate from the main area where others are gathering; secured to control the flow of people through the area; provide children with distraction devices to assist them with coping; and shelter children to prevent further exposure to the event as well as others who may be expressing negative coping or uncontrolled emotional responses to the event. Children should be shielded from seeing any severe damage or injuries. If available, keep the child with any known siblings and if familiar peers are nearby as well, it may benefit the child to be around them. Security mechanisms should be put into place to protect unaccompanied children. Any suspicious people or activity should be reported.

Psychological First Aid
Addresses: Safety Ability to calm oneself or others Basic needs Disruptions in social connections Interventions: Focus on the here and now Enhance current functioning Prevent further injury Psychological First Aid, or PFA, is a post-disaster intervention technique that addresses survivors’ basic needs, their safety, their ability to calm themselves or others and their disrupted social connections following a disaster. It focuses on the here and now and provides practical assistance that does not directly resemble traditional therapy. All providers can benefit from training on PFA. Psychological First Aid trains providers to administer support to survivors to enhance their current functioning and support them in a way that will prevent further injury. (La Greca, Silverman, Vernberg, & Roberts, 2002; Brymer et al., 2006)

Psychological First Aid
8 basic actions: Contact and Engagement Safety and Comfort Stabilization Information Gathering Practical Assistance Connection with Support Information on Coping Linkage with Services Psychological First Aid is comprised of eight basic actions that guides the provider though the helping process in a post-disaster setting. These steps will be discussed over the next few slides. For the complete Psychological First Aid Manual, click the link on the slide. PFA Manual (Brymer et al., 2006)

Step 1: Contact and Engagement
Introduce self Ask about immediate needs Maintain confidentiality When a provider establishes contact with a survivor for the first time, it is important to remember to be non-intrusive and compassionate. In this initial contact, a provider’s sensitivity to the survivor and their needs may have a large impact on their willingness to seek help throughout the rest of their recovery. Survivors that seek out help should be a provider’s first priority. Remember to fully introduce yourself and explain your role in the disaster response setting. Always ask for permission to help a survivor and remember to keep information confidential to respect a survivor’s privacy. If a child’s parent or caregiver is available, remember to ask for permission to speak with the child before initiating contact with them. (Brymer et al., 2006; Photo Credit: Bob Carey/Red Cross)

Step 1: Contact and Engagement
Adult/Caregiver* “Hello, My name is I work with I’m checking in with people to see how they are doing and to see if I can help in any way. Is it okay if I talk to you for a few minutes? May I ask your name? Before we talk, is there something right now that you need like some water or fruit juice?” Child* “And is this your daughter? Hi, I’m and I’m here to help you and your family. Is there anything you need right now? There is some water and juice over there, and we have a few blankets and toys in those boxes.” The Psychological First Aid manual provides dialogue examples to help providers know the best age appropriate language to use. The dialogue on this slide is an example of what a provider might say when contact is first established with a family. It is recommended that a provider first introduce himself or herself to the parent or caregiver and ask for permission to speak to both the adult and the child before offering assistance. *Sample Dialogue (Brymer et al., 2006)

Step 2: Safety and Comfort
Immediate physical safety Attend to children separated from caregivers Attend to physical comfort Promote social engagement Information about disaster response Protect from additional traumatic experiences Other support services After contact has been initiated with a survivor, the next priority should be establishing a sense of safety and comfort for the child and his or her family. The steps on how to do this will be reviewed in the next few slides. (Brymer et al., 2006)

Step 2: Safety and Comfort Immediate Physical Safety
Find officials Help make environment more safe Provide safe area for children Remove dangerous objects Ask about specific needs Document survivors with special needs Look for signs of threat to self/others Look for signs of shock When addressing a child or adolescent’s safety, consider the immediate physical safety of the setting that they are in. A provider may need to find necessary officials if the survivor is in an unsafe environment and immediate threats such as weapons or downed electrical wires need to be removed. Providing a safe area that is free of dangerous objects for children to play in freely can be helpful in alleviating some of the survivor’s stress. Remember to ask a survivor about specific needs, such as necessary medication, and document these needs so that they can be followed up with as soon as possible. Look for signs of ineffective coping such as the survivor being at risk to themselves or others. Always take it very seriously if a survivor mentions thoughts about harming themselves or others. Seek necessary medical or mental health personnel if necessary. (Brymer et al., 2006)

Step 2: Safety and Comfort
Child/ Adolescent* “Do you need anything to drink or eat? Is your family here with you?” “Do you have a place to stay?” “We are working hard to make you and your family safe.” “Do you have any questions about what we’re doing to keep you safe?” When working to establish safety and comfort for a child or adolescent, a provider could say something similar to the dialogue included on this slide. It is important to ask many questions to gather information about what the child or adolescent feels they need the most. Making assumptions about their needs could unintentionally contribute to feelings of helplessness. A child or adolescent should be empowered to make decisions for themselves and to ask for help when they need it. *Sample Dialogue (Illinois EMSC, 2014)

Step 2: Safety and Comfort Attend to Children Separated From Caregivers
Set up a secure child-friendly space Safe, designated space Experienced caregivers Monitor who comes and goes Stock with materials Plan soothing activities Invite older children to help Include activities for adolescents Parents or caregivers are central to a child’s sense of safety and well-being. If a child is separated from their parent or caregiver, it will be important for a calm, responsible adult to remain with that child until they can be reunited with their parent, caregiver or a familiar adult. It is also common practice in a post-disaster setting to set up a child friendly space. This space should be in an area that is safe and away from rescue activities. The area should be staffed with caring adults that have experience with children and who will monitor the children’s safety closely. A child should not be allowed to leave the space unless they are leaving with a confirmed parent or guardian. Play areas should be stocked with age-appropriate play materials as quickly as possible. Children process their thoughts and feelings through play so it will be important to allow them the freedom to be creative and engage in imaginative activities. Drawing supplies, games, bubbles, chalk and stuffed animals are common play materials for safe areas. A space for adolescents to participate in their own activities should also be designated as soon as possible. Adolescents depend on peers for support much more than younger children and will benefit from the opportunity to socialize, write, draw or listen to music in a common area. Caring for younger children may also comfort older children. They should be invited to help with younger children as long as they are helping appropriately. (Brymer et al., 2006)

Step 2: Safety and Comfort Attend to Physical Comfort
Look for ways to make physical environment more comfortable Encourage survivors to get things they need Help children find a toy to “care” for Demonstrating concern for a child or adolescent‘s physical well being and comfort is very important. A responder can look for ways to make the physical environment more comfortable by providing blankets or helping a parent or caregiver find food or temporary shelter. Encourage children and adolescents to seek out things that they need and help them problem solve if they appear to have difficulties making decisions. Children process their emotions through play, therefore, helping them find a toy to care for may be very soothing for them. (Brymer et al., 2006; Photo Credit: Bob Carey/American Red Cross)

Step 2: Safety and Comfort Promote Social Engagement
Facilitate group/social interactions Keep children with family/primary caregiver as much as possible Place children by calm adults A pediatric disaster survivor can find great comfort in knowing that they were not alone in the event that they just endured and others are having similar feelings and fears. Providing opportunities for survivors to be together to share their stories and support each other can be very healing. Though children may not talk directly about the event, being in the presence of other children and engaging in familiar play activities can provide a great deal of comfort for them. It is important to also remember that children who have just experienced a disaster event should not be separated from parents or caregivers right away. A parent, caregiver or calm adult should remain in close proximity to a child at all times. While play areas provide time for parents or caregivers to have a break and care for themselves, it is recommended that they stay within the child’s line of sight immediately after a disaster event. (Brymer et al., 2006; Photo Credit: Bob Carey/Red Cross)

Step 2: Safety and Comfort Information about Disaster Response
What to do next What is being done to help What is known about the event Available services Common stress reactions Self-care, coping After a disaster event, a child or adolescent may feel disoriented and overwhelmed with what has just happened. Providing straight forward, honest and age appropriate information about the events of the disaster and disaster response activities can help re-orient a confused survivor. Information regarding what to do next, what is being done to help them, what is currently known about the event, available services, common stress reactions, self-care, family care and coping can all be very comforting for a pediatric disaster survivor. (Brymer et al., 2006)

Step 2: Safety and Comfort Protect from Additional Traumatic Experiences
Reduce exposure to reminders Protect privacy of survivors Discuss risks of media exposure After a disaster, providers should remember to help shield survivors from additional traumatic experiences. Sights, sounds or smells that remind survivors of the experience may cause further fear and harm for pediatric survivors. Limiting a child or adolescent’s media exposure should be encouraged. Replaying images from the event can cause further damage and children should be encouraged to seek information from trusted adults rather than media sources. Inform adolescents that they can refuse to speak to media representatives and providers should work to protect survivors from individuals seeking information or attention. Social networking technologies such as Facebook, Twitter, and texting, can also be a source of additional information, some of which may be disturbing or inaccurate. Adolescents should be made aware of this as well and encouraged to limit their exposure. (Brymer et al., 2006)

Step 2: Safety and Comfort Protect from Additional Traumatic Experiences
Adolescent/ Child* “You’ve been through a lot already. People often want to watch TV or go to the internet after something like this, but doing this can be pretty scary. It’s best to stay away from TV or radio programs that show this stuff. You can also tell your mom or dad if you see something that bothers you.” When speaking to a child or adolescent about protecting themselves from additional traumatic reminders, a provider could say something similar to the dialogue example on this slide. This example educates children and adolescents about the possible desire to seek additional information from media and the potential consequences of doing this. Encouraging survivors to seek information from knowledgeable adults and sources is recommended. *Sample Dialogue (Brymer et al., 2006)

Step 2: Safety and Comfort Other Support Services
Help survivors who have a missing family member Help survivors when a family member or close friend has died Support survivors who receive death notification Attend to grief and spiritual issues Support survivors involved in body identification Help caregivers confirm body identification to a child or adolescent Listed on this slide are other support services that providers may need to provide to children, adolescents and their parents or caregivers. The situations that a survivor may be placed in after a disaster are extraordinary. Events such as identifying the body of a loved one or informing a child about the loss of a parent are examples of these extraordinary situations. Simply being available, listening and helping a survivor plan for these situations can be tremendously helpful. (Brymer et al., 2006)

Step 3: Stabilization Stabilize emotionally overwhelmed survivors
Orient survivors Consider medication The next step in Psychological First Aid addresses the need for stabilizing survivors that are having an extreme reaction. An adolescent or child in crisis may appear disoriented, may look like they are in a daze, or they may be screaming, crying or hyperventilating. If a child survivor appears to be having a very strong reaction, a provider should help them move into a private space if possible. Parents, caregivers or family members should be enlisted to help comfort their children if they appear to be calm themselves and are able to do so appropriately. Listen to the distraught child to try to understand what their primary concern is so that this may be addressed first. Though it is difficult to sit with a very distressed child, allow them a few minutes of crying and expressing emotion before intervening. Make sure the parent or caregiver and child know that you are there if they need assistance. Remain calm and quiet and help the child focus on specific, manageable thoughts, feelings or goals. Help the child to remain oriented by reminding them where they are and answer questions about what has happened while reassuring them that they are safe now and adults are here to help them. Sometimes when other measures fail, medication is needed in order to stabilize children and adolescent survivors after a traumatic event. Medication should only be administered by trained medical professionals. In the event that a survivor is so overwhelmed that they need medical or emotional stabilization, involvement of trained medical or mental health professionals may be indicated. Many believe that it is most appropriate for only certain professionals to be involved in stabilization. For example, the American Red Cross feels that only trained mental health professionals should address emotional stabilization activities. If a mental health professional is available, seek their assistance in calming the overwhelmed survivor. (Brymer et al., 2006)

Step 3: Stabilization Child*
“After bad things happen, your body may have strong feelings that come and go like waves in the ocean. Even grown-ups need help at times like this. Is there anyone who can help you feel better when you talk to them? Can I help you get in touch with them?” The dialogue on this slide is an example of what a provider may say when speaking to an overwhelmed child that is separated from their parents or caregivers. Helping a child to understand what they are experiencing and reminding them that their feelings are temporary and manageable is an important part of stabilization. *Sample Dialogue (Illinois EMSC, 2014)

Step 4: Information Gathering
Gather information on current needs and concerns: Nature/severity of experience Death of loved one Concerns about ongoing threat Concern for loved ones Losses Guilt/shame Available social support Other risk factors After a provider has made efforts to establish a sense of safety and comfort for a survivor, they should work with the child or adolescent to gather further information regarding their experiences and needs. It is likely that a survivor will have a large number of needs and ongoing concerns but may feel so overwhelmed that they are not able to organize their thoughts and articulate all of these needs and concerns right away. This will be especially true for child survivors. Having a list of things to ask pediatric survivors may be helpful. Allowing a child or adolescent to talk about their experience can help them to process what has just happened and it can give a provider a sense of how serious the event was for them. Questions about risk factors and their available support systems could help a provider begin to prioritize which survivors are in need of immediate assistance. After gathering all of this information, it will be easier for a provider to tailor their response activities to the specific needs of the individual that they are helping. Click the link on the slide to access provider worksheets to use when gathering information on current needs and concerns. Provider Worksheets (Brymer et al., 2006)

Step 5: Practical Assistance
Offer physical assistance Identify most immediate needs Develop an action plan Act After a provider has collected information regarding the survivor’s experience and concerns, it will be easier to provide practical assistance to begin addressing their needs. A provider can help children and adolescents by first clarifying their needs. Next, providers can help them develop a plan to address these needs by helping the child or adolescent to identify options that are available to assist them. When a disaster survivor is feeling overwhelmed, helping with basic problem solving can be very beneficial. Offering physical assistance such as helping to move their things to a safe place or walking with them to a shelter shows support and helps communicate to the child or adolescent and their families that they are not alone. (Brymer et al., 2006; Photo Credit: Bob Carey/Red Cross)

Step 6: Connection with Support
Access to primary support persons Encourage use of available support Discuss support-seeking and giving Modeling support Both giving and receiving social support can aid a disaster survivor in their recovery. Associating with friends, family and community members can promote feelings of togetherness and hope. One of the most important ways a provider can help a survivor is to connect them with a member of their primary support system. For a child, this is usually a parent or caregiver. A teacher or other familiar adult could provide the child with a great deal of comfort as well. Encouraging the use of available resources is another way that providers can help encourage connection with social support. A child can be led to a safe area or invited to join a group activity. Simple activities such as a game of tic-tac-toe or coloring a picture with other children can help provide a sense of connection with others. Emotionally overwhelmed children may isolate themselves from groups, leading to feelings of disconnection. Talking and sharing with adults and other children will begin a process of coping and healing. Providers should make every attempt possible to get children to engage socially as soon as they are ready. Modeling appropriate support can teach children how to provide support to each other. Using good listening skills and making reflective comments such as, It sounds like you’re saying, and supportive comments such as, It sounds really hard, can help children learn how to provide positive support. When survivors are overwhelmed, they may need reminders about how to seek support and give support. The Psychological First Aid manual offers a tip sheet that provides useful information on giving and seeking support. Click on the link provided to access tip sheets in Appendix E of the Psychological First Aid manual. Connecting with Others Tip Sheet (Brymer et al., 2006)

Step 6: Connection with Support
Adolescent* “When something really upsetting like this happens, even if you don’t feel like talking, be sure to ask for what you need.” Child* “You are doing a great job letting grown-ups know what you need. It is important to keep letting people know how they can help you. The more help you get, the more you can make things better. Even grown-ups need help at a time like this.” By using dialogue similar to the sample provided on this slide, providers encourage pediatric survivors to talk to others about their needs and avoid isolating themselves or bottling up their feelings. This gives them permission to ask others for help and encourages them to continue to pro-actively seek the help that they need. *Sample Dialogue (Brymer et al, 2006)

Step 7: Information on Coping
Provide information about coping Relaxation techniques Assist with developmental issues Providing basic information about coping after a disaster can help a survivor begin to focus on healing. A provider may need to remind pediatric survivors and their families that attending to basic self care needs is important to help them cope with the experience and move forward. For children, establishing a regular, predictable and familiar schedule as soon as possible will be very important. Eating and sleeping well and exercising can also be helpful in reducing stress. Drawing, playing and cuddling is important for younger children while time with friends, music and writing are common, positive coping activities for older children and adolescents. Relaxation exercises such as slow breathing techniques can help calm a survivor’s mind and body. Blowing up balloons or blowing bubbles can help younger children engage in slow and deep breathing. The Psychological First Aid manual offers a tip sheet that provides useful information on common relaxation techniques. Click on the link provided to access these. Children sometimes act out with behaviors such as anger and aggression. Assisting with anger management and encouraging both physical activity and verbal expression of feelings may be helpful. Adolescents may respond with defiant behaviors such as substance use. It will be important for parents, caregivers and providers to discuss the possible consequences of risk taking behaviors and encourage more positive coping. Tips for Relaxation (Brymer et al, 2006)

Step 8: Linkage with Services
Assist children and families in connecting to community resources Provide referrals for additional assistance Promote continuity in helping relationships Assist with reunifying unaccompanied children with caregivers The final step in Psychological First Aid addresses the need to ensure that continuity of care is provided for survivors. A list of local agencies to help with medical and mental health needs as well as social service agencies, financial assistance options, and religious organizations that may offer continued assistance after a disaster should be complied and provided to survivors. The needs of children and their families in the aftermath of a disaster will be vast and ongoing. Long term community support will need to provide ongoing help when initial disaster response groups such as FEMA leave the area. (Brymer et al., 2006)

Additional Intervention: PsySTART
Evidence based mental health screening system Used for rapid triage decisions for emergency mental health interventions Flexible and scalable PsySTART is an evidenced based mental health triage screening system developed at the University of California Irvine Center for Disaster Medical Services. PsySTART assists emergency responders with developing a list of needed mental health interventions for children. The triage system helps guide response activities by identifying those who have the greatest need or are at the greatest risk and allows responders to match the available mental health resources to those individuals. PsySTART is flexible and can be used on child and adult victims as well as responders in disasters. The system is also scalable. It performs rapid triage for an individual as well as for the population affected by the disaster in near real time. Information is entered into a phone app and can provide almost instant situational awareness of the mental health needs of those affected by the disaster. PsySTART triage does not need to be completed by mental health professionals. School staff, nurses, physicians, or other types of disaster responders can complete the PsySTART triage tag to assess the mental health needs of children after a disaster. For more information and to learn how to receive training on PsySTART, click on the link found on the slide. PsySTART was initially developed in the late 1990s and became a Triage Tag in In 2006, the mHealth mobile application was developed and the phone app was developed in A number of organizations around the country use PsySTART, including the American Red Cross and the U. S Public Health Service. PsySTART has been used in trainings across the country as well as in real world events such as during the Southeast Asian Tsunami, Hurricane Ike, Tennessee floods, the American Samoa Tsunami Response, Superstorm Sandy, Joplin and Alabama tornados and in the mass shooting as Sandy Hook Elementary School. Click for more information on PsySTART

PsySTART Triage Stepped Care Continuum Model
The PsySTART triage system does more than screen children and others involved in a disaster regarding the mental health resources they may need. This system also provides responders with a care continuum based on the triage level assigned to the patient in the screening step. It helps to identify the recommended care strategy based on the triage risk level from the triage tag. On this slide is the PsySTART Triage Stepped Care Continuum Model. The next few slides will illustrate the range of risk versus resilience of the child and adolescent and the intensity of interventions that may be needed based on the assessment. Click for more information on PsySTART

Click for more information on PsySTART
PsySTART triage “tag” seeks to identify: Key risk factors (e.g. witnessed death of loved one) Ongoing/evolving post event stressors (e.g. housing issues) Four triage risk levels The PsySTART triage tag seeks to identify the key risk factors that put a child at higher risk for long term mental health issues following a disaster. The excerpt of the tag that is seen on this slide shows some examples of high risk factors. These risk factors are similar to those discussed earlier in this presentation when reviewing the event, personal characteristics and pre-event risk factors for developing PTSD. Responders who are completing the assessment of a child using this tag will triage the child into one of four triage risk levels, which will be discussed on the next slide. Click for more information on PsySTART

Click for more information on PsySTART
Triage Risk Levels and Care Strategy Purple: Acute danger to self/others Emergency care to evaluate for danger by clinical providers and trained mental health professional-immediate interventions to be implemented to protect from harm Red: High risk Immediate disaster crisis intervention by trained mental health professional (clinical providers) Yellow: Moderate risk Secondary mental health screening (non-clinical providers) Green: Low risk “Listen, Protect and Connect” approach with PFA The four risk levels within PsySTART are color coded and range from purple which is the highest acuity to green, which is the lowest acuity. Anyone who is identified as being at risk of harming themselves or others should be triaged as purple and receive emergency care to protect them and others from danger. They would need to be evaluated by clinical providers in an emergency department setting (or equivalent, depending on the available resources) and by a mental health professional. If any of the risk factors labeled as red on the triage tag are identified, immediate crisis intervention by trained mental health professionals is needed for that child. If any of the risk factors labeled as yellow on the triage tag are identified, a secondary mental health screening exam will be needed. This can be completed by non-clinical based providers such as those performed during school based screenings. Children triaged as green would not be identified as having any high risk factors during the time of the exam. Following the Psychological First Aid Listen, Protect and Connect approach would be appropriate care for these children. Links to the Listen, Protect and Connect approach can be found in the resource list at the end of this module.

Using PsySTART PsySTART used for mental health screening only
Does not replace mass casualty incident medical triage systems (e.g. START, JumpSTART©) Used with victims after medical needs have been attended to PsySTART is designed to provide a triage system for mental health screenings. Although there is some overlap in the color coded system with other disaster triage systems, PsySTART is not meant to replace mass casualty triage systems used to identify the medical needs of patients such as START and JumpSTART triage. These triage systems are typically completed by EMS at the disaster scene or at the time of initial presentation to a hospital or alternate care site. PsySTART is designed to specifically identify the mental health needs of patients after their medical needs have been addressed. It is not intended to be used at the initial scene of the incident, but rather in shelters, schools and public health departments or in health care settings after initial medical needs are addressed. EMS would not perform PsySTART on victims prior to transporting them from the initial scene. Finally, PsySTART does not need to be completed by a mental health professional. Professionals such as school staff, health care workers, disaster responders and public health personnel who have received training on PsySTART can perform the triage. Not intended to be used by EMS on initial scene Does not need to be completed by mental health professionals

PsySTART For more information or to become trained on using PsySTART, visit: This was a brief review of the overall concepts of PsySTART. In order to utilize the PsySTART triage system, training is needed for responders. To find out more information about the system, how to become trained in PsySTART or to obtain the app and other materials, please click on the link on the slide.

Conclusion In concluding this web seminar, we will review some of the main points discussed in this presentation. It is important for providers to be aware of the common and abnormal responses to disaster and trauma in order to provide appropriate care, educate parents and caregivers and identify when additional help is needed. Children have specific needs in the post disaster setting and Psychological First Aid can give providers the practical assistance to help children and adolescents begin their path to recovery. Resources are provided at the end of this module that may be helpful to have in the event of a disaster. Thank you for attending our educational web seminar. We hope that you will find the information provided to be helpful in your interventions with children who have experienced a disaster. (Photo Credit: Chuck Haupt/Red Cross)

Resources: Websites Illinois EMS for Children: Mental Health for Children Resources The National Child Traumatic Stress Network FEMA for Kids CDC: Emergency Preparedness and Response: Coping with a Disaster or Traumatic Event Substance Abuse and Mental Health Services Administration (SAMHSA)

Resources: Tip Sheets & Documents
CDC: Helping Parents Cope with Disasters SAMHSA: Tips for Talking to Children and Youth after Traumatic Events: A Guide for Parents and Educators Psychological First Aid Tip Sheets Parent Tips for Helping Infants and Toddlers Parent Tips for Helping Preschool-Age Children Parent Tips for Helping School-Age Children Parent Tips for Helping Adolescents Connecting with Others: Seeking Social Support Connecting with Others: Giving Social Support When Terrible Things Happen Tips for Adults Basic Relaxation Techniques Alcohol and Drug Use after Disasters

Resources: Tip Sheets & Documents (continued)
Psychological First Aid (PFA) Field Operations Guide Listen, Protect, Connect-Psychological First Aid for Children and Parents Listen, Protect, Connect-Psychological First Aid for Students and Teachers National Child Traumatic Stress Network: Childhood Traumatic Grief Educational Material for Parents Childhood Traumatic Grief Educational Material for Pediatricians and Pediatric Nurses Childhood Traumatic Grief Educational Material for School Personnel

References/Works Cited
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J, Steinberg, A., Vernberg, E., & Watson, P. (2006). Psychological First Aid: Field Operations Guide, 2nd Edition. National Traumatic Stress Network and National Center for PTSD. Retrieved from (Information and document used with permission) Centers for Disease Control and Prevention (CDC). (n.d.). Helping parents cope with disasters. Retrieved from La Greca, A. M. , Silverman, W. K., Vernberg, E. M., & Roberts, M. C. (2002). Helping children cope with disasters and terrorism . Washington, DC.: American Psychological Association.

References/Works Cited
Mitchell, J.T. (2006). Critical incident stress management (CISM): Group crisis intervention (4th Ed). Ellicott City, MD: International Critical Incident Stress Foundation, Inc. Schreiber, M. (2010). The PsySTART Rapid Mental Health Triage and Incident Management System. Information and documents used with permission. Retrieved from The American Red Cross. (n.d.). Permission was granted to use the photos in this educational module. The National Child Traumatic Stress Network (NCTSN). (n.d.). What is childhood traumatic grief? Retrieved from Wolfelt, A.D. (n.d.). Helping children cope with grief. Center for Loss and Life Transitions. (Document used with permission).

Disaster Mental Health Response for Children

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