TEAM RESPONSIBILITIES: School Mental Health Crisis Intervention Teams

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TEAM RESPONSIBILITIESSchool Mental Health
Crisis Intervention Teams

• Eric M. Vernberg, Ph.D.
• University of Kansas
• Clinical Child Psychology Program
• Terrorism and Disaster Branch, NCTSN

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• The Educators Mantra
• There cannot be a crisis next
• week
• My schedule is already full.
• -Henry Kissinger

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Managing the Crisis

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

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Four Phases of Disasters
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Mitigation

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

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Current Mitigation Measures - Examples

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

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Mitigation Measures - Mental Health

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

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From the Field of Brain Research

• In order for children to learn
• Eliminate Threat from the Environment
• Enrich the Learning Environment

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Rationale for Screening Children

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

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Important Aspects of Good Screenings

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

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Resilience

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

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Resilience

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

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Resilient Characteristics

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

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Actions to Promote Resilience - Examples
Goal Increasing connectedness to others

• Preparedness
• Assess and address social isolation and bullying
• Classroom projects that promote teamwork,
  respect, and bonding to the school

• During Response
• Keep students grouped with familiar peers
• Have distraught students comforted by familiar
  adults
• Reunification plan

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Actions to Promote Resilience - Examples
Goal Increasing feelings of empowerment (active
coping)

• Preparedness
• Practice safety plans
• Find ways to help others as a class (e.g.,
  raising , writing letters)

• During Response
• Ask students to help you w/ a manageable task
• Give students age-appropriate duties (handing out
  water, comforting younger students)

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Actions to Promote Resilience - Examples
Goal Maintaining consistency and predictability

• Preparedness
• Keep a daily routine
• Encourage family members to provide structure for
  students

• During Response
• Remind students about safety plan
• Keep students informed using easy-to-understand
  language

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Actions to Promote Resilience - Examples
Goal Take a break

• Preparedness
• Help students focus on positive images in the
  media
• Brainstorm healthy activities that are not
  associated with anxious feelings

• During Response
• Limit graphic talk or media exposure of the
  trauma
• Shield students from further exposure to
  traumatic stimuli/scenes

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Actions to Promote Resilience - Examples
Goal Teach self-care skills

• Preparedness
• Teach basic relaxation skills (e.g., test
  preparation)
• Encourage healthy habits exercise, eating, and
  sleeping

• During Response
• Shield students from further exposure to
  traumatic stimuli/scenes
• Prompt students to use positive coping skills
  (relaxation, verbalizing feelings, social
  support)

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Promoting Resilience -What Doesnt Work

• Forcing students to talk about feelings
• Avoiding all discussion about traumatic event
• Being a poor model
• Allowing your personal resources to be drained
• Using negative coping
• Showing uncontrolled emotions in front of
  students

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Risk Factors

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

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Types of Exposure

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

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Exposure Screening

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

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Threat Assessment - Overview

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

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Threat Assessment Step 1

• Multidisciplinary Team
• School administrator
• Faculty member
• School resource officer (where available)
• Counselor
• Mental health professional

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Threat Assessment Step 1

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

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Threat Assessment Step 2

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

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Threat Assessment Step 3

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

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Threat Assessment Step 3

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

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Threat Assessment Step 3

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

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Threat Assessment Step 3

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

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Threat Assessment Step 3

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

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Threat Assessment Step 4

• Involve law enforcement
• conducting a threat investigation as appropriate
• deciding on the threat level and appropriate
  response

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TEAM RESPONSIBILITIESDuring the Disaster

• Eric M. Vernberg, Ph.D.
• University of Kansas
• Terrorism and Disaster Branch, NCTSN

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Four Phases of Disasters
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TriageFrench to sort

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

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First Aid Team Duties

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

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Triage
PERSONNEL STATUS
Injured/Sick as of time/date___________ Location
________________ Number of personnel in
attendance this date Students_____ Staff_____
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Triage
Triage Accountability Form
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The First Few Hours On Your Own

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

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Mental Health Objectives in School Settings

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

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Teacher Interventions

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

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The First Few Hours What Students Will Need to
Know

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

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The First Few Hours What to Do

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

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The First Few Hours What to Do -2

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

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The First Few Hours What to Say

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

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The First Few Hours What to Say - 2

• Reflect students feelings, but redirect them
  from talking excessively about gruesome or
  terrifying details
• Praise students for their bravery, helping peers,
  following your directions, etc.
• Before students are released to caregivers,
  summarize the disaster and its resolution to the
  class.

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Goals at Disaster Site

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

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Crisis Response

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

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Immediate Crisis Intervention

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

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Psychological First Aid

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

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Crisis Intervention for Acute Stress Reactions
Definition

• Frontline interventions delivered during
  the emergency phase to individuals
  experiencing acute stress reactions or who
  appear to be at risk for not being able to
  regain sufficient functional equilibrium on
  their own.

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On-Scene Support and Psychological First Aid
What would you expect to observe in individuals
experiencing acute stress reactions or in people
who appear to be at risk for not being able to
regain sufficient functional equilibrium on their
own?
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On-Scene Support and Psychological First Aid
Signs of Acute Stress Reactions and Insufficient
Functional Equilibrium

• Extreme anxiety (e.g., fear, panic, worry).
• Dissociative reactions (e.g., experiencing the
  world as dreamlike, marked detachment,
  depersonalization).
• Uncontrollable intense grief (i.e., incongruent
  with cultural norm.
• Marked sleep difficulties, loss of appetite, or
  poor hygiene.
• Extreme cognitive impairment (e.g., confusion,
  poor concentration, poor judgment and poor
  decision-making, inability to make decisions,
  overwhelming feelings of helplessness resulting
  compromised self-care.
• Marked intrusive thoughts including traumatic
  imagery.

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On-Scene Support and Psychological First Aid
When acute stress reactions or insufficient
functional equilibrium are present, what might be
the the objectives of providing support and
psychological first aid? That is, what would you
try to do?
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On-Scene Support and Psychological First Aid
PRIMARY GOALS

• Establish safety and security
• Reduce stress-related reactions
• Connect to restorative resources

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On-Scene Support and Psychological First Aid

• Establishment of safety and security

GOAL
Principal Interventions
Direct survivors to safe and secure areas If
first on-scene give direction to areas away
from life threatening danger, toxic and harsh
elements, and exposure to additional traumatic
stimuli.
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On scene Support and Psychological First Aid

• Stress-related reaction reduction

GOAL
Principal Interventions
Protect survivors from exposure to traumatic
stimuli Examples of traumatic
stimuli Witnessing grotesque death, dead bodies,
strong odors, frightening sounds (including those
from dying, injured, or emotionally distressed
survivors), and disturbing media coverage (e.g.,
extensive print media/television coverage).
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On-scene Support and Psychological First Aid

• Reducing stress-related reactions

GOAL
Principal Interventions
Educate survivors about common stress
reactions Mental health responders must become
familiar, (i.e., memorize) types of common and
acute stress reactions to be able to validate
survivor reactions and to be able to provide
anticipatory guidance about what survivors can
expect over the course of time in themselves,
significant others, and children.
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On-scene support and Psychological First Aid
GOAL

• Reducing stress-related reactions

Instruct survivors how to use breathing
techniques to lower arousal
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• Reducing stress-related reactions

GOAL
Coping With Distressing Intrusive
Thoughts Arrange an activity that orients the
individual to the the present, such as After
acknowledging distress, gently suggest an
activity (e.g., walking, washing face and hands,
deep breathing, eating), and redirect attention
to the experience of the activity to disrupt the
flow of intrusive thoughts or distressing
anxiety. Give person something to hold or to
touch, (e.g., a pen, a purse, a book, clothing,
chair) and ask him or her to describe what each
feels like. Give orientation to environment
(date, time, and place) and ask the person repeat
back his or her orientation to the environment.
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On-scene support and Psychological First Aid

• Reducing stress-related reactions

GOAL
Reframing cognitive distortions It is not
uncommon for clinicians to encounter survivors
who have quickly developed cognitive distortions
related to helplessness, fear, guilt, anger and
rage. Such encounters present an opportunity for
mental health responders to deliver an early
intervention, that is, cognitive restructuring or
reframing to counter such distortions.
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Reframing cognitive distortions
THEME Guilt and thoughts about self

• NEGATIVE THOUGHTS
• I was a coward.
• Because of me, other people died.
• I should this have gotten over this by now.

REFRAME You felt afraid, but your actions kept
you from further injury. Many factors beyond
your control resulted in the deaths that
occurred. You feel inpatient with yourself. It
takes time get through something like this.
Many other survivors are at the same place that
you are right now.
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Reframing cognitive distortions
Theme Helplessness and fear

• REFRAME
• You felt helpless, and your actions saved your
  life and it appears that you continue to help
  yourself.
• Fear is natural and helped you to survive.
  Gradually you can ease out of it.
• You feel it is important to protect your family.
  There will be times when you need to be on guard
  but there are times that when you wont. You
  dont always have to be on guard.

NEGATIVE THOUGHTS I was helpless then I wont be
able to cope with future events either. Its
unacceptable to experience fear The world is
extremely dangerous. I must constantly be on
guard to protect myself and family.
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Psychological First Aid

• Connection to restorative resources

GOAL
Principal Interventions
In addition to directing survivors to restorative
resources, there are times when the mental health
responder takes a more active role (than
conventional clinical work) to ensure the linkage
or connection to restorative resources.
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On-scene support and Psychological First Aid
GOAL

• Connection to restorative resources

• Examples of active help (i.e. problem solving)
• Helping survivor to obtain food, liquid,
  necessary clothing
• Helping survivor to replace or obtain new
  medications
• Arranging transportation for survivor to a
  shelter, emergency mental health services
  clinic (ER), or relief and information centers
• Helping survivor to connect to social support
  (family, significant others,
  friends) making phone calls for survivor
• Helping survivor to link to information providers
• Advocating on behalf of the survivor
• Referring survivor

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Psychological First Aid for Children Preschool
Through Second Grade

• Provide support, rest, comfort, food, opportunity
  to play
• or draw
• Reestablish adult protective shield reassure
  that adults will keep them safe and meet their
  needs
• Give repeated concrete clarifications for
  anticipated
• confusions
• Provide emotional labels for common reactions
• Help to verbalize general feelings/complaints so
  they will not feel alone with their feelings

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Psychological First Aid for Children Preschool
Through Second Grade

• Separate what happened from physical reminders
  (e.g., monkey-
• bars, parking lot) to counter children
  attributing magical
• qualities to traumatic reminders
• Encourage them to let their parents and teachers
  know when
• thoughts and feelings interfere with learning
• Provide consistent caretaking (e.g. assurance of
  being picked up
• from school, knowledge of caretakers
  whereabouts)
• Tolerate regressive symptoms in a time-limited
  manner
• Give explanations about the physical reality of
  death

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Psychological First Aid for Children Third
Through Fifth Grade

• Help to express their secretive imaginings about
  the event
• Help to identify and articulate traumatic
  reminders and anxieties
• encourage them not to generalize
• Permit them to talk and act it out address
  distortions, and
• acknowledge normality of feelings and reactions
• Encourage expression of fear, anger, sadness, in
  your supportive
• presence
• Encourage to let teachers know when thoughts and
  feelings interfere
• with learning
• Support them in reporting dreams, provide
  information about why we
• have bad dreams

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Psychological First Aid for Children Third
Through Fifth Grade

• Help to share worries reassurance with realistic
  information
• Help to cope with the challenge to their own
  impulse control (e.g.
• acknowledge It must be hard to feel so angry)
• Offer to meet with children and parent(s) to help
  children let parents
• know how they are feeling
• Encourage constructive activities on behalf of
  the injured or deceased
• Help to retain positive memories as they work
  through the more
• intrusive traumatic memories

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Psychological First Aid for Children Sixth Grade
and Up

• Encourage discussion of the event, feelings about
  it, and realistic
• expectations of what could have been done
• Help them understand the adult nature of these
  feelings
• Encourage peer understanding and support
• Help to understand their acting out behavior as
  an effort to numb their
• responses to, or to voice their anger over, the
  event
• Address the impulse toward reckless behavior in
  the acute aftermath
• link it to the challenge to impulse control
  associated with violence

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Psychological First Aid for Children Sixth Grade
and Up

• Discuss the expectable strain on relationships
  with family and peers
• Elicit their actual plans of revenge address the
  realistic consequences
• of these actions encourage constructive
  alternatives that lessen the traumatic sense of
  helplessness
• Link attitude changes to the events impact
• Encourage postponing radical decisions in order
  to allow time to work
• through their responses to the event and to
  grieve

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Student/Family Reunification Team

• Responsible for supervising the reunification
  site and the releasing of students to their
  parents/guardians
• Oversee location where students assemble
• Attend to student needs when providing shelter
• Reunite students with their parents or guardians
  in an efficient and orderly manner
• Materials needed Radios/pagers, cell phones,
  clipboards, paper, pens, markers, rosters,
  student emergency medical cards, yellow caution
  tape or portable plastic construction fencing

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Student/Family Reunification
Adult Report Point
Runner
Student Holding Area
Runner
Student Release Point
Mental Health Team
Security Team
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Student/Family Reunification
Adult Report Point
Runner
Student Holding Area
Runner
Student Release Point
Mental Health Team
Security Team
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Adult Report Point

• 2 or more members of the Student/Family
  Reunification Team will greet arriving adults
• Provide the adult a copy of the Student Release
  Form, adult completes the first section
• Confirm the adults id (government issued picture
  identification)
• Confirm that the adult is listed on the emergency
  data card for the student as being authorized to
  pick up the student
• Complete the second section of the Student
  Release Form, hand it to a Runner to be carried
  to the Student Holding Area
• Adult will step around to the Student Release
  Point and wait for the Runner to return

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Student/Family Reunification
Adult Report Point
Runner
Student Holding Area
Runner
Student Release Point
Mental Health Team
Security Team
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Student Holding Area

• Runner will deliver the Student Release Form to
  the 2 or more members working at the entrance to
  the Student Holding Area.
• If the requested student is present in the
  holding area
• Requested student will report to team members
• Record on roster that the student has been
  released
• Check off the Sent with Runner entry in the
  third section of the Student Release Form
• Send the student with a Runner to the Student
  Release Point
• If the student is not available for pickup or is
  missing
• Make the appropriate entry in third section of
  the Student Release Form
• Enter comments to clarify the status
• Runner will deliver the Student Release Form to
  the Student Release Point.

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Student/Family Reunification
Adult Report Point
Runner
Student Holding Area
Runner
Student Release Point
Mental Health Team
Security Team
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Student Release Point

• If the student is available for pickup
• When the Runner delivers the Student Release
  Form to the Student
• Release Point, the Team Members will call for
  the adult
• Adults id will again be confirmed (govt issued
  picture id)
• Adult will sign for the student and depart the
  area with the student
• If the student is not available for pickup
• Team member will link the adult with a MH Team
  Member
• MH team member will make the notification
  privately based on the information provided in
  the third section of the Student Release Form
• The MH Team will be responsible for helping the
  adult and finding answers to the resulting
  questions

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Psychological First Aid for the Bereaved

• Possible talking points
• When did you and your family get the news of the
  death(s)?
• How were you notified?
• Who told you?
• Are you in touch with relatives or friends who
  are able to provide emotional support and help?
• Do you need assistance in contacting relatives
  and friends either to notify them or ask for
  help.
• Have strategy in place to make it easier for
  contact. Have phones available in quiet place.

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Psychological First Aid for the Bereaved

• INITIAL CONTACT
• Do you know anyone who was killed or injured?
• Be prepared to be present with survivors intense
  emotions and stay with them as a steady and safe
  personal presence.
• Acknowledge the relationship and seriousness of
  the loss.

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Psychological first aid for the bereaved

• Things to Say and Do
• I am sorry that she/he is gone.
• I cant imagine what you are going through.
• Mention the name of the deceased during
  conversations.
• Continue to offer your presence to help.
• Acknowledge the degree of distress and painful
  emotion that the survivor is willing to express.
• Respect the way in which the survivor is coping
  with his/her emotions. Some avoidance and denial
  may be expected according to cultural or gender
  differences.

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Psychological first aid for the bereaved

• INITIAL CONTACT Things not to say
• I know how you feel.
• It was probably for the best.
• She/Hes happy now.
• It is Gods will.
• It was his or hers time to go.
• Lets change the subject.
• You should work towards getting over this/you are
  strong enough to deal with it.
• You should be glad the deceased passed quickly.

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Psychological first aid for the bereaved

• THINGS TO REMEMBER
• Respect individual timing
• Avoidance may be a way to cope with grief
  intensity
• Be ready to offer supportive listening
• Encourage bereaved to talk with other survivors
  who are suffering losses
• Enhance realistic beliefs
• Help the bereaved to identify their resilience
  including past successful coping, support and
  spirituality
• Encourage positive memories of the deceased

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Psychological first aid for the bereaved

• Educate
• Intense emotions may come and go like waves
• Self-care
• It is normal to feel and express intense emotions
  at this time
• Do not feel guilty to take a time-out to restore
  yourself
• Avoidance and distraction in the early stages can
  be positive coping tools in the early stages
• Make sure you are eating well
• Social support is important
• Do not feel bad calling on others for support for
  emotional comfort or current needs
• Give feedback to your supporters so that they
  know the best way to help you

86
Student Release Form
First section completed by the adult picking up a
student Please Print Students Name
__________________________________________________
________ Teacher ______________________________
Grade _________________________ Name of
Adult Picking Up the Student ____________________
___________________ ------------------------------
--------------------------------------------------
---------------------------------------------- To
be filled in by Reporting Point staff Proof of
I.D. Yes ______ No ______ Emergency
card gives permission for pickup by this adult
Yes ______ No ______ To be taken by
Runner -------------------------------------------
--------------------------------------------------
--------------------------------- Students
Status To be filled in by Holding Area staff Sent
with Runner ? Not Available for Release
? Absent ? First Aid ? Hospital ?
Missing ? Other Comments -------------------
--------------------------------------------------
--------------------------------------------------
------- To be filled in by Release Point
staff Confirm the student is being matched with
the correct adult. Have the requesting adult
sign for the student. Parent/Guardian/Care
Giver Signature _________________________________
_______ Date ___________________ Time
_____________________ Form adapted from
Multi-Hazard Emergency Planning for Schools
Participant Handbook, FEMA, p. E-12.
87
Child-Caregiver Reunification
Family Reunification as of time/date___________

88
Incident Management System
89
Requesting Support and Managing Resources
90
Multi-Level Intervention Options

• Tier 1 General School-Based Interventions
• Psychoeducation
• Coping Skills
• Support
• Tier 2 Specialized School-Based Interventions
• Trauma / Grief - Focused Counseling
• Group, Individual, Family
• Short-Term
• Tier 3 Specialized Community-Based
  Interventions
• Referral to On or Off-Site MH Services

91
Regional Homeland Security Mental Health
Activation
1. First Responder system or by Emergency
Management notifies the Red Cross 2. Red Cross
contacts Heart of America Family Services (HAFS)
- requests activation of the RHSMH Response
System. 3. HAFS contacts each agency and tells
them who to call at Red Cross and what telephone
numbers to use. 4. Each agency (including
HAFS) contacts Red Cross with their response
capability. 5. Responders from each agency
may be instructed to report to a designated
location or to be on stand by for activation
92
Team Exercise
Scenario 1 Your class has been evacuated to a
secure location. While the rest of the students
are asking you questions or talking amongst
themselves, you notice one student sitting
quietly apart from the group. This student does
not respond when you call his name.
93
Team Exercise
Scenario 2 You class has been evacuated to a
safe location. It seems likely that you all will
be in that location for several hours before the
students can be reunited with their parents. How
do you keep your class calm and pass the time?
94
Team Exercise
Scenario 3 During the crisis, one of your
students sustained a compound fracture in her
leg. She is crying uncontrollably. How do you
handle the situation?
95
Team Exercise
Scenario 4 The classrooms have been evacuated
to a safe location for a tornado, you notice a
fellow teacher across the room. This teacher
appears to be checking out, not responding to
student needs or giving the students directions.
What should you do?
96
Team Exercise
Scenario 5 There is a lockdown situation in
your school due to a possible armed intruder. You
are beginning to feel extremely panicked (heart
racing, sweating, difficulty breathing). What
should you do?
97
Extra Slides
98
Bioterrorism and Children

• Physical/Medical Considerations
• Increased respiratory exposure (? respiration,
  closer to ground)
• Gas masks risk of poor fit, suffocation
• Increased dermal exposure (thinner, more
  permeable skin)
• Problems using bleach solutions to decontaminate
• Increased risk of dehydration
• Increased risk of hypothermia during
  decontamination
• Increased susceptibility to certain agents

99
Bioterrorism and Children

• Emotional/Behavioral Considerations
• Agents may cause reactions that mimic psychiatric
  symptoms
• Less ability to escape physically
• Greater reliance on caregivers who may be injured
  or dead
• Fewer or less developed coping skills
• Greater anxiety over reported incidents, hoaxes,
  media coverage
• Difficulty adequately describing symptoms
• Problems understanding commands from safety
  personnel
• Scared of responders dressed in protective suits

100
Bioterrorism and Children

• Suggestions for Children and Painful Procedures
• Children show more distress behaviors with
  caregivers present, but they generally prefer to
  have caregivers present
• Distraction is more effective than reassuring
  children or providing no intervention in
  reducing distress
• Effective distractions appeal to multiple senses,
  motor skills
• playing with developmentally appropriate toy or a
  pager/flashlight as opposed to looking at a
  poster or listening to a story

101
Controlling Your Own Arousal

• Step 1 Slow Down (Take a Time Out Calm Your
  Body One Thought at a Time)
• Start by telling yourself Slow down--I can
  deal with this if I just do one thing a time.
• Step 2 Orient Yourself (Bring Your Mind Body
  Back to the Present Time/Place)
• Talk to yourself calmly and gently I can look
  around and see that Im in a safe and familiar
  place. I can feel my body sitting in this chair
  and feel the floor under my feet. I can see the
  people Im with, and I know who they are and that
  I can trust them.

102
Step 3 Self Check (How Much Distress? How Much
Control? The Worst Ever?) Ask yourself calmly
and supportively, Is this the worst Ive ever
felt? Are there still some ways in which I still
feel in control and can deal with this situation
effectively? Tell yourself, calmy and
supportively, If Ive gotten through other times
feeling as bad or worse than this, I can get
through this! I am still in control in some
important ways, so I can handle this! There are
people in my life who are helping me to get
through this okay!