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Office of Human Services Emergency Preparedness and Response
National Commission on Children and Disasters: 2010 Report to the President and Congress

2. Mental Health

Recommendation 2.1: HHS should lead efforts to integrate mental and behavioral health for children into public health, medical, and other relevant disaster management activities.
  • Congress should direct HHS to lead the development of a disaster mental and behavioral health Concept of Operations (CONOPS) to formalize disaster mental and behavioral health as a core component of disaster preparedness, response, and recovery efforts.

Children are particularly vulnerable to the mental health impact of disasters and lack the experience, skills, and resources to independently meet their mental and behavioral health needs.42 Mental and behavioral health effects are of specific concern in children of all ages due to the likelihood of lasting reactions.43 Studies show that following disasters many children experience academic failure, post-traumatic stress disorder (PTSD), depression, anxiety, bereavement, and other behavioral problems such as delinquency and substance abuse.44,45,46 A report by the National Center for Disaster Preparedness on the impact of the 2010 Gulf of Mexico oil spill disaster on children and families estimated that over 19 percent of the pediatric population in coastal Louisiana and Mississippi experienced emotional or behavioral distress related to the oil spill.47 However, as indicated in the Commission's Interim Report, the mental health effects of disasters are typically overlooked in disaster management and often are not considered until well after an event when it is too late to affect optimal response or recovery efforts.48 A greater focus on the disaster mental and behavioral health needs of children is necessary throughout Federal, State, and local preparedness activities, including planning, training, and exercises, and response and recovery efforts.

The Commission recommends that Congress direct the Department of Health and Human Services (HHS) to develop a disaster mental health Concept of Operations (CONOPS) to formalize disaster mental and behavioral health as a core component of disaster preparedness, response, and recovery efforts. The CONOPS would establish a national disaster mental health strategy and identify goals and activities necessary for building local, State, and Federal disaster mental and behavioral health capabilities for children and families in disaster preparedness, response, and recovery. The CONOPS would also outline the coordination of Federal and non-Federal disaster mental health capabilities and programs for children and families. Both the Commission, in its Interim Report, and the National Biodefense Science Board have previously recommended that HHS develop a disaster mental health CONOPS. HHS, in response to the Commission's request for information on progress in implementing its Interim Report recommendations, reported that the development of a disaster mental health CONOPS requires the designation of a lead agency with requisite authority and funding.49

Recommendation 2.2: HHS should enhance the research agenda for children's disaster mental and behavioral health, including psychological first aid, cognitive-behavioral interventions, social support interventions, bereavement counseling and support, and programs intended to enhance children's resilience in the aftermath of a disaster.
  • HHS should convene a working group of children's disaster mental health and pediatric experts to review the research portfolios of relevant agencies, identify gaps in knowledge, and recommend a national research agenda across the full spectrum of disaster mental health for children and families.

Although research has repeatedly documented the adverse impact of trauma and loss on children, little research exists evaluating the effectiveness of services and interventions to address these impacts.50 As noted in the Commission's Interim Report, evidence suggests that some commonly used interventions, such as critical incident stress debriefing or management, are not effective and may instead be damaging, especially when used with children.51,52 Even less research has been conducted regarding the effectiveness of services and interventions for grieving children or those experiencing adjustment problems related to other stressors prevalent in the aftermath of a disaster. A new, expanded national agenda for disaster mental health research is necessary to prioritize and facilitate exploration of the full spectrum of mental health services for children and families.

The Commission recommends that a working group of children's disaster mental health and pediatric experts be convened to review the research portfolios of relevant agencies that fund Federal research. The working group would identify gaps in knowledge, areas of recent progress, and priorities for research. The goal is to ensure that the full spectrum of disaster mental and behavioral health is addressed within this research portfolio, including, but not limited to, psychological first aid, cognitive-behavioral interventions (including those that can be delivered to children in schools and other group settings), social support interventions, bereavement counseling and support, and programs intended to enhance children's resilience in the aftermath of disaster.

A priority of this effort should be to support research that further defines resilience and evaluates the effectiveness of resilience programs and support services for children and communities recovering from disasters. "Resilience and Sustainability" is identified as one of nine core principles of recovery in the draft National Disaster Recovery Framework, which links resilience building efforts with the capacity of communities to recover from future disasters.53 However, little is known about the characteristics that make children and communities resilient or the effectiveness of various programs that purport to build or enhance resilience.

The National Institutes of Health (NIH) expressed support for the establishment of the proposed working group. NIH also indicated that an opportunity to conduct an annual review of research on children's disaster and mental health research may be available via the Behavioral and Social Science Consortium. The Commission recommends that NIH vigorously pursue these opportunities in partnership with the Substance Abuse & Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), the HHS Assistant Secretary for Preparedness and Response (ASPR), and, as appropriate, the Federal Emergency Management Agency (FEMA).

Recommendation 2.3: Federal agencies and non-Federal partners should enhance predisaster preparedness and just-in-time training in pediatric disaster mental and behavioral health, including psychological first aid, bereavement support, and brief supportive interventions, for mental health professionals and individuals, such as teachers, who work with children.

As a result of limited access to formal mental health services and treatment following a disaster, communities depend on persons who are not mental health professionals but who routinely interact with children—such as teachers and school staff, first responders, health care professionals, child care and early education providers, child welfare and juvenile justice professionals, and members of the faith-based community—to provide basic support services and brief interventions. As indicated in the Commission's Interim Report, these individuals must have basic knowledge of how to recognize signs of distress, assist children in adjusting and coping, and identify children who require more advanced care.54

The Commission continues to recommend that professionals and others who work with children receive basic training in a range of disaster mental and behavioral health issues, to include psychological first aid, cognitive-behavioral interventions, social support interventions, and bereavement counseling and support. Mental health professionals, including those working in schools and other child congregate care settings, must also receive adequate training related to disaster mental health care for children.

Optimally, training for mental health professionals and other individuals who work with children should be provided prior to an event, since supportive services should begin during the disaster or in the immediate aftermath. Finding adequate time and resources for staff to receive training in the immediate aftermath of a disaster is difficult. Staff, who may be affected by the disaster themselves, will likely have to attend to a range of increased demands in adverse conditions. At the Commission's January 2010 field visit to Iowa, school officials expressed the need for pre-event training for school and mental health officials.55

The Commission's Progress Report notes that, through the Crisis Counseling Assistance and Training Program (CCP), personnel at schools and faith-based organizations have received just-in-time training after disasters on providing support to children and families.56 While these efforts are important, the Commission urges HHS, FEMA, the Department of Education, and the Department of Justice to expand efforts to provide pediatric disaster mental and behavioral health training, both before and after disasters, to a larger consortium of professionals and other individuals who work with children.

Recommendation 2.4: DHS/FEMA and SAMHSA should strengthen the Crisis Counseling Assistance and Training Program (CCP) to better meet the mental health needs of children and families.
  • Simplify the Immediate Services Program (ISP) grant application to minimize the burden on communities affected by a disaster and facilitate the rapid allocation of funding and initiation of services.
  • Establish the position of Children's Disaster Mental Health Coordinator within State level CCPs.
  • Formally modify the CCP model to indicate and promote "enhanced services" where the mental health impact is unlikely to be adequately addressed by "typical" CCP services.
  • Include bereavement support and education within services typically provided under the CCP.

CCP is a post-disaster grant program administered by FEMA and SAMHSA and awarded to State mental health agencies or other local or private mental health organizations. CCP provides Federal funding to help States relieve mental health problems caused or aggravated by major disasters through the provision of "professional counseling services."57,58 The current CCP model is designed to address the short-term mental health needs of children and adults affected by disasters by supporting services focusing on individual and group counseling, education and referrals, and training of lay-person or "paraprofessional" counselors.59 CCP does not provide mental health treatment or substance abuse services.60

CCP should be strengthened to better meet the needs of children, families, and communities affected by disasters. Several States have encountered challenges applying for CCP funding, implementing programs, and assisting people who need more intensive services than those traditionally provided through CCP.61,62

The Commission recommends that FEMA and SAMHSA simplify the CCP application process. To receive CCP funding from FEMA following a Presidentially declared disaster, States must first apply for an immediate grant and, if there is a continuing need, a longerterm grant.63 The Immediate Services Program (ISP) grant funds CCP services for up to 60 days following a disaster declaration, while the Regular Services Program (RSP) grant can help States meet service needs for an additional nine months.64 To apply for the ISP grant, States must, within 14 days of the disaster declaration, submit a formula-based needs assessment documenting the inadequacy of their available resources and presenting a plan for service delivery.65 States with a continuing need for CCP services must submit an additional application for an RSP within 60 days of the declaration.66

In 2008, the Government Accountability Office (GAO) chronicled the experiences of six States in obtaining and using CCP grants to respond to either 9/11 or Hurricane Katrina and found that all six States encountered difficulties in collecting information required for their ISP applications within established deadlines and in preparing parts of their ISP applications.67 Officials indicated to GAO "that the amount of information required for their applications was difficult to collect because of the scope of the disasters and the necessity for responding on other fronts, such as ensuring the safety of patients and personnel at State-run mental health facilities."68 Several State officials also noted that in the immediate aftermath of a catastrophic disaster, preliminary damage assessments, the location of people in need of services, and other information required for the ISP application is not always available or reliable.69 Although Federal agency officials reported to GAO that changes were implemented in 2007 to decrease information requirements in the ISP and RSP applications, revise the needs assessment formula, and clarify the applications and corresponding guidance,70 Iowa officials reported many of the same challenges in applying for and implementing their State CCP program in response to a series of tornadoes and floods in 2008.71

The Commission recommends that FEMA and SAMHSA, with input from States, simplify the ISP application so that it can be easily completed in the aftermath of a disaster. In addition, States may benefit by developing a generic plan for the ISP phase of their program prior to an event, so that it can be pre-approved by FEMA and SAMHSA. In this manner, funds could be immediately allocated based on a pre-identified formula using certain measurable benchmarks related to the damage and the affected population. This would reduce the burden on affected States and communities and promote the immediate allocation of funding and initiation of services. If States find that there is a continuing need for services past the initial 60 day phase supported by the ISP, they would then still apply for the additional longer-term RSP grant, at which time they would have a more informed idea of the particular needs of their population and program modifications needed to better address those needs.

Any CCP needs assessment or funding formula should include the presence of population groups, such as children, who are at increased risk for psychological distress. Officials in State programs reviewed by the GAO expressed concern that the CCP application's needs assessment formula did not capture data on the percentage of children and other particularly vulnerable groups in the affected population, which they considered to be critical in assessing communities' mental health needs.72

To further ensure that the needs of children are not overlooked, the Commission recommends that State-level CCP programs establish a Children's Mental Health Coordinator position. After a request from the State-level program in Iowa and much negotiation, this position was created and funded within Project Recovery Iowa to provide specific support and oversight of the services offered to children and to ensure that developmentally-appropriate training and materials were provided to crisis counselors.73 This position also helped to ensure that a focus was placed on children in the service delivery model and that their unique needs and sensitivities were taken into account.74 FEMA and SAMHSA should support the institutionalization of this position in other State programs by incorporating the position into guidance and automatically funding it, without a State having to negotiate for its creation.

With regard to the scope of services provided under the CCP, the Commission recommends a formal enhancement of the current CCP model to better serve children and families with mental health impacts that are more serious than what CCP was designed to address. The scope of CCP's services does not include "long term, formal mental health services such as medications, office-based therapy, diagnostic services, psychiatric treatment, or substance abuse treatment."75 Rather, CCP services are designed to be delivered in familiar community settings by teams of non-mental health providers from the community (paraprofessionals), who are trained by mental health professionals with specialized mental health or counseling training.76 Children and families in need of treatment are intended to be referred to existing service systems.77

Although CCP provides referrals for treatment services, children and families often have limited access to traditional mental health providers due to a chronic shortage of mental health providers,78 and limited insurance coverage in connection with mental health and substance abuse services.79 Mississippi officials implementing the State-level CCP after Hurricane Katrina reported to the GAO that they wanted to serve as many people as possible because fewer providers were available to accept referrals.80 According to New York, Louisiana, and Mississippi officials who spoke with the GAO, CCP clients could have benefited from improved crisis counseling beyond the CCP model whether or not they displayed symptoms indicating the need for referrals.81

In response to requests from New York, Louisiana, and Mississippi to allow their CCPs to offer enhanced services, FEMA and SAMHSA permitted the development of pilot programs offering enhanced crisis counseling services "consistent with the non-clinical, short-term focus of the CCP model."82,83 New York's enhanced services after 9/11 were provided by mental health professionals based on cognitive behavioral approaches and included up to 12 counseling sessions to help individuals referred for enhanced services develop skills to cope with anxiety, depression, or other symptoms of post-disaster stress.84 In Louisiana and Mississippi, individuals who were referred for enhanced services following Hurricane Katrina were provided services by mental health professionals in a single "stand-alone" session.85 However, if needed, clients could obtain additional enhanced sessions or referrals for mental health and substance abuse treatment services.86

The Commission urges FEMA and SAMHSA to formally modify the current CCP model to include the provision of "enhanced services" in large-scale disasters where the mental health impact is unlikely to be adequately addressed by "typical" CCP services. In February 2008, the GAO recommended that FEMA and SAMHSA expeditiously "determine what types of [enhanced] crisis counseling services should be formally incorporated into CCP and make necessary revisions to program policy."87 In response, FEMA and SAMHSA officials indicated they intended to consider incorporating certain types of enhanced services into the CCP model.88 However, no form of enhanced services has yet been codified or communicated to communities as a program enhancement that can be made available after a disaster.

Without enhanced services being formally incorporated into the CCP model, some States or communities may lack knowledge of the potential availability of enhanced services and therefore may not request or plan to provide them. Institutionalizing the availability of enhanced services by formally incorporating them into the CCP model for disasters where the mental health impact is unlikely to be adequately addressed by "typical" CCP services would enable any State to more effectively prepare prior to a disaster, develop their CCP proposals, and provide their populations with needed counseling services.

Finally, while the CCP does provide a means to address bereavement support, the services reflect a focus on trauma treatment. Reliance on a professional network that has an exclusive trauma focus to provide technical assistance, support, and just-in-time training has resulted in limited attention to bereavement support outside the context of addressing trauma syndromes or symptoms. The inclusion of broader bereavement subject matter expertise is a critical gap, and more conscious and thoughtful attention to bereavement support within outreach, education, and counseling services delivered through the CCP would be an important step toward addressing broader disaster mental health needs of children and families.

Recommendation 2.5: Congress should establish a single, flexible grant funding mechanism to specifically support the delivery of mental health treatment services that address the full spectrum of behavioral health needs of children including treatment of disaster-related adjustment difficulties, psychiatric disorders, and substance abuse.

Despite the existence of CCP and other Federal assistance programs, the Commission remains concerned that the mental health needs of many children and families affected by disasters will go unmet. As the Congressional Research Service noted in a 2006 report: "Survivors of a disaster often need a range of mental health services that go beyond those provided for by CCP, which only provides referral to mental health services."89 Without additional assistance to address barriers to mental health treatment for children, which commonly preexist disasters and preclude surge capacity thereafter, many children will be unable to access the treatment they need.

As previously noted, children often go without needed mental health services on a daily basis due to a chronic shortage of pediatric mental health professionals90 and limited insurance reimbursement for these services.91 This gap worsens following disasters because of increased demand, limited surge capacity among providers, limited transportation, and other competing family recovery needs.92,93 Resources must be provided to ensure that children have access to immediate and long-term mental health interventions following disasters in order to address disaster-caused mental health issues, as well as pre-existing mental health conditions exacerbated by the disaster.

The Commission recommends that Congress authorize and provide appropriations to support a single, flexible grant funding mechanism with the specific purpose of addressing barriers to mental health treatment services for children following disasters. Congress may choose to modify and adequately appropriate funds through an existing grant program such as SAMHSA Emergency Response Grants or authorize a new grant program for use after Presidentially declared disasters.94

Adequate funding should be targeted to States and communities in need, for the specific purpose of supporting disaster mental health treatment services immediately following a Presidentially declared disaster and throughout long-term recovery efforts. After catastrophic disasters such as Hurricane Katrina and 9/11, a variety of different established programs, such as block grants and other ad hoc grants, have provided pools of funding to States from which funds could be used to support mental health services. However, States recovering from disasters face many competing priorities and may not choose to expend funds on mental health services, which often do not receive attention equivalent to that given to other health needs.

Funding should be used to support the full range of mental health and substance abuse treatment services that are not covered by the CCP, including the treatment of disaster-related adjustment difficulties such as bereavement; psychiatric disorders such as PTSD and acute trauma syndromes, depression, and anxiety; substance abuse; and psychotropic medication expenses. Funds should also support the anticipated increase in mental health services after a disaster that may be required for children with mental health problems that predated the disaster.

Furthermore, the funding mechanism must provide sufficient flexibility to address other barriers that prevent access to services such as a lack of mental health providers and transportation. For example, State and local governments must have the ability to use grant funds to hire additional mental health providers and train mental health providers in disaster mental health for children.

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