Pediatric Disaster Behavioral Health (PDBH) Toolbox

3. The Toolbox - Implementation & Tactical Resources

3.3. Pediatric Disaster Behavioral Health (PDBH) – Operational Overview Table

Overview: This table serves as an expanded reference to support the operational implementation of the Pediatric Disaster Behavioral Health Framework. It outlines each PDBH goal, the broad response/recovery functions to support each goal, and the strategies, considerations, models, and tools to consider when implementing each function. In addition to providing recommendations and considerations, each section is embedded with links to examples and tools to support each function. “Functions” in this context refers to the grouping of structures, strategies, processes, resources, and personnel working to achieve a specific PDBH goal.

For additional references, tools, and examples, please see the Toolbox Overview at the start of the appendix section. For examples and recommendations on how to structure these efforts within response and recovery systems, please see the ICS & HICS Integration section.

PDBH Goals and Associated Functions

PDBH Goal & Associated PDBH Function	Key Considerations
PDBH Goal: Assess Impacts, Capacity, & Gaps Identify, characterize, and assess both the behavioral health impacts of an incident and the capacity of a children’s hospital-led response to provide care – both initially and over time. PDBH Function: Situational Awareness This function provides the means to capture, understand, and thus respond to the behavioral health impacts from a disaster. The primary objective of this function is to identify the initial and potential behavioral health impacts from an incident, monitor those impacts over time, identify existing/reduced/added capacity for care within the community, and identify gaps for response and recovery actions. Critically, this function disseminates this information to the disaster behavioral health and broader response efforts (including external partners) to inform response and recovery actions over time. *All other PDBH functions should be informed, both initially and over time, by what this function identifies in terms of estimated impacts and available services.*	Primary Components: Behavioral Health Impact Assessment: Forecasted/initial and ongoing impacts including but not limited to individual impact data (triage, emergency department (ED) visits/boarding, etc.), population-level data (behavioral health epidemiology, surveys, tax data, call lines, etc.), and forecasts based on prior research and data from similar incidents (synthesis of data, research, and expertise). Capacity Assessment: The existing capacity within the system and any reduction caused from the incident itself, new resources established and available due to the incident (call lines, support centers, expanded community services), and an evaluation of the gap between these available resources and the needs identified from impact assessments. Key tools to fulfill this role include: Behavioral Health Essential Elements of Information (several lists exist, an example of these elements) Behavioral Health Situational Report (public health example), to inform the response/community of the current status of behavioral health impacts Impact Forecast, which is used to inform the response/community of anticipated behavioral health impacts from the incident ASPR Disaster Behavioral Health Capacity Tool, to guide community/jurisdictional behavioral health capacity assessments. Implementation Notes: This function should be assigned to a specific person or team. There are multiple documented positions within Hospital/Incident Command System (HICS/ICS) that fit into this role. Specifically, within the Situation Unit in the Planning Section is a natural fit. Alternatively, this function can be embedded within a behavioral health operations team as an element from the Planning Section. This function can be filled by various types of expertise and data sources. For example, this may include primarily triage data from a tool like PsySTART, information about behavioral health boarders, crisis call numbers for the impacted area, or behavioral health epidemiology measures such as psychological distress. See the Triage vs Screening vs Assessment in Disasters or Mass Casualty Incidents (MCIs)appendix for a review of triage, screening, and assessment tools. Information approaches should be based on available data, incident needs, and timelines required for action. Consider potential Behavioral Health Essential Elements of Information (outlined above). Additionally, the Monitoring and Surveillance of Behavioral Health in the Context of Public Health Emergencies: A Toolkit for Public Health Officials by RAND Corporation provides an overview and potential approaches to population-level surveillance of behavioral health impacts from disasters.
PDBH Goal: Right Supports, Right Time Mitigate behavioral health impacts by providing the right level of support, at the right time, to both youth and responding personnel, and facilitate a transition to resilience for the community during recovery. PDBH Function: Care This function focuses on providing timely access to effective behavioral health care during disasters for survivors, responders, and the community. Specifically, this function involves removing/reducing barriers to behavioral health care (policy, regulatory, legal, telehealth, etc.), increasing capacity by providing additional services (crisis lines/community expansions/initiatives), and prioritizing/triaging existing resources to achieve the most good for the most kids. This requires early action to identify, prioritize, and address psychological needs. *The strategies taken, levels of support, and specific interventions should be informed by information gathered by the PDBH Situational Awareness Function.*	Primary Components: Audiences: youth/survivors, families/caregivers, and the responders/personnel (first-responders/facility staff/emergency management/community) within the children’s hospital-led response, as well as the overall community. Levels of support: Population-level support: Public education and skills building via training (e.g., Psychological First Aid, Listen Protect Connect, Skills for Psychological Recovery, Health Support Team) and public communication Individual-level support: Higher acuity interventions (beyond PFA/community-based supports) and surge management approaches within systems Timeliness: Immediate response: Early identification of potential psychological exposure, prioritization based on need, and appropriate provision of care is critical to mitigate long-term behavioral health impacts. This should occur within the first couple of months post-incident, if at all possible. Needs change over time: Behavioral health impacts and needs will change over time. These phases and transitions are covered in the Phase-based section of this Toolkit. 3 broad strategies to mitigate impacts: Reduce barriers to care: Policy, regulatory, legal, and other actions taken to reduce barriers to care, such as modifying requirements related to telehealth to improve access for rural communities. It may also include services that provide knowledge of the available resources, such as referral hotlines or navigators. Additionally, this includes both activities taken to maintain existing community capacity (e.g., providing personal protective equipment (PPE) during a pandemic to keep existing facilities open/healthy) or alter standards of care to improve access for those with critical needs (behavioral health crisis standards of care, such as delaying or suspending services for patients with mild or moderate symptoms and reserving care for high-acuity or severe cases). Critically, this includes ensuring ongoing access to psychiatric medication – see the Management of Prescription Medications of the SAMHSA Disaster Planning Handbook for Behavioral Health Service Programs for considerations and recommendations. Expand capacity to provide care: This is highly contextual depending on the incident and organization(s) responding and includes any activity taken to expand the capacity of behavioral health resources in the community. Often, this includes delivery of FEMA’s Crisis Counseling Program (in presidentially declared disasters), additional staff support for responding personnel, and services/supports provided by Voluntary Organizations Active in Disasters (VOADs) or Long-term Recovery Organizations (LTROs). Additionally, this may reflect additional services provided by the organization or community itself. See the Implementation Notes below for this function for specific models, tools, and interventions. Utilize existing resources effectively (surge management): Early prioritization and potential triage of limited services to achieve the greatest good for the greatest number of kids. This includes strategies such as psychological triage (e.g., PsySTART), stepped care, interagency activities such as load leveling and care/case coordination, in addition to other joint-response efforts to manage system-wide behavioral health surge. If utilized, psychological triage may rest within this function or the situational awareness function (both are ICS/HICS compatible strategies). Implementation Notes: The PDBH Care Guidelines outlines the considerations and broad approach to advance from initial impact evaluation, to identify potential care needs, and develop a service delivery approach. Models: Continuum of Behavioral Health Care Pediatric Psychosocial Preventative Health Model Stepped-Care approaches National Children’s Disaster Mental Health Concept of Operations, supporting Just-in-Time Checklist Structures and Systems: Interagency case coordination, such as Kids Mental Health WA Behavioral Health Navigator Teams Referral and resource hotlines 988 and other crisis lines such as the Crisis Counseling & Technical Assistance Program Resiliency centers, such as the Resiliency & Justice Center Reference the ICS/HICS Integration section for in-depth guidance on how to integrate into those systems ICS/HICS technical specialist approach to leverage pediatric behavioral health subject matter expertise within Incident Management Teams (IMTs) Tools, Trainings, and Supports: Triage, prioritization, and assessments - see the Triage vs Screening vs Assessment in Disasters or Mass Casualty Incidents (MCIs) appendix for a review of triage, screening, and assessment tools Disaster Behavioral Health Interventions Inventory Includes both trainings/supports that are appropriate to the broad population, and acute individual interventions Educational and guidance materials (pre-created and just-in-time), see the PDBH Resource Catalogue Disaster Behavioral Health trainings (see resource catalogue)
PDBH Goal: Educate Community, Inform Response Provide education and facilitate a “behavioral health-informed response” by providing subject matter expertise and resources to the impacted community, response staff and leadership, and relevant response functions PDBH Function: Education & Technical Assistance This function focuses on ensuring that the community, community leaders, and response/recovery efforts are informed with key disaster behavioral health concepts and resources. Specifically, this involves key disaster behavioral health subject matter experts providing technical assistance, training and presentations, and developing resources to empower disaster behavioral health informed strategies. This function will collaborate heavily with internal partners such as operational groups (e.g., behavioral health considerations for isolation/quarantine) and public communications (e.g., development of behavioral health messaging, informing other messages with behavioral health considerations), or with external groups such as Unified Command groups or governmental leadership (e.g., briefing on “key things to know” about behavioral health impacts from this incident). *Intended audiences, public communication strategies, and needed educational resources should be informed by the PDBH Situational Awareness Function.*	Primary Components: Trainings and presentations to increase core disaster behavioral health knowledge and other key concepts, such as trauma-informed care/principles Public communication consultations for disaster behavioral health messaging, and behavioral health informed messaging in general Resource development to communicate key information or actions (guidance, fact sheets, resource guides, etc.) Response consultations (internal and external): technical assistance provided by disaster behavioral health subject matter expert to inform response strategies or actions (e.g., how to support unaccompanied minors during family reunification, safety planning, education on coping skills, etc.) Implementation notes: Key examples of intersections: Public communications – for evidence-based, behavioral health informed guidance on how to support your children during this time, what to look for and when to seek professional help Operations – informing implementation of operational strategies such as isolation and quarantine with key behavioral health considerations and concerns Staff Safety/Wellness – Responder wellness considerations and protocols such as work to rest ratios, Employee Assistance Programs, etc.) Leadership – Awareness of disaster behavioral health impacts on the community behavioral health and related response and recovery considerations Audiences for this function are broad and include the internal response, internal leadership, responders/staff including leadership, survivors, the community at large, and community leadership. Each element of the function described above can potentially be applied to each audience. For example, internal response teams may need consultation on how to prepare for behavioral health needs (such as during decontamination or reunification) while leadership may want to understand how to mitigate staff behavioral health impacts. Education, training, and public communication approaches, particularly those that build skills/capacity within a community, become more critical as the gap between resources and needs grows in an incident. These approaches allow the ability to significantly scale the subject matter expertise of a few individuals via presentations, trainings (particularly those with train-the-trainer components), and public messaging resources. When effective, these activities will ideally reduce impacts for lower acuity patients and reduce demand for higher acuity services.
PDBH Goal: Coordinate Internally & Externally Coordinate children’s hospital-led, behavioral health response and recovery activities across all engaged entities to develop a unified response for the impacted community, reduce duplication of services and unmet needs, and remove silos to improve access to behavioral health care and supports. PDBH Function: Coordination This includes all activities taken to plan and coordinate disaster behavioral health response and recovery internally and externally. This may be achieved through formal systems, such as ICS/HICS or Emergency Support Functions (e.g., ESF#8), or through informal systems based on the incident and readiness of the impacted community. This is often the function of emergency management within the context of disaster behavioral health. This function should both share information gathered by the PDBH Situational Awareness Function with internal and external partners as appropriate, while also providing information shared by partners to the rest of the PDBH response/recovery operation.	Primary Components: Develop broad response/recovery strategies and implementation planning. Coordinate internal and external components of disaster behavioral health response. Support ICS/HICS/ESF/RSF components, coordinate collaboration and support to those entities Secure needed support for team operations. Manage reporting to leadership. Implementation notes: ICS/HICS Incident Action Planning Process: This is fully compatible with this disaster behavioral health framework and is considered a best practice for effective response and recovery activities. ICS is a required component of most governmental response efforts, and many organizations utilize HICS for health care response activities. This toolkit provides a compatible PDBH Operational Planning Process. This function is essentially the coordination/management element of disaster behavioral health and maps directly to similar roles for other response functions. Within ICS/HICS, this role may be reflected either as a Task Force Leader, Group Supervisor, or Branch Director within the Operations Section depending on the size and scope of the incident and response efforts. During recovery periods, these functions may be represented via established recovery coalitions, in Recovery Support Functions (RSFs), or may be conducted by the “day-to-day” departments which provide this care.

PDBH Goal & Associated PDBH Function

Key Considerations

PDBH Goal: Assess Impacts, Capacity, & Gaps

Identify, characterize, and assess both the behavioral health impacts of an incident and the capacity of a children’s hospital-led response to provide care – both initially and over time.

PDBH Function: Situational Awareness

This function provides the means to capture, understand, and thus respond to the behavioral health impacts from a disaster.

The primary objective of this function is to identify the initial and potential behavioral health impacts from an incident, monitor those impacts over time, identify existing/reduced/added capacity for care within the community, and identify gaps for response and recovery actions.

Critically, this function disseminates this information to the disaster behavioral health and broader response efforts (including external partners) to inform response and recovery actions over time.

All other PDBH functions should be informed, both initially and over time, by what this function identifies in terms of estimated impacts and available services.

Primary Components:

Behavioral Health Impact Assessment: Forecasted/initial and ongoing impacts including but not limited to individual impact data (triage, emergency department (ED) visits/boarding, etc.), population-level data (behavioral health epidemiology, surveys, tax data, call lines, etc.), and forecasts based on prior research and data from similar incidents (synthesis of data, research, and expertise).
Capacity Assessment: The existing capacity within the system and any reduction caused from the incident itself, new resources established and available due to the incident (call lines, support centers, expanded community services), and an evaluation of the gap between these available resources and the needs identified from impact assessments.
Key tools to fulfill this role include:
- Behavioral Health Essential Elements of Information (several lists exist, an example of these elements)
- Behavioral Health Situational Report (public health example), to inform the response/community of the current status of behavioral health impacts
- Impact Forecast, which is used to inform the response/community of anticipated behavioral health impacts from the incident
- ASPR Disaster Behavioral Health Capacity Tool, to guide community/jurisdictional behavioral health capacity assessments.

Implementation Notes:

This function should be assigned to a specific person or team. There are multiple documented positions within Hospital/Incident Command System (HICS/ICS) that fit into this role. Specifically, within the Situation Unit in the Planning Section is a natural fit. Alternatively, this function can be embedded within a behavioral health operations team as an element from the Planning Section.
This function can be filled by various types of expertise and data sources. For example, this may include primarily triage data from a tool like PsySTART, information about behavioral health boarders, crisis call numbers for the impacted area, or behavioral health epidemiology measures such as psychological distress. See the Triage vs Screening vs Assessment in Disasters or Mass Casualty Incidents (MCIs)appendix for a review of triage, screening, and assessment tools.
Information approaches should be based on available data, incident needs, and timelines required for action. Consider potential Behavioral Health Essential Elements of Information (outlined above). Additionally, the Monitoring and Surveillance of Behavioral Health in the Context of Public Health Emergencies: A Toolkit for Public Health Officials by RAND Corporation provides an overview and potential approaches to population-level surveillance of behavioral health impacts from disasters.

PDBH Goal: Right Supports, Right Time

Mitigate behavioral health impacts by providing the right level of support, at the right time, to both youth and responding personnel, and facilitate a transition to resilience for the community during recovery.

PDBH Function: Care

This function focuses on providing timely access to effective behavioral health care during disasters for survivors, responders, and the community.

Specifically, this function involves removing/reducing barriers to behavioral health care (policy, regulatory, legal, telehealth, etc.), increasing capacity by providing additional services (crisis lines/community expansions/initiatives), and prioritizing/triaging existing resources to achieve the most good for the most kids. This requires early action to identify, prioritize, and address psychological needs.

The strategies taken, levels of support, and specific interventions should be informed by information gathered by the PDBH Situational Awareness Function.

Primary Components:

Audiences: youth/survivors, families/caregivers, and the responders/personnel (first-responders/facility staff/emergency management/community) within the children’s hospital-led response, as well as the overall community.
Levels of support:
- Population-level support: Public education and skills building via training (e.g., Psychological First Aid, Listen Protect Connect, Skills for Psychological Recovery, Health Support Team) and public communication
- Individual-level support: Higher acuity interventions (beyond PFA/community-based supports) and surge management approaches within systems
Timeliness:
- Immediate response: Early identification of potential psychological exposure, prioritization based on need, and appropriate provision of care is critical to mitigate long-term behavioral health impacts. This should occur within the first couple of months post-incident, if at all possible.
- Needs change over time: Behavioral health impacts and needs will change over time. These phases and transitions are covered in the Phase-based section of this Toolkit.
3 broad strategies to mitigate impacts:
- Reduce barriers to care: Policy, regulatory, legal, and other actions taken to reduce barriers to care, such as modifying requirements related to telehealth to improve access for rural communities. It may also include services that provide knowledge of the available resources, such as referral hotlines or navigators. Additionally, this includes both activities taken to maintain existing community capacity (e.g., providing personal protective equipment (PPE) during a pandemic to keep existing facilities open/healthy) or alter standards of care to improve access for those with critical needs (behavioral health crisis standards of care, such as delaying or suspending services for patients with mild or moderate symptoms and reserving care for high-acuity or severe cases). Critically, this includes ensuring ongoing access to psychiatric medication – see the Management of Prescription Medications of the SAMHSA Disaster Planning Handbook for Behavioral Health Service Programs for considerations and recommendations.
- Expand capacity to provide care: This is highly contextual depending on the incident and organization(s) responding and includes any activity taken to expand the capacity of behavioral health resources in the community. Often, this includes delivery of FEMA’s Crisis Counseling Program (in presidentially declared disasters), additional staff support for responding personnel, and services/supports provided by Voluntary Organizations Active in Disasters (VOADs) or Long-term Recovery Organizations (LTROs). Additionally, this may reflect additional services provided by the organization or community itself. See the Implementation Notes below for this function for specific models, tools, and interventions.
- Utilize existing resources effectively (surge management): Early prioritization and potential triage of limited services to achieve the greatest good for the greatest number of kids. This includes strategies such as psychological triage (e.g., PsySTART), stepped care, interagency activities such as load leveling and care/case coordination, in addition to other joint-response efforts to manage system-wide behavioral health surge. If utilized, psychological triage may rest within this function or the situational awareness function (both are ICS/HICS compatible strategies).

Implementation Notes:

The PDBH Care Guidelines outlines the considerations and broad approach to advance from initial impact evaluation, to identify potential care needs, and develop a service delivery approach.
Models:
Structures and Systems:
- Interagency case coordination, such as Kids Mental Health WA Behavioral Health Navigator Teams
- Referral and resource hotlines
- 988 and other crisis lines such as the Crisis Counseling & Technical Assistance Program
- Resiliency centers, such as the Resiliency & Justice Center
- Reference the ICS/HICS Integration section for in-depth guidance on how to integrate into those systems
- ICS/HICS technical specialist approach to leverage pediatric behavioral health subject matter expertise within Incident Management Teams (IMTs)
Tools, Trainings, and Supports:
- Triage, prioritization, and assessments - see the Triage vs Screening vs Assessment in Disasters or Mass Casualty Incidents (MCIs) appendix for a review of triage, screening, and assessment tools
- Disaster Behavioral Health Interventions Inventory
  - Includes both trainings/supports that are appropriate to the broad population, and acute individual interventions
- Educational and guidance materials (pre-created and just-in-time), see the PDBH Resource Catalogue
- Disaster Behavioral Health trainings (see resource catalogue)

PDBH Goal: Educate Community, Inform Response

Provide education and facilitate a “behavioral health-informed response” by providing subject matter expertise and resources to the impacted community, response staff and leadership, and relevant response functions

PDBH Function: Education & Technical Assistance

This function focuses on ensuring that the community, community leaders, and response/recovery efforts are informed with key disaster behavioral health concepts and resources. Specifically, this involves key disaster behavioral health subject matter experts providing technical assistance, training and presentations, and developing resources to empower disaster behavioral health informed strategies.

This function will collaborate heavily with internal partners such as operational groups (e.g., behavioral health considerations for isolation/quarantine) and public communications (e.g., development of behavioral health messaging, informing other messages with behavioral health considerations), or with external groups such as Unified Command groups or governmental leadership (e.g., briefing on “key things to know” about behavioral health impacts from this incident).

Intended audiences, public communication strategies, and needed educational resources should be informed by the PDBH Situational Awareness Function.

Primary Components:

Trainings and presentations to increase core disaster behavioral health knowledge and other key concepts, such as trauma-informed care/principles
Public communication consultations for disaster behavioral health messaging, and behavioral health informed messaging in general
Resource development to communicate key information or actions (guidance, fact sheets, resource guides, etc.)
Response consultations (internal and external): technical assistance provided by disaster behavioral health subject matter expert to inform response strategies or actions (e.g., how to support unaccompanied minors during family reunification, safety planning, education on coping skills, etc.)

Implementation notes:

Key examples of intersections:
- Public communications – for evidence-based, behavioral health informed guidance on how to support your children during this time, what to look for and when to seek professional help
- Operations – informing implementation of operational strategies such as isolation and quarantine with key behavioral health considerations and concerns
- Staff Safety/Wellness – Responder wellness considerations and protocols such as work to rest ratios, Employee Assistance Programs, etc.)
- Leadership – Awareness of disaster behavioral health impacts on the community behavioral health and related response and recovery considerations
Audiences for this function are broad and include the internal response, internal leadership, responders/staff including leadership, survivors, the community at large, and community leadership. Each element of the function described above can potentially be applied to each audience. For example, internal response teams may need consultation on how to prepare for behavioral health needs (such as during decontamination or reunification) while leadership may want to understand how to mitigate staff behavioral health impacts.
Education, training, and public communication approaches, particularly those that build skills/capacity within a community, become more critical as the gap between resources and needs grows in an incident. These approaches allow the ability to significantly scale the subject matter expertise of a few individuals via presentations, trainings (particularly those with train-the-trainer components), and public messaging resources. When effective, these activities will ideally reduce impacts for lower acuity patients and reduce demand for higher acuity services.

PDBH Goal: Coordinate Internally & Externally

Coordinate children’s hospital-led, behavioral health response and recovery activities across all engaged entities to develop a unified response for the impacted community, reduce duplication of services and unmet needs, and remove silos to improve access to behavioral health care and supports.

PDBH Function: Coordination

This includes all activities taken to plan and coordinate disaster behavioral health response and recovery internally and externally. This may be achieved through formal systems, such as ICS/HICS or Emergency Support Functions (e.g., ESF#8), or through informal systems based on the incident and readiness of the impacted community.

This is often the function of emergency management within the context of disaster behavioral health.

This function should both share information gathered by the PDBH Situational Awareness Function with internal and external partners as appropriate, while also providing information shared by partners to the rest of the PDBH response/recovery operation.

Primary Components:

Develop broad response/recovery strategies and implementation planning.
Coordinate internal and external components of disaster behavioral health response.
- Support ICS/HICS/ESF/RSF components, coordinate collaboration and support to those entities
Secure needed support for team operations.
Manage reporting to leadership.

Implementation notes:

ICS/HICS Incident Action Planning Process: This is fully compatible with this disaster behavioral health framework and is considered a best practice for effective response and recovery activities. ICS is a required component of most governmental response efforts, and many organizations utilize HICS for health care response activities. This toolkit provides a compatible PDBH Operational Planning Process.
This function is essentially the coordination/management element of disaster behavioral health and maps directly to similar roles for other response functions.
Within ICS/HICS, this role may be reflected either as a Task Force Leader, Group Supervisor, or Branch Director within the Operations Section depending on the size and scope of the incident and response efforts. During recovery periods, these functions may be represented via established recovery coalitions, in Recovery Support Functions (RSFs), or may be conducted by the “day-to-day” departments which provide this care.