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Pediatric Behavioral Health in Disasters

5. Mitigation

5.3. Catastrophic Events: Behavioral Health Considerations in the Medical Home

Eva Johnson, M.D.

Objectives

  1. Identify three behavioral health interventions that can be incorporated into a primary care office’s disaster mitigation or preparedness plan.
  2. Identify three opportunities for behavioral health clinicians and primary care providers to partner in supporting the disaster-related mental health needs of patients and staff.

Introduction

As the United States is increasingly affected by large-scale disasters and catastrophic events, behavioral health clinicians and pediatric primary care providers have opportunities to optimize patient care throughout the disaster cycle.

Children are particularly vulnerable during disasters, making it essential for disaster plans to address their specific needs. Although pediatric primary care offices may have plans for maintaining clinical operations, many plans do not adequately address patients’ mental health needs.

This article describes how behavioral health clinicians and primary care providers can collaborate throughout the disaster cycle to mitigate the psychological effects of disasters on children.

Building a Primary Care and Behavioral Health Partnership

Combining the expertise of primary care providers and behavioral health specialists can improve the integration of behavioral health interventions into disaster planning and response.

Begin by using existing collaborative-care relationships or connections established through shared patients. If no relationship exists, contact a local health system, health department, or disaster-response agency that can help facilitate connections.

Local partnerships can strengthen disaster response while also improving communication and collaboration for shared patients during routine operations.

Mitigation: Minimizing the Impact of Disasters

The mental health effects of a disaster may be reduced when children and caregivers begin with a strong mental health foundation. Routine screening supports earlier identification of common mental health conditions, including anxiety and depression, and allows families to connect with evidence-based interventions.

Patients already engaged with mental health services may be better prepared to manage disaster-related stressors. Screening for adverse childhood experiences and health-related social needs can also identify factors that affect resilience and connect families with community resources before a disaster occurs.

Mental Health Screening

Trauma and Health-Related Social Needs Screening

Behavioral health clinicians can also educate primary care providers about strategies that promote resilience, including:

  • Positive parenting practices that strengthen secure attachment, confidence, and caring relationships.
  • Stress-management skills that support emotional regulation.
  • Strategies that promote family, peer, and community connection.

Preparedness: Planning and Training

Every primary care office should maintain a disaster-preparedness plan. Plans commonly address vaccine storage, tiered operations, communication with patients and staff, and office and household emergency kits. Behavioral health preparations, however, may be absent.

The Pediatric Preparedness Checklist can help practices review their operational planning.

Patient Preparedness

  • Anticipate increased stress reactions, including anxiety, after a disaster.
  • Plan for additional office support or scheduling adjustments to accommodate increased patient needs.
  • Establish procedures for screening and triaging patients experiencing psychological trauma.
  • Prepare to address common mental health responses such as stress and anxiety.

Staff Preparedness

  • Prepare for staff stress related to personal disaster exposure and the demands of supporting affected patients.
  • Clearly define each staff member’s disaster role and practice those roles during drills.
  • Establish mechanisms for assessing staff stress and providing additional support when significant reactions occur.

Educational Materials and Referral Resources

Collaborate with the local health department or emergency services agency to obtain or develop materials addressing:

  • Common mental health reactions to disasters
  • Strategies for reducing distress
  • Local mental health and crisis resources

When local resources are unavailable, practices may adapt the SAMHSA resource Helping Your Child Recover from the Emotional Aftermath of a Disaster.

Do not assume that distress immediately following a disaster represents a psychiatric disorder. Stress reactions are common, and most children will recover with appropriate support.

Response: Immediate Actions During a Disaster

Disasters are disruptive, and stress reactions are common and expected. Most children will not develop a long-term disaster-related psychiatric disorder, but all can benefit from psychoeducation, reassurance, and support in processing the event.

Create a Safe Clinical Environment

  • Keep a parent or guardian with the child during the visit when possible. Offer caregivers guidance on supporting positive coping.
  • Limit exposure to images, videos, or sounds that may remind the child of the disaster.
  • Minimize painful procedures when possible. Explain required interventions in developmentally appropriate language and connect them to safety and recovery.

For example: “To help your body stay strong and healthy after the cut on your foot, we are giving you a tetanus shot.”

Implement Behavioral Health Components of the Disaster Plan

  • Provide patients, families, and staff with materials describing common reactions, coping strategies, and local resources.
  • Screen and triage patients for psychological trauma.
  • Assess staff stress and provide additional support to staff experiencing significant reactions.
  • Ensure staff can address their own safety and psychological needs while caring for disaster-affected patients.

Provide Early Psychological Support

Educate primary care providers about evidence-based interventions that can be used immediately after a disaster. When possible, behavioral health clinicians can provide these services in the primary care office or community.

Psychological First Aid (PFA) is commonly used to reduce immediate distress and promote adaptive coping.

National Support Resources

  • Disaster Distress Helpline: Call or text 1-800-985-5990 for multilingual, 24/7 disaster crisis counseling for people in the United States and its territories.
  • American Red Cross Disaster Mental Health Services: Provides mental health support to people affected by disasters and emergencies.

Consultation and Referral

  • Help primary care providers differentiate expected stress reactions from persistent or maladaptive responses.
  • Refer children whose symptoms persist after the disaster threat has ended for additional behavioral health care.
  • Offer consultation to help primary care providers assess and manage patients with mild symptoms.
  • Reserve appointment availability for patients with reactions that cannot be managed within primary care.

Recovery: Returning to Baseline or a New Normal

Most children recover from a disaster without lasting psychological impairment. A smaller group will experience longer-term effects. Posttraumatic stress symptoms and posttraumatic stress disorder are among the most common mental health consequences.

Other possible effects include anxiety, depression, grief, bereavement, substance use, behavioral problems, and academic difficulties.

Understand the Expected Recovery Trajectory

It is common for children to experience stress reactions during the first several weeks after a disaster, followed by gradual improvement over subsequent months. Children with significant functional impairment or persistent symptoms should be referred for specialty mental health care.

Identify Children at Elevated Risk

Children at greater risk may benefit from closer primary care monitoring or referral to a behavioral health specialist. Relevant factors include:

  1. Pre-existing factors: Previous mental health diagnoses or traumatic experiences.
  2. Nature of the disaster: Injury, extent of exposure, and the child’s perception of events.
  3. Subsequent factors: Caregiver difficulty coping, poor family communication, limited social support, or loss of property.

Recognize and Screen for PTSD

Train primary care providers to recognize posttraumatic stress symptoms in pediatric patients and use appropriate child and adolescent trauma assessment tools.

Children and adolescents may conceal or minimize symptoms, so providers may need to ask proactively about trauma reactions. Patients may also experience renewed psychological reactions around disaster anniversaries or during events that resemble the original disaster, such as heavy rain following a flood.

Takeaway Points

Primary care providers and behavioral health specialists can collaborate before a disaster to promote resilience, identify mental health concerns, and connect families with treatment and resources.

  • Including behavioral health interventions in primary care disaster plans helps ensure that both physical and psychological needs are addressed.
  • Preparedness may include educational handouts, screening and triage protocols, staff-support plans, and pathways to evidence-based interventions.
  • Although most children will not develop long-term mental health conditions, children with elevated risk or persistent symptoms may need closer monitoring or referral.

Action Item

What behavioral health disaster-mitigation or preparedness intervention could primary care providers and mental health specialists jointly implement in your health system?

Resources and References

Family and Staff Resources

References

  • Bonanno, G. A., Brewin, C. R., Kaniasty, K., and La Greca, A. M. (2010). “Weighing the Costs of Disaster: Consequences, Risks, and Resilience in Individuals, Families, and Communities.” Psychological Science in the Public Interest, 11(1), 1–49. doi:10.1177/1529100610387086.
  • Meredith, L. S., Eisenman, D. P., Tanielian, T., Taylor, S. L., Basurto-Davila, R., Zazzali, J., Diamond, D., Cienfuegos, B., and Shields, S. (2011). “Prioritizing Psychological Consequences for Disaster Preparedness and Response.” Disaster Medicine and Public Health Preparedness, 5(1), 73–80. doi:10.1001/dmp.2010.47.
  • Pfefferbaum, B., Noffsinger, M. A., Wind, L. H., and Allen, J. R. (2014). “Children’s Coping in the Context of Disasters and Terrorism.” Journal of Loss and Trauma, 19(1), 78–97. doi:10.1080/15325024.2013.791797.
  • Schonfeld, D. J., and Demaria, T. (2015). “Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crises.” Pediatrics, 136(4), e1120–e1130. doi:10.1542/peds.2015-2861.