Disaster Mental Health and Crisis Stabilization for Children
By Dr. Jennifer Baggerly
University of South Florida Counselor Education
I.
Introduction (2 minutes)
A. Hello, I am Dr. Jennifer Baggerly, an associate professor in counselor
education at the University of South Florida, a Licensed Mental Health
Counselor – Supervisor, a Registered Play Therapist – Supervisor, and a
field traumatologist. With Florida’s annual hurricane season, I get lots of
practice providing disaster mental health for children. I also provided
intervention for children in Sri Lanka after the tsunami and in Louisiana
after Hurricane Katrina. Today, I’ll share with you many of evidenceinformed interventions that you can use with children who experienced
disasters and crises such as school shootings, death of a family member, or
any unusual event that overwhelms their ability to cope. [Voice over
demo]
B. Rationale (Jennifer sitting with children)
Children are one of the most vulnerable populations during a disaster or
other crisis. Simply, their neuro-physiological, cognitive abilities, and
coping strategies are not developed enough to handle an overwhelming,
life-threatening event. [Voice over video of children acting distressed.]
Too few mental health and medical professionals are trained to respond
specifically to children after a disaster or crisis. Yet you will be much
better prepared to mitigate the devastating impact of disaster on children
after viewing this program.
C. Objectives
You will learn:
1. The “big 5” impact of disaster and crises on children [Voice over
video of children’s brain demonstration.]
2. Guiding principles for responding to children
3. Basic grounding and containment skills [Voice over demo]
4. Initial individual interventions [Voice over demo]
5. Group interventions [Voice over demo]
II.
Impact of disaster and crisis on children (15 minutes: will show PowerPoint
slides and pictures as I talk)
A. Understanding the impact of disaster and crises on children is important
for three reasons. First, it will provide purposeful direction so your
interventions will not be hap-hazard in their interventions. Second, you
will need to explain the impact of disaster on children to parents and
teachers so they’ll have developmentally appropriate expectations. Finally,
you will need to explain the impact of a disaster to children so they won’t
be confused and worried about their symptoms.
B. The “Big 5”: Impact of disasters and crisis on children.
One easy way to conceptualize information about the impact of disaster on
children is to organize responses or symptoms into the “big 5.” In adult
language, the big 5 categories for symptoms are (1) physiological, (2)
cognitive, (3) emotional, (4) behavioral, and (5) spiritual.
1. Physiological
Here’s a simple explanation of the neuro-physiological impact of a
disaster on children.
1. Usually ordinary memories are stored in the left side of our
brain. [PowerPoint of brain and talking points]
2. During a traumatic event, the brain turns on the “fight-orflight” response. Hormones become higher to keep us alert for
fight or flight or freeze.
3. The parts of the brain that are responsible for speech and
comprehension (Broca’s and Wernicke’s areas) shut down.
4. Vivid images or pictures and feelings of the traumatic event get
stuck on the right side of the brain. They keep coming up
(intruding) trying to go to the left side of the brain where they
are usually stored. Fritz Perls said “unfinished business
clamors for our attention.”
5. However the images are so scary that the person tries to get rid
of them by being overly active such as being hyper-vigilant or
aggressive or by avoiding them via substance abuse or
dissociation.
6. It is important to learn ways to decrease anxiety and process by
talking or playing the traumatic memory so it can be stored in
the left side of the brain. Then the child has more energy to
think clearly, feel better, and get along with others.
A more detailed explanation is given in the handout. Now stop and
practice explaining this physiological process to an adult.
I’ll demonstrate how to explain this to a child. [Demonstrate with child.]
“Let’s pretend that this container is your brain. Do you know where happy
memories go in your brain? They go to the top left side and are placed
neatly so you can see the picture. [Tape 4 small puzzle pieces in the top
left side]. Tell me about your last birthday party . . . . .So that picture of
your birthday party is placed neatly right up here where you can see it.
When something scary happens, guess what happens to the picture of the
scary thing! Your brain is so busy trying to keep you safe that it doesn’t
have time to put it up neatly. Like sometimes when you are in a hurry and
you might just leave your toys dumped on the floor. The picture of the
scary thing gets stuck on the bottom right side of your brain like these
puzzle pieces. [Place 4 other puzzle pieces at the bottom]. Then they start
rattling around, making noise when you are trying to do something else.
You might be trying to read and learn at school but those rattling pieces
keep bothering you. So you put your head down or jump around to get rid
of it but it doesn’t work. You might be trying to play with your friends but
those rattling pieces bother you so much that you are angry and hit your
friend or you just run away. Guess what helps put those rattling pieces at
the top left side of your brain where they are suppose to go? First, learning
to calm yourself down and then talking or playing about the scary thing
that happened. When the picture gets put away by talking or playing, then
you’ll have more time to learn and play with others!”
2. Cognitive
From what we learned about neuro-physiology, we can see that disasters
and crisis impact children in the cognitive area. Children who experience
traumatic events may have
• difficulty concentrating or making decisions
• memory problems
• intrusive thoughts and images
• difficulty establishing safety and trust
• skewed perceptions of morality.
3. Emotional
The impact of disasters on children’s emotions may include
• Moodiness and inability to manage feelings
• Ongoing sadness or depression
• Intense anger
• Self-blame and guilt
• Embarrassment of not having basic needs met
• Inability to maintain intimacy and connections with others
• Lower self-esteem
4. Behavioral
Behavioral changes as a result of a disaster or crisis may include
• Loss of interest in school and play
• Social withdrawal
• Hyper-vigilance
• Hyperactivity
• Aggressiveness and fighting
• Regressive behavior such as bedwetting and thumb sucking
• Alcohol and drug abuse
•
•
Poor hygiene
Sexual acting out
5. Spiritual
Spirituality is often overlooked but can be impacted by disasters as
follows:
• Doubts about God or religious beliefs
• Loss of spiritual identity
• Apathy in religious practices or rituals they previously performed
• Shattered world view such as seeing everyone and everything as
“bad”
•
Stop and identify one response in each of the “Big 5” categories
that you observed in yourself or a child during a recent crisis.
C. How can we explain the big 5 impact of disaster to children? We need to
use words, actions, and songs that children already know. In children’s
language, the big 5 will be simplified to (1) brain, (2) body, (3) heart, (4)
hands, and (5) knees. Brain will represent the neuro-physiological and
cognitive; body represents the physical, heart represents the emotional,
hands represent the behavioral, and knees represent the spiritual. I choose
these words to explain the big 5 to children so we can put it to a familiar
children’s song of “head, shoulders, knees, and toes.” We’ll just use the
same tune but change the words and actions as follows:
“Brain, body, heart, hands, and knees, hands and knees. Brain, body, heart,
hands, and knees, hands and knees. I can calm down, this is key. Brain,
body, heart, hands, and knees; hands and knees.”
Then we can give a simple explanation, using the handout available on
with this DVD or video. The most important part in explaining the “big 5”
is to emphasize that these responses are normal (happens to a lot of
people) and usually temporary (only lasts a short time).
[Demonstrate with child].
“Let’s look at some things that happen to lots of kids after something
scary happens. Usually these are things that last only a short time. In the
brain some kids are . . . In the body, some kids have . . . In the heart, some
kids feel . . . For the hands, some kids do things like . . . For the knees or
religious/spiritual things, some kids . . . Which ones, if any have you
noticed in yourself for the brain, . . . body, . . ., heart, . . . , hands, . . .
knees?”
“Now, let’s look at some things kids can do to feel better. For the brain,
kids can . . . (body, heart, hands, knees). Which ones usually work for you
in the brain . . . (body, heart, hands, knees).
III.
Guiding principles for responding to children (4 minutes: will show
PowerPoint slides and pictures as I talk)
A. The first principle in disaster response is to submit to the Incident
Command Structure. This is a paramilitary structure that brings order to
chaos by identifying team leaders who follow predetermined procedures.
You must check in with the Incident Commander or designee on scene
before providing interventions. Do not go to an incident unless you are
deployed by an identified person in an identified organization to a specific
place at a specific time. [Voice over video of me checking in with police
officer].
B. The second principle is to follow the "six C's" of disaster mental health as
identified by the World Health Organization. These 6 C’s of calmness,
common sense, compassion, collaboration, communication, and control of
self are described in your handout.
C. Third, maintain hardiness and flexibility. You need to be physically and
emotionally hardy (healthy and strong) to endure long hours in
uncomfortable settings. Flexibility is essential to work in constantly
changing situations with diverse people.
D. The fourth principle is having an expectation that children and their
families will have a normal recovery. Rather than seeing all symptoms as
pathological, hold the view that most children are simply having normal
responses to abnormal experiences.
E. Fifth, a safe space is essential in order for stabilization and trauma
recovery to occur. You may need to help create a safe space for children
by moving chairs to be a boundary for a children’s area or informing the
incident commander of unsafe people in the area.
F. The sixth principle is to utilize developmentally appropriate approaches
with children. Children are not miniature adults. Engage children in their
natural language of play by using toys, puppets, art materials, and story
books.
G. The last principle is that crisis situations require more directive approaches
so children have a sense of order and safety. In the earlier disaster phases,
the goal is to stabilize and assess. Stabilization requires directives in order
to teach children coping skills and keep them safe.
•
IV.
Stop and discuss which guiding principle will be most difficult for you. Develop a
plan to improve in this area.
Basic grounding and containment skills (20: Demonstrations as I explain)
Stabilization of children during a disaster or crises can be accomplished by
implementing grounding and containment skills. These basic skills are derived
from evidenced-based practice of Cognitive-Behavioral Therapy. Teaching
children these will help them increase their sense of safety by stabilizing their
body, cognitions, behavior, emotions, and social relationships
A. Controlled Breathing to Decrease Hyperarousal and Avoidance [Voice
over demo of each].
• The purpose of teaching children slow, deep breathing is to lower
their heart rate, decrease hyperarousal and anxiety, and help them
feel more relaxed. Teach children to breathe slowly and deeply
from their diaphragms, rather than their chest.
• In disaster situations, professionals will need quick and
convenient ways to teach this skill. One way to do this is to ask
them to lock their hands behind their head. This promotes
breathing from the diaphragm. Ask them to inhale slowly to the
count of five and exhale even more slowly to the count of 8. You
can ask them to move their elbows back and forth, like butterfly
wings. They are doing butterfly breathing.
• Another fun way to teach young children deep breathing is by
having them blow soap bubbles. Show them that only slow
blowing will make the bubbles. Many children delight in
watching the bubbles float in the air and catching them.
• An alternative to soap bubbles is making pinwheels with
children, although this requires materials and time.
• If time permits, you can ask the child to lie on their back and
place a cup on their stomach. Their job is to make the cup rise
when they inhale and make the cup go down when they exhale.
B. Body Relaxation to Decrease Hyperarousal and Avoidance
• Body relaxation will also help children decrease hyperarousal
and anxiety and increase their sense of self control.
• A quick, fun way to relax the body is the butterfly hug,
developed by Eye Movement Desensitization and Reprocessing
therapists. Just ask children to cross their arms like this. Now
pat one side at a time. EMDR therapists report that this
provides a soothing bilateral stimulation. Try the butterfly hug.
Then rub your arms up and down for extra self-soothing.
• Progressive muscle tension and relaxation is also important for
children. Tell them “we are going to learn to ‘tense like a tinman and relax like a rag-doll’ starting from the top of your
head and going down to your toes. First, tense your head and
shoulders like a tin-man and hold it for 10 seconds while you
breathe deep, now relax like a ragdoll. Next, tense your arms . .
., stomach . . , rear . . . , legs . . ., and toes.
C. Controlling Thoughts to Manage Intrusive Re-experiencing
• Teaching children to control their thoughts will help children
recover when they have intrusive memories. Remember, the
goal during disaster and crisis response is stabilization. If the
child goes to counseling at a later date, then the therapist will
•
•
•
•
•
help the child process memories in a different way. However,
for disaster response, our goal is stabilization.
Teaching children thought stopping is important so they can
control intrusive memories. Ask them to draw a stop sign.
Then practice saying “Stop!” Ask them to picture the stop
sign in their mind, yell stop, and clap their hands. Practice
doing this. Ask them to do this when they have a memory
they don’t like.
“Changing the tape/CD” helps children replace negative
thoughts with predetermined positive thoughts. Tell children
that their brain is like a tape/CD player. When they have a
negative thought such as “you should have done more” tell
them to say “stop” and change the tape/CD to a
predetermined, positive thought of “I did the best I could. I’m
only a kid” or “I know I’m safe now because . . .”
Singing Positive Songs is a fun way to increase positive
thoughts. Try changing the words to a familiar children’s
song. For example, Association for Play Therapy members
working in Sri Lanka made up this song to the tune of
“Twinkle, Twinkle, Little Star::
o I am safe and I am strong
o Take a breath and sing this song
o I’m growing stronger everyday
o I know that I’ll be O.K.
o I am safe and I am strong
o Take a breath and sing along.
Visualizing a safe, happy place is another important step in
teaching children to control their thoughts. Ask the child to
“relax by sitting comfortably and taking deep breaths; close
your eyes and think of a safe, happy place; look at the colors
and the shapes in your safe happy place; listen to the sounds
and smell the smells in your safe happy place; open your eyes
and draw a picture of your safe happy place.”
The 3-2-1 game is another method of bringing children’s
attention into the “here and now” instead of the fear of the
past or the worry of the future. For this procedure ask
children to identify three objects above eye level, three
sounds everyone can hear, and three things they can touch;
then two things they see, hear, and touch; followed by one
thing they see, hear, and touch
D. Containment to Manage Intrusive Re-experiencing
• Containment skills provide further methods for managing
intrusive re-experiencing.
• Many children will spontaneously draw a scary picture of the
event. You can help them contain this image by saying, “I
•
•
V.
know a way to keep that picture from being so overwhelming.
Fold it up into a tight little square, put it in this envelope, and
then we’ll find a safe place to put it like your mother’s purse or
your pocket.”
Making a “Play-Doh worry object” to keep or take away
worries is another fun activity. Give the child some Play-Doh
and ask them to make a “worry object” that will keep or take
away their worries like a box or bowl or dolphin to swim away
their worries or bird or plane to fly their worries away.
Body Burrito is a way to physically contain feelings. It is based
on the old practice of swaddling a child. Occupation therapists
often use this for sensory integration. Ask the child if they
would like to make a body burrito by rolling up tightly in a
blanket or sheet. Help them do so and ask them to sit still until
they feel very calm. Help them unwrapped when they are
ready.
Initial individual interventions (20 minutes)
Child C3ARE model – Initial Individual Intervention
An initial disaster response individual intervention that helps children
stabilize after a trauma is the Child C3ARE model (Baggerly & Mescia, 2005). In
this six step procedure, play therapists will Check, Connect, Comfort, Assess,
Refer, and Educate as follows:
1. Check the scene to ensure it is safe to enter; the structure to identify the head
authority on scene; self to ensure you are prepared; and the survivor to ensure
the child is physically safe.
2. Connect with the child by being calm, getting on the child’s eye level, and
using a puppet to establish rapport; with the child’s guardian by introducing
yourself; and with specialized services that are needed immediately such as
Emergency Medical Services. For example, play therapists could say, “Hello,
my name is ________, and I’m helping out here today. This is my puppet
_______. Is this your family member or friend? Is it O.K. if I visit with you?
Does anything hurt or feel bad? What do you need right now?”
3. Comfort the child with calm, reassuring words; provide food, drinks, and
blankets; guide in body relaxation through deep breathing, blowing bubbles,
and progressive muscle relaxation; and encourage them to draw a safe, happy
place. For example, say “You’ve been through a difficult time but you are safe
right now. Would you like something to eat or drink? I know a way to help
you be calm. Blow these bubbles. Now tense your muscles like a tin-man and
relax like a rag-doll. Draw a safe and happy place on this paper.
4. Assess (informally through observation) child’s coping and functioning;
monitor physical and behavioral status; identify child’s risk and resiliency
factors; and determine current and potential needs. You can ask, “What do
you think you need right now and in the future to help you get along? In a
little while, I’ll help your family find out how to get those things”
5. Refer the child and guardian to needed services and resources; connect with
indigenous helpers and safe peers; and provide written handouts of typical
trauma symptoms and coping strategies. Say “You said you needed _____.
This information may help you and your family. What questions do you have?
Let me know when you have other questions or need help with something.”
6. Educate children and guardians about typical trauma responses; normalize
these responses; and encourage positive coping strategies such as thought
stopping, distraction techniques, singing, praying/meditating, and playing with
other children. You can say, “Many children notices changes in their body or
in the things they do after something scary happens. Some have bad dreams
or cry a lot or don’t like to play outsidet. Here is a paper with different
changes that happen to some kids. What changes have you noticed in you?
These are normal changes that happen in normal kids like you when
something different and scary happens. What do you usually do to feel better
when you feel bad? I know some other things you can do. Would you like to
learn? Try this . . .Here’s a paper that tells you lots of things you can do/ I’m
going to get kids together later to play games. Would you like to come? I’m
going to visit some other kids now. I’ll come back later to let you know when
the games start. Thank you for visiting with me. It was nice to meet you. Bye.”
Throughout this intervention, the mental health professional should use basic skills of
listening carefully, reflecting feelings, communicating clearly, focusing on concerns,
and keeping confidentiality.
I’ll demonstrate how to do the CARE model now.
VI.
Group interventions (30 minutes)
Forming groups is an efficient way to provide psycho-education for lots of
children who experienced a disaster or crisis. The National Child Traumatic
Stress Network and the UCLA team have identified the goals for psychoeducation are as follows:
1. Normalize symptoms
2. Manage hyper-arousal
3. Manage intrusive re-experiencing
4. Increase accurate cognitions
5. Increase effective coping
6. Facilitate social support
7. Foster hope
These goals can be accomplished in groups by many of the grounding and
containment activities that I demonstrated before and by reading storybooks such
as “A Terrible Thing Happened,” “Brave Bart” and “Don’t Pop Your Cork On
Monday.” I’ll describe and demonstrate several other group interventions.
1. Puppet shows can be used to address common cognitive distortions held by
children after a disaster. For example, after the tsunami many Sri Lankan
children believed that the tsunami happened because God was made at them.
Puppet shows can also inform children about normal symptoms and coping
strategies.
2. Delightful Detective – in this game, children look for evidence that people are
safe now and will be O.K. after the disaster. Children can interview people
and collect evidence or point to evidence.
3. Garbage or Treasure – make cards with wasteful and valuable thoughts and
actions as well as true and untrue reasons the disaster happened; have the
children sort them into groups of garbage (wasteful) or treasure (useful)
4. Radio Talk Show – appoint children to be experts on a radio talk show;
pretend to call in with common questions children may have about the
disaster, symptoms, and coping; ask experts to answer them
5. Shield of Faith or Heart Blanket – draw a cross or X on a sheet of paper or
white paper plate. Ask children to identify 4 coping strategies they can do to
feel better and draw these into each section. Make two holes at the top, thread
a string through it, and put it around the child’s neck so it hangs over the
heart.
6. Symptom and Coping Charades – ask children to act out a normal symptom
children may have after a disaster. The child who guesses correctly acts out a
helpful coping strategy to manage this symptom.
7. Role-plays –ask children to role-play how to ask for help from parents, other
children, and trusted adults.
8. Paper-doll-support chain or coping necklace – create a paper doll support
chain in which linked images of dolls are labeled with names of people who
provide support; or create a coping necklace in which loops of connected
paper are labeled with coping strategies
9. Rebuild your world sand tray – if sand is available, place sand in a box or a
boundary of rocks or wood around sand in the ground. Ask children to find
things from nature such as rocks, sticks, leaves that they can use to rebuild
their world.
10. Group Games – sometimes children just need gross motor activity such as
running and jumping. Organize games like “duck, duck, goose,” relay races,
crab soccer, volley-beachball, “Red light, Green Light” and dancing.
11. Group free play – sometimes children just need time to play with toys in any
way they choose. Structure the setting with limits on space and number of
children. Appropriate toys include dolls, toy soldiers, animal families, cars,
rescue vehicles, medical kit, Nerf balls, blocks, and paper and crayons.
12. Consult with parents and teachers – teach parents and guardians to conduct
soothing sessions that might include massaging, rocking, and singing to their
children. Provide written information on normal symptoms children
experience after disasters, warning signs, coping strategies, and resources.
Children’s Responses to Traumatic Events
(Normal things that happen to normal kids after something scary happened)
Thoughts (Brain)
Body
Confused
Can't think
Can't remember
Mean thoughts
Scary thoughts
Always thinking about it
Always remembering what happened
Always looking around
Headache
Stomachache
Not hungry or always hungry
Dizzy
Sweaty for no reason
Cold for no reason
Jumpy
Nightmares
Staring off in the distance
Feelings (Heart)
Scared
Sad
Mad
Don't feel anything
Crying
Guilty
Embarrassed
Don't want to feel
Really, really angry
Too much all at once
Things We Do (Hands)
Sit alone
Always looking around
Can't sit still
Yelling
Hitting
Fighting
Can't do homework anymore
Can't sleep or always sleep
Don’t do things you used to like
Don’t go places you used to like
God (Knees)
Think God left
Don't want to pray, sing, or read spiritual books
Don’t want to go to church, temple, or mosque
Mad at God
Confused with God
Children’s Coping Strategies
(Things you can do to feel better)
Thoughts (Brain)
Write things down
Decide to do one thing at a time
Ask for help
Think about what you need
Think of a plan
Ask questions
Think of a nice place to be
Think of nice people
Yell stop when you have bad thoughts
Feelings (Heart)
It is O.K. to cry
It is O.K. to feel angry
Say what you feel
Talk about your feelings to your family and
friends
Laugh and smile 5 times a day
Remember happy feelings
Body
Run and jump
Ride bike
Don't eat to many sweets
Drink water
Take deep breathes
Blow bubbles
Tense like a tin man, relax like a rag doll
Take a hot bath
Things We Do (Hands)
Play with others
Cuddle with family
Help others
Ask for help
Have fun
Relax, relax, relax
Go outside
Read books
Sing and dance
God (Knees)
Pray
Read spiritual books
Sing
Go to church, temple, or mosque
Talk to your parents and priest, minister, or Rabbi about God