Crisis Intervention

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Core Elements for Responding to Mental Health Crises

Many such individuals experience a cascade of crisis events that place them in more than one of these statistical groups. For instance, readmission to a psychiatric institution—a high probability for adults who have been discharged from a state psychiatric hospital, based on these data—may feature a series of crisis events for the individual: the psychiatric emergency itself; forcible removal from one’s home; being taken into police custody, handcuffed and transported in the back of a police car; evaluation in the emergency department of a general hospital; transfer to a psychiatric hospital; a civil commitment hearing; and so on.And at multiple points in this series of interventions, there is a likelihood that physical restraints, seclusion, involuntary medication or other coercion may be used. Intense feelings of disempowerment are definitional of mental health crises, yet as the individual becomes the subject of a “disposition” at each juncture, that person may experience a diminishing sense of control.

In the wake of rare but highly publicized tragedies attributed to people with mental illnesses, there is often a temporary surge in political concern about mental healthcare and expanding crisis interventions. Sadly, the more commonplace crises endured every day by many thousands of adults, older adults and children with serious mental or emotional problems tend to generate neither media attention nor political concern.

While no one with a mental or emotional disorder is immune from crises, people with what are termed serious mental illnesses—defined as schizophrenia, bipolar disorder and major depression—may be most reliant on public systems. They also may be at great risk of recurrent crises and interventions that exacerbate their clinical and social problems. These guidelines focus most specifically on individuals with serious mental or emotional problems who tend to encounter an assortment of governmental or publicly funded interveners when they are in crisis. Nevertheless, the values, principles and strategies embedded in the guidelines that follow are applicable to all individuals with mental healthcare needs, across populations and service settings.

Individuals whose diagnoses do not fit “serious mental illnesses” may be vulnerable to serious mental health crises that can have devastating outcomes. Interventions on their behalf are more likely to occur within the private healthcare sector, which mirrors public mental health systems’ problems in providing early and meaningful access to help.Within these parallel systems, crisis services are provided in a broad array of settings that ultimately will require translation of the guidelines presented here into specific protocols that break cycles of crises and advance the prospects of recovery for people with mental illnesses.

What It means to be in a mental health Crisis

Too often, public systems respond as if a mental health crisis and danger to self or others were one and the same. In fact, danger to self or others derives from common legal language defining when involuntary psychiatric hospitalization may occur—at best, this is a blunt measure of an extreme emergency.A narrow focus on dangerousness is not a valid approach to addressing a mental health crisis.To identify crises accurately requires a much more nuanced understanding and a perspective that looks beyond whether an individual is dangerous or immediate psychiatric hospitalization is indicated.

While behaviors that represent an imminent danger certainly indicate the need for some sort of an emergency response, these behaviors may well be the culmination of a crisis episode, rather than the episode in its entirety. Situations involving mental health crises may follow trajectories that include intense feelings of personal distress (e.g., anxiety, depression, anger, panic, hopelessness), obvious changes in functioning (e.g., neglect of personal hygiene, unusual behavior) or catastrophic life events (e.g., disruptions in personal relationships, support systems or living arrangements; loss of autonomy or parental rights; victimization or natural disasters).

Because only a portion of real-life crises may actually result in serious harm to self or others, a response that is activated only when physical safety becomes an issue is often too little, too late or no help at all in addressing the root of the crisis.And a response that does not meaningfully address the actual issues underlying a crisis may do more harm than good.

Individuals experiencing mental health crises may encounter an array of professionals and non-professionals trying to intervene and help: family members, peers, healthcare personnel, police, advocates, clergy, educators and others.The specific crisis response offered is influenced by a number of variables, among them:

where the intervention occurs,

at what time of day it occurs,

when it occurs within the course of the crisis episode,

the familiarity of the intervener with the individual or with the type of problem experienced by the individual,

interveners’ training relating to crisis services,

resources of the mental health system and the ready availability of services and supports, and

professional, organizational or legal norms that define the nature of the encounter and the assistance offered.

Essential Values

Essential values are inherent in an appropriate crisis response, regardless of the
nature of the crisis, the situations where assistance is offered or the individuals providing
assistance:

1. Avoiding harm. Sometimes mental health crises place the safety of the person, the crisis responders or others in jeopardy.An appropriate response establishes physical safety, but it also establishes the individual’s psychological safety. For instance, restraints are sometimes used in situations where there is an immediate risk of physical harm, yet this intervention has inherent physical and psychological risks that can cause injury and even death. Precipitous responses to individuals in mental health crises—often initiated with the intention of establishing physical safety—sometimes result in harm to the individual. An appropriate response to mental health crises considers the risks and benefits attendant to interventions and whenever possible employs alternative approaches, such as controlling danger sufficiently to allow a period of “watchful waiting.” In circumstances where there is an urgent need to establish physical safety and few viable alternatives to address an immediate risk of significant harm to the individual or others, an appropriate crisis response incorporates measures to minimize the duration and negative impact of interventions used.

2. emergency interventions consider the context of the individual’s overall plan of services. Many individuals with serious mental illnesses go into mental health crises while receiving some sort of services and supports.Appropriate crisis services consider whether the crisis is, wholly or partly attributable to gaps or other problems in the individual’s current plan of care and provide crisis measures in ways that are consistent with services the individual receives (or should receive) in the community. In addition, appropriate crisis services place value on earlier efforts by the individual and his or her service providers to be prepared for emergencies, for instance, by having executed psychiatric advance directives or other crisis plans. Incorporating such measures in a crisis response requires that interveners be knowledgeable about these approaches, their immediate and longer-term value, and how to implement them. Appropriate crisis interventions also include post-event reviews that may produce information that is helpful to the individual and his or her customary service providers in refining ongoing services and crisis plans.

3. Crisis intervention may be considered a high-end service, that is high-risk and demanding a high level of skill.Within the course of a psychiatric emergency, various types of crisis interventions may occur—some by healthcare professionals, some by peers and some by personnel (such as police) who are outside of healthcare.Throughout, the individual experiencing a mental health crisis should be assured that all interveners have an appropriate level of training and competence.What that means may vary considerably between scenarios. For instance, a significant number of instances of police involvement with individuals in mental health crises result in injuries or even death.15 Accordingly, some police departments have taken special measures to train officers in identifying and de-escalating mental health crises. Many have also established links with mental health professionals who can provide timely on-site assistance. These efforts have required police and health care professionals to connect across traditional bureaucratic boundaries.

4. individuals in a self-defined crisis are not turned away. People who seek crisis services but do not meet the service criteria of an organization should receive meaningful guidance and assistance in accessing alternative resources.This is particularly applicable in organizations or programs that carry out a screening or gatekeeping function. For instance, it is not sufficient, upon determining that an individual fails to meet the criteria for hospitalization, to tell the individual or family members to make contact again if the situation worsens. Such practices tacitly encourage the escalation of crises. Individuals and their families should be assisted in accessing services and supports that resolve issues early on, and an organization providing screening or gatekeeping services should be fluent with alternatives for when service thresholds are not met.When these alternatives are lacking, the organization should consider this a problem in care and take action accordingly. Likewise, an organization providing early intervention that routinely receives referrals from hospital gatekeepers might consider improving its outreach so that individuals seeking help are more likely to access their services directly, without placing demands on programs designed for late-stage emergencies.

5. interveners have a comprehensive understanding of the crisis. Meaningful crisis response requires a thorough understanding of the issues at play.Yet, for people with serious mental illnesses, interventions are commonly based on a superficial set of facts: behaviors are seen to present a safety issue, the individual national resource center on Psychiatric Advance directives Psychiatric advance directives (PADs) are relatively new legal instruments that may be used to document a competent person’s specific instructions or preferences regarding future mental health treatment, in preparation for the possibility that the person may lose capacity to give or withhold informed consent to treatment during acute episodes of psychiatric illness. Almost all states permit some form of legal advance directive (AD) for healthcare, which can be used to direct at least some forms of psychiatric treatment. In the past decade, 25 states have adopted specific PAD statutes.

Mobile outreach services, which have the capacity to evaluate and intervene within the individual’s natural environment, have inherent advantages over facility-based crisis intervention, especially when an individual who has personal experience with mental illness and mental health crises is a part of the intervention team. Such mobile outreach capacity is even more meaningful when it is not restricted to a special crisis team, but rather when staff and peers familiar with the individual have the ability to literally meet the individual where he or she is.When intervention within an individual’s normal living environment is not feasible, hospitalization is not the inevitable alternative; for many individuals facing civil commitment, consumer-managed crisis residential programs can represent a viable, more normalized alternative that produces good outcome.

Helping the individual to regain a sense of control is a priority. Regaining a sense of control over thoughts, feelings and events that seem to be spinning out of control may be paramount for an individual in mental health crisis. Staff interventions that occur without opportunities for the individual to understand what is happening and to make choices among options (including the choice to defer to staff) may reinforce feelings that control is being further wrested away.The individual’s resistance to this may be inaccurately regarded as additional evidence of his or her incapacity to understand the crisis situation. Incorporating personal choice in a crisis response requires not only appropriate training, but also a setting with the flexibility to allow the exercise of options. Informed decision-making in this context is not a matter of simply apprising the individual of the empirically derived risks and benefits associated with various interventions; it also includes an understanding among staff that an ostensibly sub-optimal intervention that is of the individual’s choosing may reinforce personal responsibility, capability and engagement and can ultimately produce better outcomes.The specific choices to be considered are not limited to the use of medications, but also include the individual’s preferences for what other approaches are to be used where crisis assistance takes place, involving whom and with what specific goals.While the urgency of a situation may limit the options available, such limitations may also highlight how earlier interventions failed to expand opportunities to exercise personal control. Post-crisis recovery plans or advance directives developed by the individual with assistance from crisis experts are important vehicles for operationalizing this principle services are congruent with the culture, gender, race, age, sexual orientation, health literacy and communication needs of the individual being served. Given the importance of understanding how an individual is experiencing a crisis and engaging that individual in the resolution process, being able to effectively connect with the individual is crucial.A host of variables reflecting the person’s identity and means of communicating can impede meaningful engagement at a time when there may be some urgency. Establishing congruence requires more than linguistic proficiency or staff training in cultural sensitivity; it may require that to the extent feasible, an individual be afforded a choice among staff providing crisis services.

Rights are respected. An individual who is in crisis is also in a state of heightened vulnerability. It is imperative that those responding to the crisis be versed in the individual’s rights, among them: the right to confidentiality, the right to legal counsel, the right to be free from unwarranted seclusion or restraint, the right to leave, the right for a minor to receive services without parental notification, the right to have one’s advance directive considered, the right to speak with an ombudsman and the right to make informed decisions about medication. It is critical that appropriately trained advocates be available to provide needed assistance. Correctly or not, many individuals with serious mental illnesses have come to regard mental health crisis interventions as episodes where they have no voice and their rights are trampled or ignored. Meaningfully enacting values of shared responsibility and recovery requires that the individual have a clear understanding of his or her rights and access to the services of an advocate. It is also critical that crisis responders not convey the impression that an individual’s exercise of rights is a hostile or defiant act.

Services are trauma-informed. Adults, children and older adults with serious mental or emotional problems often have histories of victimization, abuse and neglect, or significant traumatic experiences.Their past trauma may be in some ways similar to the mental health crisis being addressed. It is essential that crisis responses evaluate an individual’s trauma history and the person’s status with respect to recovery from those experiences. Similarly, it is critical to understand how the individual’s response within the current crisis may reflect past traumatic reactions and what interventions may pose particular risks to that individual based on that history. Because of the nature of trauma, appropriately evaluating an individual requires far more sensitivity and expertise than simply asking a series of blunt, potentially embarrassing questions about abuse and checking off some boxes on a form. It requires establishing a safe atmosphere for the individual to discuss these issues and to explore their possible relationship to the crisis event.

Recurring crises signal problems in assessment or care. Many organizations providing crisis services—including emergency departments, psychiatric hospitals and police—are familiar with certain individuals who experience recurrent crises.They have come to be regarded as “high-end users.” In some settings, processing these individuals through repeated admissions within relatively short periods of time becomes so routine that full reassessments are not conducted; rather, clinical evaluations simply refer back to assessments and interventions that were conducted in previous (unsuccessful) episodes of care. While staff sometimes assume that these scenarios reflect a patient’s lack of understanding or willful failure to comply with treatment, recurrent crises are more appropriately regarded as a failure in the partnership to achieve the desired outcomes of care.And rather than reverting to expedient clinical evaluations and 15. meaningful measures are taken to reduce the likelihood of future emergencies. Considering the deleterious impact of recurrent crises on the individual, interventions must focus on lowering the risk of future episodes. Crisis intervention must be more than another installment in an ongoing traumatic cycle. Meaningfully improving an individual’s prospects for success requires not only good crisis services and good discharge planning, but also an understanding that the crisis intervener—be it police, hospital emergency department, community mental health program, or protective service agency—is part of a much larger system. Performance-improvement activities that are confined to activities within the walls of a single facility or a specific program are sharply limited if they do not also identify external gaps in services and supports that caused an individual to come into crisis.

An organization’s infrastructure should support interventions consistent with the values and principles listed above. Given the nature of crises affecting individuals with serious mental or emotional problems, these values and principles are applicable to a very broad array of organizations—hospital emergency departments, psychiatric programs, foster care, education, police, schools, and courts.While needed infrastructure will necessarily vary by setting, population served and the acuteness of crises being addressed, there are some important common denominators:


• staff that is appropriately trained and that has demonstrated competence
in understanding the population of individuals served, including not only a clinical perspective, but also their lived experiences.

staff and staff leadership that understands, accepts and promotes the concepts of recovery and resilience, the value of consumer partnerships and consumer choice, and the balance between protection from harm and personal dignity.

staff that has timely access to critical information, such as an individual’s health history, psychiatric advance directive or crisis plan. Such access is, in part, reliant on effective systems for the retrieval of records, whether paper or electronic.

staff that is afforded the flexibility and the resources, including the resource of time, to establish truly individualized person-centered plans to address the immediate crisis and beyond.

staff that is empowered to work in partnership with individuals being served and that is encouraged, with appropriate organizational oversight, to craft and implement novel solutions.

An organizational culture that does not isolate its programs or its staff from its surrounding community and from the community of individuals being served.This means that the organization does not limit its focus to “specific” patient-level interventions, but also positions itself to play a meaningful role in promoting “indicated” strategies for the high-risk population it serves and “universal” strategies that target prevention within the general population.The intent here is not to dissipate the resources or dilute the focus of an organization, but to assure recognition that its services are a part of a larger spectrum and that it actively contributes to and benefits from overall system refinements.

Coordination and collaboration with outside entities that serve as sources of referrals and to which the organization may make referrals. Such engagement should not be limited to service providers within formal networks, but should also include natural networks of support relevant to the individuals being served.

Rigorous performance-improvement programs that use data meaningfully to refine individuals’ crisis care and improve program outcomes. Performance improvement programs should also be used to identify and address risk factors or unmet needs that have an impact on referrals to the organization and the vulnerability to continuing crises of individuals served.

The need for major improvements in crisis services for adults, children and older adults with serious mental or emotional problems is obvious.The statistics presented in the introduction to these guidelines make a clear case that people with mental illnesses are vulnerable to repeated clinical and life crises that can have deleterious effects on the individual, families and social networks, and communities. Many interventions could have a significant, positive impact on the frequency and severity of mental health crises, but they are not readily available to most of the individuals who need them.

Properly applied, these guidelines should work to improve the quality of services for people who are in or are vulnerable to mental health crises. Embedded in the guidelines is the notion that crisis services should not exist in isolation; crises are a part of an individual’s life experiences and the assistance provided during crisis periods is part of a larger set of services and supports provided to the individual.While the values, principles and infrastructure recommendations presented here focus on crises affecting people with serious mental illnesses, they also have wider application; they reflect generally accepted approaches to working with individuals who have mental or emotional problems, whether or not they are in crisis. Stated differently, these guidelines challenge any disjuncture between responses to mental health crises and routine mental healthcare.They demonstrate how appropriate emergency mental health responses should affirm the principles of recovery and resilience that are the benchmarks for appropriate mental healthcare even though crisis scenarios may test the application of these values.

From a practice standpoint, these guidelines may be most effectively enacted when they are embedded in the various quality-control and performance-improvement mechanisms that operate within an organization.When appropriately conducted, quality control and performance-improvement processes should be data-driven and attuned to demonstrating not only what segments of the service population are prone to mental health crises,but also what factors underlie their vulnerability.An adequate understanding of these factors requires much more than the “encounter” data now routinely collected by both healthcare organizations and police. Data collection should clearly reflect the premise that mental health crises represent problems in care (whether individual or systemic) and should facilitate the root-cause analyses that are required when significant problems in care occur. Similarly, data should be used as tools for identifying gaps, developing remedies and monitoring the impact of these remedies. Providers and provider organizations should have access to these data for purposes of ensuring the quality of care and the appropriate use of resources.To the extent that the causes of mental health crises extend beyond the domains of an emergency department, a hospital, a mental health system, a police department, and/ or a housing authority, data without personal identifiers should be routinely shared across systems. Entities having oversight responsibility should ensure that these performance-improvement activities are being carried out and that opportunities exist for cross-agency/ cross-system analysis of information and the implementation of strategies to reduce mental health crises.And the partnerships between providers and consumers that are appropriate in the context of individual crises should be mirrored at the performance-improvement level.

In addition to the human case for improving crisis services, a strong business case can be made and data should be collected accordingly. Current approaches to crisis services needlessly perpetuate reliance on expensive, late-stage interventions (such as hospital emergency departments) and on settings that have inherent risks for harm for people with mental health needs (for instance, jails and juvenile justice facilities). Resources and personnel that might otherwise be available for more effective, less risky and less expensive interventions are now channeled into these costly and suboptimal settings.The factors that sustain late-stage crisis interventions may be linked to reimbursement practices and political considerations, yet in some ways the service system is itself complicit. Performance-improvement data derived from on-the-ground case experience can paint a compelling story of how “the right services at the right time” would look for individuals who are currently at high risk for future crises. These data can also set the stage for concrete discussions of the costs and the benefits of changes in policies governing the provision and funding of services and supports.

In short, the approach to crisis services must be forward-looking rather than merely reactive, with success seen as the ability of the individual served to return to a stable life in the community. Rather than leading merely to an increase in the number of beds available for mental health care, it must have as its goal a reduction in the number of crises among people with mental illnesses and therefore a reduced need for emergency services.

Crisis Services are a continuum of services that are provided to individuals experiencing a psychiatric emergency. The primary goal of these services is to stabilize and improve psychological symptoms of distress and to engage individuals in an appropriate treatment service to address the problem that led to the crisis. Core crisis services include: 23-hour crisis stabilization/observation beds, short term crisis residential services and crisis stabilization, mobile crisis services, 24/7 crisis hotlines, warm lines, psychiatric advance directive statements, and peer crisis services.

The research base on the effectiveness of crisis services is growing. There is evidence that crisis stabilization, community-based residential crisis care, and mobile crisis services can divert individuals from unnecessary hospitalizations and ensure the least restrictive treatment option is available to people experiencing behavioral health crises. Additionally, a continuum of crisis services can assist in reducing costs for psychiatric hospitalization, without negatively impacting clinical outcomes.

Our environmental scan revealed that most states provide a continuum of crisis services including residential, mobile crisis, and hotlines. Additional core crisis services are available in some states, including warm lines, crisis respite, and crisis intervention teams, depending upon available funding, state and local infrastructure, and state program and funding polices. In our interviews with states, states reported using several different strategies in the provision of crisis services including co-locating different crisis services in facilities that covered a specific geographic region, including trained mental health consumers (i.e. peers) in the provision of crisis services and collaborating with other partners, such as law enforcement.

Our interviews also revealed states are providing services using different payment mechanisms. Some states such as Massachusetts, Tennessee and Michigan have used Medicaid managed care waivers to expand their crisis services continuum, while other states have used purchasing contracts and collaborative relationships with other partners to support the crisis services continuum.

The most frequently reported funding sources for crisis services are state and county general funds and Medicaid. Although states finance crisis services in different ways, many are using multiple funding sources to ensure that a continuum of crisis care can be provided to all who present for services, regardless of insurance status. Each of the states indicated that using funding from multiple sources has been an effective way to support a continuum of crisis care.

States reported opportunities, challenges and lessons learned in implementing and financing crisis services. Opportunities included updating consumer information to streamline identification of payer source, including peers in various roles in the provision of crisis services and collaborating with other partners to improve crisis services. Challenges included difficulties in obtaining reimbursement for crisis services to individuals with dual mental health and substance abuse disorders and difficulties in obtaining crisis services reimbursement from private insurance due to differences in provider qualifications from Medicaid.

Finally, states provided valuable insight into lessons learned regarding providing crisis services. Some states reported that they were able to use the flexibility of Medicaid waivers to increase the provision of crisis services tailored to their specific delivery system while other states have used purchasing contracts and collaborative relationships with other partners to support the crisis services continuum. Particularly, states with Medicaid managed care behavioral health carve outs were better able to create a full 6 continuum of crisis services whereas states that operated under the Medicaid fee-for-service model faced challenges in implementing a full complement of crisis services. States also emphasized the value of collecting data on crisis services quality indicators to inform policy decisions around crisis care.

Historically, individuals who experienced acute psychiatric or substance abuse symptoms, such as an acute disturbance in thought, mood, behavior, or social relations that required immediate attention, would be treated in a general hospital emergency department or admitted to a hospital. Subsequently, they would receive less intensive outpatient treatment. It has become increasingly apparent that this service mix is frequently inadequate and expensive. Emergency rooms often lack staff with specialized psychiatric training as well as the time and infrastructure to appropriately address the needs of individuals experiencing psychiatric or substance abuse crises. Furthermore, an emphasis on delivering the most appropriate care in the most appropriate setting has led to greater care provided in the community, lessening the reliance on admitting individuals to hospitals. While the move to community-base treatment has led to a reduction in the number of psychiatric beds, in some instances, it has led to an unintended shortage.

This situation has led to the development of a continuum of alternative psychiatric emergency services, or “crisis services” (Allen, M. H., Forster, P., Silver, J., & Currier, G, 2002). The primary goals of these services are to stabilize and improve psychological symptoms of distress and to engage individuals in the most appropriate course of treatment. In contrast to the traditional hospital inpatient-based care settings available to individuals in need of immediate attention for psychiatric or substance abuse symptoms, crisis services include an array of services that are designed to reach individuals in their communities through telephone “hotlines” or “warm lines,” and mobile outreach; and to provide alternatives to costly hospitalizations—such as short-term crisis stabilization units and 23-observation beds.

Like emergency medical services, crisis services are intended to be available to the entire community. Those receiving services may include individuals with a history of severe and persistent mental illness or a substance use disorder (SUD), or those who have never before used behavioral health services. They may be children, adults, or the elderly.

National statistics attest to the significant need for crisis services. In 2010, 2.2 million hospitalizations and 5.3 million emergency department visits involved a diagnosis related to a mental health condition (Agency for Healthcare Research and Quality, 2010). Moreover, in any given year approximately one-fourth of adult Americans will have a mental disorder and about five percent of children aged 4–17 years have serious emotional distress (National Center for Health Statistics, National Health Interview Survey, 2009).


Although not everyone with a mental health or substance use disorder will experience a need for crisis services, some factors may increase the risk of crisis and the need for individuals to access essential services and supports. These factors include poverty, unstable housing, coexisting substance use, and other physical health problems associated with mental illness.


The nature of comprehensive crisis systems, with their complex range of programs and services for addressing various individual situations, makes it difficult to finance crisis services within the constraints of one particular funding stream. Although many crisis services are provided from within the behavioral health system, some are hospital-based, and others are cut across the broader community (e.g., schools or the justice system). In many cases, crisis programs that are operated by different agencies or organizations have separate eligibility criteria and funding. In addition, there are multiple categorical funding streams to address specific problems or specific target populations, such as youth in foster care, elders, or individuals with developmental disabilities. For certain individuals, categorical funding results in the receipt of intended and needed services. However, through collaborative funding, funders of categorical dollars could also play a role in addressing the broader fundamental situation that often surrounds a crisis.

Funding that is tied to serving a specifically defined population can limit the financial feasibility of a program, particularly in rural areas or other areas that have a limited population base to draw upon. Also, funding that is tied to delivering units of pre-defined treatment to individuals who are eligible for specific types of insurance make it difficult for communities to build a continuum of crisis services. Due to the nature of behavioral health crises, many communities require a program with a “fire-house” staffing model that needs to respond to individuals immediately, often prior to establishing insurance status. These issues present limitations to states and communities who wish to build a continuum of crisis services.

Overcoming eligible individual limitations imposed by categorical and single-service dedicated funding streams requires mobilizing multiple resources to address the diverse needs of individuals experiencing a behavioral health crisis. Such a collaborative funding approach would create an overall strategy that reconciles the many separate funding strands, and would have greater potential to meet the immediate needs of individuals in crisis, that extends beyond the scope of what a single system could have mobilized on its own (National Gains Center for People with Co-occurring Disorders in the Justice System, 2004).
This report summarizes the evidence base on the clinical effectiveness and cost-effectiveness of different types of crisis services, and then presents case studies of different approaches that states are using to coordinate, consolidate, and blend fund sources in order to provide robust crisis services.

Effectiveness of Crisis Services

The empirical evidence on the effectiveness of crisis services in addressing the needs of individuals with mental or substance use disorders is growing. In this section, we summarize the evidence on the effectiveness of the following types of crisis services:

23-hour crisis stabilization/observation beds

Short term crisis residential services and crisis stabilization

Mobile crisis services

24/7 crisis hotlines

Warm lines

Psychiatric advance directive statements

Peer crisis services

The review was based on a systematic search of systematic reviews of the effectiveness of crisis services, which included the Cochrane Collaboration, the Campbell Collaboration, and SAMHSA’s National Registry of Evidence-Based Programs and Practices. In addition, studies were identified through searches of PubMed (U.S. National Library of Medicine and National Institutes of Health), Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, and Google Scholar to identify relevant peer-reviewed studies or review articles. Search terms were specific to each service. To make the review as extensive as possible, the searches were not restricted to randomized controlled trials (RCTs). In addition, the research team manually reviewed references contained in the retrieved literature.

23-Hour Crisis Stabilization/Observation Beds

23-hour crisis observation or stabilization is a direct service that provides individuals in severe distress with up to 23 consecutive hours of supervised care to assist with deescalating the severity of their crisis and/or need for urgent care. The primary objectives of this level of care are prompt assessments, stabilization, and/or a determination of the appropriate level of care. The main outcome of 23-hour observation beds is the avoidance of unnecessary hospitalizations for persons whose crisis may resolve with time and observation (SAMHSA, 2012).

Two studies have evaluated the effectiveness of 23-hour crisis stabilization/observation beds. A quasi-experimental study by Gillig and colleagues (1989) compared two psychiatric emergency services and found that the service with the emergency evaluation unit had a significantly lower rate of hospital admissions (36 percent) compared to the one without the unit (52 percent). Clinicians in the program reported that 65 of the 134 patients admitted to the observation unit would have been admitted to the hospital if the unit had not been available.

An observational study by Francis and colleagues (2000) examined the effectiveness of a 23-hour observation program at a Veterans Affairs medical center. The program was designed to avoid unnecessary hospitalization of patients experiencing acute psychiatric crises. The most frequent psychiatric diagnosis among program participants was substance abuse or dependence (77 percent). During the 6 months before admission to the 23-hour program, 38 percent had been admitted at least once to an inpatient psychiatric unit. Following the program, only 12 percent of the patients were admitted to inpatient care. Reasons for the decrease in inpatient services were not systematically explored as part of the study design. However, participating staff members hypothesized that the short duration of the observation period facilitated rapid decision making and referrals to outpatient programs—such as residential substance abuse treatment and partial hospitalization programs—and capitalized on the fact that a high level of distress often motivates patients to accept treatment programs that are immediately available.

Short-Term Crisis Residential Stabilization Services

Crisis stabilization is defined as “a direct service that assists with deescalating the severity of a person’s level of distress and/or need for urgent care associated with a substance use or mental health disorder. Crisis stabilization services are designed to prevent or ameliorate a behavioral health crisis and/or reduce acute symptoms of mental illness by providing continuous 24-hour observation and supervision for persons who do not require inpatient services” (SAMHSA 2012). Short-term crisis residential stabilization services include a range of community-based resources that can meet the needs of an individual with an acute psychiatric crisis and provide a safe environment for care and recovery. Core attributes of residential crisis services include providing housing during a crisis with services that are short term, serving individuals or small groups of clients, and are used to avoid hospitalization (Stroul, 1988).

The current literature generally supports that crisis residential care is as effective as other longer psychiatric inpatient care at improving symptoms and functioning. It also demonstrates that the satisfaction of these services is strong, and the overall costs for residential crisis services are less than traditional inpatient care.


For the studies examined in this review, the populations range from late adolescence (aged 16-18 years) through adulthood. This review excluded programs in which substance use disorder was the primary diagnosis, as these programs are usually much longer in duration, and complicated by the need for medical detoxification. A substance use condition requiring inpatient care is often preceded by a period of detoxification in an appropriate facility. Studies on crisis residential service generally compare community-based or hospital facility programs with a time-limited intervention focus to traditional hospital care.


Regarding mental health and crisis residential, a recent systematic review examined the effectiveness of residential alternatives to hospital inpatient services for acute psychiatric conditions (Lloyd-Evans, et al., 2009). This review included randomized control trials or studies that provided specific quantitative comparisons of effectiveness of alternatives to standard acute inpatient care. Based on 9 out of the 27 studies reviewed, which were rated as of moderate or high quality methodological rigor, the authors concluded that there is preliminary evidence to suggest that residential alternatives may be as effective and potentially less costly than standard inpatient units. The authors note, however, that more research is needed given the heterogeneity of the services and patients studied to date, and rigor of the study designs.

Mobile Crisis Services

The American Psychiatric Association (APA) Task Force defines mobile crisis services as having the “capacity to go out into the community to begin the process of assessment and definitive treatment outside of a hospital or health care facility,” along with a staff including “a psychiatrist available by phone or for in-person assessment as needed and clinically indicated” (Allen et al., 2002). Mobile crisis teams provide acute mental health crisis stabilization and psychiatric assessment services to individuals within their own homes and in other sites outside of a traditional clinical setting (Scott, 2000).

The main objectives of mobile crisis services are to provide rapid response, assess the individual, and resolve crisis situations that involve children and adults who are presumed or known to have a behavioral health disorder (Allen et al., 2002; Fisher, Geller, and Wirth-Cauchon, 1990; Geller, Fisher, and McDermeit, 1995). Additional objectives may include linking people to needed services and finding hard-to-reach individuals (Gillig, 1995). Although most mobile crisis teams are a link between the community and the emergency department (ED), some are co-located in facilities that have both outpatient and ED services, fewer are co-located in inpatient services and outpatient services, and some operate in more than one of these domains (Allen et al., 2002; Gillig, 1995). The main outcome objective of mobile crisis teams is to reduce psychiatric hospitalizations, including hospitalizations that follow psychiatric ED admission. Some mobile teams are focused on reducing arrests of mentally ill offenders (Lamb, Weinberger, and DeCuir, Jr., 2002). Diversion is also a main goal of police-based teams, which may be staffed by mental health consultants or exclusively by police officers with mental health training (Compton, Bahora, Watson, and Oliva, 2008; Lamb et al., 2002; Steadman, Deane, Borum, and Morrissey, 2000).

Four studies were identified with empirical evidence on the effectiveness of mobile crisis services: one randomized controlled trial (Currier et al., 2010) and three that used quasi-experimental designs (Guo, Biegel, Johnsen, and Dyches, 2001; Hugo, Smout, and Bannister, 2002; Scott, 2000; Dyches, Biegel, Johnsen, Guo, and Min, 2002). The studies suggest that mobile crisis services are effective at diverting people in crisis from psychiatric hospitalization, effective at linking suicidal individuals discharged from the emergency department to services; and better than hospitalization at linking people in crisis to outpatient services.

24/7 Crisis Hotlines

Crisis hotlines are defined as “a direct service delivered via telephone that provides a person who is experiencing distress with immediate support and/or facilitated referrals. This service provides a person with a confidential venue to seek immediate support with the goal of decreasing hopelessness; promotes problem-solving and coping skills; and identifies persons who are in need of facilitated referrals to medical, healthcare, and/or community support services” (SAMHSA, 2012).

The goals of most crisis hotlines are to provide support to callers who are feeling hopeless and overwhelmed and to help the caller find a plan for coping with the situation or other resources that can provide further assistance (Kalafat, Gould, Munfakh, and Kleinman, 2007). Most hotlines are available to entire populations, rather than to individuals with specific characteristics or diagnoses. Insurance is not required to use these services. They are available to individuals with mental illnesses and to those with substance use disorders.

An example of a crisis hotline in the United States is the National Suicide Prevention Lifeline, which is a national, toll-free hotline that combines 24/7 crisis centers into a single network. Calls originating from anywhere in the country are routed to the nearest available crisis center, based on capacity and availability. With few exceptions (for example, services that are created specifically for adolescents), crisis hotlines are available to all callers (Samaritans USA, 2010).

Investigators have been able to demonstrate that the mental status of many callers improves during and after calls to a hotline. Qualitative reports as well as some evaluative studies indicate that hotlines have value for numerous suicidal and troubled people—especially those with depression—and that the hotlines represent an asset in the service continuum.

Studies of crisis hotlines often focus on a reduction in suicide as their outcome. Early studies that aimed to assess the effectiveness of hotline services compared suicide rates in towns with and without suicide prevention facilities (Jennings, Barraclough, and Moss, 1978; Miller, Coombs, Leeper, and Barton, 1984). Miller et al. (1984) studied mortality data from the National Center for Health Statistics for 226 central city counties in the contiguous United States (except for those in New England and Virginia) for the years 1968 through 1973. The investigators found that young, white females demonstrated a significant (p = .005) difference in suicide rate between counties that initiated crisis centers and those that did not. Using 1980 census data, the authors concluded that each year these services saved the lives of 637 white females under the age of 25 years, per year.

A more recent study examined how individuals with serious mental illness and a history of suicidal behavior cope with suicidal thoughts (Alexander, Haughland, Ashenden, Knight, and Brown, 2009). Using the mental health system—including crisis hotlines, emergency services, or speaking to a therapist—was the fourth-most cited coping strategy. The first three coping strategies were: spirituality and religious practices; talking to someone and companionship; and positive thinking.

In 1983, Hoult, Reynolds, Charbonneau-Powis, Weekes, and Briggs found that 24-hour crisis hotlines combined with community treatment provided positive outcomes such as reduction in cost, and 12 patients and their families were satisfied with this combined approach. Participants in this program spent an average of 8.4 days in psychiatric hospitals, compared to an average of 53.5 days for controls.

Although few studies of crisis hotline services discuss individuals with substance use or co-occurring mental and substance use disorders, one review noted that callers who had “drug problems or more serious emotional/behavior disorders rated telephone counselors as significantly less effective” than did callers with other problems (Stein and Lambert, 1984, p. 120).

A rigorous study of crisis hotline outcomes was reported in two parts—one devoted to nonsuicidal callers and one to suicidal callers (Kalafat et al., 2007; Gould, Kalafat, Munfakh, and Kleinman, 2007). These investigators studied 240 counselors who worked at eight telephone crisis services across the United States, seven of which were members of the 1-800-SUICIDE National Suicide Prevention Lifeline network mentioned above. Suicidal and nonsuicidal callers completed baseline and follow-up assessments approximately two weeks following the use of the service. Among nonsuicidal callers, distress was significantly reduced from the beginning to the end of the call, and there was a significant reduction in callers’ distress levels from the end of the call to follow-up (Kalafat et al., 2007). Among suicidal callers, there was a significant reduction in suicide status from the beginning to the end of the call on intent to die, hopelessness, and psychological pain. There were also significant reductions in callers’ psychological pain and hopelessness from the end of the call to follow-up (Gould et al., 2007).

Warm Lines

Warm lines are telephone lines that are run by trained mental health consumers (i.e., peers) and staffed by people who are also in recovery (SAMHSA, 2010). A warm line is “a direct service delivered via telephone by a [peer] that provides a person in distress with a confidential venue to discuss their current status and/or needs SAMHSA, 2012). Unlike hotlines, warm lines are for situations that are not considered emergencies but could potentially escalate if left unaddressed. Peer telephone operators can offer compassion, and support callers on topics such as loneliness, anxiety, and sleeplessness. When individuals use warm lines, they are encouraged to talk through their concerns with operators and, in turn, operators may relate information about their own experiences to help the caller to address their own concerns. Operators can help callers that may feel isolated or “stuck” and, as a result, they may calm or reassure the callers. Operators refrain from offering advice; rather, they give a message of hope and provide resources. As a result of warm lines and their operators, situations that may have resulted in a crisis-related trip to a local ED before the call may be prevented (U.S. Department of Health and Human Services, 2010).

In 2011, Dalgin, Maline, and Driscoll administered telephone surveys to 480 warm line callers over a period of four years. They found that callers saw a reduction in both the use of crisis services and feelings of isolation. They also found that keeping telephone lines open after 5:00 p.m. was especially helpful, as they were available after most office hours.

Psychiatric Advanced Directive Statements

An advanced directive statement is a document that specifies a person’s future preferences for treatment, should he or she lose the mental ability to make treatment decisions. Advanced directives are typically used in end-of-life situations. However, people with mental illness may also benefit from having an advanced directive statement, in the advent of a crisis rendering them unable to make treatment or life decisions (Campbell and Kisely, 2009). Twenty-five states have statutes authorizing psychiatric advanced directive statements (PADs). Minnesota was the first state to legislate for psychiatric advance directives in 1991. None of the statutes allow patients to use directives to avoid emergency involuntary detention (Morrissey, 2010).

A study by Flood and colleagues (2006) found that an advanced directive plan formulated by the patient, coordinator, psychiatrist, and project worker led to lower costs and less service use, but these findings were not statistically significant. A more recent review by Campbell and Kisley (2009) found no differences in hospitalization rates for those with advance directive statements and those without. Our review suggests that more research is needed to determine the impact of these statements on mental health costs or health outcomes.

Henderson and colleagues (2004) investigated the impact of a joint advanced directive plan developed by the patient and his or her outpatient treatment team on hospital admission outcomes. A group of psychiatric patients having the 'joint crisis or advanced directive plan' was compared to a group of psychiatric patients without a plan in place. Among those with severe mental illness, the use of an advanced directive plan reduced compulsory admissions and treatment compared to patients without a plan by 13 percent and 27 percent, respectively. In a similar study by Papageorgiou and colleagues (2002), patients who developed advanced directives (but without assistance from the outpatient mental health team) were compared to patients without an advanced directive plan in place. The study found no difference in the number of psychiatric hospital admissions. Findings from the two studies suggest that the involvement of facilitator and outpatient mental health team in the development of an advanced directive plan may be a critical factor for preventing compulsory hospital admissions.

Mobile Crisis Programs

Scott, (2000) analyzed the effectiveness and efficiency of a mobile crisis program by comparing it to regular police intervention. The average cost per case was $1,520 for mobile crisis program services, which included $455 for program costs and $1,065 for psychiatric hospitalization. For regular police intervention, the average cost per case was $1,963, which consisted of $73 for police services and $1,890 for psychiatric hospitalization. In this study, mobile crisis services resulted in a 23 percent lower average cost per case. In another study analyzing the cost impact of mobile crisis intervention, Bengelsdorf et al., (1993) found that mobile crisis intervention services can reduce costs associated with inpatient hospitalization by approximately 79 percent in a six-month follow-up period after the crisis episode.

Following a disaster of such magnitude that the President has declared it as eligible for Federal assistance, communities are often in chaos and individual survivors are undergoing their own feelings of disbelief and shock. It is within this context communities must respond to the emotional needs of their residents: adults and children. Adults living in the impacted area must balance their roles as survivors, responders and caregivers during this time of turmoil. They are often overwhelmed with the responsibility and immediate tasks of crisis response and recovery and must take time to meet the physical and emotional needs of themselves and family members and respond to the needs of the larger community. Consequently, children may be left in the care of unfamiliar persons or provided with limited explanations of what has actually happened.

Disaster response workers, who are providing crisis counseling and emotional recovery assistance, need to be sensitive to the emotional vulnerability of children. The materials discussed herein will give crisis response workers essential infor­mation about the impact of disasters on individuals, how the trauma associated with such events impacts children, the unique world of children, and the diversity of family structures in which children reside.

A special emphasis is placed on assisting child health workers to understand children as uniquely different from adults, and childhood as distinct from adult­hood. Child health workers must engage children in the ever changing and qualitatively distinct world of emotional and cognitive stages of development in which children find themselves. The purpose of the manual is to achieve a better understanding of the world of children and the nature of disaster response.

Information and guidance for the broader group of individuals concerned with the mental health needs of children who experience major disasters, and may include the following:

Experienced mental health professionals who specialize in working with families and their children who experience serious emotional disorders;
Experienced mental health professionals who specialize in working with families and their children who experience serious emotional disorders;
Other health professionals such as physicians, physician assistants, nurses, and rehabilitation specialists who are experienced in working with children;
Professional and paraprofessional workers who provide crisis and suicide intervention services, case managers, and other public health and social service personnel who work with children on a regular basis;x Introduction

School and licensed day care center personnel, including teachers, teach­ers’ aides, guidance counselors, school social workers and psychologists, and administrators;
Nonprofessional volunteers from the community who have little or no training, but who have had personal experience with their own and neigh­bor’s children; and,
Adults who routinely work with children either as volunteers, or as paid service providers or caregivers who have a strong commitment to helping children in times of crisis. 1 The World of Childhood and the Developing Child

The World of Childhood and the Developing Child


Children are one of the most vulnerable groups during and following a disaster. A disaster is a strange event that is not easily understood. It is emo­tionally confusing and frightening and results in children needing significant instrumental and emotional support from adults. Children, parents, and whole families in need of assistance are found at shelters, recovery centers, and other locations. A review of some basic principles and reminders from child devel­opmental theory show how a child’s current stage of development influences their behavior and their understanding of traumatic events associated with the disaster. Below is a list of basic principles that may be helpful as we, the helpers, are rapidly trying to determine the best strategy for providing assistance to chil­dren in both the early stages of crisis response and the later stages of emotional recovery from the disaster:

Be a supportive listener.
Be sensitive to the child’s cultural, ethnic, and racial experiences.
Respond in a way that is consistent with the child’s level of development.
Be aware of the child’s emotional status. Is the child actively afraid or withdrawn?
Determine if the child is comfortable/secure about his/her current surround­ings and those of his or her parents, and other significant persons/pets,
Assist the child in normalizing his/her experiences.
Seek assistance from a child specialist or mental health professional, if necessary. Assistance is needed when the helper does not know what to do or think or if he or she is making things worse.

Theories of Child Development


An abundance of popular press is available on the subject of children. Topical areas of interest include how to raise, parent, educate, and discipline children. It is important, especially when one is in a period of stress and turmoil, to step back from the issues at hand and assess the current situation from the perspective of life during non-crisis routine times. This is especially true when engaging children.

The most important concept to remember is that children are different from adults; childhood is different from adulthood. As trained child health workers or 2 The World of Childhood and the Developing Child disaster mental health outreach workers who encounter children as survivors of a disaster, the preceding statement seems with a moment’s reflection as obvious. In fact, the reality is so obvious that it is often overlooked.

Jean Piaget, renowned for his elegant theory of child development, formulated much of his theory from simply observing how his own children responded to their environment. Piaget, the scientist-observer, systematically confronted his children at different chronological ages with various mental challenges and recorded his observations of their responses. Classic examples from his work illustrate how children perceive the world differently at various chronological ages.

Piaget (Flavell, 1963) noted young children have difficulty observing objects from more than one perspective. For example, a seven-year-old is shown two glass containers: one is short, wide, and filled with water; the other is empty, tall, and slim in shape. The child is convinced that when the liquid from the short container is transferred to the tall one, the volume of the contents actu­ally changes as well. Similarly, when a child of ten or eleven is asked to solve a problem that requires abstract reasoning, such as a problem of logical infer­ence (i.e., a>b and b>c; therefore, a>c), the child is often baffled by the solution. However, when the same problem is presented with solid objects, it is easily solved. Because the objects are concrete and readily visible, he or she easily recognizes the relationship. An adolescent, on the other hand, can solve this problem in the “abstract” by creating mental images of a, b, and c and then solving the problem in his or her head.

Piaget was trained as a biologist and based much of his theory of development on the notion that organisms seek homeostasis or a steady state of balance or equilib­rium. With respect to humans, he postulated that as we grow we change internally and thus, our capacity to engage the environment changes as well. Throughout our development we experience states of disequilibrium and seek to return to a state of equilibrium. The mechanisms he proposed are two active processes of assimilation and accommodation. Simply put, assimilation is the process of interpreting new information within the context of our existing cognitive structure, while simultane­ously accommodating to the new information or demands of our environment. Through the tension of these two ongoing processes we develop our cognitive knowledge and capacities. Thus, we develop from an infant who responds primarily to sensations to an adult who is capable of complex abstract reasoning.

All of us can recall conversations with friends who related their frustration as parents, complaining that their children are disobedient and refuse to do their chores. Is this refusal to behave and do the chores simply because the child is disobedient? Or is it because the parent is issuing commands in a manner that requires the child to translate the “abstract” orders into concrete actions, when they have not yet developed the necessary cognitive skills? While a comprehen­sive discussion of cognitive developmental theories is beyond the scope of the subject at hand, it is important to recognize that children think and construct their responses to the world in different ways depending on their current level or stage of cognitive development.

In summary, we should be aware when we meet a child that they are operat­ing in the world with a different set of cognitive structures than adults and are interpreting information from the environment in a different fashion. In the next chapter, there are a number of illustrations of how this actually works.


Cosario (1997) recently reasserted that when trying to understand children, we must remember that childhood is not simply an apprenticeship to the “real” world of adulthood, but is the current world in which children operate. It is the environment in which cognitive, social, and emotional development occur for individual children. “Children create and participate in their own unique peer cultures by creatively taking or appropriating information from the adult world to address their own peer concerns” (p.18). Hartup (1979) suggests that children really experience two worlds: the world of adult-child interactions, such as with teachers and parents, and the world of peer interactions with children of similar age. We must be aware of the simultaneous presence of both these environments to understand and relate to children as developing individuals.

The emotional development of children parallels, complements, and interacts with their cognitive development. Kagan (1982) has shown in studies of normal infant development that when confronted with new and different information infants may smile if the information is successfully integrated, and they show fear by crying or withdrawing if they cannot make sense of the information. The study of emotional development affirms that emotions are central to survival. Through emotional expression the infant expresses distress (a soiled diaper or hunger), pleasure (being comfortable and having a full stomach), and fear of strangers. As children in middle school and high school, we learn to respect the social standard of non-aggression toward peers and acquire the skills necessary to problem solve conflicts and modulate emotional expression accordingly. By adolescence we are well skilled in expressing empathy, pride, shame, guilt, and other emotions. Thus, throughout normal development we learn more sophisticated strategies of emotional expression.

Closely tied to emotional development is the development of attachment. Attachment theory as originally developed by John Bowlby (1982) integrates 4 The World of Childhood and the Developing Child psychoanalytic concepts of child development with parts of cognitive psychol­ogy, ethnology, and human information processing. He defines attachment theory as a way of conceptualizing “… the propensity of human beings to make strong affectional bonds to particular others, and of explaining the many forms of emotional distress and personality disturbance including anxiety, anger, depres­sion, and emotional detachment to which unwilling separation and loss give rise” (Bowlby, 1982, p. 39). Attachment refers to the affectional bond that forms between a nurturing figure, usually the mother, and her child in the course of time and in response to consistent care. Bowlby states that there is an innate tendency within the human baby to seek and maintain proximity to the attach­ment figure. This behavior has the function of protecting children from the risk of harm.

Mary Main (1996) recently reviewed the field of attachment research. In the years since Bowlby’s original formulation, the concept of attachment has been extended beyond infancy to account for behavior throughout the life span. Main has affirmed that the development of the attachment relationship is based on social interaction. In the overwhelming majority of instances children become securely attached to a nurturing caregiver. Children also become attached to mal­treating parents and the resulting attachment bond is expressed as an insecure attachment. The quality of the attachment bond is usually established by seven to eight months of age and is characterized as secure or insecure. Secure attach­ment is the result of an infant being able to rely on the caregiver as consistently available and nurturing. Infants who have incompetent, uncaring, or inconsistent caregivers express insecure attachment behavior. Insecure attachment behaviors related to separation and reunion with the caregiver range from ignoring the caregiver to excessive and disquieting expressions of distress.

Being securely attached to a nurturing caregiver is further expressed by using the caregiver as a “secure base” for exploring one’s immediate environment. For example, a small child playing in the park will run and play far away from his or her mother as long as he or she is in visual proximity. The child will wander farther and farther away only to spontaneously return to his or her mother and soon wander off again in spirited play. Just as the child displays organized and confident behaviors while in the comforting presence of the caregiver, he or she can also appear disorganized and highly anxious or fearful upon separation or loss of the caregiver. Brief separations from one’s parents is a common event in disasters.

Upon separation and loss of proximity to the caregiver, the child will express fear and anxiety until again secure in the knowledge of the availability of the caregiver. As discussed earlier, infants and very young children must be ablephysically to see objects to keep them psychologically available. However, with time, children can build psychological representations of objects, people, and relationships. Recent research suggests that through maintenance of mental models of caregivers, children are influenced in their formation of relationships with peers and in the development of successful interactions with friends. In a similar vein, adolescents are influenced by models of adult caregivers as they begin developing long-term relationships with significant others.

To better understand normal and abnormal child development, much research has been conducted comparing the behavior of securely attached and insecurely attached children. Carlson and Sroufe (Main, 1996) have reported “ … in peer and school settings, children who felt secure as infants with their mother exhibit greater ego resilience as well as social and exploratory competence than insecure infants … Security with fathers also contributes favorably to outcome” (p. 240).

Disasters are events postulated with separation and loss. Irrespective of the quality of the child’s attachment to the caregiver as secure or insecure, unexpected separation and disruption of one’s secure environment results in fear, anxiety, and disorganization of one’s own behavior. Children who have experienced secure attachment relationships with a nurturing caregiver are the most resilient in reconcil­ing the disruption and recovering from traumatic events. The disruption and loss experienced will most likely be more difficult to resolve for children who have experienced insecure attachment relationships.

Cassidy (1996) summarized some basic findings from the study of attachment relationships:

Linkages exist between family and peer systems.
Children’s daily experiences with parents affect their concept of self and relationships with others.
Children with more positive relationships with peers express more positive behaviors.
More positive behaviors result in being better liked by peers.
In summary, the quality of parents’ caregiving behavior initiates a process linked with the quality of peer relationships throughout childhood and early adolescence.

Erik Erickson’s theory of psychosocial development (Santrock and Yussen, 1987) offers a perspective on a child’s social development. Erickson proposed that social development is the result of the interaction between internal biological forces and external cultural pressures. As such, he proposed eight stages of development throughout the life span. The conflicts one experiences at each stage can be resolved in either a positive (adaptive) or negative (mal-adaptive) way. For Erickson, the development of a psychologically healthy adult required the successful resolution of conflict at each developmental stage. He accounted for variation of emotional expression and behavior among individuals on their reso­lution of conflict along a continuum of healthy to unhealthy outcomes. The eight stages of psychosocial development coincide loosely with eight life stages. Five of these stages occur from infancy through adolescence.

Early infancy is the stage of ‘trust versus mistrust’ in which the infant learns to view the world as a place where one can trust others to be supportive and car­ing, or a place where the infant cannot consistently rely on the support and nur­turing of others. Late infancy is the stage of ‘autonomy versus shame and doubt’. In this stage autonomy is the ability to control one’s own actions, such as success­ful toileting. An inability to learn such control may result in feelings of shame and doubt. Early childhood is the stage of ‘initiative versus guilt’. The child is confronted with the conflict of relationships with parents and unresolved feelings of love and hate. Taking the initiative and engaging in positive social activities resolves conflict; failure to do so results in unresolved guilt. Middle childhood is the stage of ‘industry versus inferiority’. During this stage, the child’s cognitive knowledge, physical abilities, and social relationships are expanded. Upon com­parison of self with others, the child ultimately measures how he or she compares to peers. If the child feels incompetent and inferior, as opposed to competent and adequate, his or her interactions with others will differ than if the child feels confident in how he or she compares with peers. During the storm and stress of adolescent years, the child is confronted with the universally known stage of Erickson’s theory ‘identity versus identity confusion’. It is during this period that the child resolves the conflict between “who I am and what I want to be” and struggles to decide the direction of his or her life. Resolution of the conflict associated with identity marks the end of childhood and the emergence of adult role-taking in society. The remaining three stages continue to deal in a similar vein with issues of role performance and development throughout adulthood.

In summary, normative development throughout childhood is generally viewed as an active and complex process. It involves the ongoing maturation of the child and how he or she engages people and events, attachment to significant adults, social relationships with peers, intellectual and emotional development, and the actual world in which he or she lives. Childhood is the culture in which individual development occurs. The quality and characteristics of their environ­ment also directly influence the healthy development of children. Is it a setting where basic needs are a struggle to meet, where danger and fear of personal safety are daily concerns? Or is it a world that is predictable in its organization and resources? Is it a nurturing place with companionship or one of disregard and isolation?

When a natural or human-caused disaster invades the world of the child, the impact disrupts the normalcy of the environment and normative function­ing. Fortunately, most children enjoy successful and normal childhoods sur­rounded by adults and peers who can help them adjust to the impact of the disaster. Traumatic events can be successfully assimilated into their worlds within the context of their own individual development. For those children who are experiencing childhood as a negative environment and are actively developing maladaptive survival strategies, recovery from traumatic events will be a complex and time-consuming process. This can result in sustained and significant altera­tions in how successfully children are functioning in their world. For example, children may experience a drop in academic performance at school and disrup­tions in their social interactions with friends, siblings, or parents. Children who are experiencing such significant disruptions in their routine social and cogni­tive functioning may be at risk for developing Post Traumatic Stress Disorder (PTSD) or another form of emotional disorder.9 Reactions of Children to Disasters

Reactions of Children to Disasters
Normal Reactions to Disaster Induced Stress

Most parents recognize when their children’s behavior indicates emotional distress. During routine, non-crisis times parents are tuned-in to the nuances of their children’s behavior. Most mothers can tell immediately if their young son or teenage daughter had a bad day at school or a fight with their best friend. A very common sign indicating distress is the sudden appearance of a very busy child, who just suddenly decides he or she will watch TV with his or her parents, and is not even particular about what they are watching. For most parents, this is when their antennae go up and somehow they know it is time to give that extra hug and just be available. Typically, a few words eventually pass between the parent and child. The parent smiles, the child looks relieved, and as quickly as the child appeared he or she vanishes back into his or her now somewhat reorganized and normal world. Under normal circumstances in the majority of nurturing families, they play this scene over and over and without really thinking anything of it. It is just a slice of daily life.

Disasters are not normal or routine and therefore, impose a significant abnor­mality on our daily routines. Everyone is affected. Typical modes of interacting with each other are strained. All of us are trying to get a grip on things and as a result focus less on supporting each other. It is within this context that children experience the aftermath of disasters.

The American Academy of Child and Adolescent Psychiatry (AACAP, 1998) suggests that a child’s reaction to a disaster, such as a hurricane, flood, fire, or earthquake, depends upon how much destruction is experienced during or after the event. The death of family members or friends is the most traumatic, followed by loss of the family home, school, special pets, and the extent of damage to the community. The degree of impact on children is also influenced by the destruction they experience second hand through television and other sources of media reports.

Generally, most children recover from the frightening experiences associ­ated with a disaster without professional intervention. Most simply need time to experience their world as a secure place again and their parents as nurturing caregivers who are also again in charge. 10 Reactions of Children to Disasters Studies of how children have reacted to catastrophic events are limited. However, in the available work done on this topic there emerges a consistent pattern of responses and factors that influence the difficulty children may have in returning to their pre-disaster state. Yule and Canterbury (1994) reviewed a number of studies concerning children exposed to traumatic events. The types of reactions experienced by many children reported include feeling irritable, alone, and having difficulty talking to their parents. Many experience guilt for not being injured or losing their homes. Adolescents are prone to bouts of depression and anxiety, while younger children demonstrate regressive behaviors associated with earlier developmental stages. Many children who have difficulty reconciling their feelings will engage in play involving disaster themes and repetitive drawings of disaster events. It has also been demonstrated that children as young as two or three can recall events associated with disasters. The child’s level of cognitive development will influence their interpretation of the stressful events. Some studies reviewed by Yule and Canterbury suggest that the intellectual ability of the child, their sex, age, and family factors influence their recovery. Girls experience greater stress reactions than boys, bright children recover their pre-disaster functioning in school more rapidly, and families who have difficulty sharing their feelings experience greater distress. As expected, there also appears to be a direct relationship between the degree of exposure to frightening events and the difficulty in emotional adjust­ment and returning to pre-disaster functioning.


Other researchers have attempted to explain what factors influence children’s reactions to traumatic or stressful events. In their review of the emotional effects of disaster, Lewis Aptekar and Judith Boore (1990) report that one’s belief as to who or what caused the disaster and the degree of destruction are major factors influencing children’s reactions. These authors have also identified five additional factors that influence recovery from the traumatic event:

child’s developmental level
child’s premorbid mental health
community’s ability to offer support
parents’ presence or absence during the event
significant adults’ reaction

A more recent review by Vogel and Vernberg (1993) also suggests the influ­ence of children’s developmental level on their ability to comprehend traumatic events, their coping repertoire, and their involvement with other groups of people beyond the immediate family.

In a longitudinal study, Vernberg, LaGreca, Silverman, and Prinstein (1996) provided a thoughtful account of how elementary school children responded to the disastrous impact of Hurricane Andrew in Dade County, Florida. These researchers concluded that many symptoms experienced by these children could be understood using an integrated conceptual model first discussed by Green et al. (1991). Green et. al. investigated four factors:

exposure to traumatic events during and after the disaster
pre-existing child characteristics
post-disaster recovery environment (social support)
coping skills of the child
The model suggested by Vernberg, et al. (1996) increased the number of factors from four to five:

exposure to traumatic events during and after the disaster
pre-existing demographic characteristics
occurrence of major life stressors
availability of social support
type of coping strategies used to manage disaster-related stress

The primary focus of this study was to ascertain what factors influence the lingering symptoms and subsequent identification of children experiencing PTSD. The authors conclude that symptoms associated with PTSD could represent normal adaptive reactions and that for many children the effects of a disaster may still be observed beyond one to two years after the event. In trying to determine what made the various symptoms persist in these elementary age children, the researchers found the daily hassles of routine life in the weeks and months following the incident interacted with the severity of the trauma experi­enced making it difficult to recover. The strains of ongoing life events (e.g., loss of employment by a parent, divorce, or other stressors) also impact the availabil­ity of a supportive environment. Other factors identified by the authors were the overall loss of essential support from the community and schools given the respective impact of the disaster on these social systems.

Typical Reactions of Children
Fears and Anxieties
Fear is a normal reaction to disaster, frequently expressed through continuing anxieties about recurrence of the disaster, injury, death, separation, and loss. Because children’s fears and anxieties after a disaster often seem strange and unconnected to anything specific in their lives, the child’s relationship to the disaster may be difficult to determine. In dealing with children’s fears and anxiet­ies, accepting them as very real to the children is generally best. For example, children’s fears of returning to the room or school they were in when the disaster struck should be accepted at face value, and interventions should begin with talk­ing about those experiences and reactions.

Before the family can help, however, they must understand the children’s needs; this also requires an understanding of the needs of the family. As discussed through­out this manual, families have their own unique pre-disaster profile of beliefs, values, fears, and anxieties. Frequently, dysfunction in the family is mirrored in the child’s malfunctioning. The disaster mental health worker may need to talk with the family as a whole to better understand the role the whole family can play in responding to its own set of fears and anxieties that may exacerbate the fears expressed by the children. Sometimes, the pre-disaster level of dysfunction in the family may be so severe that referral for more formal mental health services may be necessary.

A parent’s or adult’s reaction to children makes a great difference in the children’s recovery. The intensity and duration of children’s symptoms decrease more rapidly when families can show that they understand their feelings. When children believe their parents do not understand their fears, they feel ashamed, rejected, and unloved. Tolerance of temporary regressive behavior allows children to redevelop those coping patterns that had been functioning before the disaster. Praise offered for positive behavior produces positive change. Routine rules need to be relaxed to allow time for regressive behaviors to run their course and the reintegration process to take place.

When children show excessive clinging and unwillingness to let their parents out of their sight, they are expressing their fears and anxieties of separation or loss. They have experienced the harmful effects of being separated from their parents and in their clinging are trying to prevent a possible recurrence. Generally, the children’s fears dissolve when the threat of danger has dissipated and they feel secure again under the parent’s protection.

Children are typically most fearful when they do not understand what is happening around them. Every effort should be made to keep them accurately informed, thereby alleviating their anxieties. Adults frequently fail to realize the capacity of children to absorb factual information and do not share what they know. Consequently, children receive only partial or erroneous information.

Most important to resolving disaster related fears and anxieties in children is the quality of safety and security present in the family. The family should make every effort to remain together as much as possible, for a disaster is a time when the children need their caregivers around them. In addition, the model adults present at this time can be growth enhancing. For example, when parents act with strength and calmness, while maintaining control and sharing feelings of being afraid, they serve the purpose of letting the children see that acting coura­geously even in times of stress and fear is possible.

Sleep Disturbances

Sleep disturbances are among the most common problems for children after a disaster. Behaviors associated with sleep disturbances are likely to take the form of resistance to bedtime, wakefulness, unwillingness to sleep in their own rooms or beds, and refusal to sleep by themselves. Children will also express a desire to be in a parent’s bed or to sleep with a light on, insist that the parent stay in the room until they fall asleep, or may begin to rise at excessively early hours. Such behaviors are disruptive to a child’s well-being. They also increase stress for parents, who may themselves be experiencing some adult counterpart of their child’s disturbed sleep behavior. More persistent bedtime problems such as sleep terrors, nightmares, continued wakening at night, and refusal to fall asleep may point to deep-seated fears and anxieties that may require professional intervention.

In working with families, exploring the family’s sleep arrangements may be helpful. Long-term adjustments in sleeping arrangements, such as allowing chil­dren to sleep routinely in the parent’s bed, will inhibit the child’s recovery pro­cess. However, temporary changes following a disaster may be in order. For very young children, it may be especially reassuring to have close contact with their parents during those times when disaster fears are most prominent. After a brief period of temporary changes, the parents should move toward the reinstatement of pre-disaster bedtime routines. Thus, the family may need to develop either new or familiar bedtime routines, such as reinstating a specific time for going to bed. The family may find it helpful to plan calming, pre-bedtime activities to reduce chaos in the evening. Teenagers may need special consideration for bedtime privacy. Developing a quiet recreation in which the whole family participates is also helpful.

Besides the above descriptions of fears, anxieties, and sleep disturbances, chil­dren’s reactions to a disaster can be expressed in many different forms. Below are some more common reactions. (For convenience, the reactions are presented for three age groups: preschool or early childhood, latency age, and pre-adolescence and adolescence.)

Preschool, Five Years Old and Younger

Most of the symptoms appearing in this young age group are nonverbal fears and anxieties expressed as the result of the disruption of the child’s secure world. These symptoms include:

crying in various forms, with whimpering, screaming, and explicit cries for help
becoming immobile, with trembling and frightened expressions
running either toward the adult or in aimless motion
excessive clinging
Regressive behavior, that is, behavior considered acceptable at an earlier age and that the parent had regarded as past may reappear. This includes the following:

thumb sucking
bed-wetting
loss of bowel/bladder control
fear of darkness or animals
fear of being left alone or of crowds or strangers
inability to dress or eat without assistance
Symptoms indicative of fears and anxieties include:

economic signs of intense anxiety. The child is unresponsive to the efforts of others to awaken or comfort him/her. If awakened, the child is confused and disoriented for several minutes and recounts a vague sense of terror usually without dream content.)
nightmares (i.e., frightening or anxiety producing dreams)
inability to sleep without a light on or someone else present
inability to sleep through the night15 Reactions of Children to Disasters

marked sensitivity to loud noises
weather fears – lightning, rain, high winds
irritability
confusion
sadness, especially over loss of persons or prized possessions
speech difficulties
eating problems


The symptoms listed above may appear immediately after the disaster or after the passage of days or weeks. Most often they are transient and soon disappear. Parents can help diminish the above symptoms in their children through under­standing the basis for the behaviors and giving extra attention and caring. If the symptoms persist for longer than a month, parents should recognize that a more serious emotional problem has developed and seek professional mental health counseling.

Latency Age, Six Years Old Through 11 Years Old

Fears and anxieties continue to predominate in the reactions of children in this age group.
However, the fears demonstrate an increasing awareness of real danger to self and to the children’s significant persons, such as family and loved ones. The reac­tions also begin to include the fear of damage to their environment. Imaginary fears that seem unrelated to the disaster also may appear.
Regressive behaviors may appear in this age group similar to those in the preschool group. Problem behaviors include the following:
Regressive behaviors may appear in this age group similar to those in the preschool group. Problem behaviors include the following:

bed-wetting
sleep terrors
nightmares
sleep problems (e.g., interrupted sleep, need for night light, or falling asleep)
weather fears
irrational fears (e.g., safety of buildings, or fear of lights in the sky) 16 Reactions of Children to Disasters
Additional behavior and emotional problems include:

irritability
disobedience
depression
excessive clinging
headaches
nausea
visual or hearing problems
The loss of prized possessions, especially pets, is very difficult for children in this age group. As noted in the previous section, the school environment and relationships with peers is central to the life of latency age children. School problems begin to appear and may take the form of:

refusal to go to school
behavior problems in school
poor school performance
fighting
withdrawal of interest
inability to concentrate
distractability
peer problems (e.g., withdrawal from play groups, friends, and previous activities or aggressive behaviors and frequent fighting with friends or siblings)

Preadolescence and Adolescence, 12 Years Old Through 17 Years Old

Adolescents have great need to appear competent to the world around them, especially to their family and friends. Individuals in this age group are struggling to achieve independence from the family and are torn between the desire for increasing responsibility and the ambivalent wish to maintain the more depen­dent role of childhood. Frequently, struggles occur with the family, because the peer group seems to have become more important than the parental world to the adolescent child. In the normal course of events, this struggle between adolescents and family plays itself out and depending on the basic relationships between the child and his or her parents, they resolve the trials and problems.17 Reactions of

Children to Disasters


The effects of a major disaster on adolescents will vary depending on the extent to which it disrupts the functioning of the family and the community. The impact of the disaster may stimulate fears related to loss of family, peer relationships, school life, and even concern over the intactness of their own bodies. Adolescents struggling to achieve their own identity and independence from the family may be set back in this personal quest with reactivated fears and anxieties from earlier stages of development. The trouble signs to watch for in pre-adolescents and adolescents include:

withdrawal and isolation
physical complaints (e.g., headaches or stomach pain)
depression and sadness
antisocial behavior (e.g., stealing, aggressive behavior, or acting out)
school problems (e.g., disruptive behavior or avoidance)
decline in academic performance
sleep disturbances (e.g., withdrawal into heavy sleep, sleep terrors, or sleeplessness)
confusion
risk taking behavior
alcohol and other drug use
avoidance of developmentally appropriate separations (e.g., going to camp or college)
Most of the above behaviors are transitory and disappear within a short period. When these behaviors persist, they are readily apparent to the family and to teachers who should respond quickly. Teenagers, who appear to be withdrawn and isolate themselves from family and friends, are experiencing emotional difficulties. They may be concealing fears they are afraid to express. Just as many adults do, adoles­cents often show their emotional distress through physical complaints.

References:

1 McQuistion, H.L., Finnerty, M, Hirschowitz, J, and Susser, E.S. (2003).“Challenges for Psychiatry in Serving Homelessness People with Psychiatric Disorders,” Psychiatric Services, 54, 669-676.
2 Deane, Martha, Steadman, Henry J., Borum, Randy,Veysey, Bonita, Morrisssey, Joseph P.“Emerging Partnerships Between Mental Health and Law Enforcement.” Psychiatric ServicesVol. 50, No. 1. January 1999: pp. 99-101.
3 Paula M. Ditton, Mental Health and Treatment of Inmates and Probationers, US Department of Justice, Bureau of Justice Statistics (Washington, DC: 1999), NCJ 174463.
4 James, D. & Glaze, L. Mental Health Problems of Prison and Jail Inmates (2006). Special Report, Bureau of Justice Statistics. Findings based on data from interviews with state prisoners in 2004 and local jail inmates in 2002, http://www.ojp.usdoj.gov/bjs/ pub/pdf/mhppji.pdf
5 Larkin, G.L., Claassen, C.A., Emond J.A., et al. (2005) Trends in U.S. emergency department visits for mental health conditions, 1992-2001. Psychiatric Services (56) 671-677
6 American College of Emergency Physicians (2008), Psychiatric and Substance Abuse Survey At http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/ PsychiatricBoardingSummary.pdf
7 Manderscheid, Ronald and Berry, Joyce (2004). Mental Health, United States 2004.
U.S. Department of Health and Human Services, Center for Mental Health Services (2004).At http://mentalhealth.samhsa.gov/publications/allpubs/sma06-4195/ default.asp
8 Ibid.
9 Abt Associates, Inc. (1994). Conditions of confinement: Juvenile detention and corrections facilities. Office of Juvenile Justice and Delinquency Prevention:Washington, DC.
10 Nicholson, J., & Henry,A.D. (2003).Achieving the goal of evidence-based psychiatric rehabilitation practices for mothers with mental illnesses. Psychiatric Rehabilitation Journal, 27:122-130.
11 Parks, J., Singer P., et al (2006) Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors,Alexandria
12 Allen, M, Carpenter, D., et al (2003) What do consumers say they want and need during a psychiatric emergency? Journal of Psychiatric Practice (9) 1, pp. 39-58.
13 Ibid.
14 Stefan, S (2006) Emergency Department Treatment of the Psychiatric Patient: Policy Issues and Legal Requirements, Oxford University Press
17 Practice Guidelines: Core Elements for Responding to Mental Health Crises
15 Stefan, S.,What is the current state of the law regarding the use of police force against people with psychiatric disabilities? Center for Public Representation, http://www.centerforpublicrep.org/community-integration/use-of-force-bypolice-against-people-with-psychiatric-disabilities
16 Greenfield,T.K., Stoneking, B.C. et al ((2008) A randomized trial of a mental health consumer-managed alternative to civil commitment for acute psychiatric crisis. American Journal of Community Psychology (42) 1-2, pp. 135-144.17 Achieving the Promise:Transforming Mental Health Care in America. Final Report. (DHHS Publication No. SMA 03-3832).Washington, DC: U.S. Government Printing Office.

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