Mass violence presents unique issues that differ from other episodes of interpersonal, community, and other forms of violence. Responding to those individuals who are directly affected by the event is not enough—a multilevel strategy is required and should include victims and witnesses, individuals with whom they are associated, and the broader community. Although crisis response providers do not have to perform all of these roles, they should work closely and collaborate with a number of individuals and agencies to ensure that the psychological impact of mass violence is addressed.
The first and foremost response to mass events is both directed and performed by the government and its agents. These are usually under the auspices of law enforcement, fire personnel, and/or emergency medical services, which are typically managed by an Incident Command System (ICS). Mental health early responders should have pre-existing relationships with the ICS to perform their duties effectively. In most States and other jurisdictions, ICS staff members meet regularly to ensure efficient operation when needed. During episodes of mass violence, mental health providers need to be part of the ICS staff whenever possible. The pre-existing relationship with emergency response commanders permits more expeditious access to affected individuals and for the community's psychological needs to be considered consonant with emergency responses.
In addition, when mental health providers are members of the ICS, access to and allocation of resources for mental health crisis responders in situations of mass violence improves. Situating providers in the most useful locations, ensuring the flow of needed information and communications, and preventing well-intended, but inexperienced and unlinked clinicians from arriving en masse in an attempt to provide services are essential to lessen the general confusion and chaos that accompany disasters.
A useful way of defining and understanding a traumatic response is that the affected individual experiences the loss of both internal and external control. Therefore, maximizing organization and structure is a necessary prerequisite in providing mental health crisis response and early intervention. Mental health crisis models are best equipped to achieve this organization and structure when they are firmly rooted in the ICS.
Unfortunately, there is no clear empirical evidence for the effectiveness of any crisis response intervention. In fact, the frequently used and previously heralded Critical Incident Stress Debriefing or Management (CISD or CISM) strategies have not demonstrated effectiveness, and in some studies they have proved detrimental. Indeed, it has been recommended that compulsory debriefing of victims of trauma should cease. However, it is possible that an alternative method of early crisis intervention may be helpful for assisting people who may be recently traumatized. The following recommendations and guidelines for early intervention strategies are based on evidence from research on the risk factors for posttraumatic stress disorder (PTSD) as well as some intervention research. Thus, they provide an empirical foundation for appropriate and useful approaches to assist potentially traumatized individuals.
Currently, there is no evidence that global intervention for all trauma survivors serves a function in preventing subsequent psychopathology. However, there is consensus that providing comfort, information, and support and meeting the immediate practical and emotional needs of affected individuals can help people cope with a highly stressful event. This intervention should be conceptualized as supportive and noninterventional but definitely not as a therapy or treatment. This suggestion recognizes that most people do not develop PTSD and other posttraumatic symptoms immediately. Instead, they usually will experience transient stress reactions that will abate with time. The goal of early intervention is to create a supportive (but not intrusive) relationship that will result in the exposed individual being open to followup, further assessment, and referral to treatment when necessary. Inherent in this early intervention is the recognition that interpretation or directive interventions are not to be provided.
After assuring that basic necessities are available and are not a pressing concern, the basic principles of intervention should be followed. These principles should ensure that no harm is being done in the intervention process and hopefully prevent or reduce symptomatology and impairment.
Handouts or flyers that describe trauma, what to expect, and where to get help should be made available. Individuals should be given an array of intervention options that may best meet their needs. The goal is not to maximize emotional processing of horrific events, as in exposure therapy, but rather to respond to the acute need that arises in many to share their experience, while at the same time respecting those who do not wish to discuss what happened.
There is not yet clear evidence to support the use of pharmacotherapy in the treatment of posttraumatic symptoms in children, and no randomized controlled trial has been completed. The first line of treatment for posttraumatic symptoms in children is trauma-focused cognitive behavioral treatments (CBT), which includes such interventions as graded desensitization and other CBT.
So, why consider the use of psychopharmacology for children with posttraumatic symptoms?
Considering the use of medications for children with early posttraumatic symptoms prompts certain considerations:
Again, psychotropics are much more difficult to use in younger children and may have an increased propensity to cause side effects.
Neurotransmitters implicated in PTSD symptoms include the following:
Symptoms that appear to be directly related to dysregulation in the adrenergic system include increased heart rate, blood pressure, and anxiety, as well as hyperarousal symptoms such as nightmares, poor sleep, hypervigilance, and panic attacks.
Blocking norepinephrine and epinephrine may treat these symptoms. The first choices, especially for sleep difficulties, are the beta-blockers clonidine and guafacine. These agents are especially good at improving sleep and decreasing nightmares acutely and may improve other hyperarousal symptoms such as impulsivity and hypervigilance.
Symptoms associated with dysregulation of the dopaminergic system include anxiety, hypervigilance, aggressive impulsivity, flashbacks, and paranoia. Studies of risperidone indicate that it may be useful for this constellation of symptoms.
There is clear evidence of dysregulation of the serotonergic system in individuals with posttraumatic symptoms. Deficit of 5-HT is associated with depression, thoughts of suicide, aggression, impulsivity, anxiety, and obsessive thoughts. This suggests that increasing 5-HT availability may treat these symptoms, and studies in adults have found selective serotonin reuptake inhibitors (SSRIs) to be the only class of drugs to decrease all three PTSD symptom clusters. However, with acute posttraumatic symptoms, 6-8 weeks may be needed for effect, so it is better used as a first-line therapy for children who meet the criteria for PTSD. At present, the SSRIs of choice are fluoxetine and citalopram.
Although benzodiazepines would seem an obvious choice for acute posttraumatic symptoms, their use is controversial. In two randomized controlled trials of benzodiazepine use for this purpose, one demonstrated moderate positive effects, while the other showed increased likelihood of the individual developing PTSD.
Most children benefit from receiving supportive services in the aftermath of a disaster or terrorist attack. Pediatricians can play a vital role in advocating for, consulting for, and actively participating in school crisis response teams to ensure that such supportive services can be provided to children within schools and other community sites.
School administrators, teachers, and other school staff will be affected by the same crisis event that is affecting their students. During such times, organizing and implementing an effective crisis response can be difficult or even impossible. Therefore, it is imperative that schools begin planning for potential crisis events before they occur, both to avert disasters whenever possible and to decrease the negative impact on students and staff when disasters cannot be prevented.
The school crisis response plan should include generic protocols for the following:
The structure provided by a preexisting plan can be very comforting in times of crisis and helps to ensure that key issues are considered, appropriate steps are taken, and necessary resources are in place.
In addition, the crisis response plan should include guidelines on the following:
All areas should be addressed concurrently and in a coordinated fashion.
Delivery of supportive services to children during a crisis can be demanding work for school staff and community mental health providers working within the schools. Plans should also include mechanisms to ensure that supportive services for staff are included as a key component of a crisis response.
As the anniversaries of stressful, critical, or traumatic events approach, many children and adults still have significant reactions. Throughout the year, reminders of the original crisis may add to children's sense of further danger and emotional distress. Those reminders of the events may also increase the reactions of peers, parents, teachers, and other adults.
Remember:
At the time of the anniversary, children frequently experience a recurrence of some of the feelings associated with a loss or tragedy. These reactions vary widely, and they can be seen in both children and adults. Some children may not be interested in revisiting the events. For these children, it may be more appropriate that they are occupied with the typical concerns of childhood.
It is important to find ways within the school to recognize the anniversary of such an important event without imposing personal emotions or expectations on either students or staff.
Some children directly affected by the traumatic event may appear to be "back to normal" but may still be feeling sad, scared, anxious, or angry. Children do not always demonstrate their feelings directly, and we should pay special attention to signs of concern or distress. Children who are known to have histories or ongoing exposure to trauma or loss, even if they are not directly related to the traumatic event, may be especially vulnerable in the days and weeks surrounding the anniversary.
Heightened media coverage and publicity of memorial events may increase reactions in children. Parents should monitor and supervise their watching of television and, especially for younger children, consider limiting the amount of television exposure.
Some signs of distress to look for include the sudden appearance of or noticeable change in the following:
The extent and nature of potential difficulties may be related to many factors, including the following:
Memorialization is any activity designed to formally mark the anniversary or memory of a significant event. Memorial events can help children express and cope with their feelings that might otherwise seem overwhelming to deal with alone. By actively planning and participating in a memorial event, children can exercise some control over how they will remember the disturbing event.
Children may have needs similar to those of adults in times of crisis, but they often meet those needs in very different ways. It is important to find out from the children what they would like to remember and what they think would be the best way to acknowledge the anniversary. Children need to be part of the planning process for memorial events. A memorial planned by adults for children is likely to be more helpful to the adults and not necessarily meet the children's needs. The planning of a memorial activity can be more therapeutic than participating in the activity itself.
Remember also that different groups of children and adults will have different needs and wishes at the time of the anniversary. Memorial activities do not need to be formal or elaborate. It is best to take cues from children, considering their age and developmental level, when planning memorial activities. Discussion allows children to explore how they are feeling and to think about what might help them feel better.
Some children may wish to acknowledge the anniversary in a personally meaningful way (e.g., drawing a picture, writing a poem or essay) but resist a group activity centered around the anniversary. Some children may prefer not to mark the anniversary with any formal or even informal activity. It is important to remember that those children who are grieving their own personal losses may resent or feel frustrated if the memorial event focuses only on the heroic efforts of rescue workers.
Memorial activities can be planned at various levels, including individual consultation with the pediatrician, with family members, in small student groups, or in larger community or school-wide committees. Children should be involved in the planning process, but it is equally important for adults to provide guidance, structure, and support.
In some instances, families may not wish to have their children participate in memorial activities. Remember that many children and their families choose not to disclose personal losses, and their privacy should be respected.
Some adults may find it difficult to discuss traumatic events, especially if dealing with their own losses. Adults should seek out support from other adults and colleagues when needed. This is difficult work for everyone, and it is important for staff to think about what their own feelings are in relation to the events. Providing an opportunity for staff to talk about their own reactions may be useful to them personally and may better prepare them to meet the children's needs.
Remember that children look to adults for guidance and support during difficult times. We need to think about how our own reactions may impact children. Children's questions may sometimes take us off guard and make us confront issues we would rather not think about.
Having a plan to address these concerns in advance will help make the task easier. If the task seems too difficult, staff should share the responsibility with a colleague or invite someone else to help with the planning and process of memorialization.
Very often, first responders and other adult service providers show signs of stress and emotional disruption after responding to situations involving disasters, including terrorism, that result in trauma. Typically, programs such as Critical Incident Stress Debriefing or Management (CISD or CISM) are effectively used with first responders. Fire departments and emergency medical teams have incorporated these strategies into the response programs to critical incidents. A short but specialized training is needed for an individual to apply this model, which basically walks the responder through a guided exploration of their experience in responding to a critical situation.
Pediatricians may be approached by a colleague, a fellow worker, or any health care provider in distress. The following basic, common sense rules can help:
Tune in—empathetic listening is a precondition for any helping activity:
Examine the dimensions of the problem. Ask questions that focus on three areas:
Take a step-by-step approach; ask first about what has already been tried, then try to get the individual to generate alternatives, and finally, add other possible solutions. Some people may need coaching to even consider the idea that a possible solution exists. Examine obstacles to implementation and address these issues before a plan is implemented. Part of the solution may include helping the individual to establish a supportive social network. Finally, it may be appropriate to suggest that the individual seek professional help for emotional difficulties.
The objective is very limited, i.e., no more than taking the best next step given the situation. Help the individual implement the agreed upon immediate solutions(s) aimed at dealing with the immediate need(s).
The last component involves establishing a way to provide the support the individual needs to ensure that the necessary steps are taken toward a satisfactory resolution of the situation.
One of the primary ways to reduce stress for first responders and other service providers is through "psychoeducational programs," especially training that emphasizes skills in the following:
These programs significantly decrease the following:
Additionally, these programs decrease anger and improve relationship adjustment.
Information should be communicated to the public in timely, accurate ways that do not heighten concern and fear. Communicating effectively during a crisis requires the following:
Each element is a challenge that can be met effectively, to the benefit of those receiving messages in times of crisis.
People often fail to communicate effectively due to a lack of clear communications goals and key messages to support them. Setting such goals and identifying support messages are tasks that should be accomplished before issuing any public comment and are especially important in a crisis.
A communications goal of "educating the public on the complexities of bioterrorism and preparing them for any eventuality" is not realistic. Informing the public of the problem and specific dangers, providing guidance on appropriate responses, and easing concerns are achievable goals. Messages in support of these goals should also be direct and speak effectively to the audience.
A risk message is a written, verbal, or visual statement containing information about risk that may or may not include advice about behaviors to reduce risk. A formal risk message is a structured written, audio, or visual package developed with the express purpose of presenting information about risk. Risk messages may aim to ease public concern or provide guidance on how to respond.
Examples of messages to ease public concern are:
Examples of messages that give guidance on how to respond include:
If the goal is to ease concern and the message in support of that goal is "the risk to the public is low," that message should be clearly stated at the outset and returned to as often as possible.
Exercise some control over the conversation you are having, be it an interview, press conference, or questions from an audience. Don't allow the conversation to be led down paths that are not pertinent to the goals or message—no matter how persistent the questioner might be in pursuing a line of inquiry.
In a risk-communication situation, there is constant tension between providing accurate information and providing information quickly. Both demands pose challenges. To wait for all information to be complete and verified before releasing it to the public can create an information vacuum that will almost certainly be filled with rumor and speculation. To release information that has not been confirmed and turns out to be inaccurate, however, runs the risk of misleading the public and undermining your credibility as a spokesperson.
Most importantly, always provide statistics and key information to the media in written form. In presenting information, always know how the information was gathered and how any conclusions were reached.2
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2. From Communicating in a Crisis: Risk Communication Guidelines for Public Officials. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2002.
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