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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Please go to www.ahrq.gov for current information.

Chapter 8. Mental Health Issues (continued)

Therapies for Psychic Trauma

Crisis Response

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.

Crisis Response for Children and Families

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.

  • Interventions should be grounded in the basic principles of child development, and providers should be experienced in working with children of different ages and levels of development.
  • Mental health providers should have collaborative relationships with community providers to ensure access and community support for children and families.
  • Children and families should be assessed for risk factors and symptoms, and interventions should be crafted to address the findings.
  • An essential objective is to improve parental attention and family cohesion through assessment, psychoeducation, and treatment, when necessary, to parents and primary caregivers.
  • Providers should make concerted efforts to prevent social disruption and displacement.
  • Providers should identify, assess, and attempt to ameliorate or remove children and families from the continued threat of danger.
  • Providers should have continued contact and monitor children for symptoms or 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.

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Medication

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?

  • Lack of availability of trauma-focused psychotherapy (CBT). In many areas of the country, these therapies are not available for children and although nondirective therapies can be helpful for children with posttraumatic symptoms, they do not appear to directly treat the symptoms.
  • Some children do not respond to trauma-focused psychotherapies. As in all situations, first-line treatments do not always work, and other interventions are required.
  • Randomized controlled trials have demonstrated the efficacy of medications in adults with posttraumatic symptoms. Although the analogy between medication effectiveness in adults and children is frequently made, extreme care is indicated. Metabolic and neurodevelopmental factors have great influence on dosage and frequency of medications and responses in children. Some medications that are effective in adults are not effective in children, and furthermore, they may have different or more dangerous side effects.

Considering the use of medications for children with early posttraumatic symptoms prompts certain considerations:

  • Is a trauma-focused therapy available, and if so, has the child completed a trial without responding?
  • What specific symptoms are being targeted?
  • Different psychotropic medications are better for different symptoms (see below).
  • What is the child's level of distress (symptomatic and functional)? In nearly 60% of cases, early post-traumatic symptoms are transient and resolve without treatment. So the question is whether the current amount of distress and functional impairment warrants a medication trial.
  • Are other family members symptomatic?
  • Ascertaining the level of untreated symptomatology of other family members, especially parents, is essential, because posttraumatic symptoms—especially anxiety and hypervigilance—are highly transferable to the child. So, treating the child may have no impact on symptoms if they originated with the parent.
  • What is the developmental or neuromaturational level of the child?

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:

  • Adrenergics (norepinephrine, epinephrine).
  • Dopamine.
  • Serotonin (5-HT).
  • Endogenous opioids.

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.

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School Crisis Response

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:

  • Notification of team members, school staff, students, and parents of a crisis event.
  • Delivery of psychoeducational services and brief crisis-oriented counseling, such as through support rooms or short-term support groups.
  • Memorialization and commemoration.
  • Followup.

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:

  • Crisis team membership.
  • Roles of crisis team members.
  • Protocols for delivery of crisis intervention services.
  • Specific guidelines for responding to unique situations, such as large-scale natural disasters or a terrorist attack.
  • Physical safety and security.
  • Rapid dissemination of accurate and appropriate information.
  • Attention to the emotional impact of the events and the crisis response.

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.

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Anniversary Reactions and Commemorative Activities

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:

  • Memorial activities can further the process of healing and learning.
  • The planning process is as important as the memorial activities themselves.
  • Doctors, teachers, parents, and children all benefit from the planning process.
  • Symptoms and reactions vary from child to child.
  • There is no one "best way" to acknowledge an anniversary.
  • Helping children deal with a difficult event is hard work; pediatricians need to take care of themselves and their staff as well.

Anniversaries

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:

  • Depressed or irritable mood.
  • Oppositional and defiant attitude.
  • Attention-getting or other behavioral problems.
  • Difficulties getting along with classmates and peer group.
  • Social isolation or withdrawal.
  • Deterioration in academic performance.
  • Physical complaints.
  • Changes in appetite.
  • Sleep disturbances.

The extent and nature of potential difficulties may be related to many factors, including the following:

  • Age and developmental level.
  • Personal history (e.g., prior trauma, loss, or emotional difficulties).
  • Support from peers, parents, and school staff.

Memorialization

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.

Planning a Memorial Activity

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.

  • Consider the children's ages and developmental levels when planning activities.
  • Some children may wish to involve other friends or family members in the planning process.
  • Coordinate the planned events with the family and the school.
  • Not all children will want to be involved in the planning process, and participation should be voluntary.
  • Don't feel pressured to plan the "perfect event." Any memorial event or activity, big or small, may be a helpful means for children to understand and mark an anniversary.
  • Activities within a school or individual classroom may affect other students and staff within the school as well as children's families at home. Therefore, other families should be informed about plans for memorial events within a school.
  • Other adults will benefit from additional support and guidance on how to mark an anniversary in a sensitive manner.
  • Awareness of school activities and plans often can help to initiate discussions at home, where children may be most comfortable talking about critical events and anniversaries.
  • Parents should be invited to share any concerns related to the anniversary or relevant family experiences with the pediatrician, teachers, and school staff. Pediatricians, teachers, and school personnel should keep the lines of communication open with parents throughout the planning process. Parents should be encouraged to continue to discuss the planned activities with their children at home.
  • Open discussion communicates to children that adults are available for further discussion and support.
  • Look for signs of distress in students, such as agitation, acting out, or other unexpected behaviors, and help teachers, parents, and school personnel to be aware of them.

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.

Supporting School Staff

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.

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Impact on Health Care Providers

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:

  • Make psychological contact.
  • Assess the individual's level of coping.
  • Explore possibilities for getting further help.
  • Assist in taking action.
  • Followup.

Make Psychological Contact

Tune in—empathetic listening is a precondition for any helping activity:

  • Invite the person to talk.
  • Listen for what happened (facts).
  • Listen for the person's reaction to the events (feelings).
  • Maintain a calm, controlled manner.

Level of Coping

Examine the dimensions of the problem. Ask questions that focus on three areas:

  • Immediate situation. What were the events leading up to the current difficulties in coping?
  • Present. What life situations may increase or decrease the level of stress (family, work, children, etc.)? Have the person tell the story.
  • Immediate future. What are the likely future difficulties? What coping strategies have been attempted?

Explore Possible Solutions

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.

Take Action

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).

Followup

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.

Basic Objectives

  • Help caregiving adults recognize the immediate emotional, cognitive, and behavioral impact of overwhelming events on themselves, typically through psychoeducational approaches.
  • Engage the responder or care provider for purposes of followup assessments and identification of service needs across multiple domains, including home, clinical, work, and community settings that involve individuals, families, and groups.

Benefits

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:

  • Coping with people. Stress reduction also occurs through increased confidence and abilities to have an impact on and help other people rather than just oneself (e.g., microcounseling, "psychological first aid," human relations training, assertiveness training).
  • Interpersonal awareness. Stress reduction also occurs through increased understanding and awareness of your own and other people's cognitive and emotional reactions to traumatic events.

These programs significantly decrease the following:

  • Depression.
  • Anxiety.
  • Psychological strain.
  • Physical strain.
  • Emotional exhaustion.
  • Vocational strain.
  • Interpersonal strain.

Additionally, these programs decrease anger and improve relationship adjustment.

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Risk Communication and Media Issues

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:

  • Planning.
  • Preparation.
  • An understanding of communications protocols, messaging, and the media.
  • The ability to manage the flow of information.

Each element is a challenge that can be met effectively, to the benefit of those receiving messages in times of crisis.

Developing Goals and Key Messages

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.

Messages To Ease Public Concern

Examples of messages to ease public concern are:

  • The risk is low.
  • The illness is treatable.
  • It is not easily contracted.
  • Symptoms are easily recognized.
Messages on How To Respond

Examples of messages that give guidance on how to respond include:

  • Take these precautions.
  • If possibly exposed, contact a physician.
  • If symptomatic, contact a physician.
  • Note possible symptoms in others.

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.

  • Raise points often enough that the audience leaves with a clear understanding of the message you wanted them to hear.
  • Take opportunities to begin or end statements with a reiteration of your message.
  • Don't be so repetitious with a single message that you appear to be trying to convince people of something that isn't true.
  • Don't repeat messages word-for-word every time you answer a question.

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.

Delivering Accurate and Timely Information

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.

  • Goals and messages should be simple, straightforward, and realistic.
  • Information should be delivered with brevity, clarity, and effectiveness.

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


1. For further information about preparation of the body for viewing, as well as additional recommendations about the death notification process, access: Leash RM. Death Notification: A Practical Guide to the Process. Hinesburg, VT: Upper Access, 1994.

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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Bibliography

Trauma-Related Disorders

American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders-IV-TR (4th ed). Washington, DC: American Psychiatric Association; 2000.

Bolton D, O'Ryan D, Udwin, et al. The long-term psychological effects of a disaster experienced in adolescence:  II: General psychopathology. J Child Psychol Psychiatry 2000;41(4):513-23.

Cohen JA, Bernet W, Dunne JE, et al. Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry 1998;37(Suppl 10):4S-26S.

Eth S, Pynoos RS. Developmental perspective on psychic trauma in childhood. In Figley CR (ed), Trauma and Its Wake. New York: Brunner/Mazel;1985:36-52.

Goenjian AK, Pynoos RS, Steinberg AM, et al. Psychiatric comorbidity in children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry 1995;34(9):1174-84.

Pfefferbaum B, Nixon SJ, Krug RS, et al. Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing. Am J Psychiatry 1999;156(7):1069-74.

Rando T. Treatment of Complicated Mourning. Champaign, IL: Research Press, 1993.

Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001;345(20):1507-12.

Steinberg AM, Brymer M, Decker K, et al. The UCLA PTSD Reaction Index. Curr Psychiatry Rep 2004;6:96-100.

Crisis Response

Leash RM. Death Notification: A Practical Guide to the Process. Hinesburg, VT: Upper Access; 1994.

Schonfeld D. Crisis intervention for bereavement support: A model of intervention in the children's school. Clin Pediatr 1989; 28(1):27-33.

Schonfeld D. Almost one year later: looking back and looking ahead. J Dev Behav Ped 2002;23(4):1-3.

Schonfeld D. School-based crisis intervention services for adolescents: Position paper of the Committees on Adolescence and School Health, Connecticut Chapter of the American Academy of Pediatrics. Pediatrics 1993;91(3):656-7.

Schonfeld D, Kline M, and Members of the Crisis Intervention Committee. School-based crisis intervention: an organizational model. Crisis Intervention and Time-Limited Treatment 1994;1(2):155-66.

Schonfeld D, Lichtenstein R, Pruett MK, et al. How to Prepare for and Respond to a Crisis (2nd ed). Alexandria, VA: Association for Supervision and Curriculum Development; 2002.

Substance Abuse and Mental Health Services Administration. National Child Traumatic Stress Network. Available at:  http://www.nctsnet.org. Accessed September 18, 2006.

Risk Communication and Media Issues

Substance Abuse and Mental Health Services Administration. Communicating in a Crisis: Risk Communication Guidelines for Public Officials. Rockville, MD: 2002. SAMHSA Publication No. SMA02-3461.

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