Hurricane Katrina was one of the worst natural disasters to ever impact the United States. On August 29, 2005 it made landfall, with subsequent flooding of New Orleans secondary to the breach of several levees and canals. There was a mandatory evacuation of the entire city plus the destruction of the living environment of over 500,000 people and the loss of over 1,000 lives. Although the majority of families escaped prior to the breach of the canals, thousands of the city's citizens, including the poor, elderly, and hundreds of children, had no means of evacuating and were forced to seek refuge in the attics or roofs of their homes or in two large emergency shelters (the Super Dome and the New Orleans Convention Center). These are the same families most likely to be exposed to previous traumas prior to the hurricanes (Stein et al., 2003a
). Many had to wade through flood waters, experienced separation from family members, or viewed dead bodies during the journey to these shelters. Others had to be rescued from rooftops or make other precarious journeys to safety. Both emergency shelters lost electricity, leaving their inhabitants without air conditioning, working toilets, water or food during the days before they were rescued. There were a number of incidents of violence in the shelters, including reported sexual assaults. During the evacuation many children were separated from family members; by the time of the evacuation, many young children and elderly had become seriously ill and had to be hospitalized. Most families were subsequently evacuated to the Astrodome in Houston where more separations, waiting, uncertainty, and ethnic tensions occurred as predominantly African American children were temporarily integrated into a predominantly Latino community. Hurricane Rita struck the Gulf Coast on September 24th
, delaying the reopening of New Orleans and causing further damage and displacement. Upon return to New Orleans, families were faced with life in FEMA trailers, and discovery that all of their possessions and homes were destroyed, and family members, friends and pets had died or moved away and their schools had closed. Many children had relocated multiple times by the start of the 2006-2007 school year. Many were still living in FEMA trailers, under over-crowded conditions. Anecdotal reports gathered during Project Fleur-de-lis (described below) detail high stress conditions and children being exposed to more adult behaviors (drinking, sexual activity, and violence) than would be the case if they were living in their own homes.
After the immediate disaster response, when “first responder” volunteers who had provided mental health care left the New Orleans area, the daunting task of providing intermediate and long-term trauma-informed treatment to the thousands of children exposed to trauma before and after Hurricane Katrina was left to those mental health professionals who remained. Project Fleur-de-lis™ (PFDL) was created by Mercy Family Center in the fall of 2005.. It has been funded by a consortium of corporations, foundations, individual donations, and non-profit agencies over the past 3 years. PFDL was designed as an intermediate and long-term school-based mental health service model for children who have been exposed to traumatic events as a result of natural and man-made disasters. PFDL is a collaborative program linking local social service agencies, schools and nationally recognized researchers, program developers and clinicians in a coordinated effort to provide state-of-the-art mental health services within schools in the greater New Orleans area. PFDL was designed to: 1) implement school-based intervention services to children exposed to trauma; 2) establish a mechanism for identification of and provision of services to children with mental health and psycho-educational needs beyond what can be addressed or identified in the school setting; 3) partner with national leaders to provide increased access to mental health care and effective trauma treatments for children in schools and the community; and 4) provide evidence that treatments for traumatized children can be effectively delivered in a three-tiered model of care utilizing school-based interventions, classroom-based interventions, and specialized community-based interventions in communities significantly impacted by natural or man made disasters.
PFDL's “Stepped Trauma Pathway” was designed to address three major factors that impact mental health intervention post-disaster, including the time when a school-based intervention can be implemented after a community disaster, the number of children served, and the severity of post-trauma symptoms of identified children. PFDL's Stepped Trauma Pathway focuses on children who have been exposed to trauma via a combination of 1) direct exposure to Hurricane Katrina and its immediate destruction in the greater New Orleans area; 2) the persistent and pervasive secondary traumas endured by way of living in the greater New Orleans area, including violence exposure and; 3) complex trauma that many financially disadvantaged and ethnic minority children have experienced prior to Hurricane Katrina.
Treatment studies of childhood PTSD have grown in numbers and empirical rigor in the past decade. Several empirical reviews and treatment guidelines (e.g., American Academy of Child & Adolescent Psychiatry, 1998
; Chadwick Center, 2003
; Foa et al., 2008
; SAMHSA Model Programs, www.modelprograms.gov
,) have recognized Trauma Focused – Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006
) as the treatment with the strongest evidence of efficacy in treating traumatized children, and have recognized Cognitive Behavioral Intervention for Trauma in Schools (CBITS; Jaycox, 2003
; Stein et al., 2003b
) as a “promising” or “proven” school-based intervention. In addition, the Classroom-based Intervention (CBI ©; Macy et al., 2006
) was being implemented by in many schools in New Orleans by Save the Children, and is also a promising practice (Jaycox et al., 2008
). Thus, these three interventions had been selected for use in Project Fleur de Lis based on their evidence-base, with CBI offered as a universal intervention, CBITS as a selected intervention for those with lingering symptoms, and TF-CBT for children with PTSD who did not respond to the school-based interventions.
In response to constraints in school priorities, timing, and staffing issues, however, the full stepped care model was not the norm. In the months following Hurricane Katrina, PFDL offered free multidisciplinary consultation to school-based mental health professionals and free psychological and psychiatric services to students identified as needing mental health care in excess of what could be provided in the school setting. During weekly “Classroom – Community Consultation”(C3) meetings, children who were identified as being in need of psychological services in participating schools were discussed at weekly meetings attended by other participating school-based mental health professionals and the social workers, psychologists and psychiatrists of Mercy Family Center, a non-profit community mental health center funded by the Sisters of Mercy Health System. Forty-five schools and 22,000 students were under the PFDL “umbrella of care” during this period. (PFDL model of care and free services continue to the present time with more schools being added on an ongoing basis.)
During the 2006-07 school year 268 students were triaged within weekly C3 meetings, 116 students were referred for psychoeducational testing, 114 students were referred for therapy, 20 students were referred for psychiatric services, and 18 were determined to be in no need of services. Of the 114 students referred for psychotherapy, 70 referrals (61%) were trauma related (half of these were related to Hurricane Katrina by way of either direct exposure or secondary loss such as damaged home, neighborhood, death of family member and pet).
The 70 referrals for trauma related events in the 2006 – 2007 school year were directly referred for individual, outpatient “third tier” services (TF-CBT) since “second tier” trauma focused groups were not up and running in the 45 participating schools as originally intended.
Significant progress has been made in establishing a sustainable stepped-care model among the 65 participating schools during the current 2008 – 2009 school year by way of 13 PFDL schools now providing CBITS groups and TF-CBT interventions on their campuses. And although current trauma exposure for our PFDL student population receiving interventions tend to be related to community / domestic violence and abuse / neglect, this stepped model is becoming established to address trauma related to future natural and manmade disasters.