All the authors except Dr. Clum are affiliated with the RAND Corporation. Dr. Clum is with the Department of Community Health Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans. Send correspondence to Dr. Jaycox at RAND, 1200 S. Hayes St., Arlington, VA 22202 (e-mail: firstname.lastname@example.org).
On August 29, 2005, Hurricane Katrina made landfall in southeast Louisiana. It was one of the deadliest and most destructive natural disasters in recent U.S. history, devastating cities as far as 100 miles from its center and causing nearly 80% of New Orleans residents to flee (1). Compounding the destruction and devastation was Hurricane Rita, which hit on September 24 near the Texas-Louisiana border.
Many displaced individuals were exposed to multiple traumatic events—the hurricanes, flooding, loss of loved ones, and violence—in addition to the general stress of displacement, job loss, and homelessness. Mental health needs appeared to be extensive among those in the region. The number of Gulf Coast residents experiencing mental illness nearly doubled after the storm (2). Yet four to seven months after the storm, only an estimated 2% of residents were receiving appropriate services (2). As for children, more than 196,000 students from kindergarten through grade 12 were displaced from Louisiana alone (3). Some reports indicated that 31% of New Orleans children had elevated symptoms of posttraumatic stress disorder (PTSD) (4).
Schools in Mississippi, Alabama, Florida, Texas, Arkansas, and Louisiana played a central role in the immediate aftermath of this disaster, serving as shelters, distribution sites, and forums for community meetings. Schools have often played such a role after communitywide traumatic events (5,6,7). Schools offer a place where children can receive mental health services with minimal logistical barriers and stigma (8,9). Schools have increasingly been recognized as an important site for delivering mental health services to children (10). In addition, the recent development of several empirically supported, school-based interventions for traumatized youths (11,12) has increased the potential for schools to implement trauma-focused programming for students after a disaster. Thus it seemed that schools were poised to help support the mental health recovery of displaced students in the wake of the hurricanes.
The purpose of this study was to examine factors related to uptake and implementation of school mental health programs for students affected by the disaster. Aims included identifying school personnel's perception of needs related to the long-term mental health recovery of affected students; providing information to schools about evidence-based mental health program options; and identifying barriers and facilitators in regard to implementing trauma-focused or other mental health programs.
Using public information, we identified schools in Louisiana, Alabama, and Texas that took in large numbers of displaced students, defined as an increase of more than 10% in the student body. We included public and private school systems (districts, parishes, and dioceses or archdioceses) that had central organization and infrastructure as well as public and private schools that were not part of a system (for example, charter schools). Because data from Mississippi were not publicly available, we worked with the Mississippi Department of Education to identify potential target school districts. In both Mississippi and Louisiana we also identified schools that closed as a result of storm damage and later reopened, such that 100% of the student body had been at least temporarily displaced. We aimed for diversity in the schools targeted, in terms of location, structure, storm damage, and student demographic characteristics.
We targeted 32 public schools (24 districts or parishes and eight charter schools) and 20 private schools (five archdiocese school systems and 15 individual private schools) in the four states. We identified individuals responsible for mental health or student support and invited them to participate via letter or email. We then followed up by telephone to confirm participation and identify the appropriate interviewees. At the beginning of each interview the study was described and verbal informed consent was obtained with a protocol approved by the RAND Institutional Review Board. We conducted interviews with representatives of 19 of the 32 public schools (13 districts or parishes and six charter schools) and 11 of the 20 private or parochial schools that were targeted.
We interviewed district and school administrators in charge of mental health or student support, social workers, counselors, and safety officers. One to four individuals per school or school system were interviewed by telephone by the first four authors. Using a semistructured interview protocol, we gathered data about school demographic characteristics and enrollment of displaced students; experiences with Hurricanes Katrina and Rita; mental health service capacity before the hurricanes; experience providing crisis intervention and trauma-related programs; current mental health needs of the affected students, their parents, and the faculty and staff; and perceived barriers to implementing mental health services after the hurricanes. In the subsequent school year (2006—2007), we reinterviewed school contacts to get updates on how the students were doing and on schools' experiences implementing mental health programs since the first interview.
Detailed notes taken during the interviews were summarized into a series of tables to capture relevant responses and examples for each school. We identified themes by categorizing responses into similar domains. Several themes emerged, including successes in helping displaced students during the acute phase after the disaster and factors that impeded delivery of mental health interventions, such as competing priorities, implementation challenges, and prior training and planning.
To provide information to schools about potential mental health programs, we developed an educational outreach packet for schools (12). We sent out a first draft to all schools and districts around the time of the first interview, so that all schools had similar information available to them.
Supporting students in the acute phase
Interviewees described a rapid and coordinated effort by school personnel to help students enroll, acquire needed school uniforms, and settle into class with desks and books. Some interviewees expressed pride in these actions and believed that rapid accommodation in the new school would provide a sense of security and normality for displaced students.
To directly address mental health issues, a few interviewees described orienting staff about what to expect from students or providing handouts and information to school administrators, families, and teachers about typical reactions to traumatic events. However, this response appeared to be more common among interviewees who were part of larger school districts or parishes with well-established mental health support systems.
Supporting students for longer-term recovery
In the postacute phase of recovery some school personnel described using existing programs and staff to accommodate the mental health needs of displaced students. Almost all the schools in our sample offered one-on-one counseling for affected students. These services were typically delivered by existing school counselors and were nonspecific and supportive in nature.
Across all the study schools and districts the time window for intervention was shorter than we expected. Most implemented services only in the first few months after the hurricanes, although some schools were planning training over the summer of 2006. Overall the use of trauma-specific programs was uncommon, although a few schools reported that they developed or used a program for some displaced students to support their long-term recovery. In some areas help was offered by an outside organization or resource specifically targeting exposure to trauma. The methods by which schools learned about or accessed these resources varied. Some schools found out about such programs when contacted by program personnel; in other cases, organizations such as Mercy Corps and Save the Children provided workbooks and trained staff to implement programs for dealing with trauma.
Factors impeding delivery of interventions
Some school personnel did not perceive a need for any mental health approaches for students beyond the immediate stabilization phase. Students were described as doing well (resilient, flexible, and well adjusted), and additional services were seen as unnecessary. One interviewee believed that any trauma that manifested itself after Katrina and Rita had existed before the hurricanes and may have been exacerbated by the storms but was not directly related. In contrast, other schools saw a high level of need among the students, and one school district that screened displaced students found 31% had a high level of posttrauma anxiety and depressive symptoms. In fact, some school personnel reported a high level of need among their regular students as well as among the displaced students and thus saw a need to balance what they could offer the displaced students with the need to continue to offer services to their regular student body.
Other school personnel described a desire to provide some type of services to the displaced students but noted that their efforts were hindered by a variety of factors, including the need to refocus on academics as the school mission, a lack of prior training, scarcity of resources, competing priorities, and other implementation issues. Each of these types of problems is described in more detail below.
Academics as the school mission. Many school districts reported refocusing on academics as the priority, in line with schools' main mission of education, in the postacute phase of recovery. In some instances, this shift in emphasis was reinforced by the approach of mandatory testing in early spring 2006 in Louisiana and Mississippi. At the same time, interviewees in some systems reported flexibility; for example, some systems did not count standardized tests toward student placements, and one school whose entire student body was living in trailers instituted a no-homework policy. In other schools, administrators specifically asked mental health personnel to allow students to "move on" from the topic of the hurricanes. Other interviewees reported that teachers wanted to get "back to normal" and wanted the counselors to stop coming into class to talk about the hurricanes.
Some interviewees noted that additional stress came from educational delays among some of the displaced students, and they saw it as a priority to assist these students in reaching the host school's academic standards. For example, some schools hired school counselors to help older students track down records and finish their credits so that they could graduate, and others described implementing tutoring and educational support to level the playing field between some of the displaced students and the regular student population.
Prior training. Implementing programs in the acute recovery phase appeared to be partly driven by prior training and availability of materials. Many interviewees described having ready access to materials and handouts about the mental health consequences of trauma that they found on Web sites of national organizations, and many had crisis teams that were trained and ready to help in that phase.
In contrast, few interviewees described their schools or districts as having the capacity to deliver interventions for children exposed to trauma who had lingering symptoms of PTSD and depression in the postacute phase. The interventions that tended to be used during the 2005—2006 school year were already "on the shelf" and used previously by counselors to address previous school crises or loss. For example, one counselor described finding the materials for a particular trauma program floating in a sealed plastic bag in her living room, when all her other counseling materials had been destroyed. She was able to implement that program. Training that was provided to counselors in the aftermath of the hurricane was described as being very general and not providing the details necessary to choose what to implement or how to go about it.
Scarcity of resources. School personnel expressed frustration at the lack of funding for services to displaced students. They believed that these funds had been promised, which left them feeling "abandoned" when the funding never came. Another interviewee mentioned applying for a grant to hire another counselor and having the request denied by the funding agencies without justification. Resources that were available may not have been allocated evenly. One interviewee noted that some schools had more resources than they could use, whereas just across town there were schools still scrambling to find the same supplies. Those that did receive funding reported that it came late in the school year, making it very difficult to launch services during that year.
Competing priorities. School personnel also discussed other competing priorities, many of which were related to pressing needs in the community to repair structural damage and staff needs in regard to rebuilding their homes. Several interviewees emphasized that staff burnout was a large issue in the schools. Many personnel described frustration and a general level of stress in their communities, with disrupted services, traffic congestion, and extra residents in many homes. These types of issues were not cited as interfering with service delivery per se but were described more as a general hassle that affected everyone and limited energy during the work day. Schools that were damaged and whose entire student bodies were displaced struggled with restaffing issues and rebuilding the school community, which often meant that remaining staff were asked to address multiple school needs.
Other implementation challenges. Interviewees also discussed barriers that impeded their implementation of mental health interventions. One issue they identified frequently was difficulty communicating with parents, both to gain consent for mental health interventions and to include them in educational or outreach programs. They reported enormous challenges both in intact communities, where jobs and cell phone numbers had changed, and in displaced communities, where many people were living in trailers and temporary housing. Similarly, transportation posed an obstacle for many displaced families who had no cars, some of whom were living in trailer areas that were not served by bus routes or other forms of public transportation. Interviewees also described extremely stressful living conditions for families in trailers, which reduced energy and motivation for participation in interventions or outreach services.
Some school personnel interviewed wanted to refer students to community mental health providers, but they found many of the usual providers were no longer available in the area or had long waiting lists. Thus school personnel had to develop a new list of referral options.
Over the past several years, particularly since the Columbine school shootings and the September 11, 2001, terrorist attacks, there has been an increasing focus on preparedness of schools for emergencies such as disasters, terrorist incidents, and mass violence. Because this study is qualitative and drew from a small sample of schools and districts, the findings may not represent the full array of issues that the schools in the Gulf States encountered in the aftermath of the 2005 hurricanes. We did not observe trends across states or types of schools, possibly because of the diversity of schools included in this sample. However, by interviewing school personnel from a wide variety of schools and types of systems, we were able to understand some of the key factors related to mental health recovery efforts implemented by schools.
The experiences of schools after Hurricanes Katrina and Rita described in this report highlight the need for advanced planning and training to respond to natural disasters. Our experiences in recruiting school personnel for this study highlighted for us the difficulties with disrupted communication, even months after the hurricanes. Multiple phone calls and e-mails were required to reach overburdened school personnel, even those who expressed interest in participating. Because it is so difficult to communicate and develop new programs after a disaster, there is a clear need for prior planning for postdisaster services.
We learned that many schools had detailed plans for helping students cope with the death of a fellow student or a teacher, and many had previous experience implementing crisis plans. Many schools had conducted the necessary precrisis planning for acute interventions—that is, they had preplanned strategies that could be called upon immediately after the event. For example, many provided psychoeducational materials to all students and their families about reactions that students might experience.
However, schools were not generally equipped to deal with the longer-term mental health consequences of natural disasters, school or community violence, a public health emergency, or terrorist incidents. In particular, key elements for successful response to mental health needs were missing, such as available funding, relationships across sectors to ensure appropriate coordination, and established methods for engaging and communicating with parents before, during, and after the emergency. We found that many schools faced difficulties learning about available resources in their community and were frustrated by the lack of local or regional coordination of information and resources. We also heard repeatedly about the difficulty schools faced in communicating with parents of displaced children.
Although schools can play a critical role in supporting the mental health of students in times of disaster, it appears to be important for school personnel to have training and experience in such interventions before a disaster. Personnel with prior experience were able to implement programs, whereas those without training and experience had difficulty. Including information for faculty and community members about self-care also appears to be important, particularly given reports of how staff were overextended and had to deal with their own responses to the hurricanes. In some cases staff members were affected personally by the hurricanes, in addition to being exposed to more work and stress at their schools. Thus supporting these staff members and attending to their mental health in order to reduce burnout may be a key ingredient in successfully supporting student mental health.
Our interviewees also noted that schools in the region were trying to learn from their experience to prepare for the next emergency. If there is a good outcome to be found, it may be best captured by the view of one interviewee who noted that at least now mental health professionals, including school counselors, were learning about evidence-based approaches for treating trauma.
The responses of these schools, and of other schools and school systems across the nation that have rallied to meet the needs of students after disasters, offer a promising model for developing capacity to respond to students' longer-term postdisaster mental health needs. At a minimum, schools' crisis plans should specify the roles, training, and resources required to address longer-term mental health consequences for students, staff members, and families. Identifying staff ahead of time who can respond to these needs and providing training would be helpful. Clearly, areas that may be exposed to repeated disasters may want to focus more attention on planning for disaster response. In addition, our interviewees noted that not only were students affected but also their families and school staff members. Thus an approach that takes into account the mental health needs of the school staff and family members would be beneficial. Efforts that enhance the infrastructure for providing support and training for school staff to deliver evidence-based interventions in advance of disasters may be especially helpful.
This study was funded by the RAND Corporation's continuing program of self-initiated research, which is supported in part by donors and the independent research and development provisions of RAND's contracts for the operation of its U.S. Department of Defense federally funded research and development centers. This research was conducted within RAND Health under the auspices of the RAND Gulf States Policy Institute.
The authors report no competing interests.