"From Hurricane to Home" by Dr. Doug.Walker

From Hurricane to Home:
Evolving Trauma Treatment
with Students and Families
Douglas W. Walker, PhD
Clinical Director
Mercy Family Center
Project Fleur-de-lis

Objectives
• 1) Participants will be able to identify the rationale
and programmatic challenges in creating this multi-
stepped approach to addressing student’s mental
health needs in the aftermath of a natural disaster.
• 2) Participants will be able to identify the types and
trends of psychological and educational problems of
over 1,000 students who have been identified as
needing intensive “third-tier” mental health services in
the New Orleans community over the past three years
via Project Fleur-de-lis’ weekly clinical triage.

Background:

Project Fleur-de-lis™ is a comprehensive
mental health care program for New Orleans
area students 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.

Best Practice:
Stepped Care Approach
to Mental Health Intervention
• Multi-tiered levels of care
• Pro-active focus is on addressing symptoms
before they interfere with child’s educational
or social emotional functioning
• Focus is upon working with child with
emotional/behavioral issues in a “non-clinical”
intervention model
• Utilize evidence-based treatment models and
identified “best practice” in the field of child
trauma

• Established in 1992 as a Sisters of Mercy
Outreach Ministry
• Managed by Sisters of Mercy Health System
• Provides outpatient psychological and psychiatry
services for children and adolescents
• Offices in Mandeville, Metairie and Algiers
• NCQA Certified
• Non-profit, 501 (c) (3) organization
• Project Fleur-de-lis is owned and managed by
Mercy Family Center
Mercy Family
Center

School Participation
• 64 participating schools
• 26,000 children under project’s umbrella of
care
• Serving the Parishes of Orleans, Jefferson,
St. John, St. Charles, St. Tammany,
Washington and Plaquemines

Continued
Success
Project Fleur-de-lis is the largest
school based mental health
program in the
Greater New Orleans Area
Princeton University – Woodrow Wilson School of Public and International
Affairs. (January 2007). Coping with Katrina: Mental health services in
New Orleans.

Collaborative Partners
• American Red Cross
• RAND Health
• Louisiana Public Health Institute
• Catholic Charities – Archdiocese of New Orleans
• Tulane University – Department of Social Work & Psychology
• LA-YES
• Morehouse School of Medicine's Regional Coordinating Center
for Hurricane Response (RCC)
• Louisiana Rural Trauma Services Center – LSUHSC
• All Participating Schools; counselors, social workers,
administrators, teachers, families

Dual Programming
Tier Three:
Community-Based Intervention
(TF-CBT)
Tier Two:
Classroom-Based Intervention
(CBITS)
Tier One:
School-Based Intervention
(CBI)
Trauma Specific
Programming
School-Wide Issues:
Collective Issues of Response and
Recovery
Classroom – Community Consultation (C3):
Triage Child Specific Issues for possible
referral into Community
Community Based Interventions:
Psychology, Psychiatry, Social Work
School-Based Identification
of All Mental Health /
Learning Issues

History & Timeline for

August 2005
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Hurricane
Katrina

January 2006
1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
30 31
CCANO and Mercy Family
Center form counselor team
and divide 73 Archdiocesan
schools among them for
initial contact and needs
assessment
Because of the team’s
success they are soon
referred as
“THE AWESOME SIX”

Needs Assessment
• 6 counselors divided among 73
schools to collect data
• Obtained information to determine
school’s interest in services and/or
interventions, need for a school
counselor, % of devastation to school,
families, & community

March 2006
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30 31
Proposal to
LPHI for
Funding to
Support ERS
Development
and
Implementation
Classroom
Based
Intervention©
Training by
Save the
Children

Stepped Trauma Pathway
Enables schools to reach all
children exposed to a
traumatic event and triage
them “up” to higher, more
appropriate levels of trauma
intervention if needed

Stepped-Care Approach
Tier One:
(CBI)

Classroom Based
Intervention (CBI®)
Robert Macy, Ph.D.
Boston Center for Trauma
Psychology
Trauma Informed,
Developmentally Specificity,
& Ethnocultural Specificity
Evidence Based Methodological Framework

July 2006
1 2
3 4 5 6 7 8 9
10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30
31
Training:
Cognitive
Behavioral
Intervention for
Trauma in Schools
(CBITS)

Tier Two:
(CBITS)
Tier One:
(CBI)

Cognitive-Behavioral
Intervention for
Trauma in Schools
(CBITS)
Lisa Jaycox, Ph.D.
RAND Corporation
Identified as a Promising Practice by SAMSHA

August 2006
1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30 31
Training: Trauma
Focused – Cognitive
Behavioral Therapy
Training
NCTSN Learning
Collaborative
Electronic Records
System becomes
fully operational

Tier Three:
Community-Based Intervention
(TF-CBT)
Tier Two:
(CBITS)
Tier One:
(CBI)

Trauma Focused-
Cognitive Behavioral Therapy
(TF-CBT)
Judith A. Cohen, M.D.
Anthony Mannarino, Ph.D.
Center for Traumatic Stress in Children & Adolescents
Allegheny General Hospital, Pittsburgh, PA
Esther Deblinger, M.D.
CARES Institute
University of Medicine & Dentistry of New Jersey School of Osteopathic
Medicine
Stratford , NJ
Identified as a Model Program by SAMHSA

September 2006
1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30
First C3 weekly
staff meeting

Dual Programming
School-Wide Issues:
Collective Issues of Response and
Recovery
Classroom – Community Consultation (C3):
Triage Child Specific Issues for possible
referral into Community
Community Based Interventions:
Psychology, Psychiatry, Social Work
School-Based Identification
of All Mental Health /
Learning Issues

Classroom - Community
Consultation (C3)
Enables schools and communities
to identify children with all types of
mental health and/or learning
issues and triage them to
appropriate care in the community

C3
School-Wide Issues
Brought to C3 by school counselors. School-wide issues and
concerns addressed by peer consultation and shared community
resources
Classroom – Community Consultation (C3)
Weekly consultation meetings with school-based counselors to
discuss students that may be in need of community based
services. Goal is to support counselor interventions with
students in schools to avoid decrease in adaptive functioning.
Rely on Electronic Records System maintained by counselors
and PFDL™ staff to promote continuity of care and quality
improvement initiatives
Community Based Interventions
Psychiatry, Psychology, Psycho-educational
Assessments, Wrap-Around Services

Hurricane Assessment
Instrument:
Summer of 2007
Survey based upon approximately 2,000
registered students summer 2007.
Currently have over 4,000 registered
students in ERS system.

Instrument:
Neighborhood Destroyed
56%
44%
Intact
Neighborhood
Destroyed

Instrument:
Witnessed Injury or Death During
Storm
97%
3%
Intact
Witnessed Injury
of Death

Instrument:
Separated from Parent/Caregiver
83%
17%
Family Together
Separated from
Parent/Caregiver

Instrument:
Family or Friend Injured
94%
6%
Healthy
Injured

Instrument:
Pet Lost/Dead
81%
19%
-
Pet Lost/Dead

Instrument:
Trapped During Storm
95%
5%
-
Trapped During
Storm

Instrument:
Displaced From Home During Storm
24%
76%
-
Displaced During
Storm

Instrument:
Past Major Trauma
82%
18%
-
Past Major
Trauma

Instrument:
Home Badly Damaged
60%
40% -
Home Badly
Damaged

Instrument:
Belongings Destroyed
62%
38%
-
Belongings
Destroyed

Number of Students
Triaged Via C3

C3 Results
250
18
539
10
0
100
200
300
400
500
600
2006-2007 2007-2008
Number of Children
Referred
Number of Children Not
Referred

C3 Results Three-Year
Totals
250
18
539
10
412
31
0
100
200
300
400
500
600
2006-2007 2007-2008 2008-2009 as
of 3/12/09
Number of Children
Referred
Referred

C3 Results Third-Year
Projected*
250
18
539
10
572*
39
0
100
200
300
400
500
600
2006-2007 2007-2008 2008-2009 as
of 3/12/09
Number of Children
Referred
Referred

Pediatric Symptom
Checklist
• Utilized as one of multiple screening
devices used during C3 meetings
• Includes all types of signs and symptoms
that occur in school age children

Developmental Trauma Disorder
• DSM-V criteria will include:
– Exposure
– Affective and physiological dysregulation
– Attention and Behavioral dysregulation
– Self and Relational dysregulation
PTSD is an adult diagnosis that does not capture
developmental impairments in emotional regulation,
attention, cognition, perception and interpersonal
relationships
van der Kolk, B. (March 19, 2009). Closing Plenary. NCTSN All
Network Conference, Orlando.

0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50% Distracted easily
School grades dropping
Has trouble concentrating
Fidgety, unable to sit
Feels sad, unhappy
Less interested in school
Is irritable, angry
Has trouble with teacher
Is down on him or herself
Does not listen to rules
Pediatric Symptom Checklist:
Top Ten Symptoms 2006-2007

0%
10%
20%
30%
40%
50%
60%
70% Has trouble concentrating
Distracted easily
School grades dropping
Fidgety, unable to sit
Daydreams too much
Feels sad, unhappy
Less interested in school
Does not listen to rules
Is irritable, angry
Worries a lot
Pediatric Symptom Checklist:
Top Ten Symptoms 2007-2008

C3 Community Triage: By Type
2006-2007 School Year
43%
7% 7%
43%
Psycho-Educational
Evaluation
Therapy
Psychiatry
No Referral Necessary

C3 Community Triage: By Type
2007-2008 School Year
53%
8%
2%
1%
36%
Psycho-Educational
Evaluation
Therapy
Psychiatry
No Referral Necessary
Case Management

C3 Referrals: Followed Through with
Services 2006-2007 School Year
58%
42% Followed Through
with services
Did Not Follow
Through with services

C3 Referrals: Followed Through with
Services 2007-2008 School Year
68%
32%
Followed Through
with services
Did Not Follow
Through with services

Combined 2006-2007 Triage
by Month (268 total)
0
10
20
30
40
50
S O N D J F M A M J J A
No Referral
Necessary
Psychiatry
Therapy
Psycho-
Educational
Evaluation

Combined 2007-2008 Triage
by Month (549 total)
0
10
20
30
40
50
60
70
80
90
S O N D J F M A M J J A
Case
Management
No Referral
Necessary
Psychiatry
Therapy
Psycho-
Educational
Evaluation

Autumn 2008 (143)
0
10
20
30
40
50
60
70
80
90
100
110
120
130
S O N D
Case
Management
No Referral
Necessary
Psychiatry
Therapy
Psycho-
Educational
Evaluation

Significant Increase
September to October 2008
• Only 2 C³ meetings in September (9/19/08
& 9/26/08)
– 9/5 meeting cancelled because we were
evacuated for Hurricane Gustav
– 9/12 meeting cancelled due to extreme
weather from Hurricane Ike
• October numbers above include 5 C³
meetings (10/3, 10/10, 10/17, 10/24, &
10/31)

Free Care Via C3
$700,000
675 Children Have Received
No Cost Outpatient Mental
Health Care Since 9/1/06

Trauma Trends
September 1, 2006
to Present
All New!!

70
124
76
0
20
40
60
80
100
120
140
2006 – 2007 2007-2008 2008-2009*
Total Trauma Referrals by Year
*To date.

89
71
44
32
11 10 9
4 2
0
10
20
30
40
50
60
70
80
90
100 Hurricane
Death/Illness of
Relative/Close Friend
Divorce/Separation
Domestic Violence
Incarceration Parent
Sexual Abuse
Death of Parent
Physical/Illness/Self
Community Violence
Types of Trauma Referrals
September 2006 to Present

0
2
4
6
8
10
12
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Referrals for Trauma Treatment by Year & Month:
Hurricane

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Divorce / Separation

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Incarceration of Parent

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Death of Parent

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Death/Illness of Relative or Close Friend

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Community Violence

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Domestic Violence

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Physical Illness/Injury Student

0
1
2
3
4
5
6
7
8
9
10
9 11 1 3 5 7 10 12 2 4 9 11 1
2006 – 2007 2007-2008 2008-2009
Sexual Abuse

Percentage Referrals for Trauma Treatment /

44
34
21
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Hurricane Trauma Treatment /
Percentage%

16 17 16
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Divorce / Separation Trauma Treatment /
Percentage%

4 1
10
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Incarceration Trauma Treatment /
Percentage%

10
0 00
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Death of Parent Trauma Treatment /
Percentage%

20
28 29
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Death/Illness of Relative or Close Friend
Trauma Treatment / Total Trauma Referrals by Year
Percentage%

0 2 00
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Community Violence Trauma Treatment /
Percentage%

3
15 14
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Domestic Violence Trauma Treatment /
Percentage%

1 1 3
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Physical Illness/Injury Student Trauma
Treatment / Total Trauma Referrals by Year
Percentage%

1 2
8
0
10
20
30
40
50
60
70
80
90
100
2006 – 2007 2007-2008 2008-2009
Percentage Referrals for Sexual Abuse Trauma Treatment / Total
Trauma Referrals by Year
Percentage%

Future Directions
• Adding and dropping schools.
Maintain 65 schools
• Continue to add schools who seek
our program
• Additional care managers
• Expand third-tier preferred provider
list
• Plan implementation of Stepped
Trauma Pathway post future
evacuation

Future Directions
• Add trauma informed evidence-based
treatments (i.e., Psychological First
Aid for Schools)
• Add Child Advocacy and Family Law
representation to C3 meetings
• Offer C3 expertise via telehealth to
other programs/regions

Future Directions
• Establish CBITS Learning Community in
New Orleans
– June 11-12
– Then offer training spring/fall each year
– Support school counselors in screening
and implementation
– Consistent peer consultation throughout
school year

Future Directions
Compile data from three years of
program into comprehensive paper
for publication

Future Expansion
• Adapt program to meet the needs of other
communities along the Gulf Coast
• Become intermediate and long-term mental
health response of choice to future
disasters through membership in NCTSN

Special Thanks to:
Kate Gegenheimer
Mimi Pecot
John Hill
Laura Danna
Jayme Bensel
Sharon Heno
Beth Cooney

Douglas W. Walker, PhD
Clinical Director – Mercy Family Center
Project Director – Project Fleur-de-lis
dwalker1@mercyfamilycenter.com

"From Hurricane to Home" by Dr. Doug.Walker

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