Children entertain themselves in a Houston shelter during Hurricane Harvey. Image Credit: All Stock Photos, 2017.

By Betty Pfefferbaum, Anne K. Jacobs, and Merritt D. Schreiber

Implications for Public Health

Implementing a stepped-care approach to mental health triage, screening, and referral for children in shelters can make sure they receive the mental health care they require sooner rather than later.

When families with children evacuate to a disaster shelter, they have likely suffered serious trauma or loss—experiences that can stress children, exacerbate pre-existing emotional and behavioral difficulties, and put them at risk for incident-related clinical disorders. The shelter experience itself can also increase the risk for maladaptive psychological outcomes, especially in children from socially disadvantaged backgrounds, those who have faced childhood adversities, and those with pre-existing mental health problems.

While responding to children’s psychological needs might seem to slow and complicate response and recovery efforts, it is important to ensure that children are referred early to appropriate services, including clinical evaluation and intervention if needed. Triage and screening in shelter situations can decrease this burden. The straightforward triage, screening, and referral process —which ideally would be applied to all children—can be performed relatively quickly and has the added benefit of informing decision-making about the allocation of limited resources.

A Stepped-Care Approach to Triage, Screening, and Referral

A stepped-care approach to triage, screening, and referral can be implemented in shelters, along with various models of psychological first aid , to make sure children receive the mental health care they require sooner rather than later. The approach relies on assessment to determine what services are appropriate and to advance successively to more intense services.

Step 1: The first step consists of rapid triage, conducted by non-mental health care providers, that ascertains a child’s disaster experience (such as sustaining an injury or witnessing a troubling scene), losses, and initial reactions (such as extreme fear or a perceived threat to their life). Initial rapid triage is a primary assessment of risk based largely on reported objective aspects of exposure. This can help distinguish children who are at risk for developing a psychiatric disorder, those with normative distress that is likely to be transitory, and those who might need crisis intervention. Children who express the intent to harm themselves or others, those who show disorganized or uncontrollable behavior, and those with an urgent need for medication require immediate crisis intervention with a mental health clinician and referral for a formal clinical evaluation.

Step 2: Children who are less vulnerable but still considered to be at moderate risk for the development or exacerbation of psychiatric disorders are prioritized for secondary mental health screening (using interviews or written instruments) and supervised by child mental health professionals trained in traumatic stress assessment. Screening is a secondary assessment that requires more in-depth interaction with children and their caregivers. Shelter workers cannot rely solely on caregivers in assessing children’s reactions to disaster or their needs, because caregivers are likely to underestimate the child’s distress and children sometimes conceal their feelings to avoid upsetting their caregiver. Caregivers are better at reporting externalized reactions, such as anger or behavior problems, while children provide more information about internalized reactions, such as sadness or worry. Therefore, in addition to questioning children directly, screeners should ask caregivers to provide information about the child’s experiences and reactions. Such screening does not establish diagnoses—for instance, post-traumatic stress disorder or major depression—but instead, identifies children who are at risk for emotional and behavioral difficulties.

Step 3: Children with positive secondary screenings should be referred for a comprehensive clinical evaluation and empirically supported clinical intervention, including traditional clinical treatment if necessary. Referral is based on triage and screening that identify not only global risk, but also the type of risk and that informs specific resources needed to help the child. Referrals can address a range of concerns from meeting basic needs to connecting children with intensive psychological interventions. For example, unaccompanied children might be referred to social services and to services for those with traumatic loss. Children who manifest normative distress can be referred to empirically supported psychosocial interventions designed to provide support, promote adaptation, and enhance coping. Examples of these brief interventions include helping children put feelings into words, strategies to improve sleep, and techniques to reduce distressing reactions to trauma reminders.

Tools, Resources, and Technology

Shelter organizers who want to implement a stepped-care approach to children’s mental health needs have a variety of resources at their disposal. For instance, PsySTART is a rapid mental health triage technology used to identify and refer children at general risk for psychiatric illness. The system also geocodes and aggregates de-identified individual triage information for real-time situational awareness. This can help to produce an overview of risk (such as the number of children involved and the severity and types of mental health risk) for the entire child population exposed to an event. There are multiple resources available to assist in screening for child trauma.

Several elements should be considered when selecting screening interviews and tools. Ideally, tools should be brief, uncomplicated, and acceptable to those being screened, as well as appropriate for the child’s developmental level and culture, the time when assessment occurs relative to the disaster, and the shelter environment. Screening items should be adapted for incident-specific features to assess the evolving aspects of children’s disaster exposure, the loss of or separation from family and pets, their initial reactions to the disaster, and existing adversities such as diminished social or economic resources.

When children suffer as a result of their disaster and sheltering experiences, their caregivers are likely to be distressed and distracted as they attend to next steps. Some children will lack the ability to effectively communicate their needs in the response to disaster and, therefore, might be overlooked. Triage and screening can quickly identify children in need and refer them to the appropriate services both within and outside shelters, thus improving post-disaster efficiency and effectiveness. A stepped-care approach connects children with appropriate services including clinical evaluation and empirically supported intervention if needed and has the additional benefit of informing decision-making about the use of limited resources.

Suggested Tools


Listen, Protect, and Connect: Family to Family, Neighbor to Neighbor
County of Los Angeles Department of Public Health Emergency Preparedness and Response Program

A psychological first aid system designed for families and communities to help each other during disasters.

Psychological First Aid Field Operations Guide
National Child Traumatic Stress Network and National Center for PTSD

A handbook detailing the tenets of delivering psychological first aid, along with resources for provider care, worksheets, and handouts for disaster survivors. This guide can be used in mass care settings such as emergency shelters.

National Children’s Disaster Mental Health Concept of Operations
Terrorism and Disaster Center at the University of Oklahoma Health Sciences Center

This tool outlines a triage-enhanced children’s disaster mental health incident response strategy for preparedness, response, and recovery operations. It outlines PsySTART, a rapid mental health triage technology used to identify and refer children at general risk for psychopathology.

Screening and Assessment Considerations for Implementation
National Child Traumatic Stress Network

A set of guidelines to consider when selecting trauma screening or assessment tools to implement in a given system.

For a list of all the tools included in this special collection, visit the Mass Sheltering Tool Index. A list of further readings are also available.