How psychological first aid can support infants, children and families who experience a disaster (part one)

Key messages

• Offering individuals, families and communities psychosocial support immediately following a disaster is crucial in responding to distress, promoting resilience and supporting their long-term mental health.
• Psychological first aid is an evidence-informed approach that can support infants and children, as well as adults.
• Psychological first aid aims to address post-disaster distress using non-intrusive, supportive and practical strategies.
• Understanding the five essential elements of psychosocial support underpinning PFA – promoting safety, calm, connectedness, self-efficacy and hope – can help you tailor your support to infants’ and children’s developmental stages and contexts.
• Psychological first aid can be implemented as direct support for infants and children but also emphasises supporting parents in self-managing their emotional reactions and in using strategies to support their own children.
• Targeted psychosocial support for expectant parents and those with infants is also essential to minimise adverse outcomes for both parents and their unborn children and infants.

Who is this resource for?

This practice paper was developed to assist practitioners who are supporting, or could support infants, children and families during and immediately after a disaster.

This includes practitioners and workers, leaders and volunteers in:

• health services
• social and community services
• education
• first response and emergency services
• government agencies and services
• non-government organisations; and
• community-led initiatives.

For ease of reading, we refer to individuals in all these roles as ‘practitioners’.

This paper will be helpful for a practitioner who:

• is curious about what PFA is
• wants to understand if and how PFA can support the mental health of infants and children exposed to a disaster
• has completed training and/or has delivered PFA previously, but wants to learn more about using the principles in ways that are child-centred and family-focused
• is expected or planning to offer, or presently implementing, PFA with infants, children, parents or expectant parents, and/or families.

Definitions

The terms ‘children’, ‘parents’ and ‘practitioners’ are used throughout this resource and we define them in the following ways.

Children: includes newborn infants, babies and children up to 12 years old.

Parents: the biological, adoptive, foster and kinship carers of a child, as well as individuals who have chosen to take up primary or shared responsibility in raising that child.

Practitioners: all individuals with a role that involves or might involve supporting infants, children, parents and/or families in the context of a disaster of any kind.

In an emergency like a disaster, response efforts primarily focus on:

• ensuring safety
• addressing physical injuries by offering first aid and medical care; and
• providing necessities like food and shelter.

Over time, and in response to an increasing number of disasters, it has become clear that people’s emotional and psychosocial needs must be attended to along with their physical needs. In the same way that traditional first aid is an immediate response to physical injuries, a psychological first aid approach is needed to manage distress and prevent psychological ‘injuries’ worsening in the early stages of disaster recovery.

This practice paper (part one) introduces psychological first aid (PFA), a psychosocial support approach that can reduce distress and promote the mental health of people who have experienced a disaster. It outlines the aims and elements of PFA, and how it may benefit infants, children and families who experience a disaster.

A complementary paper (part two) provides guidance on using a PFA approach with infants, children and families, offering practical strategies for applying key elements of psychosocial support in a disaster context.

Stress and survival responses

During a distressing event such as a disaster, the human body can automatically activate a stress response sometimes referred to as ‘fight, flight, freeze, or fawn’. This is an important way that people adapt to survive when under threat or feeling unsafe. However, if this acute stress response continues once the threat has passed, it can disrupt the development, functioning, and potentially the mental health, of infants and children, as well as their parents, leading to poorer long-term outcomes (Lai et al., 2017).

Evidence and expert consensus have found that the short- and long-term recovery of individuals, families and communities who experience potentially traumatic events is best supported by actions that help them to:

• feel safe, calm, hopeful and connected to others
• have access to social, physical and emotional support; and
• regain a sense of control by being able to help themselves (WHO et al., 2011).

Timely and tailored support

Experts including practitioners and volunteers working in disaster settings, and families with lived experience of disasters, emphasise the importance of providing timely and tailored emotional support. As such, several psychological first aid models have been developed to meet the psychosocial needs of different populations, contexts and cultural backgrounds in the immediate aftermath of potentially traumatic events, such as disasters.

Adapting PFA for infants, children and families

Psychological first aid can be adapted to suit the developmental stages, communication abilities, and unique needs of infants and children. But before you can consider how to modify PFA for this purpose, including how to involve parents, you first need to understand the foundations of PFA, its aims, core principles and models/frameworks.

Psychological first aid is a psychosocial approach designed to reduce the immediate emotional and psychological distress experienced by people who have been affected by a disaster. It focuses on addressing their fundamental needs, including safety, shelter, food and medical care, while also promoting emotional safety, stability and coping. PFA is designed to help individuals regain control over their emotions and cognitive function – which is the foundation for long-term adjustment, healing and recovery.

It adopts a person-centred approach that acknowledges common stress responses and prioritises human connection during and after a disaster. By reducing distress, enhancing safety and promoting adaptive coping, PFA helps prevent the longer-term impacts of stress on the mental health of infants, children and adults (Brymer et al., 2006).

Psychological first aid is based on evidence-informed observations that acknowledge:

• early reactions and responses to disaster vary
• people have different needs and preferences for how they cope and receive help
• people are more likely to benefit from help that is respectful, compassionate and culturally appropriate
• with effective support and adequate resources, people and can move forward and adapt after disasters; and
• people are more likely to experience recovery after disaster and adapt if they have a sense of agency and are supported to make their own decisions and choices (Rosenberg et al., 2022).

Psychological first aid can be delivered in many different locations, including homes, workplaces, and sites where people who have been affected by disasters gather, such as evacuation/relief centres, hospitals, community centres, early learning services (ELS) or schools.

Promoted by the World Health Organization (WHO) as a universal intervention, PFA is often described as an essential initial emergency management response for individuals, families or workers in the immediate aftermath of a disaster, but can also be used in the longer term. As such, it can be delivered as a prevention program or early intervention support approach.

While PFA is most needed during or shortly after the threat has passed, it is important to note that some people – including infants and children – will benefit from mental health support even after the threat no longer exists. They may feel the impact of a disaster much later, and PFA can be an important recovery tool in the weeks, months and sometimes years following. It can be beneficial for people who experience strong stress reactions or are triggered by reminders of the experience, such as an anniversary or in anticipation of another disaster. Effective PFA includes recognising the need for more specialised mental health support and linking of people with services that can help them cope with their responses to an event and support their recovery in the longer term.

Five essential elements of psychosocial support are found in the various models of PFA. These are widely recognised as foundational principles for providing people in distress with psychosocial support during and after a disaster (Hobfoll et al., 2007).

The five elements of psychosocial support are:

• Promoting a sense of safety
• Promoting calm
• Promoting connectedness
• Promoting self-efficacy and collective efficacy
• Promoting hope

The essential elements were developed through expert consensus, informed by international research and practice experience, to guide care and support for individuals affected by disasters or other potentially traumatic events (Hobfoll et al., 2007; International Federation of Red Cross and Red Crescent Societies, 2009).

These five principles can inform your responses and provide a framework for your engagement with infants, children and families. Strategies for applying these five elements in your work supporting children, parents or whole families in a disaster context are provided in part two of this paper, Psychological first aid with infants and children: Practice guidance.

Psychological first aid with infants and children

Although infants and young children may not be aware of the risks or danger of potentially traumatic events, such as disasters, they are one of the groups most vulnerable to adverse impacts (Norris et al., 2002; Bothe et al., 2018).

Every infant and child, even those within the same family, will have a different experience of, and response to, a disaster. This depends on a range of personal, family, community and societal risk and protective factors. Unlike adults, children are still:

• developing emotionally and physically
• learning how to cope; and
• dependent on their parents for protection and support.

Infants and children have distinct needs, capabilities and responses influenced by their developmental stage.

Tailoring psychological first aid to age and developmental stages

Providing PFA that is tailored to developmental stages can significantly lessen the negative impacts of these potentially traumatic circumstances on infants and children by addressing their immediate needs and providing long-term benefits for emotional recovery, resilience and healing.

You can tailor interventions to children’s age and developmental stage by adjusting support to align with their level of comprehension and cognitive abilities. For example, to promote safety when speaking with children of different ages who ask about when is it safe to go home in the aftermath a bushfire, you might say:

• To a four-year-old: ‘Sometimes, big fires happen. Our house got hurt by the fire, and the firefighters put the fire out with their big hose. Right now, we’re all safe, Grandma is safe, and we’re going to be OK. That’s what matters most.’
• To a 10-year-old: ‘The fire damaged our house and the firefighters did their best to save it. It might take some time to fix everything. But we’re going to work together to make sure we have a safe place to stay in the meantime. We’ll talk to people who can help us rebuild and we’ll be involved in decisions about our home. It might be tough, but we’ll get through it together as a family. Right now, we’re all safe, and Grandma is safe, and that’s what matters most.’

In the first example, the young child is offered simple reassurance, and encouraged to make meaning of their safety status. In the second example, the 10-year-old is offered more detail in the explanation, while recognising their safety and emphasising hope about the rebuild.

PFA can also assist children to build on their current coping strategies and develop new skills to regulate their emotions and avoid feeling overwhelmed. You’ll find recommended strategies in the section ‘Providing child-centred and family-focused psychosocial support after a disaster’ (in part two of this paper).

Acknowledging worries

The mental health of children after a disaster is influenced by their perception of threat, which can vary depending on various factors such as their age, developmental stage, prior experiences and the way adults around them react to the situation. Perception of threat refers to how children interpret and understand the danger or risk posed by the disaster or its aftermath. Based on their perceptions, children can be especially vulnerable to experiences of fear, confusion and distress following a disaster. Younger children may have a limited understanding of the disaster and its implications, which can lead to heightened fear and confusion. Older children may have a better grasp of the situation but may also experience increased anxiety about their own safety or the safety of loved ones.

By providing children with an opportunity to express their thoughts and worries in a safe and supportive environment, PFA respects children’s rights to:

• be heard and valued
• their opinions; and
• their agency in their own recovery journey.

Psychological first aid with parents

Psychological first aid with distressed parents is important not only for those adults, but also for the safety and wellbeing of their children. Parents, and the whole family unit, have a crucial role in supporting infants’ and children’s safety and wellbeing, especially during disasters. Infants and children often look to adults, particularly parents and caregivers, for cues on how to interpret and respond to threatening situations. If the adults around them exhibit high levels of fear or distress, children may perceive the threat as greater than it actually is. PFA encourages parents to manage their own emotional reactions and provide calm, reassuring support to children, which can help ease children’s perception of threat.

Implementing targeted PFA for mothers and birthing parents who are expectant, pregnant and/or currently breastfeeding can minimise the risk of adverse outcomes. Exposure to stressful and potentially traumatic events that escalate their concern for themselves, their family, children and community can impact an expectant parent’s health and the development and health of their unborn child or infant.

Psychological first aid can also be an opportunity to provide guidance regarding the support services available to children and families affected by disasters. It may include linking children and families with practical supports and services, and appropriate mental health services where relevant.

A foundational understanding of infant and child mental health will help ensure you can provide effective support tailored to the unique needs of infants and children who have experienced disasters or potentially traumatic events.

There is no single model of, or ‘one-size-fits-all’ approach, to PFA. Various models or frameworks, differing in structure and method, have been developed to meet the unique needs of different populations, contexts and cultural backgrounds, and enhance the preparedness of responders. The different models/frameworks commonly integrate or have an emphasis on the five essential elements of psychosocial support described previously.

There are few PFA models specifically tailored to respond to the unique needs of infants, children and families in the immediate aftermath of a disaster or emergency.

Infant, child and family-specific PFA models

The US National Child Traumatic Stress Network (NCTSN) and collaborators developed the PFA field operations guide (Brymer et al., 2006) for use with children, adults (including parents), and families in the immediate aftermath of a disaster. It is one of the few models that incorporates developmentally appropriate strategies to specifically support children of any age with adaptive functioning and coping in the short and long term after a disaster.

This model describes the following eight actions with infants, children and adults:

1. Contact and engagement: Establishing a connection in a calm and respectful manner.
2. Safety and comfort: Enhancing immediate safety, and physical and emotional comfort.
3. Stabilisation: Helping the individual to cope with overwhelming emotions and reactions.
4. Information gathering: Identifying immediate needs and concerns.
5. Practical assistance: Providing or facilitating access to basic services and resources that address immediate needs and concerns.
6. Connection with social supports: Helping people contact and mobilise their family, friends and other sources of support.
7. Information on coping: Providing information and guidance on managing stress reactions.
8. Linkage with collaborative services: Where appropriate, referring to other supports or services to address specific needs.

The NCTSN specifically tailored Psychological first aid for schools (PFA-S) (Brymer et al., 2012) for use in education settings. PFA-S recognises the critical role that learning communities play in supporting children’s mental health and wellbeing, particularly in the aftermath of potentially traumatic events or disasters.

Building on the principles and strategies outlined in the PFA field operations guide, Listen, protect, connect – model and teach: Psychological first aid (PFA) for students and teachers, is another model developed for students and teachers (Schreiber et al., 2006). It aims to provide a simple and practical framework that emphasises the importance of listening to children’s and families’ experiences, protecting their safety and wellbeing, and connecting them with appropriate support and resources.

Psychological first aid: An Australian guide (Australian Red Cross & Australian Psychological Society, 2020) is one of the most well-known and frequently used local PFA resources. It gives practical guidance and strategies for individuals and communities to provide immediate support to people affected by disasters, emergencies or other traumatic events in Australia. The guide describes the PFA action principles – look, listen and link – from the PFA model published by the WHO. While the Australian Red Cross PFA guide was not specifically designed to respond to the unique needs of infants and children, it highlights some of the key differences between helping children and helping adults using this model.

The second part of this paper, Psychological first aid with infants and children: Practice guidance, includes strategies for applying the five elements of psychosocial support that underpin PFA to support infants, children and families who have experienced a disaster.

Psychological first aid is a valuable and effective way to support infants, children and families who are or have been affected by a disaster. By increasing your understanding of ways to use PFA with infants and children, and the five core elements underpinning this approach, you can be prepared to offer psychosocial support with children and families in times of distress.

For more guidance on using PFA in response to disaster and potentially traumatic events read the second part to this paper, Psychological first aid with infants and children: Practice guidance (part two).

To learn more about offering psychosocial support with infants, children and families during and after disasters, you may wish to read these papers next:

Learn more about infant and child mental health with the following Emerging Minds resources:

Australian Red Cross & Australian Psychological Society. (2020). Psychological first aid: Supporting people affected by disaster in Australia. Australian Red Cross.

Bothe, D. A., Olness, K. N., & Reyes, C. (2018). Overview of children and disasters. Journal of Developmental & Behavioral Pediatrics, 39(8), 652–662. DOI: 10.1097/DBP.0000000000000600

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (2006). Psychological first aid: Field operations guide (2nd ed.). National Child Traumatic Stress Network and National Center for PTSD.

Brymer, M., Taylor, M., Escudero, P., Jacobs, A., Kronenberg, M., Macy, R., Mock, L., Payne, L., Pynoos, R., & Vogel, J. (2012). Psychological first aid for schools: Field operations guide (2nd ed.). National Child Traumatic Stress Network.

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P. R., de Jong, J. T. V. M., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A. M., & Ursano, R. J. (2007). Five essential elements of immediate and midterm mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283–315. DOI: 10.1521/psyc.2007.70.4.283

International Federation of Red Cross and Red Crescent Societies. (2009). Psychosocial handbook. IFRC Reference Centre for Psychosocial Support.

Lai, B. S., Osborne, M. C., Piscitello, J., Self-Brown, S., & Kelley, M. L. (2018). The relationship between social support and posttraumatic stress symptoms among youth exposed to a natural disaster. European Journal of Psychotraumatology, 9 (Suppl 2), 1450042. DOI: 10.1080/20008198.2018.1450042

Lai, B. S., La Greca, A. M., Auslander, B. A., & Short, M. B. (2013). Children’s symptoms of posttraumatic stress and depression after a natural disaster: Comorbidity and risk factors. Journal of Affective Disorders, 146(1), 71–78. DOI: 10.1016/j.jad.2012.08.041

Rosenberg, H., Errett, N. A., & Eisenman, D. P. (2022). Working with disaster-affected communities to envision healthier futures: A trauma-informed approach to post-disaster recovery planning. International Journal of Environmental Research and Public Health, 19(3), 1723. DOI: 10.3390/ijerph19031723

Schreiber, M., Gurwitch, R., & Wong, M. (2006). Listen, protect, connect – model & teach: Psychological first aid for students and teachers. University of California Los Angeles, School of Public Health.

World Health Organization (WHO), War Trauma Foundation & World Vision International. (2011). Psychological first aid: Guide for field workers. WHO.