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Bioterrorism preparedness: what school counselors need to know.

Bioterrorism within the United States is a continuing threat. Because children and adolescents are among the most vulnerable populations during a bioterrorist attack, school counselors must be prepared with knowledge and skills. This article provides pertinent information including (a) a description of bioterrorism and biological agents, (b) the psychological impact of bioterrorism, (c) school counselors' role in a school-related incident, and (d) disaster mental health principles and procedures. Implications for school counselors are discussed in the context of the ASCA National Model[R].

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Bioterrorism in the United States is a continuing threat and immediate preparation is needed, as indicated in the Homeland Security Act of 2002 (H.R. 5005-2) and the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (P.L. 107-188). National leaders have stated that we must confront the real threat of bioterrorism and prepare for future emergencies (Department of Homeland Security, 2004). Recent anthrax threats are evidence that all citizens in the United States are vulnerable to bioterrorism (Jernigan et al., 2002). The National Advisory Committee on Children and Terrorism (NACCT, 2003) has warned that "in the event of a terrorist attack, children would be among the most vulnerable populations in our society" (p. i).

To ensure the safety of school-aged children and adolescents, school counselors must not ignore or deny the public health threat of bioterrorism (Henderson, 1998). Rather, school counselors must be prepared with knowledge about bioterrorism and intervention skills. The purpose of this article is to increase school counselors' bioterrorism preparedness by providing information as follows: (a) a description of bioterrorism and biological agents, (b) the psychological impact of bioterrorism, (c) school counselors' role in a school-related incident, (d) disaster mental health principles and procedures, and (e) implications for school counselors in the context of the American School Counselor Association (ASCA) National Model.

BIOTERRORISM DESCRIPTION

What is bioterrorism? The Federal Emergency Management Agency (FEMA, n.d.) has defined terrorism as "the use of force or violence against people or property to create fear and to get publicity for political causes" ([paragraph] 3). Bioterrorism is terrorism that uses biological weapons, which are organisms (bacteria or viruses) or toxins that can kill or injure people, livestock, or crops. According to the Centers for Disease Control and Prevention (CDC, 2001), the four categories of bioweapons are as follows: (a) bacteria such as plague, anthrax, and tularemia; (b) viruses such as smallpox and viral hemorrhagic fevers; (c) rickettsias such as Q fever; and (d) toxins such as botulinum, ricin, and mycotoxins. The CDC also has identified an "A" list of biological agents of highest concern, which includes (a) variola major (smallpox), (b) Bacillus anthracis (anthrax), (c) Yersinia pestis (plague), (d) Francisella tularensis (tularemia), (e) botulinum toxin (botulism), and (f) filoviruses and arenaviruses (viral hemorrhagic fevers). A description of these biological agents can be found at the CDC Web site, listed in the Appendix of this article.

Knowing the history of bioterrorism provides a helpful perspective. Biological weapons are the oldest of the triad of nuclear, biological, and chemical forms of terrorism and have been used for more than 2,500 years. The first recorded incident of bioterrorism was in 1340 when soldiers catapulted dead horses at a castle in Northern France (Public Broadcasting System, 2003). Closely following, in 1346, Tartars threw corpses infected with the plague over a city wall in Italy. In the 1760s, British soldiers spread smallpox in Boston and Quebec by giving Native Americans blankets with smallpox scabs. In World War II, Japanese soldiers used anthrax and plague against Chinese people, killing 10,000 (Public Broadcasting System). In 1984, cult members in Oregon spread salmonella in salad bars in an attempt to prevent people from voting in local elections. In 1995, the Japanese cult Aum Shinrikyo successfully used satin gas and attempted to use bioweapons in a Tokyo subway. Most recently, in October 2001, anthrax was placed in letters mailed to congressmen and other citizens, and anthrax threats continue to date.

Despite this history, biological agents have not been instruments of choice for terrorism as explosives and guns account for more than 99% of all weapons used by terrorists (Global Center for Traumatology, 2003). However, if biochemical agents are used, the potential for mass casualties is horrific. Biological toxins are more deadly than chemical agents. Biological pathogens are relatively inexpensive and easy to produce. Terrorists can disseminate them from a great distance (e.g., an airplane or shipping infected animals) without being exposed themselves. Biological agents are odorless, tasteless, and colorless, and therefore very difficult to detect. Because some agents are contagious (e.g., smallpox and pneumonic plague), victims can widely disperse the biological agent without knowing it.

PSYCHOLOGICAL IMPACT

The terror created from an unknown, undetectable biological agent can be greater than the terror from explosives and natural disasters, because people do not know if they may be infected. Consequently, the biggest impact of bioterrorism is psychological, initially in the form of mass panic and later ranging from acute stress disorder, anger, or guilt to posttraumatic stress disorder, phobias, sleep disorders, depression, or substance abuse (DiGiovanni, 1999). "It will generally be the terror generated by a major event, not the event itself, that will have the greatest long-term negative impact on children and families throughout the nation" (NACCT, 2003, p. i).

The phenomenon of mass panic was illustrated during the Persian Gulf War when nearly 40% of Israeli citizens near the first missile attack feared bioterrorism and reported difficulty breathing, tremors, sweating, anxiety, and moodiness (Carmeli, Liberman, & Mevorach, 1991).

More recently in the United States, public panic was seen during the first anthrax attacks, when only 22 cases of anthrax were identified, with 5 resulting in death; yet up to 40,000 individuals took the antibiotic ciprofloxacin (Shine, 2003). Mass panic was seen in public schools as Auger, Seymour, and Roberts (2004) reported that 21.3% of school counselor questionnaire respondents indicated students feared anthrax attacks 6 weeks after September 11, 2001.

Mass sociogenic illness--that is, the rapid spread of psychosomatic symptoms in a group due to hysteria--occurred on September 29, 2001, when 16 middle school students and a teacher went to a hospital because they mistook paint fumes for bioterrorism (Wessely, Hyams, & Bartholomew, 2001). This mass sociogenic illness also was seen in Manila, Philippines, on October 3, 2001, when 1,000 students went to health clinics because they mistook cold symptoms for bioterrorism symptoms after a rumor of a bioterrorist incident (Wessely et al.).

Due to this likelihood of mass panic and sociogenic illness, school counselors must respond immediately to a bioterrorist incident in their own school. Although most school districts have a crisis response team, during a bioterrorist event outside personnel will not be allowed in the building because first responders will most likely lock down the building. Therefore, each school counselor must be prepared for his or her role in a bioterrorist crisis.

SCHOOL COUNSELORS' ROLE

To provide a context for school counselors' role, other professionals' roles in a bioterrorist incident must be described first. If there is a potential bioterrorist incident at a school, first responders (e.g., firefighters and police) have the responsibility of assessing and securing the scene and identifying the potential bioterrorist agent. An incident commander will be determined, who will be the highest-ranking official (local law enforcement, state, or federal agent) on scene, not the school principal. The incident command structure is paramilitary and brings structure to chaos by identifying team leaders who follow predetermined procedures (FEMA, 2003).

For example, the incident commander Hill establish a public information officer to brief media, family, and friends, a safety officer to establish safety, and an operations director to arrange for food services, bedding, and so forth. The incident commander may order a quarantine to observe students and staff for symptoms and to protect the general public from those who are infected. Emergency Medical Services' (EMS) role is to triage victims, provide basic medical care, and decontaminate victims if necessary. Community mental health and crisis responders' role is to provide emergency mental health to family members and friends of people inside the building or restricted area.

Under this structure, school counselors will likely take directions from the incident commander. Although school administrators and counselors should be following their school crisis plan, it is extremely important to defer to all instructions given by the incident commander. Overall, school counselors' role is to address the psychosocial needs of students and staff. Yet, unlike in other disasters, in a bioterrorist event, school counselors must be especially vigilant to defuse mass panic and sociogenic illness by employing basic disaster mental health principles and procedures.

DISASTER MENTAL HEALTH PRINCIPLES AND PROCEDURES

During a bioterrorist event, school counselors must exhibit the "six Cs" of disaster mental health (Mitchell & Everly, 2001; World Health Organization, 2003). "Calmness" is the first principle school counselors must employ. In the midst of chaos and distress, school counselors can maintain a non-anxious presence by eliciting the dominance of the parasympathetic nervous system over the sympathetic nervous system (i.e., taking slow, deep breaths to lower heart rate and relaxing their pelvic muscles) (Rank & Gentry, 2003; Sapolsky, 1998). Because students and teachers most likely will be confined in classrooms or strictly designated areas outside, school counselors may need to go to each classroom and demonstrate how to achieve a calm demeanor.

"Common sense" is the second principle. During traumas, people's brains respond with a survival mechanism of "fight or flight," which hinders higher-order reasoning (Schwarz & Perry, 1994). Thus, school counselors may need to provide common sense such as huddling together for warmth or placing cold water on the face and neck to stay cool. (Note: school ventilation systems will be turned off to prevent biological agents from spreading.)

"Compassion," the third principle, is a familiar counseling skill that will be needed. Reassuring words and a gentle physical touch may ease students' minds, even for seemingly unreasonable concerns such as thinking a mosquito bite is smallpox. "Collaboration," the fourth principle, is paramount, especially with the incident command system. Many outside professionals may need school counselors to guide them around the building and staff may need school counselors to obtain resources for them. "Communication," the fifth principle, Hill be key as school counselors may be the only communication link between some staff and students and their families. School counselors may need to communicate the facts of symptoms from particular biological agents.

Finally, "control of self" is needed so that school counselors can effectively fulfill their roles. Taking a break to cry, contact a comforting family member, eat, or rest are all expected self-care strategies that school counselors can enact to maintain self-control while interacting with students and staff.

Procedures During an Incident

Personal safety. During an incident, helper safety is paramount (Mitchell & Everly, 2001). Therefore, the first procedure for school counselors is to make certain they are in safe, protected areas cleared by the incident commander. If skin or clothing comes in contact with a visible, potentially infectious substance, school counselors should remove and bag clothes and personal items, wash with warm, soapy water immediately, put on clean clothes, and seek medical assistance from EMS (Department of Homeland Security, n.d.).

Conveying credible information. After establishing personal safety, the second procedure is to ensure that everyone receives credible information about what is happening (World Health Organization, 2003). The principal may give this information out over the public announcement system or through e-mails sent to classrooms. The school counselor should inform the principal if certain student groups (e.g., special education or English as a Second Language students) do not receive the information in a way they can understand. It also may be helpful to remind principals that the manner in which they present the information will influence students' and staff's ability to cope with the trauma. Thus, the principal or another authority figure should calmly and confidently state that the situation is under control and/or that help is on the way (Gal, 2003).

Defusing. Upon approval of the incident commander, the third procedure is to begin individual and group defusing by making contact with students and staff, assessing their functioning level, and stabilizing the situation (Gentry, 2001; Young, Ford, Ruzek, Friedman, & Gusman, 1998). When making contact, school counselors should employ the above-listed principles of calmness, compassion, and control. They should observe and informally assess if someone's physical or emotional needs warrant EMS evaluation. To stabilize those who are emotionally or behaviorally out of control, school counselors can provide grounding and containment techniques of deep breathing by placing hands behind the head; describing objects above eye level, sounds, and things one can touch; muscle relaxation; or visual imagery of a safe place (Baranowsky, Gentry, & Schultz, in press; Levine & Frederick, 1997; Sapolsky, 1998).

Normalizing responses. The fourth procedure is to ask students and staff to briefly express their thoughts and feelings and to educate them about normal responses to trauma (Gentry, 2001; Mitchell & Everly, 2001; National Institute for Mental Health, 2001). Normal responses may range from a strong affect of wailing to a quiet, fixed downward stare (Rank & Gentry, 2003). Students' developmental level and culture must be taken into account when assessing normal response because an Asian American 1st-grade student's response may be different from an African American 10th-grade student's response.

According to Gal's (2003) Acute Stress Model, symptoms will be in five areas as follows: (a) physiological such as increased heart rate or dilated pupils; (b) emotional such as anxiety, anger, or numbness; (c) cognitive such as confusion or selective attention; (d) social such as withdrawal or clinginess; and (e) spiritual such as questioning belief systems or God. When these responses are identified, school counselors should offer this helpful mantra from the International Critical Incident Stress Foundation: "You are a normal person having a normal response to an abnormal event" (Rank & Gentry, 2003, p. 211).

Coping strategies. The fifth procedure is to provide students and staff with information about positive coping strategies that they can use immediately and after the incident. One model that facilitates trauma resiliency is the "BASIC Ph"--that is, Beliefs, Affect, Social, Imagination, Cognition, and Physical (Lahad & Cohen, 1997). For the category of "Beliefs," which entails attitudes, values, and meaning, coping strategies are activating faith acts of prayer or scripture readings, cultural rituals, and works of hope such as planning memorials. For "Affect" or emotional expression, coping strategies include bibliotherapy, play therapy, art therapy, and metaphors.

For the "Social" category, coping strategies include being involved in social support systems, classroom meetings, teams, family gatherings, and role-playing situations. For "Imagination," which entails creativity and symbols, coping strategies include psychodrama, guided imagery, creative games, and "as-if" symbols. For "Cognition," coping strategies include reading, reappraisal or reframing, problem solving, and stress inoculation. For "Physical," coping strategies include aerobic exercise, movement activity, games, and relaxation techniques.

Connecting with families. Finally, and perhaps most importantly, school counselors should facilitate students' and staff's contact with their families as soon as possible (NACCT, 2003). Organizing a system so that each person can have brief phone contact with a family member will provide the most amount of reassurance. Once the incident commander clears students for release, school counselors should help organize a system to reunite students with their families as soon as possible. For example, one class could be released at a time; or students whose last name starts with A-E could be with staff on the east side of the building, F-K on the west side, and so forth, so that siblings can huddle together until a family member arrives.

Procedures After an Incident

Returning to routine. After a bioterrorist incident has ended, the NACCT (2003) recommends to "prioritize returning children to normal routines with appropriate supports as soon as possible to promote family and community resilience" (p. ii). Appropriate supports within the school would include allowing children to talk and express their feelings within the classroom, psychological debriefings, psychoeducation, play therapy, and art therapy (Cohen, Berliner, & March, 2000; National Institute for Mental Health, 2001). Rather than having an open-door approach, school counselors should be proactive in providing these supports by "visiting classrooms, roaming halls looking for affected students, and organizing supportive activities" (Auger et al., 2004, p. 229). School counselors may need to request help from the school district crisis response team, which can employ standard critical incident stress debriefing protocol for numerous groups of students (Mitchell & Everly, 2001; Steele, 1998).

Assessing students. Another role for school counselors after an incident is to assess students for mental health and psychosocial needs as soon as possible (NACCT, 2003). School counselors should advise teachers and parents of normal responses to trauma, indicators for at-risk students, and warning signs that indicate more intensive help is needed (National Institute for Mental Health, 2001). Resources for this information are referenced in the Appendix. School counselors also should reach out to students who have additional stressors such as being in foster care or a recent family death as well as students with known mental health issues such as depression, substance abuse, or anger management problems (Auger et al., 2004).

When at-risk students are identified, school counselors may use common trauma assessment instruments for children and adolescents such as the Trauma Symptom Checklist for Children (Briere, 1996), the children's version of the Impact of Events Scale-Revised (Weiss & Marmar, 1997), the Revised Children's Manifest Anxiety Scale (Reynolds & Richmond, 1985), and the Children's Depression Inventory (Kovacs, 1992). It should be noted that when the President declares a national disaster, school-based screening to identify students who need psychological help can be conducted without parent consent (NACCT, 2003). In keeping with the ASCA National Model's recommendation for responsive services, school counselors should provide group and individual counseling for students who have trauma symptoms that distract them from academic and social achievement. They also should provide referrals to community mental health counseling as well as other community resources such as public health information about potential symptoms and medical clinics.

IMPLICATIONS FOR SCHOOL COUNSELORS

By increasing knowledge and skills in bioterrorism preparedness, school counselors will fulfill the ASCA National Model (ASCA, 2003) in three respects. First, ASCA recommends that school counseling programs have mission statements that align with the school and district mission, which often includes creating a safe environment for students (Hernandez & Seem, 2004). School counselors can add to this mission of creating a safe school environment by increasing their knowledge and skills in bioterrorism preparedness and consulting with school administrators in the development of a bioterrorism crisis plan.

Second, ASCA (2003) states that all school counseling programs should help students develop competencies in personal/social development. School counselors who understand the psychological impact of bioterrorism and acquire appropriate intervention skills will be able to facilitate students' and staff's safety and survival skills during a bioterrorist incident. In preparation for bioterrorism and other disasters, school counselors can provide counseling and guidance lessons on managing anxiety and cooperating with authority figures. Third, ASCA states that the delivery system includes systems support of collaborating with administrators. School counselors will be able to assist principals in resolving bioterrorism crises by informing them of bioterrorism agents and appropriate roles and implementing disaster principles and procedures. School counselors can prepare for an event through consultation with administrators and coordination of emergency response drills.

In addition to knowledge of bioterrorism preparedness, training for skill development is essential. Auger et al. (2004) found that 36% of school counselor questionnaire respondents did not feel they had adequate training to respond to traumatic events. Hence, it is likely that the majority of school counselors do not have adequate training in bioterrorism preparedness and response. We recommend that school counselors not only increase their knowledge of bioterrorism through reading articles such as this one but also seek training to develop bioterrorism intervention skills. Training can be obtained by collaborating with public health agencies, joining community crisis support teams, or contacting national agencies that specialize in bioterrorism preparedness such as the Global Center for Traumatology or the Florida Center for Public Health Preparedness (see Appendix).

CONCLUSION

Although thinking about bioterrorism may be alarming, we recommend that school counselors do not avoid this disturbing topic but rather assimilate this bioterrorism preparedness information, acquire skills, and develop and practice a schoolwide preparedness plan with their school administrators. In so doing, they will carry out the ASCA National Model by fulfilling the mission of creating a safe school, facilitating students' safety and survival skills, and assisting principals in a bioterrorism crisis.

APPENDIX

Resources for Bioterrorism Preparedness

American Red Cross, http://www.redcross.org/ "Terrorism: Preparing for the Unexpected" manual http://www.tallytown.com/redcross/library/ TerrorismPreparingForTheUnexpected.pdf

American School Counselor Association, http://www.schoolcounselor.org Crisis information; how to help kids in time of crisis and stress http://www.schoolcounselor.org/content.cfm?L1 = 1000&L2=99

Centers for Disease Control and Prevention, http://www.cdc.gov/ Bioterrorism agents/diseases listed at http://www.bt.cdc.gov/agent/agentlist.asp "Children and Anthrax: A Fact Sheet for Parents" http://www.bt.cdc.gov/agent/anthrax/parentsfactsheet.asp

Department of Homeland Security, http://www.dhs.gov/dhspublic/ "Emergencies & Disasters Planning and Prevention" (what to do during a bioterrorist attack) http://www.dhs.gov/dhspublic/display?them e=14&content=446

Federal Emergency Management Agency (FEMA), http://www.fema.gov/ FEMA for Kids offers information and games for children http://www.fema.gov/kids/

Florida Center for Public Health Preparedness, http://www.FCPHP.org Bioterrorism preparedness courses http://www.FCPHP.org/courses/courses.htm

Global Center for Traumatology, http://www.bioterrorhelp.usf.edu/ "Online Training in Bioterrorism and Trauma Preparedness" http://www.bioterrorhelp.usf.edu/onlinetraining.htm

National Institute on Mental Health, http://www.nimh.nih.gov/publicat/index.cfm "Helping Children and Adolescents Cope with Violence and Disasters" "How Children and Adolescents React to Trauma" http://www.nimh.nih.gov/publicat/violcnce.cfm#viol8

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Jernigan, D. B., Raghunathan, P. L., Bell, B. P., Brechner, R., Bresnitz, E. A., Butler, J. C., et al. (2002). Investigation of bioterrorism-related anthrax, United States, 2001: Epidemiologic findings. Emerging Infectious Diseases, 8(10), 1019-1028.

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Public Broadcasting System. (2003). History of biological warfare. Retrieved April 29, 2004, from http://www.pbs.org/ wgbh/nova/bioterror/hist_nf.html

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Shine, K. I. (2003). Bioterrorism: From panic to preparedness: Retrieved April 30, 2004, from http://www.rand.org/ publications/randreview/issues/rr.08.02/bioterrorism. html

Steele, W. (1998). Trauma debriefing for schools and agencies. Grosse Pointe Woods, MI: Institute for Trauma and Loss in Children.

Weiss, D., & Marmar, C. (1997). The impact of event scale--revised. In J. Wilson & T. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399-411). New York: Guildford.

Wessely, S., Hyams, K. C., & Bartholomew, R. (2001). Psychological implications of chemical and biological weapons. BMJ, 323, 878-879. Retrieved March 4, 2003, from http://bmj.com/cgi/content/full/323/7318/878

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Young, B. H., Ford, J. D., Ruzek, J. I., Friedman, M. J., & Gusman, T. D. (1998). Disaster mental health services: A guidebook for clinicians and administrators. Retrieved April 30, 2004, from the National Center for Post-traumatic Stress Disorder Web site: www.ncptsd.org

Jennifer N. Baggerly is an assistant professor and Michael G. Rank is an associate professor in Counselor Education, University of South Florida, Tampa. E-mail: Baggerly@tempest. coedu.usf.edu
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