Children who misuse fire pose a substantial threat to the health and safety of every community throughout the Unites States. Yet among behavioral health care providers, many are minimally aware of the scope of the problem, strategies for assessment and the most effective interventions.

Some 30-40% of children seen in outpatient behavioral health settings report starting fires or misusing matches or lighters (Kolko, 2002). Among inpatient children, fire-starting is nearly twice as prevalent. FBI statistics indicate that child-set fires are responsible for two out of five child deaths by fire (Hall, 2001). Over the past two decades, anywhere from 275 to 400 people have died annually in the United States in a fire set by a child. The majority of arson charges in the U.S. are made against older children and adolescents, though the problem spans childhood and even preschoolers as young as age three have set fires with the intention to harm others (Hanson, MacKay, Atkinson, Staley, & Pignatiello, 1995).

Behavioral health clinicians may find many of these facts surprising because the scope and impact of juvenile firesetting remains difficult to identify. In most states, children who start fires often fall through the cracks of the public health system due to the lack of a coordinated response from professionals in the areas of juvenile justice, fire prevention and behavioral health care. Until recently, professionals have developed isolated approaches with relatively little attention to inter-agency service coordination, treatment outcome or program evaluation.

Despite the limited resources dedicated to this often devastating national problem, promising developments in coordinated service delivery and outcome research have emerged over the last few years. Most notably, several regional or statewide networks have emerged to sponsor interdisciplinary continuing education programs bringing together intervention specialists from the fields of fire prevention, juvenile justice, child welfare and behavioral health.

In addition, there is a small but growing number of empirical studies that have identified several promising treatment interventions. These studies suggest that combined and collaborative approaches may be effective in reducing the risk of repeat firesetting. Promising interventions that may eventually receive empirical support include fire safety education and psychosocial interventions delivered by mental health professionals. Education programs as brief as a few hours or a full day have been shown to reduce the risk of repeat firesetting for one to two years in community samples.

The elements of fire safety education have yet to be systematically examined. Content areas of fire safety education may include:
1) The properties of fire (what is fire, how rapidly does it spread and how is it controlled).
2) Education about fire safety hazards and the dangers of smoke inhalation.
3) Fire survival (dangers of smoke inhalation, the need for adult supervision, emergency procedures).
4) The costs of arson to the community and the legal consequences.
5) Restitution.

A close look at the curriculum of some of the programs reveals substantial variability in content, format of delivery and training of educators. For example, programs vary in their use of aversive stimuli - e.g., touring burn units and talking with burn survivors and admonitions of future juvenile justice incarceration - and use of positive peer modeling -e.g., peer graduates of programs returning to lecture in programs.

Differences in the duration, amount, and focus of educational interventions, parental participation, educator training and experience, and developmental emphasis of the curriculum may affect outcome and should be systematically examined in treatment research.

Fire safety education may be the best intervention for children at low risk for recidivism. In such cases, additional psychosocial therapy may not be necessary or effective. The most rigorous study design to date has shown no significant difference between the impact of fire safety education and a cognitive-behavioral intervention among 5 - 13 year olds and their parents (Kolko, 2002). In this study the psychosocial treatment was very heterogeneous, weaving a widerange of techniques into a single intervention (fire specific self-monitoring, CBT, problem-solving/decision making, parent training/home contingency management), making it difficult to determine which treatment elements were more or less effective.

Diagnostic profiles of these youngsters are far more complex than the stereotype of conduct disorder and many are not captured by this diagnostic classification. A significant number of child and adolescent firestarters display externalizing and internalizing behavior problems. Many have intense fascination or curiosity with fire and are easily aroused by affect when engaged in firesetting behavior. In addition, they may show significant social problem-solving deficits and dramatically overestimate their ability to manage fire safely.

Over the last few years the most innovative juvenile firesetting programs have begun to educate and counsel parents to address family functioning risk factors. Parents of children who set fires report greater psychological distress, heightened marital conflict, less acceptance of and involvement with the child, less frequent and effective parental supervision, inconsistent and harsh discipline strategies and a greater number of stressful life events.

Features common to most parent focused psychosocial intervention programs include the sharing of fire related thoughts, feelings and behaviors, education in a cognitive model applied specifically to fire behaviors and the identification of cognitive and behavioral alternative strategies to substitute for firesetting behavior, and brief parent training approaches. When parents are included the objective is to reduce defensiveness, blame and denial while improving the quality of communication between parent and child about fire. Parents are also encouraged to learn fire safety skills along with their children.

Counseling can help parents develop a better understanding of the multiple individual, family and community influences on fire behavior, while at the same time learning to talk with their child more effectively about fire, fire risk and fire safety. Parents may then discuss with their children how they can better support child coping strategies that lead to improved family problem solving related to fire.

Typologies of firesetters abound without research support or scholarly examination. The ideal clinical practice advocates an extremely comprehensive clinical assessment, which is often simply not possible in the age of managed care. Knowing how long a child has been misusing fire and whether he or she has progressed to more impulsive, harm-directed or incendiary activities (e.g. using gasoline or hair spray to "throw" fire), how these were obtained and whether they are storing away ignition sources can help to determine immediate risk to the family. In addition, a clinical determination must be made about whether parents have adequately fireproofed their home (smoke detectors, fire escape plans, locking up lighters/matches, supervision changes).

Programs should link practical assessment directly to treatment intervention and therefore provide meaningful information to clinicians about fire history, individual motivation (anger or curiosity/fascination), child psychopathology and family functioning and the risk of repeat firesetting.

Quality evaluation of outcomes will be enhanced by the development of manualized treatment protocols, firespecific measures of child coping, parent-child communication about fire and parental supervision. In our experience, clinical assessment of firesetting behavior with an emphasis on multi-agency intervention is not a core component of child and adolescent behavioral health training. The most forward thinking agency collaborations are committed to forging enduring links through continuing education across behavioral health, fire service and juvenile justice to address this complex public health problem.

Not all children need a lot of treatment and communities need to allocate scarce resources well. In our view, the safe bet is on programs that involve parents and offer fire safety education and skills training. For children and families with more significant mental health needs, a fire specific psychosocial group or parentchild intervention may be appropriate. Thus a behavioral health clinician may provide a fire specific brief treatment while simultaneously facilitating a referral of the family to a fire safety education program run by a fire department.

Where safety is an immediate concern, residential or inpatient treatment may be needed. Clinicians can contact their local fire department's prevention programs to find education in their community. In some cases, the larger fire departments will have someone trained and even certified in providing fire safety education to children.

Some States or counties offer programs where children and parents can receive a collaborative intervention designed to address the needs of youngsters with significant psychopathology. These larger prevention efforts - e.g. Oregon, Arizona, Michigan, California, Massachusetts, and Rhode Island - can provide a well established referral network or comprehensive education/counseling program and/or can link parents to education and specialized counseling services among independent practitioners. In the absence of such established networks, parents should inquire specifically about what is taught in any fire safety education "program."

A brief visit to the fire house with a ride on a truck or a brief "lecture" from a local fire Chief may not be enough for a youngster with a history of impulsivity, depression and/or family conflict. We offer a few references at the end of this article and continuing education programs (see box page 5) for the clinician interested in developing more specialized intervention skills.

Steven J. Barreto, Ph.D., and John R. Boekamp, Ph.D., are Co-Directors of the Bradley Hospital FireSafe Families Program and Clinical Asst. Professors, Brown University Medical School, Department of Psychiatry and Human Behavior.

References
Barreto SJ, Boekamp JR, Armstrong LM, Gillen P: Community-based interventions for juvenile firestarters: A brief family-centered model. Psychological Services 2004; 2:158-168.

Hall JR Jr: Children playing with fire. Quincy, MA: National Fire Protection Association, 2001.

Hanson M, MacKay S, Atkinson L, Staley S, Pignatiello A: Firesetting during the preschool period: Assessment and intervention issues. Can J Psychiatry 1995; 40: 299-303.

Kolko DJ: Research studies on the problem. In DJ Kolko (Ed.) Handbook on firesetting in children and youth (pp. 33-56). San Diego, CA: Academic Press, 2002.

No cost resources
www.sfm.state.or.us - download free fire safety education curriculum, Hot Issues newsletter, lists of low cost videos and educational programs.
www.sosfires.com - articles on programs with links to free or low cost educational tools.
Phoenix Fire Department Youth Firesetting Intervention Program 607-262-771 - free 35 page curriculum.

Keep Your Eye On...post 9/11 psychiatric disorders

Many children in New York City experienced lingering anxiety or depression following the World Trade Center (WTC) attacks of September 11, 2001. Results from a survey of 8,236 New York City projected 205,000 students (28.6%) in grades 4 through 12 suffer from one or more depressive/anxiety disorders. The most prevalent disorders among the students were agoraphobia (14.8%), separation anxiety (12.3%), and post-traumatic stress disorder (10.6%). One surprising finding was that going to a school close to the site of the attack was associated with lower rates of mental disorder. The investigators suggest that these children were probably recipients of significant mental health intervention immediately after the attacks. They suggest that future post-disaster interventions should not be confined exclusively to those in close proximity to a disaster "but should incorporate the disaster's reach, both physically and psychologically." They also recommend population-based psychiatric screening in children after major disasters so that interventions can be properly targeted and broadly focused to include the experience and loss of parents and other family members. [Hoven CW, et al.: Archives of General Psychiatry 2005; 62(5):545-552.]

The Brown University Child and Adolescent Behavior Letter, June 2005
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