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Introduction and Overview
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Communities across the United States face the threat of emergencies and disasters almost every day, natural and man-made, urban and rural, large and small. Although children represent nearly 25 percent of the U.S. population, current state and local disaster preparedness plans often do not include specific considerations for children and families. The preparedness and resilience of communities related to children will require a systems framework for disaster preparedness across traditional and nontraditional medical and public health stakeholders, including community organizations, schools, and other partners in municipal planning.

BACKGROUND

On June 11 and 12, 2013, the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events convened a workshop in Washington, DC, to discuss disaster preparedness, response, and resilience relative to the needs of children and families, including children with special health care needs. Participants included traditional and nontraditional medical and public health stakeholders from across federal, state, and local government,

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1This report has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the Institute of Medicine.



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1 Introduction and Overview1 Communities across the United States face the threat of emergencies and disasters almost every day, natural and man-made, urban and rural, large and small. Although children represent nearly 25 percent of the U.S. population, current state and local disaster preparedness plans often do not include specific considerations for children and families. The preparedness and resilience of communities related to children will require a systems framework for disaster preparedness across traditional and nontraditional medical and public health stakeholders, including community organizations, schools, and other partners in municipal planning. BACKGROUND On June 11 and 12, 2013, the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events convened a workshop in Washington, DC, to discuss disaster preparedness, response, and resilience relative to the needs of children and families, including children with special health care needs. Participants included traditional and nontraditional medical and public health stakeholders from across federal, state, and local government, 1 This report has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the Institute of Medicine. 1

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2 CONSIDERATIONS FOR CHILDREN AND FAMILIES health care coalitions, community organizations, school districts, child care providers, hospitals, private health care providers, insurers, academia, and other partners in municipal planning. The workshop was designed to review existing tools and frameworks that can be modified to include children’s needs; identify child-serving partners and organizations that can be leveraged in planning to improve outcomes for children; highlight best practices in resilience and recovery strategies for children; and raise awareness of the need to integrate children’s considerations throughout local and state emergency plans. The specific workshop objectives can be found in Box 1-1.2 BOX 1-1 Workshop Objectives  Discuss progress being made in different sectors around the country related to the 2010 recommendations of the National Commission on Children and Disasters (NCCD; the Commission), and opportunities for integrating related children’s disaster pre- paredness efforts into local and state planning efforts.  Discuss opportunities to augment children’s benefits by leveraging existing coalitions. o Explore coalition challenges and successes from federal, state, local, and provider perspectives.  Describe opportunities to strengthen public health partnerships to address the needs of children and families.  Understand barriers and challenges to better financial systems related to preparedness for children and families. o Discuss importance of health care financing education among stakeholders. o Consider strategies to reduce the financial burden on public health and health care facilities.  Emphasize different capabilities needed for mass care and sheltering to provide for families and children with special health care needs.  Examine resilience strategies that lead to successful recovery in children after a disaster.  Understand current approaches and interventions to improve recovery in children after any type of emergency or disaster. 2 A full statement of task can be found in Appendix C.

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INTRODUCTION AND OVERVIEW 3 ABOUT THIS SUMMARY The report that follows summarizes the presentations and discussions by the expert panelists and participants during the workshop. Chapter 2 provides background on some of the issues surrounding planning for children in disasters, an overview of the recommendations from the 2010 National Commission on Children and Disasters (NCCD) report, and progress thus far in integrating the needs of children into preparedness planning. Chapter 3 discusses leveraging health care coalitions to meet the needs of children in disasters, while Chapter 4 focuses on tools and studies done to augment state and local planning for children. Chapter 5 includes provider, hospital, insurer, and health system perspectives on the challenges of funding preparedness and response activities. The importance of public health partnerships and collaboration with community organizations in planning is discussed in Chapter 6. In Chapter 7, some of the specific needs of children during response are discussed (functional needs, nutritional needs, family reunification, temporary child care). Chapters 8 and 9 focus on the importance of tracking mental and behavioral health recovery of children and families, as well as strategies to foster resilience, and interventions that promote the social and economic well-being of children. Finally, Chapter 10 looks at the recovery experience after Hurricane Sandy from child and family agencies and their plans moving forward. Resources and other materials from the workshop can be found in the appendixes, and, specifically, a paper that was commissioned for this workshop is provided in Appendix G, and a resource list of all the tools mentioned throughout the report can be found in Appendix F. HIGHLIGHTED TOPICS3 Throughout the 2-day workshop, a variety of themes emerged across multiple workshop presentations and discussions. The following topics were highlighted by Anderson and the session chairs in summary statements at the close of the workshop. Each of these topics will be discussed at greater length throughout the report. 3 Rapporteurs’ summary based on the presentations, discussions, and summary remarks by the meeting and session chairs.

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4 CONSIDERATIONS FOR CHILDREN AND FAMILIES  Ongoing concerns: National advocates remain concerned regarding children’s needs and trends. The ability to make progress is impeded by the federal fiscal crisis and competing institutional and organizational priorities. Although the NCCD report provides good baseline recommendations, there are still other areas that need attention.  Federal engagement: Federal partners are engaged and trying to move issues and policies related to children’s disaster preparedness forward. There are working groups at the White House, the Department of Health and Human Services, the Federal Emergency Management Agency (FEMA), the Centers for Disease Control and Prevention, and others, and there are actions being taken on the NCCD recommendations.  Need for central coordination: The 2013 Pandemic and All- Hazards Preparedness Act reauthorization includes a new advisory committee on children and disasters, but as of yet it has not been appointed.  Lack of centralized information and resources: Many participants stressed the need for a national clearinghouse of tools and resources. There were numerous examples of tools and trainings shared at the workshop, and many lessons learned and best practices were shared from recent events such as Hurricane Sandy, the tornadoes in Joplin, Missouri, and Moore, Oklahoma, and the Newtown, Connecticut, school shooting. However, there is no centralized location to share these resources across jurisdictions, or any way for those who need them to easily find them. Similarly, there is no central coordination of the various recovery assets available to individuals from federal, state, and local agencies, nonprofit organizations, and others. Since the workshop, the Administration for Children and Families has created a webpage of early childhood disaster resources organized for providers, children and families, and policy makers.4  Building and sustaining health care coalitions: Successful coalition building involves sharing information, working together to set and achieve goals, and developing formal relationships of commitment. Throughout the workshop, there 4 See http://www.acf.hhs.gov/programs/ohsepr/early-childhood (accessed November 12, 2013).

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INTRODUCTION AND OVERVIEW 5 were what Anderson called “world-class examples of coalitions.” The operational question is how to replicate these examples, and to expand them beyond pediatric providers and hospitals.  Broader engagement of stakeholders: There are many dif- ferent settings and systems that serve children. Many speakers and participants stressed the need to build partnerships across sectors (e.g., behavioral health, public health, medical services, human services, educational systems, emergency management systems, community organizations) with a constant focus on children as they are, and in the environments where they live. Some participants who had previously worked with only clinical and emergency partners highlighted the need for more training and planning with community partners, and suggested thinking more broadly about collaborating with other child- serving community groups that can contribute to community preparedness. o Youth: Youth involvement in preparedness fosters resilience, and youth can serve as messengers to their peers and parents. Hearing from Ashley Houston from FEMA’s Youth Preparedness Council, it became more apparent that engaging youth today will ensure future generations of better prepared adults. Social media can be a powerful outreach tool. o People with disabilities: Several presentations stressed the importance of planning for the evacuation, transport, and sheltering needs of children with disabilities or access and functional needs. Presenters said that people with disabilities, or their representatives, should be included in planning groups, and children with disabilities should have a say in their own evacuation and transportation plans when they are old enough. o Community providers/private physicians: Concerns were raised about the need to better integrate private-sector practitioners into local disaster planning. A key barrier to preparedness at the practice level is the lack of payment for time spent in preparedness activities (as these are not reimbursable). o Child care providers: Participants at the state and national level raised many child care–related issues, from the importance of getting child care up and running after a

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6 CONSIDERATIONS FOR CHILDREN AND FAMILIES disaster, to temporary child care in shelters, to the difficulties locating and communicating with impacted pro- viders in a disaster, including both family- and center-based providers. Several participants discussed the importance of including child care providers as stakeholders in pre- paredness planning, and increasing the focus on plans for sheltering in place and communication with parents. They also highlighted barriers to the preparedness, response, and recovery of child care facilities.  Financing: There was much interest in finding new models of financing preparedness efforts and care during disasters to make sure that resilience, preparedness, and response for children and families are integral parts of preparedness planning. As Scott Needle of the Healthcare Network of Southwest Florida highlighted, making the business case for financing preparedness is challenging, as disasters are low-frequency events with a low financial return on investment, but can have a huge economic impact. Insurance reimbursement pays for intervention, not for preparedness. However, hospitals that are more prepared before a disaster will have better outcomes and less need for reimbursement assistance. Participants discussed the relevance of dual use capabilities to preparedness, noting that improved day-to-day operations can reap benefits for emergency preparedness.  Ability to surge: There were many concerns expressed about pediatric bed capacity and the ability to surge when needed, especially noted by Patricia Frost of Contra Costa County. How can the best practices of some institutions and regions be developed into a national model?  Exercises and drills: Participants repeatedly stressed the importance of drills and of exercising preparedness plans. Beyond practice, there also needs to be some level of competency. Speakers and participants called for national-level pediatric exercises and suggested that pediatric preparedness exercises should perhaps be a regulatory requirement for hospitals.  Workarounds versus safety and quality: It was discussed that in the absence of feasible solutions to complex preparedness and response problems, workarounds are often developed. However, this raised concerns from a patient safety and quality of care

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INTRODUCTION AND OVERVIEW 7 perspective. It was suggested that process engineers also be included in preparedness planning.  Disaster education: While emergency preparedness is built on the strength of everyday health systems, professionals and the public should be better informed about their expected roles in a disaster, especially related to children. To be effective, pediatric training for providers must be built on comprehensive education and training in disaster management and emergency preparedness for all our nation’s public health and health care providers, adult as well as pediatric. It must also ensure that pediatric-specific basic education and training in pediatric disaster management and emergency preparedness is offered not only to health care providers who have dedicated their professional lives to the care of children, but also to adult health care providers who in times of contingency or crisis may be called on to treat children until definitive pediatric care is available. Jeff Upperman presented innovative strategies on developing competencies in health care professionals, but more emphasis is needed both for providers and the general public on their role in disasters.  Lessons learned versus actions taken: Disasters create moments of opportunity for advocacy and action. It is important to seize these moments when the public and policy makers are engaged to make change. Irwin Redlener of the National Center for Disaster Medicine and Public Health pointed out that lessons learned are nothing if they do not lead to action. Some suggested that after the near-steady stream of recent man-made and natural disasters and emergencies, the moment of opportunity is now.

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