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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Page 41
Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
×
Page 42
Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
×
Page 43
Suggested Citation:"3 Effect of Disasters on Critical Child Infrastructure." National Academies of Sciences, Engineering, and Medicine. 2021. Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26158.
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Page 44

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

3 Effect of Disasters on Critical Child Infrastructure Children and families have unique needs in disaster response and recov- ery. The second panel of the workshop aimed to consider how the systems and networks of social and human services that serve children and youth are affected during and after a major federally declared natural or environ- mental disaster; participants also explored how services are delivered dur- ing and after a disaster. The panel was moderated by Robert Amler, dean of the New York Medical College School of Health Sciences and Practices. OFFICE OF CHILD CARE AND THE CHILD CARE DEVELOPMENT FUND Shannon Christian, director of the Office of Child Care (OCC) at the Department of Health and Human Services’ (HHS’s) Administration for Children and Families (ACF), provided an overview of the Child Care Development Fund (CCDF) administered by OCC. She described OCC’s role in disaster preparation and response, from requiring disaster plans of grantees to offering grant flexibilities after an event to providing coordina- tion and technical support. Overview of the Child Care Development Fund Christian explained that OCC administers the CCDF, which is a $8.7 billion block grant from the federal government to state, territorial, and tribal grantees to help eligible low-income families pay for child care for children from birth through age 12. Grantees must reserve a minimum 29 PREPUBLICATION COPY—Uncorrected Proofs

30 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH set of funding to improve the quality of care for all children, which can also be used in responding to disasters. Combined with funds from state matching, maintenance-of-effort funding, and Temporary Assistance for Needy Families (TANF) transfers, the grant totals $11.7 billion. Christian noted that the CCDF provides grantees with flexibilities in program design. Some program areas must be designed within federal parameters, including the population subsets grantees can focus on, as well as provider payment rates, parent copay amounts, and eligibility criteria. Other components of program design are flexible. The CCDF also has a set percentage of funds from Congress that can be used to support the development of research and technical assistance centers, which include staff dedicated to emergency and disaster plan development and support. Grantee Disaster Plans CCDF grantees are required to develop disaster plans for prepared- ness, response, and recovery, said Christian. Plans must include policy and c ­ apacity to continue paying child care providers when a child care program is closed because of a disaster. Guidelines for the continuation of child care services must be outlined, which may include the provision of emergency and temporary child care services and temporary operating standards dur- ing a disaster and recovery. Response provisions must include how grantees will use the assistance program’s flexibility in making changes to their child care assistance program. In addition, plans must outline procedures for evacuation, relocation, shelter in place, and lockdown. Recovery activities include building the supply of child care after a disaster. Christian noted that one method of increasing supply is to provide grants to providers to reopen classrooms and serve additional children. OCC provides technical assistance to grantees to improve these disaster plans. Office of Child Care Responses to Disasters OCC provides technical assistance to grantees to help them understand and use flexibilities available in their child care funds, said Christian. OCC also coordinates support for grantees in partnership with ACF and other federal government programs, such as the Federal Emergency Management Agency (FEMA). Additionally, OCC helps grantees identify national organi- zations that can provide support, such as Save the Children, the American Red Cross (ARC), and Child Care Aware of America. One of OCC’s major roles is to coordinate support, while the state, tribe, or territory takes the lead in conducting on-the-ground response activity. PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 31 Child Care Development Fund Flexibilities to Address Disasters Christian outlined certain flexibilities in the use of CCDF funds that come into play during disasters and emergencies. In these events, a state, territory, or tribal grantee can change the eligibility or priority criteria for services. This can be done via income threshold adjustments for subsidy eligibility and exclusion of disaster and temporary assistance from income considerations. Furthermore, parent copays can be waived. Grantees can broaden the definition of protective services to include children affected by a federal or state-declared emergency, thereby waiving eligibility criteria, such as work/training requirements, for child care services. Christian noted that quality dollars—that is, the funds grantees are required to set aside to improve child care for all children—can be used to provide immediate child care assistance to displaced families. Flexibility ­ also allows grantees to eliminate the quality spending percentage in order to redirect those funds to direct services. CCDF grants can always be used to fund mental health consultants and trauma training as part of pro- fessional development, she added. Grantees can provide supply-building grants to child care providers to be used for equipment, supplies, profes- sional development and staffing, minor repair and remodeling, and ongoing financial assistance while a provider is rebuilding. Although using most of these flexibilities requires obtaining waivers or plan amendments, this can be done retroactively. Grantees can also request temporary waivers for extraordinary circumstances, which temporarily exempt grantees from meeting specific requirements. Finally, states have the flexibility to use TANF for child care services. Christian noted that this is not under OCC control and that TANF may have fewer requirements than CCDF and therefore may be better suited to emergency use in some cases.1 Supplemental Funding Christian said that in a disaster, OCC can access additional funding. For example, after the federally declared natural disasters in 2018 and 2019, OCC received $30 million in supplemental funding for grantees affected by these events. Grantees received funding by way of an application process, which could include retroactive funds for documented expenses. This was the first time that OCC received direct supplemental disaster fund- ing appropriated specifically for child care. She suggested that this process will likely be more effective than directing monies to partner agencies and hoping they will allocate some of it to child care services. Recently, the 1  More information about flexibilities related to these funding streams is available at https:// www.acf.hhs.gov/occ/resource/im-2017-02 (accessed October 29, 2020). PREPUBLICATION COPY—Uncorrected Proofs

32 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH Coronavirus Aid, Relief, and Economic Security (CARES) Act allocated $3.5 billion to OCC to enable grantees to address COVID-19, she added. Challenges in Supporting Children Affected by Disasters The COVID-19 pandemic ushered in new challenges that were not part of grantee emergency and disaster plans, said Christian. For example, some states ordered providers to close completely or limit services solely to essential workers, and concerns of virus spread led some centers to opt to close. As of July 2020, many had yet to reopen and many of those that had reopened had far fewer children. Christian stated that funding from the CARES Act is being used to meet new demands on child care systems, including (1) serving children of essential workers; (2) sustaining the child care industry in spite of reduced numbers of children served; (3) making hygiene products such as masks, gloves, hand sanitizer, and cleaning solu- tions available; and (4) installing safety measures (e.g., space dividers) between napping children. Challenges also stem from the way the COVID-19 pandemic appears to be changing the nature of child care, said Christian. Although the influ- ence of pandemic-related parent safety concerns on the supply and demand for child care is not yet fully understood, there seems to be an increased preference for small settings, such as child care providers offering services in their homes and smaller child care centers. Furthermore, recommended safety policies and practices are raising costs while decreasing revenue for these providers, Christian added. For example, social distancing results in fewer children per classroom, thereby increasing the cost per child. Other expenses are incurred by sanitation screening, arrival and departure proce- dures where teachers walk children to and from the classroom to avoid hav- ing parents inside the building, and the increased staffing needs associated with hand washing between all activities. She added that because of changes in the child care funding model, both open and closed centers are requesting support in order to remain in business until the economy reopens. Christian outlined several additional challenges that were faced before the COVID-19 pandemic. Stating that child care is “a market, not a pro- gram,” she explained that this industry is a varied mix of public and privately funded organizations that are not coordinated by a single entity. Despite increased awareness of brain science and the effect of adverse childhood experiences, allowable spending on child trauma expert services has not translated into use of this resource on the level it should. Another challenge is the lack of a mechanism for OCC to deploy volunteers to disas- ter sites to meet the demand. Furthermore, OCC is not close enough to disaster sites to be able to intervene directly. She added that the COVID-19 pandemic has caused uncertainty as to how OCC may need to alter its PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 33 approach to disaster planning, response, and recovery. Potential changes could include modifying state disaster plan requirements and making inter- nal adjustments to address any future widespread health emergency, she suggested. DISASTER PLANNING AND COLLABORATION TO SUPPORT CHILDREN, YOUTH, AND FAMILIES Lauralee Koziol, national advisor on children and disasters at FEMA, described the collaborative disaster planning, response, and recovery efforts needed to support children and families. She highlighted three common ways that children, youth, and families need to be supported after disasters (see Box 3-1). She noted that the need for emotional and mental health sup- port appears to have grown over the past couple of years, but in her own experience the number of children requiring these services seems to have decreased in the past 4 years. Disaster Planning and Preparedness Koziol remarked that because disasters begin and end locally, strong local plans can reduce the level of need during response and recovery if they include robust plans for continuity of operations, emergency operations, and recovery. A continuity-of-operations plan addresses how to resume business immediately after the disaster and how to communicate with staff and clients in the absence of electricity or Internet service. An emergency operations plan addresses how to meet the needs of the organization, staff, and children and youth under care during an emergency. An emergency operations plan should include procedures for evacuation, communication BOX 3-1 Support Needs for Disaster-Affected Children, Youth, and Families 1.  Address immediate and unmet needs, such as food and commodities (e.g., infant formula, diapers, wipes). 2.  Reestablish infrastructure and support services, including schools, child care, and other human and support services that allow parents and guardians to return to work and help the economy recover. 3.  Provide emotional and mental health support. SOURCE: Koziol presentation, July 22, 2020. PREPUBLICATION COPY—Uncorrected Proofs

34 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH with parents and guardians, and reunification in the event that children and youth are separated from their parents for a few hours or longer. Additionally, the emergency operations plan should include provisions for sheltering for an extended period of time in the event of infrastructure and road damage. Koziol added that plans should consider scenarios such as sheltering children who may need critical medical care while communica- tion lines are down. Recovery plans should preidentify resources that will enable services to resume quickly after a disaster, said Koziol. These may include alternate facilities that can be used and community stakeholders who can collaborate as partners. Addressing these aspects of recovery during the planning pro- cess provides viable options in the event of a disaster. Recovery plans also include housing important documents in areas where they will not be dam- aged by a disaster, being aware of insurance plan coverage and deductibles, and having an idea of the documentation that will be required during the insurance claims process. She added that having an ongoing relationship with the local emergency manager can be helpful in identifying resources should a disaster occur. An additional component of recovery planning is familiarity with potential sources of support, such as the Small Business Administration, FEMA public assistance, and provisions for private, non- profit organizations. Collaboration in Disaster Response Koziol maintained that collaboration is one of the most important aspects of disaster response. She added that addressing the needs of children and families should be approached as a joint planning and development effort among FEMA, HHS, the Department of Education, nonprofit orga- nizations, and the private sector. Identifying partners, understanding their programs, and seeing how programs intersect is invaluable, she noted. A disaster will often increase the number of stakeholders involved, which war- rants flexibility in accommodating the needs of disaster survivors. Having ongoing working relationships already in place can enable organizations to develop trust and respect for one another, as well as creating a greater breadth of perspectives that can be pooled together for the benefit of sur- vivors, she added. AMERICAN RED CROSS: SUPPORT FOR CHILDREN ACROSS ALL PHASES OF DISASTERS Trevor Riggen, senior vice president of disaster cycle services at ARC, described preparedness programs delivered by his organization and described the role that youth can play in helping their families during a PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 35 disaster. He discussed how ARC’s partnerships with smaller organizations with expertise tailored to a community’s specific needs can support long- term recovery efforts and highlighted the values of cultural competence and self-determination that drive the organization. American Red Cross Preparedness Programs Riggen remarked that children can play a role in changing the culture of preparedness in the United States because they often serve as a catalyst for changing the way a crisis is addressed. To that end, ARC offers three children’s preparedness programs. The Prepare with Pedro program, deliv- ered in partnership with FEMA, has been successful in reaching younger children in schools, Riggen said. The Pillowcase Project was born out of Hurricane Katrina, when ARC leadership in Louisiana observed college students stuffing belongings into pillowcases while rushing to evacuate. This program involves visits to classrooms to teach youth how to prepare, stay safe, and remain calm during a crisis. The Sound the Alarm program installs smoke alarms in individuals’ homes across the country while edu- cating families on how to exit their homes in a crisis. These programs have demonstrated how children and youth can lead their families by example, he noted. For example, a school superintendent reported that 3 weeks after an in-classroom lesson on staying safe in a house fire, one of the students had a fire in his home. The parents told the superintendent that the only reason they were able to get out was because their son stayed calm and told his parents what to do to exit safely. This exemplifies how an entire community can be thought of as a resource, he said, with children repre- senting “perhaps one of our greatest resources” in disaster preparedness and response. American Red Cross Response Activities Riggen noted that ARC is associated primarily with providing response activities, playing a leadership role in FEMA Emergency Support Function 6 by providing and coordinating sheltering, community feeding, and distribu- tion of supplies. However, the provision of health and mental health services is a function of ARC that is often overlooked, he noted. Although the tacti- cal work of sheltering people is often the focus, the health and mental health services provided within the shelters can be one of the most powerful ele- ments of support. He recounted video footage of a family escaping the 2018 Camp Fire in Paradise, California, in which a terrified group is seen driving through debris with flames on both sides of the street. The parents struggle to remain calm, the mother praying out loud, while the children cry in the backseat. In the last 10 seconds of the video, the car emerges from the nearly PREPUBLICATION COPY—Uncorrected Proofs

36 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH complete darkness of the smoke into blue skies that represent safety. Riggen said that when he watched the video, his immediate response was imagin- ing their next stop, whether it be an ARC shelter or some other safe haven. Riggen described how children who must evacuate in such circum- stances can experience multiple traumas: escaping the hazard, fearing for their lives, and adjusting to a new and unfamiliar environment. Further- more, these children may not understand what is happening and may think they are now homeless; they may see their parents struggling to gain some control over their circumstances. ARC is working to help their volunteers and workers better understand the trauma caused by these types of experi- ences so they can support those children more effectively. He emphasized that while much of the work in the disaster response enterprise focuses on matters of scale—such as how to shelter 10,000 or feed 1 million people— ARC is also trying to drive work at the individual level. Understanding a child’s context and emotional experiences creates space and flexibility within which to serve. Volunteers and workers can help individual families and children solve their problems in the moment, rather than treating them as one mass group. He added that when 100 people are treated as a group of 100 people, nuances can be overlooked that could substantially change the outcome for a child who has experienced a large disaster. American Red Cross Programs to Support Long-Term Recovery Over the course of ARC’s history, the scale of the organization’s role in long-term recovery efforts has varied depending on the specific disaster. However, Riggen noted that the past 4 years have been a watershed for ARC’s approach to field operations, which is reflected in the organiza- tion’s establishment of a formal program for long-term recovery. ARC is funded entirely by donations from the public, and long-term operations are established as funding allows. This can take the form of rounds of financial assistance for families, as is currently the case for survivors of Hurricanes Harvey, Florence, Irma, and Maria, as well as the California wildfires. In addition, ARC has established large grant programs and, in some cases, as much as one-third of grant funding is provided to other agencies with more expertise than ARC in specific areas (e.g., serving children). Riggen provided three examples of ARC grant partnerships that sup- port long-term recovery. One is a nearly complete project in which a large investment from ARC—of more than $40 million over 4 years—was used to place solar panels on 125 schools and to create 30–40 community wells with solar backup power that can remain operational even during a category 5 hurricane. In Puerto Rico, the government (not ARC) operates shelters during disasters, and schools are often used as shelters. The aim of this project was to ensure that schools were (1) safe places for families PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 37 to be sheltered after a disaster and (2) available for children to return to for classes as quickly as possible. The solar panels provide power and keep water safe for all of the families served by these schools. He added that in the 2 years that some project sites have been up and running, schools have been affected by earthquakes and storms yet have been able to continue operating. An ARC grant provided to Hope Worldwide was used to offer 8-week therapeutic performing arts programs for children directly affected by Hurricane Harvey, primarily in vulnerable neighbor- hoods across Texas. The positive outcomes from this program demonstrate the benefit of ARC’s role in shepherding donor funding to organizations such as Hope Worldwide, said Riggen. Another large grant was provided to California CareForce, a group of volunteer medical professionals that provides free medical, dental, and vision care to those in need at temporary clinics in the wildfire-affected areas. Riggen noted that some recipients may not have had care even before the disaster, but other families lost health care after the disaster as a consequence of losing their jobs, businesses, or other sources of funding necessary to pay for care. This type of recovery work can contribute meaningfully to families’ long-term recovery, he said. An Individualized Perspective on Disaster Services Riggen illustrated the individualized perspective that ARC brings to disaster services by sharing the story of a 10-year-old named Destiny. Dis- placed by Hurricane Dorian, Destiny and her family were in a shelter in Georgia. Riggen’s colleague saw her talking to her parents while peering out from beneath the covers on her cot. He said that her hiding did not stem from a desire to avoid people, but because she had sensory overload. The noise and chaos in shelters and other environments can simply be too much for many children. Destiny was struggling to cope with sensory overload while her parents were focused on the multiple issues faced by their family. Fortunately, the shelter had sensory kits and ARC was able to provide Destiny with a weighted blanket, a stress ball, and headphones to play music and drown out the noise of the shelter. ARC workers saw a complete turnaround in Destiny within a few hours. Riggen commented that this simple intervention exemplifies ARC’s individualized approach and reflects the need to design and deliver care in a way that is responsive to individual needs and values. This includes both cultural competence and the cultural humility to provide authority and self-determination to those ARC serves, he added. The focus is not on the number of meals that can be brought into a shelter, but rather on understanding people’s condition, which extends beyond their needs to include their skills and experiences. Riggen emphasized that serving people should include giving them some power and authority over their own experiences. PREPUBLICATION COPY—Uncorrected Proofs

38 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH DISASTER MEDICINE INFRASTRUCTURE PLANNING: HEALTH CARE SYSTEM CONSIDERATIONS FOR CHILDREN Drawing from two decades spent working in disaster medicine and planning, David Markenson, director and medical director of the Center of Excellence in Precision Responses to Bioterrorism and Disasters, New York Medical College, discussed disaster medicine infrastructure planning with a focus on health care system considerations for children. He shared challenges faced by pediatric systems in planning for response, mitigation, and recovery, and he suggested strategies for improvement. General Pediatric System Challenges Many of the planning challenges related to pediatrics stem from a “plan for the population and later address special populations” approach, said Markenson. This perspective is problematic because it can lead to u ­ naddressed needs among special populations and it overlooks special populations as part of the population at large. Recent data indicate that at least 26 percent of the U.S. population is children and youth, with more than 20 million Americans under the age of 6 years.2 Many of these young children are infants, who have their own set of challenges. Markenson noted that disaster planning and research efforts have tradi­ tionally focused on adults, in large part because of the dearth of data on pediatric and other special populations. Much of the relevant research— especially as it pertains to environmental hazards and terrorism—has come ­ from the military; thus, it does not include data on pediatrics. Similarly, pharmaceutical, medical, and population research typically focuses on adults first in considering planning, preparedness, and access. He described an example of the exclusion of pediatric populations from disaster plan- ning. When the Response Federal Interagency Operation Plan was being developed and federal agencies were being assigned roles, only operational entities were given a role in planning.3 The Department of Education was primarily a grant funding agency to education entities at the time, so it was not part of the planning process and had no primary role. Even when children are included in planning, those with special health care needs are generally excluded and their medical, mental health, and access issues 2  While a source for these exact numbers was unavailable, more information on demo- graphic trends is available on the Kaiser Family Foundation website at https://www.kff. org/other/state-indicator/distribution-by-age/?currentTimeframe=0&selectedRows=%7B%22 wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22: %22Location%22,%22sort%22:%22asc%22%7D. 3  More information about the Response Federal Interagency Operation Plan, 2nd ed., is available at fema.gov (accessed December 2020). PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 39 are not addressed. This provides context for some of the challenges faced in pediatric response efforts, he added. Pediatric Health Care System Challenges Markenson characterized health care challenges as fundamentally related to capability and capacity. Several decades ago, emergency medi- cal services had almost no capability for children and, although this has markedly improved over time, emergency medical services capability can be quickly exhausted in a time of challenge. A hospital may be linked to two or three pediatric specialty transport teams, and if a disaster damages that hos- pital or renders it inaccessible—as was the case with Hurricane Katrina and the Joplin tornado—then the teams are no longer available. He explained that hospital capability is also a challenge. The advent of children’s hospi- tals has greatly advanced pediatric care, but it has also created a disaster gap. Even as capacity and capability have increased in pediatric hospitals, they have decreased in nonpediatric hospitals. In many settings, a children’s hospital is the only such facility in a town, city, or even region. Therefore, if a hurricane, tornado, wildfire, electrical event, or other disaster takes out a children’s hospital, young patients will be sent to nonpediatric hospitals. It is incumbent upon all hospitals to have the capability to handle the needs of children during a disaster, he said. Capability limitations also apply to specialty care, said Markenson. For instance, in the United States, burn care is limited and can become unavail- able during disasters; this is especially true for pediatric burn capability. As a critical care physician, he has struggled to find rehabilitation facilities for children during typical times. When a system is taxed by increased numbers of children in need during a disaster, these services become even more dif- ficult to access. He added that surge capacity is also affected by capability limitations. If a system’s capacity is limited during nondisaster times, it will not be able to adequately handle the surge in patients during a disaster. Markenson explained that in some communities, an event that simultane- ously injures four or five children would exceed capacity and be considered a mass casualty event, while an event would have to injure hundreds of adults to be considered a mass casualty event and compromise care. Disaster Planning for Child Congregate Facilities Markenson highlighted the need for greater consideration of child congregate facilities in disaster planning, given that children spend much of their time at schools and other facilities. Despite recent improvements in planning and providing resources for emergency and continuity-of-oper- ations plans for businesses (e.g., parallel processing planning for children PREPUBLICATION COPY—Uncorrected Proofs

40 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH and child congregate facilities has not received the same consideration or resourcing). Even when a setting has a good plan in place—which is rare—systems and plans that are disrupted can fail quickly, he warned. Both research and anecdotal experiences during disasters demonstrate that many parents do not know the emergency plan for their child’s school and, even if they do, most will disregard official emergency evacuation plans and instead go directly to where their child is. Even when the setting has a plan to take children to a safe place for reunification, many parents go against orders to retrieve their children, which can disrupt child movement. These issues are rooted in lack of communication and can place the plan for an entire community at risk of failure, he added. Although some schools are improving their plans and systems, many challenges remain. To illustrate, Markenson described a procedure he con- ducts when he visits emergency management offices. When asked where shelters are likely to be created if there is a need, schools are almost always first, second, or third on the list of potential shelter sites. During separate meetings with school officials, he asks about the school’s plan for its stu- dents in the event of a natural disaster. Typically, the plan is to evacuate the schools and send children home. Therefore, in the event of a disaster, children would be moved out of their schools to their homes, and then addi- tional resources would be needed to bring family units back from homes to the schools. It is commendable that schools generally have some plans in place, problematic though they may be, he added. Other types of child congregate facilities (e.g., camps, after-school programs, religious settings) are largely without plans or adequate resources. Ways to Address Pediatric System Challenges Markenson suggested several ways to address the challenges facing the pediatric health care system. The disaster response system lacks adequate pediatric-specific supplies and resources, such as diapers and formula, which needs to be addressed. Family units are excluded when the planning approach is to focus on “population first” and others second. Instead, disaster planning should consider families as units: families do not want to be separated during routine times, much less during a disaster. Plans should recognize that during the day, most parents will be at work and children will be at congregate facilities; therefore, families will need to be reunited. Additionally, until families are together, they will need to be assured that they will be reunited. Coordination of support for children across all sectors also needs consideration in planning, he added. The local, state, and federal levels should all have pediatric-specific plans, resources, and tools. At the federal level, this includes ensuring appropriate focus and expertise regard- PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 41 ing children’s issues, as well as equipping the Strategic National Stockpile with necessary pediatric resources and supplies. DISCUSSION Changing the Culture to Focus on Supporting Children’s Needs Patricia Frost, National Pediatric Disaster Coalition, asked how the systemic culture of prioritizing adults over children can be appropriately rebalanced in the emergency management, hospital, and first-responder community. Markenson replied that this process begins with how the makeup of the population is conceived. Often, the problem begins with the concept of “the population” being comprised of adult males aged 18–55 years, without recognizing that 25–30 percent of the population is comprised of children and youth. He maintained that any local, state, or federal organization with a legal responsibility to plan should, by definition, direct 30 percent of its effort, time, and resources to children. Changing the culture begins with the obligation to prepare for the population and recognize the percentage of children and youth within the general popula- tion, he added. A participant asked Koziol whether she has seen any changes in the years since Hurricane Katrina in how federal emergency managers work to identify and support the needs of children. Koziol replied that she has seen change evolve slowly over time. For example, FEMA did not focus on children until 2009–2010. At that time, the approach was to build resources throughout programs and then partner with governmental agencies such as HHS or the Department of Education. Progress has been made since then, but there is still work to be done, especially in training and further socialization. A participant asked if the change in the CCDF requirements that required grantees to develop an emergency plan served to increase aware- ness of the importance of emergency preparedness and planning among child care providers or lead state agencies for child care. Christian replied that it has, noting that when this requirement was strengthened in the 2014 reauthorization, several states asked to update their disaster plans. Further- more, ACF now brings more attention to disaster plans by reviewing them as part of the onsite monitoring process, as well as offering trainings at conferences that are generally well attended. She added that the COVID-19 pandemic has increased interest in this area, because planning and response efforts that were adequate for previous events are not sufficient for the pandemic response. PREPUBLICATION COPY—Uncorrected Proofs

42 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH Restoration and Continuity of Child Care In the context of the importance of restoring and ensuring continuity of child care after a disaster, a participant asked which entity is responsible for assessing child care facilities to ensure that they are safe for the return of children and staff. Christian clarified that depending on the specific issue, the safety of facilities is a state or local responsibility rather than a federal one. She said that child care is necessary for recovery after a disaster. While many natural disasters have a smaller scope than is currently the case with COVID-19, the need for child care is common among affected families. Parents often require child care while they are involved in disaster-related tasks, such as dealing with what is left of their homes, going through the paperwork process, and standing in lines at agencies. Child care is some- times provided at the disaster site itself, funded by ACF, ARC, and other organizations. However, it is important to restore normal child care services as soon as possible. Christian added that extra support and training are needed to support teachers and children who may be traumatized. Addressing Challenges Related to Reunification A participant asked for suggestions to improve communication with parents and guardians about reunification. Markenson replied that the major missing element is communicating the plan to parents. In his experi- ence both as a professional who visits schools and as a parent of children attending elementary, middle, and high schools, he has not seen information shared during orientation or the school year about what would happen during an emergency. A parent’s social and behavioral goal is naturally to get to their child immediately in an emergency, so parents will go to what- ever location they know their child will be. He added that parents will go directly to a reunification site if they know that the children will be moved to that location and it is the only way to reunite with their child. Riggen noted that after Hurricane Katrina and other disasters, the focus shifted to the use of technology for reunification. Although technol- ogy can be useful, it can also blind people to the simple challenges of stay- ing connected. He suggested that expectations regarding communications should be established prior to a disaster so that they are understood by both parents and children. Parents should be aware of the reunification location and know what the messaging will look like, so they will not question the validity of a text or other communication they receive. He added that tech- nology tools including ARC’s Safe and Well website,4 Facebook, and other 4  ARC’s Safe and Well website is available at https://safeandwell.communityos.org/cms/ index.php (accessed October 23, 2020). PREPUBLICATION COPY—Uncorrected Proofs

EFFECT OF DISASTERS ON CRITICAL CHILD INFRASTRUCTURE 43 social media sites can be helpful; however, the formal plan needs to be well understood by everyone involved prior to a crisis situation. This can be achieved by communicating the plan well ahead of time and on a regular basis throughout the year so that families know what to expect. Christian asked if ARC teams are in contact with individual child care providers about the plan for reunifying children with parents after a disaster ­ that occurs during a child care day. Riggen replied that the coordina­ion t strategy depends on the setting and other circumstances. ARC partners with agencies that are in communication with many different providers in order to stay connected. He added that most ARC shelters are open for 24–36 hours, but some recent large-scale disasters have required extended sheltering of 2–3 months. In extended sheltering situations, ARC collects information from families to assist them in reaching out to pro­ iders to v learn their plan for resuming child care services. He added that health services workers often provide this assistance because they are accustomed to handling confidential information and working through channels and processes. PREPUBLICATION COPY—Uncorrected Proofs

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Exploring Disaster Human Services for Children and Youth: From Hurricane Katrina to the Paradise Wildfires: Proceedings of a Workshop Series Get This Book
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To explore issues related to the effects of disasters on children and youth and lessons learned from experiences during previous disasters, the virtual workshop From Hurricane Katrina to Paradise Wildfires, Exploring Themes in Disaster Human Services was convened on July 22 and 23, 2020, by the National Academies of Sciences, Engineering, and Medicine. The workshop was designed to focus on families engaged with federal, state or local supportive programs prior to disasters. Additional areas of focus were the coordination of disaster response efforts and the transition to reestablishing routine service delivery programs post-disaster by human services, social services, and public health agencies at the state, local, tribal, and territorial levels. The workshop was also intended to provide a platform for highlighting promising practices, ongoing challenges, and potential opportunities for coordinated delivery and restoration of social and human services programs. This publication summarizes the presentations and discussion of the workshop.

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