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Suggested Citation:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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 50
Suggested Citation:"4 Exploring the Gaps in Evidence." 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 51
Suggested Citation:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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 55
Suggested Citation:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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 59
Suggested Citation:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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:"4 Exploring the Gaps in Evidence." 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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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.

4 Exploring the Gaps in Evidence Although the body of data and evidence on children and disasters has increased since Hurricane Katrina, many gaps remain. This session of the workshop featured three presentations that explored the gaps in the knowl- edge base related to the delivery of services to children after disasters. The discussion included specific gaps that persist, emergency function support status, uniform data collection and sharing methods, and school-based clinics. The session was moderated by Heather Beal, founder and president of BLOCKS Inc. PROGRESS AND GAPS IN SUPPORTING CHILDREN, YOUTH, FAMILIES, AND SERVICE PROVIDERS Lori Peek, director of the Natural Hazards Center and professor at the University of Colorado Boulder, provided an overview of federal programs addressing child, youth, and family needs; identified gaps in knowledge; and highlighted opportunities to address those gaps. She also described an ongoing project focused on identifying federal resources targeting children and disasters.1 Such resources have increased since Hurricane Katrina, and 1  Peek noted that much of information she presented is drawn from a chapter she co- authored called “Recognizing Vulnerability and Capacity: Federal Initiatives Focused on Children and Youth Across the Disaster Life Cycle,” which is a summary and descriptive analysis of all federal programs geared specifically for children and youth, as well as available guidance documents aimed at caregivers, child care centers, schools, and other child-centric institutions (Peek and Domingue, 2020). 45 PREPUBLICATION COPY—Uncorrected Proofs

46 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH children are increasingly recognized as both being vulnerable and having the capacity to engage in emergency management activities. Federal Programs Addressing Child, Youth, and Family Needs Peek and colleagues conducted an exhaustive Internet search and col- laborated with federal government colleagues working on child-centered programs to assess the federal resources available that focus on children and disasters (Peek and Domingue, 2020). For each resource identified, they collected the following information: the name of the program, document, or resource; the sponsoring agency; a program overview; and the target age group of the program or audience. This enabled them to determine whether more resources are targeting younger children or teens and whether the audience is children and youth or adult caregivers. They found that Hurri­ cane Katrina caused a dramatic shift in terms of a focus on children and families, said Peek. Since 2005, numerous federal agencies have offered programs or guidance documents for the benefit of children experiencing disasters,2 and children are increasingly being recognized as resources as well as a vulnerable group. Instead of characterizing children as victims, efforts are now engaging the capacity of children in emergency manage- ment activities. Many agencies offer child- and disaster-focused educational programs and guidance documents aimed at parents, schools, child care centers, and child service providers. Gaps and Opportunities in Federal Programs for Children and Disasters Peek also identified gaps and the opportunities in federal programs that focus on children and disasters. Currently, most programs and documents focus on individual or household preparedness and emergency planning and response. Many do not use participatory activities, and there is a tendency to treat children as a monolithic group. Peek outlined opportunities to shift this service landscape. She put forward the idea that participatory programs should be best practice because children and youth learn and retain infor- mation most effectively through those types of programs. Thus, there is an opportunity to increase the active engagement of children and youth when developing guidance documents, curricular programs, and other resources. 2  These agencies include the Federal Emergency Management Agency, the U.S. Army Corps of Engineers, the National Oceanic and Atmospheric Administration, the National Weather Service, the National Institutes of Health, the Environmental Protection Agency, the Depart- ment of Health and Human Services, the Department of Education, the Centers for Disease Control and Prevention, the Department of Justice, the Federal Bureau of Investigation, the Department of Homeland Security, and the U.S. Geological Survey (Peek and Domingue, 2020). PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 47 Additionally, most of the programs focus on personal or household prepared­ess. Peek suggested shifting toward collective empowerment n m ­ odels and coproduction of services to consider individuals within inter- connected webs of families and communities, rather than considering them in isolation. She added that teaching children and youth how entire commu- nities can work together to achieve change can promote preparedness for children, families, schools, and child care centers. Child-serving institutions also warrant greater focus, as much of the available guidance is centered around individual children or households. Another gap is that most of the available programs focus on emergency planning and response, with far less guidance on recovery. Peek contended that children, youth, and those who care for them can engage in mitigating disaster losses and be involved in long-term recovery efforts. Finally, Peek said that children are often depicted as a monolithic group, without taking their full diversity into account. She recommended an intersectional lens be used to consider the incredible diversity within the child population. Support for Service Providers: Building Capacity Among Voluntary Organizations Active in Disaster Peek described a project to build capacity among voluntary organiza- tions active in disaster (VOAD) to provide support for service providers and protect children in emergencies. In partnership with Save the Children, the Natural Hazards Center is conducting a collaborative project focusing on VOADs. She explained that the Natural Hazards Center and Save the Children recognize and honor the role VOADs play in delivering services to affected communities, and the aim of the project is to build the capacities of VOADs to ensure that children’s needs are considered. Beginning with two initial focal states, the project is currently being carried out in Nebraska and Arkansas. Project goals include (1) assessing child-specific knowledge, skills, and attitudes in two state VOADs; (2) increasing the knowledge and awareness of children’s needs in disasters within VOADs and emergency management; (3) advancing the prioritization of children’s needs and abili- ties to meet those needs in VOAD and emergency management organiza- tions; and (4) assessing project interventions. Peek said that according to initial surveys they conducted, VOADs reported relatively low levels of knowledge about children and youth in disaster and had relatively small skill sets in working with this population, yet they had high levels of desire to learn more about children and youth. Save the Children is leading project efforts to increase VOAD and emergency man- agement knowledge and awareness of children’s needs in disasters by devel- oping and implementing interventions that are then assessed by the Natural Hazards Center to determine whether project goals are achieved. Assessment PREPUBLICATION COPY—Uncorrected Proofs

48 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH involves baseline surveys, participatory asset mapping with VOAD members, and geographic information system mapping using the Centers for Disease Control and Prevention (CDC) social vulnerability index to determine where potentially vulnerable children are located within each state. Additionally, the Natural Hazards Center is performing social network analysis to under- stand how VOADs are enhancing and deepening communication, coopera- tion, coordination, and collaboration. The Natural Hazards Center is also examining how much engagement exists between nonmember, child-serving organizations and VOAD member organizations, as well as looking at the child-specific resource exchanges between VOAD member organizations and child-focused experts in comparison to VOAD member organizations’ other resource exchanges. Social network analysis categorizes resources into four groups: infor- mation, equipment, training, and child-specific resources, said Peek. Analy- sis indicated that of these categories, VOAD organizations reported that they seek information from one another most frequently and that they seek child-specific resources the least frequently, with some VOADs seeking no child-specific resources. Peek hypothesized that these organizations are not seeking child-specific resources because they are not accessible, rather than a perceived lack of need for them. When VOADs do seek child-specific resources, social network analysis data revealed that they all seek it from the same node—Save the Children. Peek suggested that if there were more well-integrated child–expert nodes, then child-specific information-seeking activity would increase commensurately. She emphasized that these types of expansive gaps can be bridged by bringing resources and expertise together. STUDY OF THE EFFECT OF HURRICANE MARIA ON CHILDREN IN PUERTO RICO Amanda Rivera, executive director of the Youth Development Institute of Puerto Rico (YDI) (see Box 4-1), described her organization’s efforts to assess the impact of disasters on families, especially those living in poverty, that can be exacerbated by disaster. She outlined the effects of Hurricane Maria on food security, early care and education, and the coordination of services among stakeholders, and she highlighted opportunities to address service gaps during future disasters. She explained that YDI, a partner of the Kids Count project, is both an advocacy entity and a think tank; this hybrid organization was formed because of the lack of entities carrying out policy, research, and advocacy work in Puerto Rico. Rivera said that when Hurricane Maria hit Puerto Rico, YDI was aware of the disproportionate impact that this massive event would have on children living in poverty. In response to the disaster, two initiatives were developed: A study on the effect of Hurricane Maria on children, and PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 49 BOX 4-1 Youth Development Institute of Puerto Rico The Youth Development Institute (YDI) of Puerto Rico is the country’s only entity exclusively dedicated to promoting research and public policies that strengthen the economic security of families with children and youth. YDI’s goal is to drastically reduce child poverty on the island and ensure that all children have opportunities that allow them to live in homes with economic security. This organi­ zation works to reduce child poverty by empowering those affected to engage in the policy process, promoting the use of data among policy makers, and activating traditional advocacy work and grassroots mobilization to raise awareness of the problem and its solutions. SOURCE: http://juventudpr.org/index.html (accessed October 30, 2020). the Puerto Rico Children and Youth Task Force. The comprehensive study conducted a representative qualitative survey to understand the areas most affected. The children and youth task force began via a joint effort of the Administration for Children and Families (ACF) and Save the Children. ­ The two initiatives revealed three major effects of Hurricane Maria: reduced food security, reduced child care, and reduced coordination of services. This task force continues to operate and is engaged in the Columbia University Resilient Children/Resilient Communities project to conduct preparedness work at the central, island-wide level. They are beginning work on economic security as well as COVID-19 response activities, she added. Demographic Context of Children in Puerto Rico During Hurricane Maria Families with children living in poverty are the most affected by disas- ters caused by natural phenomena, said Rivera. When Hurricane Maria occurred, 58 percent (343,000) of Puerto Rico’s children were living in poverty.3 Rivera pointed out this rate has only varied by 1–2 percentage points over the past 20–30 years, although demographics can vary by juris- diction within Puerto Rico. The study confirmed that response and recovery scenarios are more complicated for children living in communities with few resources where the majority of families are living in poverty. Rivera likened this to the effect of demographics on communities in New Orleans 3  More information on the demographic context of children in Puerto Rico is available at YDI | Child Poverty Infographics. See juventudpr.org (accessed April 6, 2021). PREPUBLICATION COPY—Uncorrected Proofs

50 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH after Hurricane Katrina. Of the children living in poverty, 78 percent were in single-parent families, typically headed by a mother. Rivera said that this is relevant in considering the resources and supports that a family has at home. Similarly, of families with incomes up to 130 percent of the pov- erty level, 29 percent do not qualify for the nutrition assistance program. Further­ ore, around 26 percent of low-income children do not have Inter- m net access. Rivera noted that lack of Internet access has become far more pertinent during the current school closings brought on by COVID-19 than it was after Hurricane Maria. When the alternative to a disruption in school is distance learning, Internet access becomes a critical resource. She added that 10 percent of children living in poverty in Puerto Rico have a physi- cal or mental disability or live with a parent who has a disability, which becomes an added vulnerability during a disaster. Effect of Hurricane Maria on Food Security Whether it is a hurricane, earthquake, or a pandemic, disasters pose many challenges to food security, said Rivera. Hurricane Maria caused a massive dislocation of the food supply chain that affected people across income levels. The survey revealed that 27.9 percent of people with annual income of $40,000 or less experienced difficulty accessing food after Hurri­ cane Maria; this percentage increased to 38.2 percent among those earning $15,000–$39,999 per year and rose to 50 percent for people earning less than $15,000 per year. Rivera noted that low-income families experience the economic impact of a disaster longer than those in higher income brackets, with many still experiencing food insecurity issues 1 year after the hurricane. When high rates of poverty already affect food security before a disaster, a hurricane will only exacerbate these deficits, she said. The COVID-19 pandemic has led to school closures in Puerto Rico that have resulted in not only a loss of education, but also a major disruption to food security for families with children. Rivera explained that not all low- income families with children can access nutrition assistance program ben- efits, but they are able to have meals provided at school. Therefore, school closures and lack of access to lunches for children puts additional strain and pressure on families. She noted that Hurricane Maria also resulted in school closures. The task force found that after the hurricane, benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children ­ (WIC) were being provided via check to most families in Puerto Rico. Because the disaster affected mail delivery, many families faced disruption in accessing those benefits. She added that the lack of electronic benefit trans- fer (EBT) cards continues to be a challenge today. Additionally, some low- income working families who were already at the brink of poverty before COVID-19 are now facing unemployment and consequent food insecurity. PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 51 Opportunities to Ensure Food Security With these challenges come opportunities to ensure food security after a disaster, Rivera said. For instance, preparedness planning can be conducted in collaboration with volunteer and community-based entities, community leaders, and municipalities. The survey indicated that community-based entities and municipalities were the first line of response supporting families with children. The response from the central government of Puerto Rico came later, followed by the U.S. federal response. She suggested investing in resources and ensuring collaboration among stakeholders to create strong preparedness plans that take into account both food security and the pos- sibility of lengthy disruptions to the food supply chain, as had occurred during Hurricane Maria. Rivera also advocated for preparedness benefits transfers at the con- gressional level because many families are living paycheck to paycheck and do not have sufficient income to stock up on supplies and food to prepare for a disaster. Although Puerto Rico does have a policy of advancing bene- fits before a predicted hurricane, these funds are not sufficient to adequately supply the resources needed for a disaster. Rather than issuing the standard benefit ahead of schedule, she suggested issuing additional benefits to low- income families before an imminent disaster—for example, through the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families, or WIC. Rivera highlighted a promising development emerging in the EBT infrastructure. In response to the COVID-19 pan- demic, EBT cards are being used for families who do not qualify for SNAP but who qualify for free school lunches. Current investment in the EBT infrastructure should be used for emergency transfer, she suggested. Effect of Hurricane Maria on Early Care and Education Rivera emphasized that the importance of early care and education is two-fold: it provides children with instructional time and affords parents the economic development opportunity of returning to work. The sooner parents can resume work, the less income they will lose, resulting in greater stability for their families. After Hurricane Maria, the survey collected information on education disruption for children aged 0–5 years. The sur- vey indicated that in Puerto Rico, the majority of child care (70 percent) takes place in informal settings in which the child is cared for by a family member or other adult caregiver. The remaining 30 percent attended Head Start centers (14 percent), public school (8 percent), private school (4 per- cent), or private or nonprofit child care (2 percent). The average number of disrupted days for children in formal preschool or child care settings after Hurricane Maria was 92 days. Rivera noted that this was greater than the PREPUBLICATION COPY—Uncorrected Proofs

52 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH number of days that schools for older children were closed. Furthermore, of the 9.2 percent of children who were receiving early intervention services prior to Hurricane Maria, 70 percent experienced a service interruption and 20 percent have yet to have their early intervention services resume. A number of factors contributed to the lengthy closures of child care and preschool settings, said Rivera. Many providers lacked basic infra- structure requirements for electricity and water (e.g., backup generators, cisterns) and many parents were unable to pay for the services after the hurricane. Furthermore, the vouchers that some child care centers receive from the government saw a delay in disbursement. Rivera stated that many providers were having cash flow issues before Hurricane Maria and were unable to pay teachers and utilities after the disaster, leading to closures. Other centers opened with providers working for free as a service to their communities’ children and families. Rivera noted that most of the centers are woman-owned small businesses with owners who did an admirable job of continuing to provide services; however, they should not have to work for free. Although the federal government provides many supports, including Small Business Association loans, many people require technical assistance in applying for these supports. She suggested provid- ing additional technical assistance to child care providers around disaster preparedness and recovery. Additionally, for-profit child care centers do not qualify for many of the donations and supports such as power generators and water filtration systems that are made available to nonprofit organiza- tions. Rivera described for-profit child care providers as being in a “gray area” of offering a social service but also operating as a business. Opportunities to Ensure Continuity of Early Care and Education Rivera outlined opportunities to ensure continuity of child care cen- ters after a disaster. First, technical assistance and resources for centers should establish robust and feasible continuity-of-operations plans. The task force has worked with the Columbia University Resilient Children/ Resilient Communities initiative to offer a number of workshops in Puerto Rico on improving continuity-of-operations plans. However, Rivera sug- gested that the civil sector should not be exclusively responsible for training and education around the development of those plans. She also suggested that emergency grants be disbursed to centers prior to the disaster. This would enable them to prepare and to have cash on hand to withstand the emergency, which may involve months of disruption. She added that small businesses should be provided with assistance in accessing loans and grants for backup generators, solar options, and other equipment that would enable them to become operational more quickly after a disaster. PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 53 Effect of Hurricane Maria on Coordination of Services Rivera explained that the Children and Youth Task Force began with ACF and Save the Children, who then brought nonprofit entities to the table. After Hurricane Maria, ACF and Save the Children organized a series of debriefing meetings in which agencies discussed their efforts and what they were observing. This revealed duplicative efforts and major service gaps, with no way to track populations served. For example, many agen- cies that focus on housing, family and children services, and education were serving the same population—sometimes targeting the same community. Some communities received resources from agencies multiple times; other communities, particularly those in more remote regions, did not receive any support. When a culture of cross-agency collaboration and coordination is lacking before a disaster, it will be challenging to establish during an emer- gency, Rivera maintained. Additionally, disaster can lead to a breakdown of all forms of communication, which further complicates these dynamics. Creating Children and Youth Task Forces to Improve Coordination Rivera suggested that nonprofit groups be integrated into task forces focused on children and youth to reduce the risk of interagency groups becoming echo chambers, with each agency stating the accomplishments of their organizations. Instead, nonprofit entities should draw attention to communities that are not being served. She outlined several opportunities that can be created by developing task forces: • Task forces bring government and nonprofit stakeholders together in a consistent, in-person forum to calibrate and coordinate services. • Task forces can bring community-based entities, service providers, day care centers, nonprofit organizations, and advocates to the table with the government to allow for respectful challenging and dialogue about gaps, both immediately after a disaster and beyond. • Task forces can facilitate rapid collection of information and iden- tification of gaps. • A task force can serve as a platform to continue collaboration beyond the disaster, helping partners stay connected. Rivera also noted several challenges tasks forces can face. These include ensuring buy-in from government agencies when the task force is outside of the government, balancing both central and regional efforts, and operating without sufficient resources for staffing and supporting participating enti- ties. Additionally, it can be difficult to keep task force members engaged PREPUBLICATION COPY—Uncorrected Proofs

54 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH beyond the disaster or emergency, as the benefits of task force efforts may not be as readily apparent outside of a crisis. RESEARCH GAPS IN CHILDREN’S DISASTER MENTAL AND BEHAVIORAL HEALTH David Schonfeld, developmental–behavioral pediatrician and professor at the University of Southern California and Children’s Hospital Los Angeles, ­ examined gaps in children’s mental and behavioral health services that per- sist a decade after recommendations made by the National Commission on Children and Disasters (NCCD). To frame his discussion, he highlighted a recommendation from NCCD’s 2010 report: The Department of Health and Human Services should enhance the research agenda for children’s disaster mental and behavioral health, including psychological first aid, cognitive-behavioral interventions, s ­ocial support interventions, bereavement counseling and support, and programs intended to enhance children’s resilience in the aftermath of a disaster. (NCCD and AHRQ, 2010) Under this recommendation, NCCD specifically called on the Depart- ment of Health and Human Services (HHS) to convene a working group of children’s disaster mental health and pediatric experts to review the research portfolios of relevant agencies, identify gaps in knowledge, and recommend a national research agenda across this full spectrum of disaster mental health for children and families. A virtual conference was convened for this purpose, and an informal review of National Institutes of Health grants over the prior 15 years was conducted prior to the conference. This review documented a paucity of funded research on interventions to pro- mote coping and adjustment for children after disasters, he said. Gaps in Research on the Effects of Disasters on Children’s Mental and Behavioral Health Schonfeld underscored three prominent research gaps pertaining to the effects of disasters on children’s mental and behavioral health: (1) research beyond the prevalence of trauma and other mental health symptoms to include a full spectrum of outcomes; (2) efficacy of prevention initiatives involving children and disasters; and (3) intervention for caregivers of chil- dren after disaster. Schonfeld and colleagues summarized these findings in a 2018 report (Grolnick et al., 2018). PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 55 Effectiveness of Interventions to Promote Behavioral Health and Coping After a Disaster Schonfeld said that some progress has been made in understanding the effects of disaster on children, but far less is known about the effec- tiveness of interventions to promote behavioral health and coping after a disaster. Furthermore, the limited intervention studies that were conducted tended to focus on the treatment or prevention of mental illness, especially trauma disorders. Studies on the effects of interventions on distress and bereavement and on the promotion of adjustment, coping, and resilience were critically lacking, he emphasized. Barriers to studying these inter- ventions include the absence of valid measures of outcomes and lack of demonstration of usefulness to research funders and policy makers, he contended. Thus, evidence-based interventions have tended to focus on the prevention or treatment of posttraumatic stress disorder, for which there are validated measures. Schonfeld stated that the report concluded that developing evidence-based interventions for children experiencing disaster is a national priority, and as such, research should be broadened beyond studying the prevalence of trauma, other mental health symptoms, and the effect of trauma approaches. He suggested that the scope of research should expand to include the full spectrum of outcomes (e.g., bereavement, distress that does not reach clinical levels of a mental health diagnosis, adjustment, coping, resilience) as well as the study of interventions in each of these domains. This gap and the urgency to address it persist today, he added. To highlight this gap, Schonfeld juxtaposed the treatment of trauma and grief responses. Drawing on his visits to New Orleans after Hurricane Katrina and to Paradise, California, after the wildfires and other disasters in the years between, he noted that trauma and grief can co-occur in the lives of children, but he has not seen this overlap mirrored in an overlap in the fields of trauma treatment and childhood bereavement. He contended that grief and trauma are viewed differently. For example, common reactions after the death of a close friend or family member are typically viewed in the mental health field as normative reactions. He explained that while people who are grieving may benefit from support, they are generally considered as not requiring treatment because bereavement is not considered a mental illness. Thus, bereavement support is generally provided by laypeople or faith-based organizations—often at no cost to families—but these profes- sionals generally do not receive reimbursement for the support services they provide. Schonfeld remarked that this type of support is infrequently evalu- ated through formal research. In contrast, reactions to grief and trauma are often similar, such as experiencing sleep problems and feeling anxious. But when these reactions arise after a person has experienced a traumatic event, they are often viewed as symptoms. When they present in sufficient number PREPUBLICATION COPY—Uncorrected Proofs

56 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH and duration, these reactions are then characterized as mental illness such as posttraumatic stress disorder and are seen as requiring treatment. This trauma treatment is provided by licensed and credentialed mental health professionals and is generally covered by health insurance, he said. While many people accept these distinctions between grief and trauma, a common view voiced by those who have actually experienced traumatic events not involving loss of life is relief that “at least no one died,” said Schonfeld. Therefore, suggesting that bereavement is categorically less of a hardship than trauma is inconsistent with the lived experiences of many— if not most—people who have experienced trauma. Furthermore, while adverse childhood experiences as classically construed include parental divorce and incarceration, they do not include the death of a parent. This classification suggests, at some level, that it would be easier to have a par- ent die than become divorced, even though that is not a commonly held belief. Schonfeld noted that the present workshop has included repeated mention of trauma but far less about the negative effects of loss and other adjustment difficulties. The National Center for School Crisis and Bereavement and the New York Life Foundation are founding members of the Coalition to Support Grieving Students.4,5,6 This coalition has 100 organizational members, including top educational and health professional organizations such as the American Academy of Pediatrics and Save the Children. The common conviction of groups in this coalition is that no child should grieve alone, said Schonfeld. To address the need for support, the coalition has developed a wide range of free and publicly available materials, including video-based and print materials for professional development as well as parent and family education. Efficacy of Prevention Initiatives Involving Children in Disasters Schonfeld remarked that in the aftermath of disaster, children’s stories, coloring books, and parent guides are often developed rapidly and dis- seminated widely by federal agencies and nongovernmental organizations. However, there is little research on the efficacy of prevention initiatives involving children (Grolnick et al., 2018). He contended that there is gen- erally no preexisting evidence base before initiatives are rolled out nor any attempt to collect evidence to guide future use. This lack of research extends 4  More information about the National Centers for School Crisis and Bereavement is avail- able at https://www.schoolcrisiscenter.org (accessed October 27, 2020). 5  More information about the New York Life Foundation is available at https://www.­ newyorklife.com/foundation (accessed October 27, 2020). 6  More information about the Coalition to Support Grieving Students is available at https:// grievingstudents.org (accessed October 27, 2020). PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 57 to formal prevention initiatives that educate children on how to prepare for disasters, which are typically promoted for broad use in schools prior to any evaluation. Schonfeld acknowledged that some students and school personnel may feel empowered and better prepared for possible events after participating in these initiatives. However, children’s responses can vary depending on personality, coping style, personal history, and individual vulnerabilities. He explained that while a child receiving training on how to respond in the event of a disaster may feel comforted, this training only provides chil- dren with an illusion of control. Furthermore, these efforts could result in increased guilt for the child if they are unable to respond in the idealized fashion in a real event in which a death or serious injury occurs. Thus, Schonfeld advised that these and other unintended consequences be care- fully considered and that programs be evaluated more consistently for efficacy before being implemented widely. Interventions for Caregivers of Children After Disaster The third research gap identified by Schonfeld and colleagues is the need for more study and intervention for caregivers of children after disaster (Grolnick et al., 2018). He gave the example of a man who shared his story during a training for foster parents in the aftermath of Superstorm Sandy. In response to a discussion about the long-term effects of disasters, this foster father said that he was happily married with a successful career in finance when his toddler became ill and died suddenly. The man said losing his son led him to question many of his life decisions, including his choice of career. Schonfeld noted he is not criticizing the field of finance in repeating this man’s realization that while he was making a lot of money, he did not feel he was contributing to society in a way he felt was meaningful. In spite of the high income his job afforded him, he quit and went back to college to become a kindergarten teacher. He found this job, involving shaping the lives of young children, to be extremely rewarding. The man went on to become a foster parent, and he was in the process of adopting a young child when Superstorm Sandy occurred. Schonfeld said this story is not unique, as many individuals that enter child-centered fields such as education, social services, child mental health, pediatrics, and so forth do so in response to experienc- ing childhood trauma, loss, or some other form of adversity in their own past. In coping with those experiences, they either benefited from the help of others, and want to similarly help someone else, or they recognized the effect that a lack of such assistance had on their own lives and they want to provide another with what they themselves did not receive. Because this type of service often focuses on ensuring that children receive critical support, Schonfeld hypothesized that a majority of foster PREPUBLICATION COPY—Uncorrected Proofs

58 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH and adoptive parents served by ACF and professionals in this field likely have personally experienced trauma and loss. Thus, when disasters occur, prior trauma and loss in the lives of “helpers” in these professions tends to be uncovered. Noting the inherent irony, Schonfeld said that the people who devote their lives to helping children are often those most likely to be hurt personally by doing so. Therefore, he finds the striking lack of evidence-based professional self-care interventions to be a particularly critical gap, especially in professions serving children. He said that a major disaster is not a pre­ equisite for children to be helped; it can happen on a r daily basis. Professionals themselves can be hurt by helping children dur- ing a disaster, so professional training and support becomes particularly important, he added. DISCUSSION Consequential Research Gaps Since Hurricane Katrina Beal asked the panel to consider documents such as NCCD’s report and events such as Superstorm Sandy, the Paradise wildfires, and Hurri­ canes Harvey, Irma, and Maria. In reflecting on these documents and events, she asked the panelists what they consider to be the most conse- quential gap that has been addressed since Hurricane Katrina. Furthermore, she queried what gap they deem to be most important that has yet to close in this same time period. Schonfeld replied that an important gap that has been addressed is rec- ognition that children are affected by disasters. He contended that before Hurricane Katrina, the effect of such events on children was not given much consideration. Children were viewed as resilient, able to “get over” the disaster, and as not having any significant problems. Schonfeld said this has since been recognized to not be the case. This is evident in the Federal Emer- gency Management Agency (FEMA) and ACF offering case management and other services around children’s needs, as well as in FEMA’s creation of a children’s coordinator. As discussed in the NCCD report, these steps represent a major advance, said Schonfeld. In terms of gaps that remain, Schonfeld commented that because it is now understood that adverse experiences cause adversity, more progress is needed on determining how to prevent, support, or ameliorate that adversity. The medical model—involving screening, diagnosis, referral, and treatment for mental illness—has been predominant in interventions. However, research suggests that the vast majority of children who experience disasters are affected. For example, Schonfeld cited research conducted in New York City schools after the 9/11 terrorist attacks, which showed that approximately 87 percent of children had a persistent adjustment problem 6 months after PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 59 9/11. Furthermore, of the children who self-identified behavioral health prob- lems and changes in daily functioning, a majority did not seek or receive mental health support within or outside of school. Schonfeld pointed out that these trends occurred despite recovery funding that provided a thera- pist offering free mental health services in every New York City school. He added that in the current situation of the COVID-19 pandemic, he believes that more than 87 percent of children will be affected and that funding to increase mental health services will not be available. In fact, he surmised that highly constrained budgets will lead to a reduction in mental health staff in order to meet budget shortfalls. Schonfeld concluded that while awareness is good, delivery of supportive services is not following awareness at this point. Rivera commented that issues of economic insecurity and the effects of poverty on children are still missing from the conversation about disas- ters. Poverty typically deepens during a disaster in many households with children. Conversations are taking place about trauma and about access to education, but there is a gap in awareness about the effects of poverty on households and children, which are exacerbated by disasters. In thinking about recovery, Rivera maintained that ensuring the economic stability of families must be a priority. Peek agreed with Schonfeld that progress has been made in increas- ing awareness of children’s needs. She said this workshop, dedicated to children’s disaster-related needs, attests to that, as does the progress made in terms of research, service provision, and policy making, much of which traces back to the NCCD report. Peek said that Children of Katrina, the book she co-authored with Alice Fothergill of the Department of Sociology at the University of Vermont, describes that children were long-depicted in contradictory ways (Fothergill and Peek, 2015). They were either con- sidered as rubber balls, hyper-resilient beings that could bounce back after disaster, or vulnerable victims that had to be completely prepared for and protected. Peek said that NCCD ushered in a much more complex depiction of children and the many systems that surround their lives. She emphasized that this is a major contribution that should not be understated. She added that ensuring educational continuity in the aftermath of disaster—such as categorizing schools as critical infrastructure—is currently the larg- est gap. She suggested that designating early and childhood education as critical infrastructure would ensure that (1) school buildings are made safe, (2) learning is recognized as a child’s primary job, and (3) schools and child care centers would become focal points. Building Awareness and Action Around Children and Youth in Disasters Michael Prasad, Barton Dunant Emergency Management Consulting & Training, highlighted the need to build awareness and action around PREPUBLICATION COPY—Uncorrected Proofs

60 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH children and disasters among federal, state, county, parish, tribal, and ter- ritorial emergency managers. He asked whether children’s needs should be considered within the scope of FEMA Emergency Support Functions (ESFs). Peek responded that issues of ESF recognition and integration across ESFs are important to discuss, because the 25 percent of the U.S. population comprised of children stands to benefit. Schonfeld said that in the work carried out by NCCD, an issue that arose was the prioritization of children’s needs. For example, the Strategic National Stockpile was discussed, as well as the major gaps that exist in supplies for children that are attributable to funding shortfalls, among other reasons. Some discussion on stockpile policy focused on having materials ­ that will save the most lives and on making determinations based on “the dollar spent on a life saved,” he continued. Children’s supplies were often more expensive. For instance, children’s medications in liquid format expired more quickly than other forms and were more expensive to store. Schonfeld referred to a national survey that was conducted to look at general community preferences; it included a question about whether participants would support preparation for a child’s needs if that involved a higher cost than preparing for adult needs. The survey respondents dem- onstrated support for preparing for children’s needs. Many people believe that women and children should come first in a disaster, yet federal policy is not following that, he added, noting that parents will risk their lives to try and save their children. Therefore, value placed on children by the general public should be more prominently recognized in disaster preparedness and response planning, Schonfeld contended. Children’s needs should be attended to because if children are not taken care of, parents will not take care of themselves. In that sense, responding to children’s needs means that adults’ needs are simultaneously being met. This is evident in the current COVID-19 pandemic, he added. Parents want schools to open so that their children are supervised and the par- ents can return to work, yet they are also worried about their children’s safety and want to make sure their children will be taken care of, so they are placing their children’s needs first. Lastly, he noted the argument that the needs of children cannot be a focus because children are a special popu- lation. Schonfeld maintained that children are not a special population; children are everyone. Childhood is simply a time period in all lives—an important, vulnerable, and critical time period that warrants special atten- tion, he concluded. Promoting Requirements for Uniform Data Collection Patricia Frost, National Pediatric Disaster Coalition, asked about how to promote requirements for the adoption of uniform data collection, based PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 61 on appropriate age groups, that can be used to inform and drive interven- tions in a disaster. Peek replied that certain organizations or agencies may have specific requirements already, but she is working to promote grass- roots, bottom-up data sharing in the academic community. The Natural Hazards Center is encouraging (but not requiring) researchers to publish their data through DesignSafe-CI funded by the National Science Foun- dation.7 This platform was predominantly created for engineers, but the Natural Hazards Center has partnered with DesignSafe-CI to ensure it is also accessible to social and behavioral scientists. Peek said that when data, data collection instruments, and protocols are shared, it expands the potential for comparison across disasters and allows trends and patterns across time and place to be identified. Publisher data events are being organized to encourage social and behavioral scien- tists to share data when possible, which can be done safely and securely, she added. Rivera said that requirements on how data is collected may also help to increase the amount of data collected. Many government programs are administered by for-profit and nonprofit service providers that are the recipients of government contracts and grants. When the government is giving providers money to execute a program, requirements to collect data can be attached to grant renewals, she suggested. Ensuring Adequate Supplies for Children in Shelters Schonfeld added that when NCCD examined gaps in data collection, it found that FEMA was not routinely inquiring and documenting whether a displaced family had children. Furthermore, shelters did not necessarily have equipment and supplies for children. Even when children’s supplies were on hand, the definition of the term child tended to include any person aged 0–18 years. Schonfeld noted the food, bedding, and equipment needs are much different for an infant than for a 17-year-old. He recalled an example from his visit to China after an earthquake in Sichuan province that killed 69,000 people in 1 day. There was a photo shared of a female first responder breastfeeding an infant in the rubble. They were not her child, but as the mother had died and there was no formula, she breastfed the baby to save their life. While shelters in the United States are likely ­ etter equipped, they are not required to be, noted Schonfeld. For instance, b a shelter that does not have a supply of infant formula may receive funding for offering sheltering services. Schonfeld suggested that reimbursement to shelters could be tied to meeting minimal requirements in terms of available supplies. Regardless of whether providers are encouraged or required to 7  Moreinformation about DesignSafe-CI is available at https://www.designsafe-ci.org (ac- cessed April 6, 2021). PREPUBLICATION COPY—Uncorrected Proofs

62 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH meet the basic needs of children, Schonfeld emphasized that these lifesaving measures must be in place. Mental Health Support for Children and Youth in Disaster Response and Recovery Beal asked how active the Puerto Rico Emergency Management Agency was in addressing the gaps Rivera identified. Rivera said that while the agency initially participated in the task force, its engagement lasted only for the first few weeks. She noted that while FEMA was engaged, the local agency was not. She said that for the first 2 months or so after Hurricane Maria, the task force was focused on emergency response, then it swiftly moved to recovery and mental health. Rivera stated that this type of work is not typically considered to be emergency services, but she believes that it should be. She pointed out that after the task force conducted the survey and presented recommendations, the local emergency management agency was receptive. Donna Wolf, a psychology instructor and school counselor, suggested using school-based mental health centers in high schools to employ youth and “adult anchors” in mitigation and recovery. Schonfeld noted that in addition to school-based mental health centers, there are also school- based clinics that integrate behavioral health services. Professionals such as school nurses examine both psychological and physical issues, which often co-present. Individuals in crisis situations will often have physical symptoms (e.g., stress hormones can cause physical problems like increases in blood pressure, worsening asthma, or a decline in diabetes control). Psychological factors can also present as physical symptoms; typically, an individual in crisis will have some combination of both psychological and physical issues. Schonfeld suggested that both school-based mental health clinics and school-based clinics that integrate mental health providers are mechanisms that can be used effectively. Ideally, students would be able to access an integrated and balanced set of physical health and mental health services. For example, a wellness center was created at Marjory Stoneman Douglas High School after the shooting that occurred at the school, with mental health providers and one full-time nurse placed in the clinic to offer integrated assessments and services. Noting the difficulty that families can have in accessing services outside of school, Schonfeld suggested that school-based clinics are often one of the best ways to provide services. However, he pointed out that some families and students prefer accessing services outside of school in order to maintain privacy and have some distance between their school setting and mental health services. Thus, both types of services should be offered in and out- side of school as the baseline practice outside of a disaster, Schonfeld said. PREPUBLICATION COPY—Uncorrected Proofs

EXPLORING THE GAPS IN EVIDENCE 63 Rivera agreed that community mental health support is a major gap, and it would be helpful to provide those services in schools, which are central to communities. An additional concern is the possibility of another major hurricane occurring during the COVID-19 pandemic, during which people are advised not to congregate. The co-occurrence of a hurricane with a pandemic would further complicate mental health challenges expe- rienced by families and simultaneously complicate access to services and community-based support, she added. Schonfeld noted that there have been guidelines developed about sheltering during a natural disaster, such as a hurricane, in the midst of a pandemic. He surmised that they pre- dominantly deal with physical distancing and infection control and less so with the behavioral health aspect of co-occurring disasters. He added that professionals have begun considering how to establish safe shelters during a pandemic because disasters not only co-occur in people’s lives, but co- occur in communities. Peek remarked that the broader question around the efficacy of school- based services is how the resources that children need can be effectively delivered to them. Schools are an obvious mechanism to turn to, but they are already overtaxed in a variety of ways. Additionally, children only spend a certain proportion of their lives in schools. She suggested that considering the issue of where to offer services for children is a prime opportunity to place children’s voices and their requests for preferred service locations in the center of the discussion. Questions for children could include “Where are you getting the things you need? Where are the spaces where you feel safe? Who are the advocates and anchors in your life? Who do you trust to provide the things you need?” Peek said that this is an opportunity to learn from children and youth and observe where they are receiving services in order to get vital resources to more of them. Schonfeld added that individuals who do not have legal status in the United States have particular difficulty accessing services. Many such indi- viduals will not go anywhere that they see as government or government affiliated, including shelters and American Red Cross sites. Thus, the only site that many undocumented people will turn to is their schools. Schonfeld said that several weeks after one of the wildfires, he was meeting with a principal of an affected elementary school. The school had yet to reopen, but she was unpacking water from the trunk of her car, saying that families would only come to the school for safe drinking water. While he com- mended her for providing this service, he also acknowledged that she was trying to get the school cleaned and reopened while contending with student deaths. Schonfeld said that school leaders cannot be expected to unpack water every morning. Better partnerships must be formed if children and families want to get services at school so that school budgets, resources, and staff are not being used to provide disaster services. He added that PREPUBLICATION COPY—Uncorrected Proofs

64 EXPLORING DISASTER HUMAN SERVICES FOR CHILDREN AND YOUTH after the 9/11 terrorist attacks, he worked with recovery efforts for New York City schools. Some students did not want the school to know that a parent had died on 9/11 because they did not want to be a “9/11 kid.” Not all students and staff are comfortable receiving services in schools and people sometimes prefer to access services in a neighboring community where they feel they have more privacy. He agreed with Peek that children and adults need to be able to voice where they want to receive support, and pro­ essionals need to provide a menu of options. However, delivering such f services requires finances and resources that schools should not be expected to cover when they are already struggling financially, he said. PREPUBLICATION COPY—Uncorrected Proofs

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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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