5

Case Studies: Effect of Disasters on Specific Populations

Workshop participants broke into four groups to discuss case studies that highlighted the effects of disasters on specific populations. The first breakout panel, moderated by Joelle Simpson, medical director of emergency preparedness at Children’s National Hospital, explored the issues brought on by, or exacerbated by, disasters. The second breakout panel, moderated by Heather Beal, founder and president of BLOCKS Inc., explored the effect of disasters on parents and guardians. The third breakout panel, moderated by Ann-Marie Sabrsula, education coordinator and co-administrator for the Arc Westchester Children’s School for Early Development, explored the effect of disasters on children with complex or special needs. The fourth breakout panel, moderated by Roberta Lavin, professor at the University of New Mexico College of Nursing, discussed the effect of disasters on unaccompanied minors.

EFFECT ON CHILDREN WITH ISSUES BROUGHT ON BY, OR EXACERBATED BY, DISASTERS

Ensuring Children’s Nutrition and Safety During and After Disasters

Scott Needle, chief medical officer at Elica Health Center, discussed nutrition, safety, and environmental concerns for children in disasters. He highlighted the shortcomings of conventional emergency nutrition provisions, which are typically aimed at the needs of adults rather than children and breastfeeding mothers. Mothers, infants, and older children have unique needs related to nutrition, feeding, restrooms, and privacy. Further-

more, these groups have unique needs in terms of supervision, safety, noise, and play spaces, especially in large-scale settings such as mass shelters during hurricanes. He described resources addressing postdisaster family reunification.¹ In the aftermath of hurricanes and floods, there are various safety and environmental hazards that children must be protected from, such as debris, mold, toxins, high temperature, sun exposure, and insects. Similarly, during wildfires and volcano disasters, smoke, soot, and particulate matter can harm the respiratory health of children within a large radius of the disaster. These safety and environmental threats not only put children’s health at risk, but they also affect and are connected to children’s behavior. Children are curious and generally unable to discern danger in the way that adults can, so children must be carefully supervised during and after disasters to ensure their health and safety. This may be a challenging task during and after disasters, when schools and child care may be closed, and parents are likely to have additional tasks and stressors to manage. Finally, Needle noted that as families return to neighborhoods after disasters, it is important to consider the psychological and environmental needs of children, who often experience a great sense of loss during the disaster experience.

Mental Health and Educational Considerations for Children in Disasters

Tara Powell, associate professor at the University of Illinois at Urbana-Champaign, described the experiences of disaster-affected children. They are often displaced from their homes, separated from loved ones, required to change schools, have unmet basic needs including food and shelter, and face loss of friends, family, and community. Depending on their developmental level, children may experience various emotional reactions and related behaviors after disasters. Young children may experience fear of strangers, separation anxiety, sleep problems, nightmares, posttraumatic play, fussiness, irritability, aggressive behavior, or regression. Children in elementary school may experience behavior changes, refuse to go to school, and have physical complaints. Adolescents may experience drug and alcohol abuse, changes in social interactions, difficulty concentrating, irritability, or other behavior changes. Because mental health is shaped by the convergence of biological, social, and psychological factors, children respond in various ways to their disaster experiences. During and after disasters, children’s

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¹ More information about postdisaster family reunification is available at https://www.fema.gov/media-library-data/1384376663394-eef4a1b4269de14faff40390e4e2f2d3/Post_Disaster_Reunification_of_Children_-_A_Nationwide_Approach.pdf (accessed October 21, 2020) and https://www.aap.org/en-us/Documents/AAP-Reunification-Toolkit.pdf (accessed October 21, 2020).

responses are shaped by their developmental level, physical health, family separation, the level of impact of the disaster event, previous trauma exposure, availability of resources, or perceived threat. She discussed the 3 Es of trauma—the event, the experience, and the effect—each of which can influence the mental health of children during disasters. Most children’s mental health does recover from disasters in the long term, she noted.

Powell described the protective factors that can help children overcome their exposure to disasters. These include supportive adults, peer and family relationships, emotional and behavioral regulation, communication skills, and access to basic needs. The social, emotional, and mental health of young people can be supported by

• normalizing their feelings and emotions,
• ensuring that their basic needs are met,
• providing them with accurate and developmentally appropriate information,
• limiting access to media,
• listening to their needs, and
• ensuring that children can engage in interpersonal connection, routines, physical activity, and play.

Powell also explored how school-based interventions can address the social and emotional needs of disaster-affected children. Such interventions may be universal, selective, indicated, or as treatment. Universal interventions may be provided through schools to all children, teaching emotional skills and developing preparedness. Selective programs can be beneficial to any child at risk (e.g., all children in a community that have been exposed to a disaster). These programs are often group based and aimed at reducing short- and long-term risks. Indicated programs are targeted at children experiencing mental health symptoms and may be conducted on the individual level or among small groups. Treatment programs are needed for individual children in need of assistance, such as one-on-one therapy.

PsySTART Pediatric Disaster Mental Health Triage System

Merritt Schreiber, professor of clinical pediatrics in the Department of Pediatrics at the David Geffen School of Medicine at the University of California, Los Angeles, discussed the PsySTART pediatric disaster mental health triage system. He explained that there are various potential trajectories that children may follow after disasters, including resilience pathways (e.g., stress, transitory distress response) and risk pathways (e.g., new incidence disorders). PsySTART is aimed at triaging to stepped care within 30 days of a disaster to interrupt children’s progress toward a risk pathway.

Schreiber said that the framework used in PsySTART was adapted from a model developed for the National Child Traumatic Stress Network.² The model is focused on integration across disaster systems of care, such as human service organizations, schools, medical settings, families, and other systems of care. Linkage to the appropriate level of care is provided through a rapid triage process. The PsySTART rapid triage model does not require direct questioning of the child, and it shifts the focus of triage from signs of distress to evidence-based risk markers (e.g., children’s experiences of being trapped, seeing serious injuries or deaths, thinking that they were going to die, having family members killed or injured, losing their homes, being unaccompanied, and being displaced from their social supports). In some settings, a simplified adverse childhood experiences (ACEs) screening, called ACEs triage, has been implemented. A PsySTART triage smartphone application can be used to conduct the triage process, he added. This triage input process is used to allocate resources based on needs. The application can also provide real-time mapping of population risk and can generate individual referrals based on risk markers. The PsySTART triage system is based on the principle that if these markers and needs are not consistently measured early in the disaster recovery process, then they tend to be missed and go unaddressed. The system has many complex functions and capacities, including mapping, rendering parameter-based risk metrics, generating incident action plans, and creating tools for aligning resources with needs.

Schreiber discussed the use of the PsySTART triage system by the Sonoma County School system in nine underserved rural districts that were significantly affected by wildfire, flooding, and mudslide emergencies. The process began with PsySTART solution-focused triage, screening as many children as possible in the affected area and aligning resources with needs. Next, a 4-hour step 1 intervention of trauma-focused cognitive behavioral therapy was provided via telehealth. If necessary, a 12-hour step 2 intervention of full cognitive behavioral therapy was provided. If these steps can be implemented in the first month after a disaster—the so-called golden month—it may result in the prevention or reduction of posttraumatic stress disorder among disaster-affected children. Sonoma County also used PsySTART to conduct a gap analysis in order to assess and align needs and resources. He added that PsySTART may also be customized to refine the alignment of needs and resources for rapid response to disasters.

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² More information about the National Children’s Disaster Health Concept of Operations is available at https://www.aap.org/en-us/Documents/disasters_dpac_NPDCCschreiber.pdf (accessed October 21, 2020).

Research Findings from Hurricane Katrina

Alice Fothergill, Department of Sociology at The University of Vermont, discussed findings from her research on children’s experiences of Hurricane Katrina. Her discussion focused on the experiences of children living in poverty before, during, and after the hurricane (Fothergill and Peek, 2015). This research was conducted through a 7-year modified naturalistic study using qualitative interviews conducted with children and various individuals from their families, schools, and communities. To understand children’s experiences, the researchers needed to observe the various spheres of children’s lives (e.g., family, housing, school, peers, health, extracurricular activities). The study revealed that there is not a definitive endpoint of the effects of Hurricane Katrina.

Three postdisaster trajectories were identified among the children studied, said Fothergill. Children in the declining trajectory experienced simultaneous and ongoing disruptions in their families, schooling, housing, health, and health care. Children in the finding equilibrium trajectory were able to regain or attain stability with mobilization of resources and social support. Children in the fluctuating trajectory experienced a mixed pattern of stability and instability. She noted the connection between economic advantage or disadvantage and the trajectories experienced by children: children of greater economic advantage tended to be in the finding equilibrium or fluctuating trajectories. In their study, they found that all children experienced a decline immediately following the disaster.

Fothergill presented three vignettes that exemplified the three trajectories. The declining trajectory reveals the effect of cumulative vulnerability (i.e., the overall effect of numerous preexisting vulnerabilities when a disaster occurs). Most children on the finding equilibrium trajectory had access to resources. However, Fothergill shared a nontypical example of a child who did not have access to resources prior to Hurricane Katrina but who benefited from resource mobilization after the hurricane. Through linkages to advocates, this child and her family were able to obtain housing, mental health care, mentoring, and other forms of assistance. Her family had no resources before the storm, so she would not have been expected to find equilibrium after losing everything in Hurricane Katrina. The fact that she found equilibrium shows the importance of resource mobilization as part of the disaster response, said Fothergill.

She described two patterns in the fluctuating trajectory: multiple spheres in flux and all spheres simultaneously in flux. She shared an example of two siblings who experienced a fluctuating trajectory with all spheres simultaneously in flux, noting that this case reveals the importance of adult “anchors.” Anchors are adults in a child’s life who prevent the children from “falling through the cracks” as they experience fluctuations in their

life spheres. They may include older siblings, grandparents, or other adults to whom they are socially connected.

Social engagement is another key factor for children who are in flux; social engagement may be the means through which children find their adult anchors (e.g., coaches, teachers). Fothergill highlighted the capacity of children to help one another as well as helping adults. Children have voices and problem-solving skills that should be involved in disaster recovery efforts to whatever extent possible. She also noted the importance of housing and returning to school for children’s recovery. While returning to school was an essential part of recovery—offering routine, stability, food, and links to other resources—children recovering from disasters also need accommodations and assistance to return to school. During Hurricane Katrina, housing programs of every kind, from many organizations, were shown to be highly beneficial to the child recipients of those programs. This illustrates how a web of mobilized resources and services are needed to help children find equilibrium after a disaster, said Fothergill.

EFFECT OF DISASTERS ON PARENTS AND GUARDIANS

Disaster Effects on Parents, Caregivers, and Child Care

Holly Nett, director of Child Care Emergency Partnerships at Child Care Aware of America, discussed how disasters can affect parents, caregivers, and child care. Child Care Aware of America is a national membership-based nonprofit focusing exclusively on child care. It serves as a leading voice in the United States advocating for child care system improvement, working with more than 600 state and local child care resource and referral agencies to help ensure that families have access to high-quality and affordable child care. These organizations typically offer child care program referrals, consumer education, and financial assistance for families and professional development and technical assistance for child care program staff, along with advocacy on early childhood issues, recruitment and retention of programs in communities, and partnership building.

Nett commented that during disasters, children under 5 years of age are among the most vulnerable. Children of this age are often separated from their families when a disaster strikes because they are in child care settings. Child care programs are especially vulnerable to disasters because children are unable to protect themselves and are reliant on their child care providers to ensure their safety. In times of calm and as well as during disasters, Child Care Aware of America uses its relationships, data, and technology to help communities understand the landscape of child care before, during, and after an emergency. It focuses its efforts on building preparedness, determining needs, mapping the effects of emergencies, and locating temporary care

during recovery. Given the inevitability of disasters, a well-prepared child care workforce is necessary to ensure children’s safety during an emergency, she noted. Parents must have a great deal of trust in their children’s health care providers, which takes on a new dimension in the context of disasters. Well-trained caregivers are more likely to be able to provide needed emotional and physical support to children during disasters.

Child Care Aware of America has also been working to address the research gap on child care emergency preparedness for infants and toddlers, said Nett. In 2018, it surveyed early learning professionals to develop evacuation recommendations for children during emergencies.³ Nearly 20 percent of survey respondents reported that they have had to evacuate infants or toddlers because of an emergency, such as fire, smoke, gas leaks or smells, and severe weather. These kinds of emergencies are an area of focus because of infants’ and toddlers’ unique reliance on caregivers for physical, nutritional, and emotional support; their limited communication abilities; their limited mobility; and their reliance on caregivers for protection from harm.

Nett also described the effects of disasters on child care since 2012. In disasters such as Superstorm Sandy, flooding in Louisiana, Hurricane Harvey, and California wildfires, numerous child care facilities reported damages and were forced to close because of these disasters. These damages and closures each displaced many children who were in need of child care, and the shortage of child care can hinder communities’ ability to recover from disasters. Child care resource and referral agencies and partners can play a major role in recovery by helping to funnel resources to communities in need of child care, she added. This kind of response requires that relationships be in place prior to disasters, however. Recognizing that emergency preparedness, response, and recovery is vital to the well-being of children, families, and communities, Child Care Aware of America’s emergency preparedness team is committed to providing resources to child care resource and referral agencies and partnering agencies to support the needs of the child care sector before, during, and after emergencies.⁴

Issues for Parents and Guardians: Housing and Mental Health

Jonathan Sury, National Center for Disaster Preparedness, discussed issues for parents and guardians related to housing and mental health and disasters. He described the evolving disaster landscape. Factors such as

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³ More information about the Child Care Aware of America 2018 survey is available at https://info.childcareaware.org/blog/child-care-prepare-infant-toddler-emergency-evacuation (accessed April 6, 2021).

⁴ More information about the Child Care Aware of America’s emergency preparedness efforts is available at https://ChildCarePrepare.org (accessed October 21, 2020).

emerging infectious diseases, extreme weather events, technological and human-made disasters, and information overload have introduced new concerns and added complexity to communications about disasters in ways that affect planning.

Sury highlighted several themes from research about Hurricane Katrina, Superstorm Sandy, Hurricane Florence, and Hurricane Maria. In communities most affected by these disasters, there were preexisting housing crises—characterized by high-risk housing, poor mitigation, and housing policies—and reconstruction and rebuilding in these communities has been slow, often owing to the lack of resources. These communities have also been affected by mental health issues, with the mental health of parents and guardians having a great effect on the mental health of children after disasters. He noted that trusted child-serving institutions are necessary for resuming economic activity after most disasters.

Sury presented a socioeconomic model of recovery that identified five predictors of postdisaster recovery: housing stability, stable economic resources, good mental health, good physical health, and positive social role adaptation (Abramson et al., 2010). He highlighted the effect of financial stressors on postdisaster recovery. After Superstorm Sandy, residents who suffered major structural damage were 2.5 times as likely to have difficulty affording rent, bills, mortgage, food, or transportation, regardless of income. Furthermore, residents living in poverty were 6.7 times as likely to have difficulty paying bills. These financial stressors translate into a decrease in mental health, he noted. In this research, housing damage, prior history of depression, and identifying as Hispanic were found to be positive predictors of posttraumatic stress disorder. He discussed unpublished data collected from households affected by Hurricane Harvey, which indicate that 40 percent of homes with children in 2017 still needed to repair damage caused by the hurricane. Moreover, 27 percent of the homes surveyed needed housing assistance, 37 percent of heads of household respondents reported that their own lives were still disrupted by the hurricane, and 60 percent of respondents said that their households had still not recovered from the hurricane. He also presented findings from a study on housing stability after Hurricane Katrina, which demonstrates the connections between housing instability and mental health disability, poor sense of community, inadequate social support, worse academic performance among children, and emotional problems among children.

Sury called for the following:

• Investing in long-term financial support for community-based organizations to offer housing repair and extend the duration of housing assistance programs,
• Building capacity among parents and guardians so they may better serve as resilient buffers for their children, and

• Formally integrate local emergency management, licensing, and social services for child-focused preparedness issues (e.g., staff, funding), perhaps including child-specific community liaisons.

He advocated for uniting preparedness planning guidance and technical and financial assistance for child care centers, particularly in Puerto Rico. He also noted that foster families generally are not required to develop their own household disaster plans, and they often require technical assistance to create such plans. Finally, he underscored the importance of connecting with, and listening to, the needs of affected communities.

Effects of Disasters on Parents and Guardians

C. J. Huff, educator and child advocate, shared his personal experience working as a part of numerous disaster responses and discussed the key role of schools as part of postdisaster recovery efforts. School systems are essential during crises, he said. They offer familiar environments, trusted relationships, access to services and support, and other valuable resources. These supports are particularly important for families and children with access and functional needs, resource-challenged families, and undocumented families. School systems that are affected by disasters face the challenge of adapting to find ways to continue to deliver school services, such as individual education plans, assistive devices, and curricula. For instance, the COVID-19 pandemic has forced schools to adapt their approach to each of these service types; these adaptations have put additional stress on parents and their children throughout the pandemic. Furthermore, the increased stresses experienced by parents during disasters often change family dynamics and may result in child abuse.

He emphasized the importance of emergency operations planning, keeping digital records, maintaining up-to-date contact information, ensuring continuity of learning planning, and developing community partnerships. All of these efforts can help schools navigate unexpected situations that arise during and after disasters, he noted. He added that other community needs should also be considered in advance of disasters, such as creating children and youth task forces, mapping resources, creating mutual aid agreements, and establishing university partnerships. At the federal level, he suggested creating assistive device inventories in advance of disasters, establishing philanthropic partnerships, creating resource databases, increasing funding for the School Emergency Response to Violence program,⁵ and placing disaster case managers in schools.

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⁵ More information about the School Emergency Response to Violence program is available at https://www2.ed.gov/programs/dvppserv/index.html (accessed April 6, 2020).

Discussion

Beal asked about data that demonstrate the effect of the loss of child care on disaster recovery. Nett said that there is much anecdotal evidence about the child care struggles of communities during disaster recovery, but more research is needed. Beal also asked whether the lessons learned during the COVID-19 pandemic may inform future responses to disasters. Huff said that schools’ COVID-19 responses have highlighted issues of equity, particularly in rural areas where connectivity is limited. Predisaster planning and educator training can enable schools to respond to disasters effectively. Furthermore, parent engagement is invaluable for supporting instruction, especially as online instruction has become the new norm during the COVID-19 pandemic response, he added.

Beal asked whether a postdisaster mental health program that is oriented to the family or the child care provider could help to address the mental health issues that arise during and after disasters. Sury replied that like all disaster response programs, trauma-informed communities should be established in advance of disasters. He cited a cadre of Community Resilience Model trainers in South Carolina who teach a wide range of professionals in all public sectors to equip them with a trauma-informed approach to interacting with their communities. People who may interact with children who have experienced a disaster should also receive training in psychological first aid, he added. However, implementing these models may give rise to resource allocation issues. He shared his experience with working in a community to create a mental health response plan. He noted that engaging all relevant stakeholders for such efforts is challenging, but a community plan may be critical for adequately providing a sustained mental health response to disasters, especially one that can address both acute and chronic mental health challenges.

Acknowledging the critical roles of child care, schools, mental health support, and housing stability for disaster recovery, Beal asked which other systems should be established and maintained prior to disasters to ensure adequate disaster recovery. Nett said that partnerships should be established and maintained to help support disaster planning systems; strong partnerships also help to ensure that resources can be mobilized during disasters. Sury said that local emergency management institutions are consistently understaffed and underresourced, often without any specific plans for children. Increasing funding and creating child-specific emergency planning positions and institutions would help to connect all of the key factors discussed by the panel and ensure that planning for disasters—including planning for the needs of children—is ongoing during “blue sky times.” Huff remarked that “cash is king:” during emergencies, cash funds should be available to address needs as they arise. He reiterated that preexisting

and well-maintained relationships in communities are the key to community resilience. By routinely convening, planning, and problem solving for disasters and other issues, community groups can “exercise their reliance muscles” so that they can be harnessed during disasters. Sury added that communities often need technical assistance to establish their disaster response plans.

Beal asked whether a federally funded mandate for children and youth task forces would be an appropriate vehicle to realize the plans and systems advocated by the panelists. Huff said that the investment into such task forces is primarily directed toward training and the establishment of frameworks. With each disaster and community being different, children and youth task forces should be designed to build on the unique strengths within each community. Thus, a federal mandate for children and youth task forces may not be warranted, but state-level encouragement of the creation of such task forces may be beneficial. In either case, the success of children and youth task forces depends on the leadership capacity in each community, he added. Sury said that tapping into preexisting community structures for any purpose would be helpful. Using community champions who have existing relationships, credibility, and convening power within the community has been shown to be an effective approach.

EFFECT OF DISASTERS ON CHILDREN WITH COMPLEX OR SPECIAL NEEDS

Needs of Students with Disabilities and Their Families During Disasters

Kate Moran and Carmen Sanchez, education program specialists at the Department of Education, shared the experiences of students with disabilities and their families during disasters. Moran shared images from Hurricane Maria depicting the destruction of roads, homes, and infrastructure and the barriers that these disruptions created for individuals with special needs. She explained that power and transportation disruptions caused difficulties for individuals who relied on wheelchairs and elevators for mobility. Similarly, individuals who relied on oxygen tanks were put at risk by infrastructure disruptions. In some cases, disaster responders have been unable to access the homes of individuals who were known to need assistance because of disruptions and damage caused by disasters. The Office of Special Education Programs (OSEP) provides disaster support including food items, durable medical equipment, breathing equipment, feeding equipment, mobility equipment, and translators to assist those with special communication needs (e.g., deaf individuals). Moran explained that OSEP works with state governments to create systems to address the loss of paper documents during disasters and the transference of data into elec-

tronic record systems. Their office plays a role in facilitating interagency collaboration by connecting disability specialists from various agencies during disaster response. This facilitating role is helpful in identifying where additional support is needed for those with special needs.

Sanchez discussed the discretionary grants provided through OSEP. Grants are given to nonprofit parent organizations and are intended to help families of children with disabilities to learn about their rights and to work with their schools and educators to provide for the needs of children with disabilities. She emphasized that for children with special needs, it is often difficult to separate their educational needs from their health needs or other fundamental needs. These grants are provided on a 5-year cycle, but many grantees have held their grants for 30 years or more. These grantees have become resource hubs, serving as “one-stop shops” for the families of children with special needs. Currently, 96 centers are supported by these grants, and a tight-knit community has been formed among these grantees.

One national center is funded by these grants, the Center for Parent Information and Resources,⁶ along with four regional centers. These national and regional technical assistance centers are important in disaster response, especially for families with children with special needs who need to relocate across states during a disaster. These national and regional centers help to facilitate the transition process and ensure that parent centers are sharing information. For instance, these centers were critical for facilitating the transitions of many families from Louisiana to Texas during Hurricane Katrina.

Sanchez shared a story of a woman in Puerto Rico who was trapped with her teenage son after Hurricane Maria. Her son used an electric wheelchair and required pureed food. She struggled to find food for her son, but the parent information center in Puerto Rico—which was funded by OSEP grants—was closed because of hurricane damage. The mother was able to contact a parent center in New Jersey and received relief through the actions of various individuals within the national network of parent centers. Sanchez added that many families with children with special needs who moved from Puerto Rico to Florida or other states used the network of parent centers to facilitate their transition. She noted that Fairfax, Virginia, has created a special needs emergency registry that allows any person to register themself or a family member that has special needs so that during an emergency, disaster responders know the location and specific needs of those registrants in advance.

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⁶ Sanchez explained that the Center for Parent Information and Resources has strategically assembled resources for parents in response to the COVID-19 pandemic. More information is available at https://www.parentcenterhub.org (accessed October 22, 2020).

Psychological and Social Effects of Disasters on Children and Youth with Disabilities

Laura Stough, associate professor and assistant director of the Center on Disability and Development at Texas A&M University, noted that research on individuals with disabilities and special health care needs during disasters has been increasing since the aftermath of Hurricane Katrina. However, this body of research is still limited and is primarily focused on adults rather than children and youth (Stough and Kelman, 2018). The evidence available, however, confirms that those with disabilities are disproportionately affected by disasters. They experience higher mortality rates and higher degrees of property loss. People with disabilities tend to be equally prepared for disasters as those without disabilities, but persons with disabilities may (1) have greater need for support during evacuation and sheltering, (2) require more intensive case management during recovery periods, and (3) take longer to recover from disasters.

Approximately 20 percent of U.S. children under 18 years of age have special health care needs, said Stough (HRSA Maternal & Child Health Bureau, 2020). Many children with disabilities have difficulties related to mobility, communication, or learning. Children with disabilities and their families often rely on education and community supports that can be disrupted in disasters (Peek and Stough, 2010). However, studies have found that levels of emergency preparedness vary among families with children with special health care needs (Baker and Baker, 2010; Baker and Cormier, 2013; Wolf-Fordham et al., 2015). Small-scale public health interventions have been successful in helping families prepare for emergencies (Bagwell et al., 2016), but families of children with disabilities may require tailored disaster information to best meet their needs (Hipper et al., 2018). She remarked that when rapid evacuation is required, preparedness for children with disabilities is critical.

Stough discussed the experiences of children who were exposed to the California wildfires in 2017.⁷ Parents of these children did not receive preparedness information or evacuation support specific to disability-related needs. Families encountered difficulties in evacuating children with disabilities along with their durable medical equipment and assistive technology. Parents often evacuated alone with their children and, after evacuating, they often faced difficulties in accommodating disability-related needs as they transitioned to multiple temporary housing situations. These families encountered psychological stresses associated with these experiences, but the postdisaster psychological supports available were not adapted for chil-

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⁷ More information about children with special health care needs being evacuated during wildfires is available at https://hazards.colorado.edu/news/research-counts/evacuating-under-fire-children-with-special-healthcare-needs-in-disaster (accessed October 22, 2020).

dren with disabilities. More collaboration is needed among voluntary agencies, disability organizations, and health care providers to deliver needed supplies, equipment, and support during and after emergencies, she said.

Few studies have looked at the psychological experiences of children with disabilities experiencing disasters (Stough et al., 2017). However, people with developmental disabilities may have difficulties when encountering unusual or unexpected stimuli, which often occur in emergency situations. Furthermore, there has been a lack of interventions adapted for children with cognitive disabilities or autism spectrum disorder. This is concerning, Stough said, given that children with developmental disabilities experience disproportionate trauma exposure. She called for trauma-informed, school-based measures to address these concerns. She said that schools have a responsibility to ensure whole community drills, evacuation plans, and sheltering in place to ensure the safety of students with disabilities. However, the needs of children with disabilities are often excluded in school disaster planning (Fifolt et al., 2017), and students with disabilities are often excluded in disaster education efforts (Boon et al., 2014; Stough et al., 2020). Several studies have demonstrated that students with disabilities can effectively participate in disaster education with curricular modifications (Ronoh et al., 2015a,b).

Despite being affected by disasters themselves, teachers provide essential support to students and their families throughout all phases of disasters, said Stough. Teachers’ roles often expand during disasters to include instrumental and psychological supports. For instance, special education teachers may provide support even when schools are closed and students have been displaced from their school districts (McAdams Ducy and Stough, 2011). School personnel need to be well trained and knowledgeable across school contexts, said Stough (Stough et al., 2020). She added that the effects of disasters on school personnel themselves must be considered postdisaster when schools begin reopening and must rely on these personnel in order to resume instruction.

Finally, Stough discussed the roles of voluntary and nonprofit organizations in disaster response. The specific needs of people with disabilities are often ignored or overlooked by volunteers providing disaster response, and volunteers are often not trained to identify and assist individuals with disabilities (International Federation of Red Cross and Red Crescent Societies, 2007). Few of the volunteer organizations active in disasters that are part of the national response framework focus specifically on the needs of persons with disabilities, she added. However, disability-related organizations have been participating more actively in issues surrounding emergency management and disaster risk reduction. She suggested that this increased interest by disability organizations may be attributable, at least in part, to the COVID-19 pandemic and the threat posed by the pandemic

to individuals with developmental disabilities. Finally, she pointed out that disability-related organizations are often not connected with local emergency management.

Discussion

Sabrsula asked whether any initiatives are under way to fill the gaps in addressing the long-term psychological effects of disasters on students with special needs. Stough said that there is a lack of modified psychological treatments for students with intellectual disabilities; she pointed out that these students are often at a greater risk of experiencing trauma, even outside of the disaster context.

Sabrsula asked whether any new efforts are under way to promote training for disaster response. Moran said that various forms of training are available that include elements of support strategies, particularly in the context of the COVID-19 pandemic. Sanchez said that the Center for Parent Information and Resources has created a webpage to direct parents to places that offer training on trauma-informed care. She mentioned two centers that focus on behavior: the Center on Positive Behavioral Interventions and Supports has begun working with trauma,⁸ and the National Center for Pyramid Model Innovations addresses behavior among younger children.⁹ Moran shared a link to the Early Childhood Technical Assistance Center website, which offers resources on disaster planning and trauma response.¹⁰ Stough explained that these and other related resources are valuable, but none of those resources or interventions are tailored to address the specific needs of children with preexisting disabilities and complex health care needs. For instance, many of these children express depression or anxiety through behavior, but many school counselors are not trained to interpret these behaviors as expressions of anxiety, trauma, or grief.

Sabrsula asked how children with disabilities can be supported while living in shelters. Moran replied that it may be possible to work with those children and their families through cooperation with the Federal Emergency Management Agency (FEMA). She suggested that disability integration specialists are often connected to FEMA, city governments, and other agencies. Thus, such specialists are likely the best point of access for assisting families with children with disabilities living in shelters.

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⁸ More information about the Center on Positive Behavioral Interventions and Supports is available at https://www.pbis.org (accessed October 22, 2020).

⁹ More information about the National Center for Pyramid Model Innovations is available at https://challengingbehavior.cbcs.usf.edu/index.html (accessed October 22, 2020).

¹⁰ More information about disaster planning and trauma response is available at https://ectacenter.org/topics/disaster/disaster.asp (accessed October 22, 2020).

EFFECT OF DISASTERS ON UNACCOMPANIED MINORS

Disasters and Unaccompanied Minors

Patricia Frost, vice chair of the National Pediatric Disaster Coalition, discussed the effects that disasters have on unaccompanied minors. If children become unaccompanied minors during disasters, they may experience lifelong consequences. While policy makers are often aware of fault lines, flood zones, or other environmental risk factors, they are often unaware of community risk factors and resources available to address them. Better awareness of community risks, including awareness of the location of at-risk children, is important for disaster preparedness.

Frost noted that the disaster response system is geared toward response rather than addressing short-term and long-term consequences. The multisectoral rescue chain—beginning at the impact zone and extending through evacuation processes and into hospitals—is often chaotic and involves multiple handoffs. This chain puts children at risk of being lost in the system, especially during no-notice and short-notice events.

Hurricane Katrina was emblematic of these challenges and brought attention to the effects of disasters on unaccompanied minors, said Frost. She cited the case of Cortez Stewart, who was not reunited with her family until 6 months after the hurricane. During Hurricane Katrina, myriad systematic breakdowns, coupled with a lack of infrastructure, made it difficult for families to keep their children with them through the response and recovery processes. Additionally, many families experienced delays in evacuation and in receiving information that affected their ability to keep their children with them. During Hurricane Katrina, many unaccompanied minors were sent to mass shelters; some of those minors arrived in the company of nonguardian adults, at least one of whom was later found to be a sexual predator. Furthermore, foster care services struggled to track and manage their more than 500 foster children, and law enforcement lost track of numerous sexual offenders during that period. Frost shared several examples of children who underwent traumatic experiences during Hurricane Katrina after being separated from their families.

Superstorm Sandy raised similar concerns about unaccompanied minors, said Frost. In New York City, 230 homeless shelters were lost because of storm surges and 300 homeless families had to be relocated. Programs for homeless youth and for lesbian, gay, bisexual, and transgender youth were also disproportionately affected by the storm. These vulnerable individuals had a desperate need to access already crowded emergency shelters. During the storm, nearly 8,700 students were dislocated to live in shelters, hotels, or with other families. Families in poverty were found to have a higher risk of being separated, she noted.

In 2018, wildfires in Paradise, California, required evacuations followed by multiple relocations of shelters owing to the rapid advancement of fires. Many children who were evacuated during this disaster were separated or at risk of being separated from their families, said Frost. In one case, a school bus driver took the initiative to evacuate 22 students directly from an elementary school without having any opportunity to contact these children’s families. Frost noted that although there are best practices for reunification, the ultimate aim should be to prevent family separation by implementing proper infrastructure, offering training, ensuring coordination, and providing other necessary resources.¹¹

Programs for Homeless and Runaway Youth and Parents

Jeff Daniels, program manager of the Runaway and Homeless Youth Program at the Administration for Children and Families (ACF), gave an overview of the programs operated by the program. It provides discretionary funds to grantees for street outreach, basic center outreach, transitional living programs, and maternity group homes.

Street outreach programs support work with homeless, runaway, and street youth to assist them in finding stable housing and accessing services,¹² said Daniels. These programs focus on developing relationships between outreach workers and young people that allow them to rebuild connections with caring adults. The programs are also aimed at preventing sexual exploitation and abuse of youth on the streets. Street outreach services include education and outreach, emergency shelter access, survival aid, treatment and counseling, crisis intervention, and follow-up support.

ACF’s Basic Center program creates and strengthens community-based programs that meet the immediate needs of runaway and homeless youth under 18 years of age. These programs also aim to reunite young people with their families or locate appropriate alternative placements, said Daniels. Basic Center program services include up to 21 days of shelter, food, clothing, medical care, crisis intervention, recreation programs, aftercare services, and counseling for individuals, groups, and families. Transitional living program services are provided to older homeless youth, with supporting projects that provide long-term residential services to

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¹¹ More information about postdisaster family reunification is available at https://www.fema.gov/media-library-data/1384376663394-eef4a1b4269de14faff40390e4e2f2d3/Post_Disaster_Reunification_of_Children_-_A_Nationwide_Approach.pdf (accessed October 21, 2020) and https://www.aap.org/en-us/Documents/AAP-Reunification-Toolkit.pdf (accessed October 21, 2020).

¹² Daniels explained that “runaway youth” are defined as youth who purposely leave their home, while “homeless youth” can describe a person 22 years of age or younger who has become homeless under certain circumstances through no fault of their own.

homeless young people. Young people aged 16–22 years are eligible for these programs. Living accommodations may include host family homes, group homes, maternity group homes, or supervised apartments owned by the program or rented in the community.

Transitional living programs offer or provide referrals to additional services, including safe and stable living accommodations, basic life skills building, educational opportunities, job attainment services, mental health care, and physical health care. Maternity group homes for pregnant youth and parenting youth programs support homeless pregnant or parenting young people (aged 16–22 years) along with their dependent children. In addition to the services offered by transitional living programs, maternity group home programs offer parenting skills, child development services, family budgeting, and health and nutrition services, said Daniels.

Daniels explained that emergency preparedness planning was critical for managing the Paradise wildfire disaster in 2018. Approximately 22,000 individuals were displaced by the fires, but within hours of the evacuation, one ACF grantee organization in Paradise had accounted for all staff and children managed by the program. Additionally, the organization was able to provide temporary housing for staff whose homes were destroyed by the wildfires.

Human Trafficking Identification and Responses in Disaster Contexts

Leanne McCallum, task force coordinator at the Greater New Orleans Human Trafficking Task Force, discussed frameworks for understanding the vulnerabilities of unaccompanied minors to human trafficking in the postdisaster context. Sex trafficking is defined as the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age (22 USC § 7102). Labor trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery (22 USC § 7102).

Unaccompanied minors are vulnerable to both sex trafficking and labor trafficking, said McCallum. In disaster contexts, some young people participate in survival sex by trading commercial sex acts for things of value (e.g., food, protection, shelter, other basic needs). As defined in the context of sex and labor trafficking, force, fraud, or coercion may include lack of mobility, debt bondage, document confiscation, recruitment fraud, lack of payment, physical or sexual abuse, threats of violence or retribution, long hours without reprieve, or the inability to walk away.

A person’s inability to walk away is the primary distinguishing factor of trafficking, she added.

Young people face particular vulnerabilities during disasters that put them at risk of becoming victims of trafficking:

• Risk of homelessness or displacement;
• Loss of jobs or other ways of making money;
• Isolation;
• Reliance on others for basic needs like food, water, and shelter;
• Lack of protection from law enforcement or labor rights agencies;
• Suspension of some labor protection systems;
• Limited interactions with mandated reporters or safe figures; and
• Other cultural factors.

Certain children are highly vulnerable to trafficking during the postdisaster period, including those without parental care or who are living on their own, living in foster care, living with mental or physical disabilities, living with special needs, and children who are members of marginalized groups.

McCallum shared lessons learned from disasters in which child trafficking was discovered. Common themes from trafficking after these disasters included displacement and movement of people as a condition in which trafficking occurred, false promises made to victims, damage to homes and livelihoods causing vulnerability to trafficking, the presence of vulnerabilities before the disaster, and the use of false adoptions for trafficking. She added that child marriage—a form of trafficking—may also increase during postdisaster periods.

National Center for Missing & Exploited Children

Joy Paluska, program manager in the disaster preparedness and response program at the National Center for Missing & Exploited Children (NCMEC), described the history of NCMEC, a nonprofit nongovernmental organization established in 1984 that receives approximately 70 percent of its funding from the Department of Justice. NCMEC was established after its founding members observed that there was no system in place for searching for missing children in the United States. NCMEC’s mission is to find missing children, reduce child sexual exploitation, and prevent future victimization. NCMEC comprises a wide variety of service and programs that liaise with various law enforcement and government agencies.

A missing child is defined as a person who has not yet reached 18 years of age whose whereabouts are unknown to a legal guardian (42 USC § 5772), said Paluska. A separated child is a child who is separated from

both parents or from their previous legal or customary primary caregiver, but not necessarily from other relatives. Unaccompanied children are children who have been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so.¹³

Paluska described NCMEC’s role in Hurricane Katrina, explaining that NCMEC’s federal mandate has expanded as NCMEC has demonstrated additional capacities related to helping missing children. After Hurricane Katrina, NCMEC provided field support to help locate missing children and family members and identify unaccompanied minors. NCMEC resolved 5,192 missing children cases reported to NCMEC after Hurricane Katrina. NCMEC also established a hotline to handle incoming calls about missing children, ultimately handling 34,045 such calls. NCMEC now operates the federally mandated National Emergency Child Locator Center, which is a call center that connects to NCMEC’s 24/7 hotline.

More than 1.5 million people were evacuated during the Hurricane Katrina disasters, including 200,000 children, said Paluska. The evacuation was conducted with no prior planning for vulnerable populations, including children—many of whom were separated from their families. For example, children were put on evacuation buses without their parents and without any tracking system in place; the buses departed in varying directions toward state-managed emergency shelters. In 2006, the Post-Katrina Emergency Management Reform Act included plans to better prepare recovery teams to reunify families. Photographs are typically the quickest way to locate missing individuals, said Paluska. However, in 2005, photos of missing individuals were not often readily available, especially during disasters.

In the years since Hurricane Katrina, improvements in disaster preparedness, technology, and other systems may help to ensure that many of the challenges related to unaccompanied minors that arose during that disaster will be less severe in future disasters, said Paluska. Currently, NCMEC has a strong focus on disaster preparedness and works in coordination with FEMA, the Salvation Army, and the American Red Cross. NCMEC missing children specialists work as FEMA contractors, assisting with issues related to unaccompanied and missing children during disasters. She added that NCMEC operates an unaccompanied minors registry, a national data collection tool used to facilitate the tracking and reunification of unaccompanied minors, expedite the reunification of unaccompanied

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¹³ Separated child and unaccompanied child are defined as per FEMA’s postdisaster family reunification approach. More information about postdisaster family reunification is available at https://www.fema.gov/media-library-data/1384376663394-eef4a1b4269de14faff40390e4e2f2d3/Post_Disaster_Reunification_of_Children_-_A_Nationwide_Approach.pdf (accessed October 21, 2020).

minors with their families, and provide reports back to law enforcement and reunification staff.¹⁴

Discussion

Lavin asked about gaps in the handling of unaccompanied minors and how they might be addressed. Frost said that many first responders and persons in emergency management roles are not aware of available disaster management and reunification resources and do not fully understand how those resources would connect to their work during a disaster. Much work remains to be done to promote awareness of such resources and ensure adequate disaster preparedness, she added. Daniels said that FEMA has an emergency operation plan that organizations can use for disaster preparedness; it identifies the critical elements of all emergencies and has some information related to unaccompanied minors.

Lavin remarked that children tend to have common core needs during disasters, but children who are being exploited before disasters and youth who are homeless before disasters are especially vulnerable during disasters. Paluska said that disasters uproot individuals’ lives and often lead individuals to make decisions that they otherwise might not—for example, during disasters, vulnerable children have a heightened risk of being trafficked. McCallum said that the commercial component distinguishes trafficking from other forms of abuse. Abusers may recruit or try to capitalize on the disaster. For instance, during the post–Hurricane Katrina period, some individuals were forced to do construction labor in unsafe conditions because they had no other way to obtain money or shelter. During that period, child sex abuse and sex trafficking were also occurring among children who became vulnerable because they were abruptly separated from their guardians and others who could identify them as victims. She said that in disaster contexts, the separation of vulnerable individuals from those who would be able to identify them as victims is a major contributing factor to increases in trafficking and abuse.

Lavin asked about the challenges to be addressed in meeting the needs of homeless and missing youth, especially during disasters. Paluska said that most missing youth recorded by NCMEC are “endangered runaways.” These individuals are highly vulnerable to exploitation and lack the protection and support networks that might otherwise prevent them from being exploited. Daniels noted that the organization that successfully accounted for its youth and staff during the 2018 Paradise wildfires benefited greatly from the preparation and action of its emergency preparedness team. He

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¹⁴ More information about NCMEC’s unaccompanied minors registry is available at http://umr.missingkids.org (accessed October 23, 2020).

said that ensuring accountability and safety during emergencies requires communicating, having resources and assets in place in advance, assigning specific staff responsibilities, and planning in advance. He noted that street outreach is another way to help ensure the safety of homeless and unaccompanied minors. In addition to drop-in centers, street outreach helps organizations ensure the safety of youth in their communities. Street outreach varies by community and geography, he added. In some areas, street outreach entails venturing into the forest where homeless youth are living. Efforts should be proactive in seeking out these youth rather than relying on youth in need to come to drop-in centers for help, he said.

Paluska emphasized the need for preparedness, because having plans in place in advance of a crisis is invaluable for ensuring the safety of youth during disasters. Frost said that FEMA Emergency Support Functions (ESFs) 6 and 8 are closely tied to supporting children.¹⁵ However, greater dialogue should be facilitated between health and human resources actors and health care system actors, as these systems operate separately in many ways. Daniels said that planning is key, invoking the adage that “failing to plan is a plan to fail.” Disaster planning should take a holistic approach that accounts for all community needs and resources, he added. McCallum called for integrating antitrafficking and domestic violence responses into postdisaster plans in order to help save lives during the disaster response period.

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¹⁵ More information about ESFs 6 and 8 is available at https://www.fema.gov/pdf/emergency/nrf/nrf-esf-06.pdf (accessed October 23, 2020) and https://www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf (accessed October 23, 2020).