National Advisory Committee on Children and Terrorism

**May 21, 2003**

**Washington, DC**

The meeting was called to order at 9:10 by Dr. Angela Diaz, Chair of the
Advisory Committee.

Committee Members Present:

Dr. Angela Diaz, Chair, Mt Sinai Medical Center, New York

Kevin Dinnin, Baptist Child and Family Services, San Antonio, Texas

Brenda Greene, National Schools Boards Association

Dr. Alexander Kelter, California Department of Health Services

Dr. Bobbie Maniece-Harrison, Dept of Health Studies, New York University

Dr. Steven Marans, Yale University School of Medicine

Dr. Angela Mickalide, National SAFE KIDS Campaign

Dr. Richard Mollica, Massachusetts General Hospital

Richard Ricciardi, Department of Ambulatory Care Center, Fort Meade

Dr. Peter Rumm, Wisconsin Department of Health and Family Services

Dr. Jean Wright, Backus Children's Hospital, Savannah, GA

The Executive Secretary, Joseph Henderson was not present. Amy Loy
represented him.

Federal Advisors Present:

Dr. Robert Amler, ATSDR

Dr. Joanne Cono, CDC

Dr. Lloyd Kolbe, CDC

Cyndi Shaffer, CDC

Dr. Wanda Jones, DHHS

Dr. Woodie Kessel, DHHS

Dr. Rosemary Roberts, FDA

Rick Smith, HRSA

Dr. Margaret Feerick, NIH

Dr. Farris Tuma, NIH

Dr. Dori Reissman, CDC

Dr. Nicki Pesik, CDC

Andrea Argabrite, HRSA

William Modzeleski

# Consultants Present

Dr. Claude Chemtob, Mt Sinai School of Medicine

Colonel Theodore Cieslak, Brooks Army Medical Center

Dr. Louis Cooper, AAP

Dr. Fred Henretig, Children's Hospital of Philadelphia

Dr. Irwin Redlener, AAP

# Committee Staff

Victor Balaban

Amy Loy

Others (sign-in list)

Sue Martone

Shannon Manzi

Erika Stewart

Lisa Barrios

Benjamin Becker

Lauren Baskin

Susan Eads Role

Ellen Gerrity

Wendy Davis, HRSA

Heather Doyle

Tom Canter (?), Washington Times

Sumana Chatterje

Drew Bernstein

Elizabeth Evans

Von Roebuck

Angela Fazah, Maximum Technology Corp.

Sharon Bell, Maximum Technology Corp.

Dr. Diaz congratulated the committee on getting everything done on time,
and explained that they would continue to refine the recommendations in
today's meeting. She asked if there were any questions or corrections to
the minutes of the last meeting. Since there were none, there was a
motion to approve the minutes; that motion was seconded and passed.

# Emergency Medical Service Systems and Protocols, Dr. Irwin Redlener 

> **Recommendation #1**: **The Secretary should support and enhance the
> existing HHS programs, which assure that the needs of children are met
> in the EMS system.**
>
> This can be accomplished through:

-   Increased funding to the EMSC Program to allow for enhanced
    activities related to Emergency and Terrorism Preparedness via:

    -   Creation and distribution of educational program and resources
        for EMS providers related to pediatric emergency and terrorism
        preparedness

    -   Revision of the Model Pediatric Protocols to include protocols
        for Emergency and Terrorism Response based on the National
        Consensus Conference

    -   Targeted issues grants focused on emergency and terrorism
        preparedness

    -   Increased program staff to provide support and consultation to
        State, Territorial and Tribal EMS Offices, Professional
        Organizations and EMS Providers

-   Integration of the EMSC program in all HHS Emergency and Terrorism
    Preparedness Activities

-   Assurance that all HHS Emergency and Terrorism Preparedness
    activities that involve EMS require that pediatric considerations be
    included in these efforts

-   Increased funding should be provided to programs such as the
    Emergency Medical Services for Children (EMSC) to develop mental
    health resources for EMS providers, including pediatric triage tools
    and information regarding the importance of pediatric mental health
    in emergency and terrorism preparedness and response.

> **Recommendation #2: The Secretary should increase funding for
> research on EMS pediatric emergency and terrorism preparedness and
> response**. This can be accomplished via:

-   Establishing EMS pediatric emergency and terrorism preparedness and
    response as a Maternal and Child Health (MCHB) Research Priority

-   Establishing research funding for studies related to EMS and
    Pediatric Emergency and Terrorism Preparedness including triage,
    assessment, treatment and including mental health, in the form of
    RFPs and RFAs from NIH and its institutes

-   Creating mechanisms for funding Pediatric Emergency and Terrorism
    Preparedness research gaps identified by the EMSC program

##### Recommendation #3: Because acts of terrorism or other disasters may occur at unpredictable times and places, it is important that emergency planning explicitly account for the possibility of children being congregated in various settings.  These settings include, but are not limited to, schools, day care programs, after-school programs, youth organizations, summer camps and others.  

> Basic information concerning appropriate preparation for disaster
> needs to be widely distributed to all potential congregate settings
> for children.  Mechanisms for identifying such settings and
> ensuring appropriate distribution should be delineated.

Comments:

Under Recommendation #1, there is one sub- bullet that reads: "Targeted
issues grants focused on emergency and terrorism preparedness." Dr.
Redlener said there should be a specific focus on children.

The last sub-bullet of that recommendation," Increased funding should be
provided to programs such as the Emergency Medical Services for Children
(EMSC) to develop mental health resources for EMS providers including
pediatric triage tools and information regarding the importance of
pediatric mental health in emergency and terrorism preparedness and
response," should talk about children and families, not just children.

Dr. Mollica recommended that the document say "children, adolescents and
families," not just "children." The language needs to be explicit. He
also said he was uncomfortable with the word "health," because policy
makers don't always think about mental health. It is important to
eliminate any ambiguity of terms.

Dr. Rumm wondered about starting the document with a list of
definitions, as one way to resolve ambiguity and insistencies. Dr.
Marans added that the introduction could also have an overarching set of
principles, showing consensus about such issues as health/mental health,
research and surveillance, clinical utility, needs assessment, etc.

Dr. Modzeleski cautioned that there are times when the terms mental
health and physical health should not be used synonymously. He
recommended being explicit throughout the document. Dr. Jones added that
policy makers might turn to just one section of the document, pulling
things out of context. She supported specifying physical and mental
health, and children, adolescents and families.

Dr. Amler noted that one purpose of this report was to remind
policymakers that this is a heterogeneous group of people. Ms. Greene
reinforced the idea of having some overarching recommendations and
principles, and noted that she had devised a few already.

Dr. Redlender turned the group's attention to the third recommendation
regarding the focus of emergency planning, which should not just be
schools but all potential areas where children congregate, including
daycare centers, after-schools programs, camps, etc. He wanted to make
sure basic information would be available at those levels.

There was also a suggested recommendation that HHS should work with the
Department of Homeland Security to establish regionally-based pediatric
response teams that would be available on a 24/7 basis. Dr. Rumm
explained that this would be a volunteer secondary response team, based
on a CDC model. Dr. Cono added that CDC was focused more on
epidemiology, surveillance and outbreak containment, but not medical
services. The latter would call for local response teams, which would
have specific responsibilities. Dr. Rumm recommended these teams be
created at the regional HHS level, with regional pediatric experts.
There are plenty of volunteers, but there are issues of coordination,
licensing, etc. to be resolved. This could build on existing emergency
preparedness system, of which DMATs are a part, with one or two
pediatric specialty systems. Rick Smith added that this could also fit
into HRSA's regional planning

Dr. Manice-Harrison pointed out that in her last draft under training,
she had suggested an increase in the number of fully formed pediatric
DMAT teams, and that all DMAT teams add pediatric component to their
current training.

Dr. Jones referred to Recommendation #3 and requested that juvenile
detention centers be added. The current wording seems to be focused on
middle class youth.

Dr. Chemtob pointed out that the French emergency response system has a
significant number of people on reserve, trained and ready to be
activated. Dr. Jones noted that the Department was working on a medical
reserve corps and Dr. Kessell clarified that it was in the Office of the
Surgeon General. Dr. Cieslak added that Texas had something called the
Texas Medical Rangers.

Dr. Kessel was concerned that pediatricians should not care for pregnant
women, and that obstetricians should be included. Dr. Rumm also wanted
to include mental health .

Dr. Marans cautioned that many states are missing levels of expertise,
so the priority should be to provide specific support to primary
providers, particularly at the local level. Dr. Redlener added that it
would be important to delineate under what circumstances different
levels would be deployed and how. The Academy of Pediatrics has been
asked by the Task Force on Terrorism to identify all people who are or
would become experts in this area. Dr. Marans asked if there was a way
of using existing networks already mobilized and tap the expertise of
the Academy via state and local health offices.

Dr. Reissman wondered if there was any way to integrate with the
American Red Cross approach to reach needed expertise.

Dr. Redlener noted that these were part of larger infrastructure issues
having to do with coordination among existing and new agencies, private
and public sector organizations. It would not be advisable to throw in
new experts and layers in during a disaster. It is preferable to
coordinate in advance with what's already on the ground. Dr. Amler added
that one way to test efficiency of such coordination is during drills.
No plan survives first contact with event.

Dr. Cooper asked where pediatricians fit into overall state plans and
whether a state-by-state assessment was needed.

Dr. Rumm said he was disappointed that in the recent HRSA and CDC RFPs,
children's issues were not mentioned and there are therefore no mandates
to assess pediatric preparedness. This should be a seminal
recommendation.

Dr. Kessel noted that the Committee's recommendations lean toward
funding, rather than organization. During 9/11it was impossible to
coordinate all the volunteers. Recommendations about organizing all
pediatric resources and creating registries would add strength to this
section. Dr. Kolbe pointed out that CDC has been trying to work more
closely with local, private sector people to develop better working
relationships. Dr. Rumm responded that at the state and local level,
evaluation, feedback and oversight were just as important as funding.
There is good language in the HRSA grant, but the amount of money
dedicated to children's health needs is only a very small percentage of
the whole. There needs to be specific language for next year.

Dr. Mickalade asked whether FEMA had a civilian corps. Dr. Shaffer
responded that there was insufficient funding to move that forward.

Dr. Marans noted that there were two issues on the table, funding and an
existing body of knowledge. The Academy has developed recommendations
and knowledge. One recommendation to the Secretary could be to mandate
formal linkages between funding and inclusion of pediatric expertise in
planning, preparedness and response at state and local levels.

Dr. Redlener suggested acknowledging throughout the document that
pediatric departments at medical centers can be tremendous resources and
they need to be encouraged.

**Strategic National Stockpile, Dr. Pesik**

> **Recommendation #1: The Committee recommends that a regular review
> process by subject matter experts of the SNS program be established to
> ensure continued and enhanced pediatric capability and capacity.**

Recommendation #2: The Committee recommends that a process be
established to determined prioritization of recommended formulary
additions or modifications to maintain and enhance pediatric capability
and capacity.

Comments:

Regarding the second recommendation, Dr. Pesik explained that CDC has
specialists continually making recommendations for modifiying the
formulary, but there is no way to prioritize recommendations. It is
partly threat driven (burn and blast, radiation). There needs to be an
overall system for prioritization (based on national shortages, surge
capacity and other criteria).

Mr. Ricchardi underscored the importance of logistics when discussing
pediatric teams and coordination. People in the field using the
equipment should be part of the decision making, and need to be familiar
with equipment. Dr. Pesik responded that CDC was working with local
communities to help them understand what type of supplies and equipment
might be brought in so they are prepared to use them. They bring in
subject matter experts for each topic, including pediatrics, transport
specialists, etc.

**Children and Schools** -- Brenda Greene

> Recommendation #5: The Secretary should ensure that each major content
> area in DHHS-funded terrorism initiatives, and in other federal
> terrorism initiatives, addresses the role and needs of schools.

This can be accomplished by:

-   Providing dedicated fiscal resources and regulatory oversight to
    ensure that state and local health departments, and other agencies
    involved in this work, truly build partnerships with state and local
    education agencies and schools.

-   Expanding CDC's School Health Program by supporting staff in every
    state education agency and health department to focus on the health
    and mental health needs of students, including emergency
    preparedness and response. State school health leads, in education
    and health agencies, should work closely with state mental health,
    law enforcement, emergency management, and homeland security
    agencies and should receive at least a one-week course on the
    essentials of terrorism preparedness and risk communication.

-   Revising the Federal Response Plan, HHS/CDC Public Health
    Preparedness and Response for Bioterrorism Continuing Grant
    Guidance, HHS/HRSA National Bioterrorism Hospital Preparedness
    Program Cooperative Agreement Guidance, and other funded programs to
    indicate the need for schools and education agencies to be an
    integral part of preparedness, response, recovery, and mitigation
    efforts.

-   Developing and disseminating information and instruments to improve
    schools' ability to prepare for and respond to chemical, biological,
    radiological, and mass trauma (physical and psychological)
    terrorism.

-   Ensuring that HHS conduct and support new research addressing issues
    affecting preparedness of schools and their ability to respond to
    terrorism with emphasis on the impact of preparedness activities on
    student mental health and wellness; the availability and preparation
    of school health and mental health personnel to triage and respond
    to chemical, biological, radiological or mass trauma events; the
    ability of school staff to balance the needs of their own children
    and families with those of the children in their care; and the
    identification of \"best practices\" related to preparedness and
    recovery mental health services.

> **Recommendation #6: The Secretary should work with the Secretary of
> Education to ensure that schools are fully integrated into
> preparedness, response, recovery, and mitigation efforts.**
>
> Specific activities on which HHS and ED can work together include:

-   Add funds to the School Emergency Response to Violence Project
    (SERV) contingency fund, increasing the government's capacity to
    respond in a fast and flexible manner to meet the critical needs of
    schools and students after a crisis in the school or community.

-   Fund demonstration projects that expand and evaluate existing models
    (e.g., New York City, Los Angeles) for involving education agencies
    and schools in a coordinated system of response and recovery.

-   Ensure that schools place a high priority on returning students to
    school and their normal routines as quickly as possible after an
    event as one important method for supporting their resiliency.

-   Train students, staff, and family members to be first responders.

-   Provide funding for additional collaborative efforts, building upon
    the May 2002 teleconference developed by the Department of
    Education, Centers for Disease Control and Prevention (CDC), Federal
    Emergency Management Agency (FEMA) and Federal Bureau of
    Investigation (FBI) to provide state and local education, public
    health, mental health, emergency management, law enforcement, and
    homeland security agencies with updated information on biological,
    chemical, and radiological threats; answer questions about school
    preparedness and response; and describe roles of partnering agencies
    in the case of a terrorist threat.

-   Ensure that schools are part of planning and training if the use of
    their facilities is cited in emergency response planning documents.
    For example, many states have said they would use schools as sites
    for mass vaccination clinics if there were a smallpox event, but it
    is unclear if the schools know of these plans or who would be
    calling to gain access to the buildings in case of emergency; nor is
    it clear if plans are in place to assist with staffing the clinics
    and maintaining the infrastructure.

Comments:

Ms. Greene explained that some changes had been made in the above
recommendations since the last meeting. In the introduction, a paragraph
about the TOPOFF drill was added. She noted that schools were apparently
not included in that drill even though it was assumed that they would be
included as sites for dispensing medications.

Ms. Greene said she would like to add that national level activities
would occur at state level as well. Dr. Rumm suggested funding one
senior official to coordinate between state health departments and
departments of public instruction. Preparedness for children would be
part of that mission. He also wondered why there was no language about
day care. Ms. Greene explained that day care had been put into the
community arena.

Dr. Cooper suggested that anxiety might be reduced if terrorism were
part of subject matter in classrooms, in social studies and history
classes. Ms. Greene explained that this was in the larger report under
curriculum decisions.

Dr. Kessel was concerned about how to differentiate what needs to be
done from how to do it in the recommendations. We need to help
policymakers understand implementation, beyond just increasing funding.

Dr. Modzeleski made a series of comments. He cautioned that it is
important to be careful about what is said to children and how. Parents
are concerned about what's being discussed in school, and high school is
different from elementary school. These are state and local issues, and
school boards make the ultimate decisions. Are we talking just about
public schools students, or private/parochial as well? A significant
number of children are not in public school. He felt the new paragraph
on TOPOFF was vague about whether schools were included. The
recommendations need to show exactly where school plans for emergencies
are inconsistent with community plans. Too often there is a lack of
coordination and communication. He thought the recommendations should be
reviewed to make sure they are clear to people without medical, or
mental health training. More specificity is needed. Finally, it would be
important to review efforts in the past and capture lessons learned.

Dr. Marans commented that a major issue of community planning is how
quickly communities can return to normal life and stability, starting
with schools. Ms. Greene explained that this was captured in one of her
overarching recommendations, as well as specific recommendations for
schools.

Dr. Reissman noted that both recommendations talk about
hazards---chemical, biological, radiation, but they don't mention terror
and fear. This is an opportunity to infuse a public health perspective
of mental health. Where can schools be brought up in other sections?
Ways to undercut fear need to be interwoven throughout the document. Dr.
Balaban responded that these concerns were addressed in the risk
communication section.

Dr. Chemtob said a major impediment to working in schools is their
immune system/barriers, unless prior relationships are set up. This
committee is recommending preparing schools to become part of an
emergency response and providing a structure that can be activated,
including psychologists. Schools are one of few *de facto* community
structures left. Under the first recommendation, he proposed that there
be a mechanism for providing technical assistance to schools to help
them make that shift. Under the next recommendation, he suggested that
the best way to help children is through Public Health screening, but
the guidance must be clear about what is permitted in emergency context,
e.g., use of passive consent for screening. Otherwise, schools tend to
take most conservative position. Dr. Rumm added that this should be
joint collaboration between CDC and the Dept of Education. Creating
synergy through coordination at state levels needs a specific bullet
under the recommendations.

Ms. Greene emphasized the need for a written report of the TOPOFF
exercise to see what heppened with children.

Dr. Modzeleski pointed to the Fairfax county smallpox plan as a model
that is built around schools working with law enforcement and public
health officials.

Ms. Greene was concerned that the recommendations make it clear where
children will be educated if schools are taken over, and how to deal
with mental health issues. Mr. Dennin indicated that some communities
are using churches rather than schools because they are empty most of
the time.

Dr. Reissman, who participated in TOPOFF representing mental health,
found that children were hardly acknowledged. Separation of children
from families has not been addressed in the recommendations, but schools
will become virtual parents during quarantine. It is still confusing as
to how information is going to move, so psychosocial input is needed at
every level. People don't see beyond saving lives right now.

Dr. Wright was concerned about the lack of chaperones, whether children
are in school, hospitals or the EMS section. Dr. Amler added that there
would be a need to identify individual children taken to hospitals, the
morgue, etc.

**Surveillance and Assessment (Health Intelligence)** \-- Alex Kelter

## Recommendation #24: The Secretary should assure that the health intelligence systems that are necessary to support emergency planning, response, and recovery are fully supported to be competent in the areas of children's physical and mental health data. 

-   Funding should be provided to allow HHS, working through the CDC and
    HRSA, to require that the Health Alert Network be linked on a 24/7
    basis to all hospitals that care for children, particularly tertiary
    care centers.

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-   In order for health intelligence systems to be in a constant state
    of maintenance and readiness, they must consist of the day-to-day
    public health and emergency medical systems tied together in
    real-time networks that are fully supported and improved to
    accommodate the jurisdiction's mental health needs and the needs of
    children.

-   Centralized local and state public health agencies must have the
    capacity to analyze and report on the patterns of physical and
    mental health diagnoses, conditions and services being rendered in
    real time. This requires the jurisdiction-wide participation of:

-   All public and non-public physical and mental health institutions

-   All hospital and pre-hospital services

-   All pediatric hospitals and trauma systems, including Emergency
    Medical Services for Children (EMSC) providers

-   Schools (absenteeism has been proposed as a "syndromic surveillance"
    system).

-   Venues where people would likely be sheltered in place must have the
    capacity to report physical and mental health needs that occur in
    schools, nursing homes, large employers, etc.

-   "Surveillance definitions" (or "case definitions") specific to
    pediatric and mental health diagnoses and conditions should be
    developed through a consensus process, and subsequently training and
    education should be conducted on these definitions for private,
    local, state and federal participants who participate in these local
    and state health intelligence networks so that there is a consistent
    flow of interpretable information available in emergency operations
    centers and government offices to support policy and emergency
    response decision-making by incident commanders and elected
    officials. These case definitions should be developed in conjunction
    with the Council of State and Territorial Epidemiologists (CSTE) to
    determine which conditions are currently legally reportable, and
    which conditions and diseases that pertain to children may need to
    be added to the Nationally Notifiable Disease List.

-   Evacuation plans should include the specific needs of seriously
    physically and mentally ill children (and their caretakers), those
    who are being home schooled, and those who are living at home and
    therefore not accounted for in the emergency response plans of any
    health institutions. Such children may be on hard-to-obtain
    medications, home dialysis machines, respirators, or may have other
    sophisticated needs that complicate such emergency procedures as
    shelter-in-place and evacuation.

## Recommendation #25: The Secretary should assure that the emergency response systems utilized to support emergency planning, response, and recovery at both the local, state and federal levels fully include trained scientific and epidemiological professionals in order to:

-   Provide real-time analysis and pattern interpretation of health
    intelligence data to support policy and emergency response
    decision-making by incident commanders and elected officials

-   Design and maintain study instruments to support short- and
    intermediate-term scientific studies of those adversely affected by
    the emergency, be they patients, their family members, neighbors,
    caretakers or co-workers

-   Design and conduct intermediate- and long-term epidemiological
    studies and analyses of patterns of injury and illness to inform
    mitigation measures that would reduce susceptibility and risk in
    future such emergencies. Examples might include:

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-   Injury patterns in buildings that would inform future building
    design and retrofit, or would suggest changes in building evacuation
    techniques or shelter-in-place decisions

-   Illness patterns that would inform future immunization, sheltering
    or isolation and treatment decisions

-   Protect the medical records departments of hospitals and emergency
    departments from repeated, high-volume requests for records from
    independent scientific researchers. Features of this process could
    include pre-arranged relationships with hospitals and nursing homes
    that:

    -   All scientific studies of the effects of the emergency be
        coordinated by the emergency response epidemiologists

    -   All requests for data be processed through the emergency
        response epidemiologists who would then make a single request
        for all the needed data from participating institutions

    -   All research reports be coordinated such that decisions about
        authorship and attribution of scientific conclusions be
        negotiated centrally early in the process.

Recommendation #26: Early detection of a release of a biological,
chemical, or radiological agent is necessary for mounting effective
responses. Funding should be provided to expand and integrate ATSDR\'s
Hazardous Substance Emergency Event Surveillance System and the CDC
collaboration with the American Association of Poison Control Centers to
broaden their Toxic Exposure Surveillance System (TESS), and to create
specific pediatric components to both programs.

> These programs can be expanded and improved into a surveillance
> network for detecting chemical and radiological terrorism events by
> allowing chemical and radiological illnesses that may indicate a
> terrorism event may be detected in a timely, effective, and integrated
> manner.

Comments:

Dr. Kelter said he wanted to discuss bridges among recommendations and
structural issues. He suggested inserting a sentence about the health
significance of children separated from parents. Recommendation #24
could be rewritten and bridged to Recommendation #3, which talks about
coordination with state, city and county public health officials and
operational planning roles. Recommendation #24 also talks about roles of
different public health specialists in response and planning.

Dr. Kelter agreed with an earlier recommendation to include correctional
facilities for young people as a venue. His main suggestion for
Recommendations #25, regarding epidemiological capacity for surveillance
and research, was that it should be bridged to Recommendations #7, #17
and #19, all of which talk about research and studies. Recommendation
#25 lends itself to another recommendation, namely that the Secretary
needs to assure epidemiological and science capacity in emergency
response and planning. One way to do this is to increase size of the CDC
and global epidemic intelligence programs. As epidemic programs expand,
they should recruit pediatricians and augment training of all EIS
officers, with additional information re the needs of children and
mental health needs.

Dr. Rumm responded that there is no federal funding for training
programs, and schools of public health aren't doing basic preparedness.
There needs to be recognition and targeting of other sources, which are
currently ignored at the national level.

Dr. Kelter replied that the Secretary would be sensitive to anything
called epidemic intelligence. The reason for making a recommendation
would be to add county and city jurisdictions to the list of places
assigned EIS officers. Any place with response teams, should have EIS
officers. Dr. Rumm commented that most EIS officers stay at CDC, and Dr.
Kelter added that those in the states have too much to do already.

Dr. Redlener felt that the larger question was a fundamental weakness in
underlying infrastructure and that the Committee was trying to add a
sophisticated level onto imperfect (crumbling) infrastructure. How do we
incorporate that concern into this document and the recommendations? It
is not possible just to recommend that the Secretary should fix whole
the public health infrastructure and make sure there is a medical home
for each child.

Dr. Mollica pointed out that surveillance is an exciting and innovative
issue for mental health. It is an issue of priority and capacity
building. Mental health hasn't been top priority at CDC. This is a great
opportunity to think about surveillance in a new way and produce useful,
valid information for many diverse populations. Dr. Kelter wondered if
that was a priority for this report.

Dr. Marans thought these were overlapping points, in terms of
establishing a critical mass of information. He preferred a centralized
approach with government leadership, using language that gets at the
issue specifically, for example, the role of time surveillance with more
information on the natural history of children's responses to terror and
disaster experiences, including the terror of threat. This makes it
possible to accurately access needs over time and eventually
interventions.

Dr. Jones pointed out that mental health wasn't part of CDC's mission
and wondered if SAMSA was prepared to talk about that. Dr. Rumm noted
that the CDC RFP does call for mental health assessments at the state
level, but it is not specific about what surveys and who should be
targeted. This committee could make it a specific recommendation,
defining what should be assessed on children.

Dr. Kolbe noted that terror is an agent and a psychological phenomenon
that needs to be measured so that it can be addressed. CDC could work
with NIH and SAMSA to develop an understanding of what is to be measured
and put systems in place.

Dr. Risssman pointed out that there were already some collaborative
efforts in agencies to look at community resilience. The data on mental
health may come from other proxy indicators, such as more accidents or
more crime. She also noted that the idea of response was not included in
the recommendations. It is important to understand people's perceptions
of danger, trust, safety, in order to direct interventions.

Dr. Redlener commented that when dealing with terror as an entity, it
would help to be able to maximize experiences in other countries that
deal with terrorism regularly, e.g., Israel, northern Ireland, etc.

Dr. Marens felt there needed to be an infusion of resources for existing
CDC capacities, taking the experiences of other countries and setting up
a joint, centralized interagency task force on terrorism.

Dr. Chemtob wondered whether it would be necessary to have legislation
or regulations that permit surveillance in times of emergency, with a
shift from privacy to health concerns. In NY after 9/11, the first
compehensive needs assessment of children's MH was carried out, but
children were anonymous. It was done to bring in money, not to help
children.

Dr. Kessel asked whether there was a need to be specific about phases of
events andwhat information would be helpful for each phase. Dr. Kelter
replied that this was why the recommendation should bridge with research
recommendations. Dr. Kessel suggested linkage back to specific topics.

Dr. Marans asked how one would bridge clinical needs, since these are
not isolated topics; they all relate and need to be bridged. At what
points is surveillance introduced and what are the time points for data
collection? Dr. Chemtob replied that communities have to be surveyed
before the event. This is a political issue, but it's also cultural
issue. People get confused about the implications of surveying for
mental health. In NY the fundamental infrastructure was so deficient
they couldn't handle the money that came in.

**Primary Care Providers and Pediatricians,** Dr. Angela Diaz

> **Recommendation #10: Ensure that all children have physical and
> mental health coverage and a medical home with a Primary Care
> Pediatric Provider (PCPP) in the aftermath of disasters and terror
> attacks.**

-   The Committee recommends that programs such as the Centers for
    Medicare and Medicaid Services (CMS) administered State Children\'s
    Health Insurance Program (SCHIP) be expanded to provide a financial
    mechanism for states to provide post-disaster physical and mental
    health care to all children affected by terror attacks, regardless
    of insurance coverage or presence of pre-existing conditions.

-   Funding should be provided to evaluate the success of the New York
    City Medicaid initiative post September 11, 2001 and consider this
    as a temporary measure while working to permanent post-disaster
    health access for children.

Recommendation #11: Involve Primary Care Pediatric Providers (PCPPs) in
all stages of preparation and response to disaster: from planning to
identification and treatment of children to ongoing care to family and
community healing.

-   Funding should be increased for programs such as the AHRQ-funded
    Pediatric Disaster Preparedness and Response Conference to develop
    standards of evidence-based best practices for physical and mental
    health interventions for teachers, school counselors/nurses, primary
    care practitioners, and families. The goal is to build a coalition
    of experts and professional organizations from the fields of
    pediatrics, disaster planning, emergency medicine, emergency
    response, trauma, and mental health.

-   Supply the PCPP with advanced equipment, personal protective
    equipment, patient informational materials, staff training, office
    "stockpile."

-   Collaborate with PCPPs to develop specific pre-event risk
    communication strategies specific to parents, schools, children,
    caregivers about the unique medical and psychological risks for
    children in a mass casualty event

-   Create mechanisms to allow PCPPs to be conduits for informing and
    updating the public via mass media, web sites, and educational
    materials.

-   Create mechanisms to allow PCPPs to partner with public health
    officials, schools, and community-based organizations in ongoing
    surveillance of health and mental health status of children exposed
    to terrorism.

-   Enhance the PCPP's ability to provide services in a
    bio-psycho-social manner, assessing all needs of children and
    ensuring all these needs are addressed in a holistic manner.

-   Enhance capacity of PCPPs to screen and treat children at
    psychological risk for traumatic exposure and loss.

-   Create and maintain mechanisms for ongoing education, training, and
    support for PCPPs and their staff.

-   Ensure the PCPP is cognizant of developmental differences between
    children and adolescents vis-à-vis treatment needs.

Comments:

Dr. Diaz's first point was that in case of terrorism, outreach will have
to be done to make sure all affected kids are identified and receive all
needed services in terms of physical and mental health. In addition,
make sure primary care providers are involved at every step, with
training and understanding of special needs of children, and collaborate
with other community agencies to best serve the needs of children. Her
major concern was how to deal with the present system to maximize the
ability of children and families to be resilient.

Dr. Rumm pointed out that pediatricians have significant experience in
rash detection, psychosocial risk behaviors, etc. We should recognize
the depth of rigorous training that ties into pediatric care, perhaps in
an introductory paragraph.

Dr. Cooper said he had struggled with terminology of provider roles and
wondered if it would be better to just say pediatricians. Mr. Ricciardi
responded that people at the front are often family practitioners, nurse
practitioners, and training shouldn't be limited to pediatricians. Dr.
Mollica added that in extreme situations, it's often a nurse or social
worker or bicultural workers (paraprofessionals) who work with
traumatized children, especially in culturally diverse communities.
Regarding the issue of every child having a medical home, including
mental health, what do we do with uninsured children, families and
adolescents, where children/families don't have good experience around
health care? How will you access these children, get them into system,
and pay for it, especially for mental health services?

Dr. Cooper, returning to the discussion of terminology, said it was more
important to include than exclude, but he had trouble with word
"provider" and suggested saying "clinician." A harder question is what
to do about those without access to care. Emergency room is not primary
care, which is continuous and longitudinal. Emergency Medicaid might be
one way to assure rapid access to care in the event of a disaster.

Dr. Redlener pointed out the dilemma that in a disaster, huge numbers of
people are not directly affected, but are highly anxious about their
children. If the connections are not there pre-event, it can impede
disaster response. There is a huge rush on emergency rooms after an
event because people have nowhere else to go. Preparedness includes
having an active, available resource for health care information
services that pre-dates the event.

Dr. Kessel noted that the whole issue of temporal, sequential systems of
care has to be addressed\--continuous, continuing, first contact,
follow-up care, which in turn raises the question of how to fix the
whole system of care, rather than just the parts. Dr. Cooper replied
that everyone agrees that all citizens should have health services, the
question is how to weave that issue into this report.

Mr. Dennin felt that the administration would not support a
recommendation for universal health care coverage at this time, but it
could provide a post-disaster mechanism. Dr. Wright noted that there was
no point in trying to create a pediatric system when the overarching
adult system doesn't exist. Dr. Rumm cautioned against softening the
wording of the recommendations too much.

Dr. Jones pointed out that there are programs and systems in existence,
even though they aren't perfect. Emergency Medicaid after 9/11 and
expansion of community health centers do provide some form of safety
net. The best services are provided when children in continuous systems,
but the other systems are out there. Capacity and surge response needs
to be part of those systems.

Dr. Balaban commented that in the literature, there was an underlying
assumption that children are small adults. The recommendations should
specify that all medical personnel with specialized pediatric training
should be incorporated into the system.

Dr. Redlener suggested that a compromise could be to articulate
explicitly that preferably all children should be connected to a primary
care relationship, prior to any event, as a preparedness modality. Also
mention that other programs already in the pipeline should be greatly
expanded/accelerated in order to be prepared for terrorism.

Dr. Mollica expressed concern about the need for interpreters when
extreme violence hits culturally diverse communities that are already in
situations of violence. There is no mechanism in many states for paying
for bicultural workers and interpreters, which means we can't reach out
to local communities because we don't have cultural and linguistic
capacity. Dr. Diaz added that in New York two-thirds of cultural
minority young people are not insured, and 70% to 80% deal with violence
and depression every day. They need help now so they are more prepared
for a terroristic event.

Dr. Dennin cautioned that if we politicize this particular issue too
much, we're programming ourselves for failure.

Dr. Marens felt that primary health providers are not adequately
prepared after a disaster to identify psychosomatic presentations or do
triage. This is an opportunity to create guidelines and do training of
primary providers.

Dr. Feerick liked the idea of pediatric providers being trained and able
to screen, but was concerned about training, ethics and licensing for
psychological treatment.

Dr.Tuma reminded the group that there were other major reviews that
should tie into these recommendations, such as the IOM review about to
be released.

Dr. Rumm wondered how to pay for psychological care after an event. The
New York model should be studied for pros and cons.

Mr. Ricciardi felt that the committee should just look to its original
charge and stick to that in terms of recommendations. Ms. Greene
responded that the challenge is making recommendations without a clear
context. The introductory paragraph should lay out some of these issues,
such as all children having a medical home.

Dr. Kessell cautioned that when using terms about insurance, such as
reimbursement, access, or services, it is important to be specific about
dimension.. Some families are insured but don't have access to services
or take advantage of them.

**Community Involvement**, Kevin Dinnin

### Recommendation #14: An RFP should be developed to identify best practices for inclusion of non-traditional first responders in emergency management planning, including: clergy, educators, members of faith-based and community-based organizations, community leaders, health and human service providers and community workers. 

Elements to be included in the RFP:

-   Integration of non-traditional first responders such as faith-based,
    social service and volunteer organizations within local emergency
    management plans.

-   Identification of the processes utilized to mitigate, prepare,
    respond and recover for and from the affects of a major event.

-   Funding to support development of integration of response plans
    within states and communities, to include congregate care settings,
    including, but not limited to, day care centers, hospitals, schools,
    houses of worship, and community centers.

### Recommendation #15: Programs such as President Bush's Faith-based and Community Initiative (FBCI) should be funded to provide child and family mental health training to members of faith and community-based organizations. 

-   Programs such as the CDC-sponsored Institute for Public Health and
    Faith Collaborations should be funded to include pediatric
    components in all training curriculum for community-based faith and
    health teams.

-   Funding should be provided for the establishment of a National
    Community Response Support Team comprising specially trained clergy,
    mental health providers, and social service professionals to provide
    post-disaster support to members of local community, social service
    and faith-based organizations affected by a major event.

### Recommendation #16: Expand funding to small-grant and outreach programs to provide networking opportunities and foster interaction between pediatric primary care providers and local volunteer, social service and faith-based organizations as a way to develop community-based disaster response networks among local groups and individuals involved in community-based efforts for children.

-   Programs such as the Community Access To Child Health (CATCH)
    Program sponsored by the American Academy of Pediatrics (AAP) and
    the SAMHSA-funded Massachusetts Initiative of Multicultural
    Community Outreach (MIMCO) can serve to strengthen the pediatric
    disaster mental health response infrastructure of communities by
    complementing existing community programs and training community
    workers in the special needs of children in emergencies. Target
    audiences can include community leaders, clergy, health and human
    service providers, educators and community workers.

-   Adopt a Community Emergency Response Teams (CERT) curriculum, such
    as the Los Angeles County model, and approach national service club
    organizations (e.g., Rotary, Lions) to adopt CERT as an official
    program of USA-based clubs.

Comments:

Community involvement as a way to approach whole terrorism issue through
resiliance. The effect of terror on society (economic and psychological)
can be greater than the event itself.

Mr. Dinnin distributed a new list of recommendations that can be done
quickly and at little cost:

-   Identify a credible spokesperson who can address the nation on how
    families can cope with the mental and emotional effect of a major
    event. The spokesperson should have the support of appropriate
    qualified personnel to formulate advice and recommendations for
    children and families.

-   Establish the National Mental Health Preparedness and Communication
    Network, a web-based information system accessible by community
    mental health providers and organizations, in which HHS and its
    agencies can post information that would be helpful to those
    actually interacting with persons and can dispel myths.

-   Develop mechanisms to develop regional response networks or centers
    to increase cooperation and resource sharing across regions, in
    addition to identifying and developing a mechanism to establish a
    network of national community response support teams comprising the
    faith community, mental health providers, and social service
    organizations, equipped to support the leadership of local
    faith-based organizations and social service organizations affected
    by major events.

-   Create a mechanism to support systematic, multi-national
    collaboration to inform of efforts to prepare for, mitigate and
    respond to the impact of terror on children, families and
    communities. Funding should be made available to support research on
    issues as a result of this collaboration.

National events affect people at the local community level. How can we
make them feel safer and be engaged in the process?

Dr. Kolbe noted that it can take a very long time between demonstration
projects and going to scale. He asked how demonstration projects would
be taken to scale. Mr. Dinnen replied that it would start with a summit
to eventually establish best practices.

Dr. Marans requested a larger explanation of what was meant by
demonstration projects. Program evaluation is labor intensive and
expensive. Mr. Dennin explained that communities would be given funds to
demonstrate how they have gotten over barriers and issues that block
coordination between faith and law enforcement community, for example,
and create models that could be replicated, especially at the
municipality level.

**Training**

Bobbie Maniece-Harrison

> Recommendation #21: The Secretary should support sustainable training
> and evaluation by funding ongoing disaster and terrorism drills.

-   Regional disaster drills must include significant proportions of
    pediatric victims and child-related scenarios, and actively involve
    the major pediatric care providers within the community (e.g.,
    children's hospitals, pediatric societies, day care centers,
    schools, etc).

-   Federal, state and local emergency managers should conduct drills
    that include exclusively pediatric victims or a majority of
    pediatric victims such as occurring in a school, day care, school
    bus, etc... to adequately test the systems capacity for pediatric
    patients.

-   Mandate the inclusion of responders with pediatric experience as
    part of response teams in all disaster and terrorism drills.

-   Simulation software as developed for disaster and terrorism planning
    should account for events with pediatric patients in proportion to
    their existence in the population, events which, as is often case,
    will disproportionately affect children and events which will have
    as a majority of the victims are children.

-   Simulation software and drill design should account for the variety
    of ages, developmental levels and sizes of children who would
    require care during a disaster or terrorism event and not merely
    create a single group labeled children.

-   Disaster and terrorism drills should involve children with special
    health care needs as part of the pool of victims. In addition
    simulation software should account for the existence of children
    with special health care needs.

> Recommendation #22: The Secretary should convene a panel of experts to
> assess all federal bioterrorism preparedness plans. The panels should
> specifically review:

-   The extent of the training component

-   Training related to the needs of children

-   Training and preparedness of the community

-   Make recommendations of training needs

> Recommendation #23: The Secretary should support an initiative whereby
> pediatric experts and academicians collaborate to identify core
> competencies necessary for responders to adequately and appropriately
> care for children exposed to a bioterrorist attack. The initiative
> should:

-   Identify the type of training needed

-   Develop training modules to meet the needs of children

-   Develop training guidelines for the community

-   Make recommendations for the inclusion of training in professional
    training programs (medical school curricula, nursing program
    curricula, residency programs, school personnel, etc.)

-   Standardize training requirements

> **Other Specific Recommendations**

-   Increase funding and add a pediatric component to the development of
    HRSA's Bioterrorism Educational Incentives for Curriculum
    Development and Training Program.

-   Increase funding of programs such as the EMSC-funded Pediatric
    Disaster Life Support (PDLS) Program, a two-day training workshop
    for emergency medical professionals, developed and conducted at the
    University of Massachusetts.

Comments:

Dr. Maniece-Harrison said she took out training needs from the other
reports, for all responders, fire, police, EMS systems, teachers, etc.
There is a need for training based on the unique needs of children, and
building interdisciplinary workforce. Two new recommendations are as
follows:

-   The Secretary should mandate that a specific pediatric training
    component be included in all bioterrorism plans at the federal,
    state and local level. All plans already in existence should be
    reviewed and a pediatric component added if necessary. Funding to
    state and local communities for bioterrorism preparedness should be
    contingent on their plans, including a training component to meet
    the needs of children. Funding should provide states and local
    communities with adequate equipment and supplies suitable to the
    needs of children. There is a need for an increase in pediatric DMAT
    teams. All existing DMAT teams need to add a pediatric component to
    their training.

-   Pediatric and public health experts should be included on all
    bioterrorism planning at all levels to advocate for the needs of
    children; assess current bioterrorism training and ascertain the
    extent to which training for children is included; and develop a
    comprehensive pediatric training component for all levels of
    responders that can be standardized, with core competencies and
    skills. School guidelines should also be developed.

Dr. Redlener informed the group that many children's hospitals surveyed
had plans in process, but were missing standardized protocols on key
issues, especially on the medical side. Training is difficult in the
absence of state of-the-art information and knowledge. This is where
academic centers and pediatric departments have a role in providing
expertise.

Dr. Mickalde wanted to see something in the recommendations about
precautions taken to protect children when they are involved in drills.
If patients are made out to look nearly dead in drills, it could
frighten children. Mr. Ricciardi emphasized the need for evaluation of
drills, based on core competencies and standards. When children are
involved in drills, there must be parental approval and follow up. A
drill is real to children, with loud noises and screaming. Dr. Jones
reminded the group that drills will include pregnant women, not just
children.

Mr. Dinnin pointed out that the challenge is to look beyond the major
communities. How do we do training and replicate models in very small
communities and border towns?

Dr. Kessel said he was struggling with generality vs. specificity in the
training. There has to be basic training, but sometimes providers need
to know what not to do, or when to seek help. Dr. Redlener replied that
there would be a layered approach to training, from hard core exact
doses, to logistics, managing kids, decontamination of a two-year-old,
etc. There is a range of training needs, but it will start with basic
treatment and psychosocial issues.

Dr. Mollica wondered about pedagogical issues in different training
cultures and environments. For example, training clergy is different
from training health care providers.

Dr. Cieslak cautioned that training is a big component and could get out
of hand. It is important to define who is being trained and in what. One
approach is to have a matrix (3 x 3 x 3) with "who" on one axis
(professionals, paraprofessionals, laymen) and "when" on the other axis
(just in time vs situation specific) and the "what" (core level vs
graduate education). Which of the 27 blocks are we trying to reach?

Dr. Shaffer reminded the group to include deaf, blind and mentally
retarded children.

**Mental Health**, Steven Marens

> **Recommendation #7: Funding should be provided for an HHS-wide
> development and funding plan to address Psychosocial Preparedness and
> Recovery for children within major HHS initiatives and Agencies.**
> **Funding should be provided to support research and activities
> relating to surveillance, monitoring and evaluation of children's
> post-disaster intervention outcomes, identifying patterns of trauma
> and recovery, and the development of simple, valid measures of
> outcomes.**

-   The Secretary should require the development of cross-Institute
    collaborative RFP's to address the development of translatable
    research related to psychosocial preparedness and recovery, and the
    development of focused research on preparedness including:

    -   Protection of first responders and their families

    -   Research on crowd behavior in emergencies

    -   Research on risk communication

    -   Research on group decision making and crisis simulation

    -   Assessment of psychosocial impacts, behavioral response, and
        family and community cohesion factors that promote resilience in
        the aftermath of disasters

-   The HHS mental health research agencies (NIMH, CDC and SAMHSA)
    should be provided with substantial funding to develop initiatives
    related to the psychosocial aspects of the effects of terrorism on
    children and families in order to close knowledge gaps and acquire
    information that will guide public policy. Topics to be funded
    include an integrated three-tier strategy for 1) monitoring
    children's reactions to national distress/disruption, 2) assessing
    local area impact of specific events, and 3) assessing intervention
    outcomes that will inform national and local level efforts to
    promote resilience in children and families.

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-   NIMH, CDC and SAMHSA funding should be increased and RFPs developed
    for pediatric and family research, including, but not limited to,
    the following areas:

    -   Development of standards of evidence-based best practices of
        post-disaster interventions.

    -   Pediatric epidemiology of post-disaster exposure and reactions.

    -   The settings where child victims/survivors present for care and
        what types of care are provided.

    -   Assessment of the effectiveness of training on pediatric
        practitioners and their patients/clients, including objective
        changes in practitioner behavior, mental health outcomes and
        sustainability over time

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-   Programs such as the SAMHSA funded National Child Traumatic Stress
    Network (NCTSN) and CDC's School Health Policies and Programs Study
    (SHPPS) should be funded to develop mechanisms to integrate child
    and adolescent mental health assessment and surveillance with
    outreach and triage, so information can be translated into program
    development.

-   Increase funding for efforts currently under way by CDC, NIMH and
    SAMHSA and by programs such as the SAMHSA-supported National Child
    Traumatic Stress Network (NCTSN) to develop brief, reliable and
    validated pediatric instruments for surveillance, monitoring and
    evaluation of outcomes in the aftermath of disasters and terror
    attacks.

> Recommendation #8: Establish a national model for training in mental
> health acute response and crisis intervention to terror and disaster
> events.

-   The Committee has determined that the full range of response to
    children's psychosocial needs, to include preparedness, mitigation,
    response and recovery, is best provided by developing an integrated
    response system that deploys multiple systems in a coordinated
    response. Thus, an effective national response to the psychosocial
    needs of children must depend on close and effective cooperation
    among all child serving systems, ranging from first responders
    (police, fire EMS) to education authorities to health authorities,
    specifically including behavioral health specialists. There are
    significant gaps, as described below, in the nation's capacity to
    mount this type of response. The Committee makes the following
    recommendations to address these gaps.

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-   Increase basic competence in responding to child needs across
    responder systems. To this end, the committee recommends convening
    an inter-departmental task force to review training systems across
    education, EMS, fire, justice, and homeland security, and to
    identify and remedy gaps in preparedness and response competencies
    to be added that address children's needs.

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-   Increase intersystem coordination at the local level. It is
    recommended that the Secretary create incentives for cooperative
    activity including service co-location between education, primary
    health care, and mental response systems. To further this goal, it
    is further recommended that the Secretary develop a series of
    demonstration projects to develop system integration and
    coordination focusing on developing improved methods to integrate
    psychosocial response that can then be disseminated.

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-   Increased funding should be provided to programs such as the
    Emergency Medical Services for Children (EMSC) to develop mental
    health resources for EMS providers including pediatric triage tools
    and information regarding the importance of pediatric mental health
    in emergency and terrorism preparedness and response.

-   Disaster mental health should be incorporated into the clinical
    training of all pediatric and mental health disciplines.

Recommendation #9: Federal funding to states should be linked to
mandated inclusion of mental health specialists in the terror and
disaster planning, preparation and response. Collaboration between
mental health specialists and others involved in emergency preparedness
and response should be at the federal, state and local levels.

-   The best response to a crisis is often a local response\-\--national
    experts should be identified in advance and be prepared to provide
    consultation to local providers regarding optimal post-event care.
    Funding should be provided for contracting with teams of
    multi-disciplinary and culturally diverse experts with input from
    parents and children to prepare toolkits of best practices for
    mental health interventions for teachers, school counselors/nurses,
    primary care practitioners, and families.

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-   In the immediate aftermath of disasters, acute mental health
    services will best be provided not only in the form of direct
    clinical interaction with children and their families but by the
    approaches of a range of emergency responders and community
    providers with whom children will have contact. Therefore, increased
    funding should be provided to develop mental health resources for
    pediatric mental health training both for existing emergency
    responders and the current local *de facto* mental health system,
    which includes primary care practitioners, school counselors and
    nurses, clergy and family members. In order to maximize their acute
    response effectiveness, acute response providers will need:

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-   Cross-training that familiarizes mental health professionals with
    activities of first providers and others involved in acute response

-   Familiarizing other professionals with principles of child, family
    and community responses to trauma/overwhelming distress (both
    psychological and physiological) in a developmental context and how
    these principles inform therapeutic interventions---both clinical
    and non-clinical

-   The best response to a crisis is a local response\-\--national
    experts should be identified in advance and be prepared to provide
    consultation to local providers regarding optimal post-event care.

-   Disaster mental health approaches---both the federal disaster mental
    health model and the American Red Cross model---tend to discourage,
    under-recognize, and under-utilize specialized expertise that may
    exist across disciplines. This should be addressed pre event and in
    vetting professionals before they become involved in the aftermath
    of an incident.

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-   Collaborations among emergency responders and community providers
    should include:

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-   Training of best practices in primary care, social work, community,
    volunteer and faith-based organizations

-   Developing formal relationships among various mental health
    providers and with other professionals that are already involved in
    emergency planning for acute response to terror events (e.g.,
    police, fire, EMS, state and municipal emergency planners, public
    health, etc.)

-   Identify mental health representative(s) that will participate in
    emergency response planning and as part of emergency response teams
    that are mobilized at the time of an event---participation in both
    areas should occur at state, regional, and local levels

-   Identify a network of mental health providers at state and local
    levels who will be part of the first response team in a terror event

-   Immediately map existing mental health resources at state, regional
    and local levels as well as existing working
    relationships/collaborations between mental health resources and
    services providers relevant to the care of children and families at
    times of terror events (e.g., law enforcement, protective services,
    hospitals and primary care facilities, schools, juvenile justice
    system, government, etc.)

-   Desired additional collaborative relationships should be identified
    and explained to relevant stakeholders (i.e., existing members of
    the state, regional and local emergency response
    teams)---responsibilities for developing and reporting on new
    collaborative efforts in training and planning of integrated
    services should be assigned

-   Practice of communication and mobilization of response team members
    using simulation scenarios should be encouraged

-   Establish protocol for clinical screening of affected children and
    families from point of immediate contact to follow-up and
    longer-term epidemiological and clinical surveillance

-   Materials that educate professionals and parents about recognizing
    and monitoring potential acute and longer-term impact of terror
    events on children's functioning and development as well as
    principles guiding intervention should be prepared in advance
    (additional information specific to the nature of attack can be
    added at the time of the event).

Comments:

The aim of terrorism is to terrify. Psychological aspects must be
addressed from the outset, using multiple therapeutic interventions from
a whole range of providers. A general statement at the beginning of the
document would help. At consensus meetings, we learn that there is no
one treatment for acute responses to trauma or disaster, but we can take
what we know and apply it to basic recommendations.

Re recommendation #7, Dr. Marans noted that federal agencies should be
included. In addition, he would say monitoring evaluation and
intervention [strategies.]{.underline} He also felt there was too much
in this section, and that some should be highlighted while the rest goes
into accompanying materials.

Ms. Greene pointed out that the bullet on the bottom of page 12 was not
quite accurate.

Dr. Feerick recommended saying "intervention development". Dr. Marans
suggested "best practices or principles that govern treatment
interventions."

For Recommendation #8, Dr. Marans cautioned against saying "establish a
national model," since there isn't one model. He would say "establish
national models for training and principles of mental health acute
response in crisis intervention to terror and disaster events, which
involve pilot research and program evaluation." We know a great deal
about principles of psychological disorganization under acute distress,
and a great deal about children's development, but these are often not
included in training. For Recommendation #9, very few states have mental
health agencies at the table in emergency response planning. Dr. Rumm
commented that this was mandated in the new RFPs, but it doesn't include
children.

Dr. Mollica said there had been a discussion about whether there should
there be up-front policy on mental health. Mental health is seriously
marginalized. How can mental health be brought into the center of
discussion? Also, somewhere in the document there has to be discussion
about developmental competence issues, cultural competence for
culturally diverse communities, and gender issues.

Dr. Reissman noted that while the RFP has language around psychosocial
issues and mental health, a next step would be to talk about joint
development of school-based community resilience plans. She wondered
whether this section was talking about public health aspects of
psychosocial interventions or just clinical service delivery. It might
require different language. Dr. Marens responded that it needs to be
more than just clinical services, and if so, there have to be basic
requirements and basic competence. The bottom line is that mental health
and EMS need to know what each other is doing. Cross training of
professionals is missing. In order not to marginalize public health, the
report needs to talk about the mission and the context of the
recommendations.

Dr. Chemtob pointed out that there has been great investment in material
things but not in intangible things such as psychosocial reactions.
During the anthrax scare, five people died, but how many were terrified?
Fear, working together, psychological casualities are all distinct
issues. We need a basic program of research, to look at crowd dynamics,
etc.

Dr. Rumm replied that there has been no mental health capacity in state
public health departments and there is resistance to change. A specific
recommendation is that there be at least one mental health expert in
government structures, or someone who knows where to find experts.

Dr. Mollica noted that in Massachusetts the Department of Mental Health
was taking over many medical issues of terrorism. However, regarding
surveillance, training, and interventions, the contextual environments
(community volunteers, families, etc.) shape the discussion and
knowledge necessary to provide effective outcomes.

Dr. Cooper commented that the Secretary would not remember every word
the Committee sends him, so it is important to emphasize a few things.
High on this group's list of unmet needs are psychosocial and emotional
issues.

Dr. Tumus felt that this report shouldn't define mental health, but
should be concerned with people who develop serious psychiatric
disorders as well as the needs of the larger population in response to
disaster and terrorism.

Dr. Feerick noted that the document seemed to be more focused on acute
services. The first sentence should include practices as well as
treatment and interventions. Minor language changes would make the
recommendations broader, addressing the social and emotional needs of
children.

Mr. Dennin added that it's not just the event that must be addressed,
it's the effect on the nation and the economy due to anxiety. How many
children miss school the next day is more important as an effect of
terrorism than the actual attack on a specific locale. Look at the
airline industry and where the money is flowing. Airlines have voice in
Congress, but children don't. How can we reach out and establish
resilience so we can continue to be a free society. The sniper attacks
are a good example of major economic impact.

**Public Health Departments, Government Agencies**, Peter Rumm

> **Recommendation #1**: **Federal funding to states through any
> terrorism-related grant or cooperative agreement should be linked to
> mandated inclusion of pediatric components in terror and disaster
> planning, preparation and response. All funds deliverable to states
> should be made conditional on adequate assurance that pediatric
> considerations are met.**
>
> How well the States and Territories respond to the CDC and HRSA 2003
> and out year RFPs that specifically call for preparedness for
> children\'s needs to be monitored closely. HHS as the lead agency for
> the protection of our residents' health status should work closely
> with other federal agencies to assure that the states and territories
> comply with the intent of the language in the RFPs and make targeted
> progress in all focus areas. Strong oversight by federal agencies and
> state health departments is needed to ensure that local health
> departments and other collaborators under their auspices use the funds
> appropriately and in fact place an emphasis on terrorism preparedness
> for children.

Recommendation #2: Funding should be provided for a national survey of
terrorism preparedness that includes a specific assessment of
preparedness for the medical and psychological effects of terrorism on
children.

> There has been no large-scale survey of terrorism preparedness.
> Specific funding should be given to the CDC, working with the
> Association of State and Territorial Health Officials (ASTHO) and the
> National Association of County and City Health Officials (NACCHO), to
> refine current state and city preparedness tools and complete an
> overall evaluation that requires states and territories to complete an
> assessment tool that studies their preparedness for the effects of
> terrorism (both mental and physical) on the children under their
> auspices.

##### Recommendation #3: After September 11, many Federal, State and City agencies reported confusion over their roles and responsibilities in responding to the needs of children in the aftermath of the terror attacks. Funding should be provided for HHS to convene a meeting with the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and other state governmental associations to:

-   Operationally define the roles and interactions of HHS and State
    Public Health Departments in training, protection and response in
    relationship to children and terrorism.

-   Identify ways to link federal funding to the inclusion of plans for
    integration of agencies into state and local pediatric disaster
    response.

-   Analyze current practices and identify ways to ensure national
    consistency on issues such as:

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-   quarantine of children

-   planning for special needs children

-   protection of temporarily and permanently displaced children, foster
    children and children in the juvenile justice system.

##### Recommendation #4: It is essential that the issues and proposals raised by the National Advisory Committee on Children and Terrorism continue to be developed. The Committee recommends that the Secretary formally recognize a working group to focus on children and terrorism under the auspices of the Secretary's Council on Emergency Public Health Preparedness.

Comments:

Take the first five pages of the document and put them in an appendix.

Send a message to the Secretary that we need stronger language in next
year's RFP on children's preparedness. We don't have framework for
assessment of children's needs and this needs to be centrally located.

There needs to be follow-up on this committee's recommendations.

Dr. Redlener suggested that the Secretary designate an empowered
individual to make sure agencies are following up on the committee's
recommendations. Ms. Greene added that this could be an overarching
recommendation. She then asked why Recommendation #1 says federal
funding to states. Dr. Rumm said it should read states, territories, and
larger local municipalities.

Dr. Rumm suggested that follow up might be better done by contracting a
professional organization/entity. There may be a change in
administration, and there is also a credibility issue.

Dr. Modzeleski noted that the issue of accountability is derived from
how the recommendations are prioritized and what recourses are
allocated.

Dr. Balaban said his understanding was that this committee's mandate
ended with the report, therefore a working group would be more feasible.

**Hospital Preparedness, Pre-Hospital and Critical Care,** Dr. Wright
and Mr. Ricciardi

> **Recommendation #12: All hospital institutions should be prepared to
> care for children in the event of a disaster or terrorist act since
> they may find themselves in the role of providing care to children,
> should they become the closest provider, or if other institutions in
> their area are overwhelmed.**

-   Increase funding to HRSA's Bioterrorism Hospital Preparedness
    Program to improve the capacity of the Nation's hospitals and
    emergency departments to respond to biological terrorist attacks and
    situations involving large scale epidemics. The program will also
    allow for State and regional planning among local hospitals, EMS
    systems, community health centers, poison control centers, and other
    health care facilities to improve their preparedness to work
    together to combat terrorist attacks.

    -   Increase funding for the EMSC initiative for Enhancing Pediatric
        Patient Safety (EPPS). The purpose of the EPPS demonstration
        project is to support the assessment and/or implementation of an
        existing strategy or tool with the potential for improving
        patient safety in pediatric emergency care delivery in multiple
        prehospital and hospital emergency department settings.

    -   Increase funding to the ATSDR-supported and maintained Pediatric
        Environmental Health Specialty Units (PEHSUs). This national
        network of pediatric specialty clinics provides expert
        consultation, training, and public education on chemical
        exposures in infants and children. Co-funded by the EPA as well
        as by local grants, these proved instrumental after the
        terrorist attacks in 2001. They are training primary healthcare
        providers to recognize chemical "toxidromes" and triage and
        treat chemical exposures. They also provide community-based
        education and information on long-term health issues of concern.

    -   Funding should be provided to expand initiatives such as HHS
        pNumber range CHAPTERartnering with the National Association of
        Children\'s Hospitals and Related Institutions (NACHRI) to
        explore the possibility of developing a Children's Collaborative
        Network for expert health services linkages to all US care
        facilities - rural- urban; level 1 hospital and other care sites

    -   There is a lack of knowledge regarding effective methodologies
        for developing pediatric preparedness. In order to address this
        need for capacity building, it is recommended that the Secretary
        develop a programmatic RFP to designate New York City and
        Washington D.C., and perhaps eight other cities, as
        demonstration projects for pediatric psychosocial preparedness.
        The model for this initiative is FEMA's initiative of developing
        ten disaster-resistant cities as models for increasing
        preparedness and mitigation. FEMA has focused on physical
        aspects of preparedness and mitigation but there has been
        insufficient efforts paid to psychosocial response. The
        initiative should solicit innovative models and maximize the
        development of alternative approaches to permit the conjoined
        evaluation of the different models in order to eventually
        disseminate effective models.

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    -   Creation, revision, distribution and ongoing evaluation of
        pediatric emergency and terrorism response plans.

    -   Funding to support integration of response plans within state
        and community to include but not limited to hospitals, schools,
        faith-based community resources, primary care pediatric health
        providers, public health departments, and mental health
        providers

##### Recommendation #13: The Secretary should support and enhance the existing HHS programs involving communication systems used during a disaster or terrorist event. Information management systems are a critical link in hospital preparedness. HHS and the CDC should work closely with other federal agencies to provide the following:

-   Creation and improvement of in-hospital communications, including
    but not limited to telephones, radios and computers.

-   Develop information systems to ensure communication exists among
    hospitals, schools, childcare facilities, faith-based community
    resources, primary care pediatric health providers, public health
    departments, pediatric mental health providers, all hospital health
    care employees, and local officials.

-   Support the Amateur (HAM) radios to communicate in the event of
    telephone failure.

-   Develop a means of bioterrorism surveillance/detection and
    notification.

-   Facilitate communication links between the hospital and children's
    specialty centers and other child health care facilities.

-   The CDC, through website and additional electronic and satellite
    technology, should develop and staff a communications center which
    will function as a hub for medical information.

Comments:

Dr. Wright recommended that the bullet points for Recommendation #12 be
re-ordered.

The first bullet should be reworded to say, "in order to address this
capacity building, we need to look at and include several models---9/11,
Columbine, sniper incident---and glean lessons from similar
circumstances." Then where it says "increased funding to HRSA's
bioterrorism hospital preparedness, add "pediatric needs" or child,
adolescent and family needs. NACRI is good at organizing, distributing
information, mobilizing other hospitals, etc. We never have addressed
the special needs kids, whether it is schools for the deaf or the child
with diabetes in a regular classroom. There is a need for mapping and
for a chaperone to stay with each child until a family member arrives.

Drills need to be robust and meaningful.

Recommendation 13 has to do with information management. This has been
arranged to address pediatric demographics. There is a whole range of
surveillance mechanisms depending on demographics.

The next part has to do with developing information systems between
hospitals, schools and other facilities. We might have to dust off ham
radios for communications.

There are three bullet points on networking in hospitals, schools and
other facilities for children.

Ms. Greene noted that when communications down after the recent spate of
tornados, CNN could still communicate with satellite dishes.

Mr. Dinnen added that there are tremendous resources in local
communities, but they aren't integrated into emergency management. Being
able to access local resources in times of crisis is critical. Dr. Rumm
suggested language to reflect that the greatest need is in local
communities.

**Risk Communication and Public Education**: Dr. Mickalide

> **Recommendation #17: Funding should be provided to allow federal
> agencies and organizations to develop clear, concise, consistent,
> evidence-based and situation-specific guidance for parents and
> teachers concerning helping children to cope with terrorism and
> disasters**.

-   Funding should be increased for existing programs at NIMH, CDC and
    SAMHSA that are developing messages for parents and caretakers based
    on what is known about decision-making behavior, and for CDC-funded
    Centers for Public Health Preparedness (CPHP) at universities to
    establish systems to inform parents and caregivers what systems are
    in place in schools, health care facilities and communities to deal
    with terrorism threats

-   Encourage all stakeholders to disseminate the same information to
    parents via websites, print materials, public service announcements
    and other communication channels.

-   HHS should identify a broadly creditable spokesperson who can
    address the nation with advice on how families can cope with the
    mental and emotional affects of a major event. The spokesperson
    should have the support of appropriate qualified personnel to
    formulate advice and recommendations for children and families. For
    example, First Lady Laura Bush was highly effective in delivering
    advice to parents post-September 11.

-   Funding should be provided to expand initiatives such as the HHS
    Number range CHAPTERpartnering with Sesame Workshop to understand
    the implications of their research findings on children 6-11 years
    of age pre-and post 9/11, entitled, "A View From the Middle," and
    its importance to media programmers, outreach coordinators and
    public television leaders.

> **Recommendation #18: Funding should be provided for a meeting of
> representatives of government agencies, national media sources and
> child mental health professionals to establish an accord on ways in
> which the media can communicate important information utilizing the
> guidance and/or counsel from official government sources and mental
> health professionals during times of crisis**.
>
> CDC, NIMH, SAMHSA and the Bureau of Primary Health Care (BPHC) should
> be funded to establish a National Mental Health Communication Network,
> a web-based information system accessible by community mental health
> providers, schools and other relevant organizations, in which HHS
> agencies can post official information and recommendations on specific
> events. Information provided from the CDC, Public Health Service, etc.
> will be extremely helpful in mitigating anxiety and post--traumatic
> stress often exacerbated through media reporting.

Recommendation #19: The Secretary should provide funding to DHHS mental
health research agencies (NIMH, CDC and SAMHSA) to conduct a
translatable initiative for developing evidence-based risk communication
strategies. Research is needed to determine the most effective methods
of communicating to the public and guiding health and human service
systems. Specific topics include:

-   How to communicate effectively both risks and protective strategies.
    Given the importance of health-risk communications prior to and
    following potential exposures, research is needed on developing and
    disseminating information to prevent negative consequences (e.g.,
    panic, stigma, blaming, requests for unnecessary/inappropriate
    services) and promote adaptive and responsible behavior to minimize
    risk and injury.

-   What are potential scenarios for the use of biological agents, and
    what health-related behavior/response is desired and what behavior
    should be discouraged?

-   What information does the public need to form a realistic appraisal
    of personal risk as well as realistic means of coping with it?

-   Possible psychosocial consequences for persons undergoing testing,
    as well as their relatives. Research is needed on communicating risk
    information to subjects and family members to reduce distress and
    best use risk status data to plan for treatment.

-   Who is perceived as trustworthy; who is best suited to communicate
    risk messages; which messages are most effective, sensitive to
    different values, which messages raise or lead to ethical questions,
    etc.

-   What factors will influence understanding of and compliance with
    public health directives about vaccination, prophylaxis, local and
    school disaster plans, including evacuation, reunion and
    unaccompanied minors.

> **Recommendation #20: Funding should be provided to ATSDR and HRSA to
> maintain a national toll free number for public information on
> chemical and biological events**.

-   ATSDR staff have considerable hands-on experience in the integrated
    response to chemical emergencies such as spills, explosions, and
    other uncontrolled releases. ATSDR maintains a 24-hour hotline and
    emergency response team that is fully integrated with the CDC
    Emergency Operations Center and has worked closely with the EPA,
    FEMA, FBI, Coast Guard, and other response agencies at the federal,
    state, and local level.

-   The HRSA Poison Control Centers (PCC) are an integral and vital part
    of the health system and part of the continuum of necessary
    emergency services which should be available to all Americans,
    particularly in light of the new bioterrorism threats. The missions
    of the ATSDR hotline and the PCC should be broadened to serve as a
    national source of public information for chemical and biological
    events.

Comments:

Mr. Dinnen explained that the national mental health communication
network was originally a web-based information system that community
mental health providers could access, that could be disseminated through
various government entities. Dr. Rumm added that it would be nice to
have a consolidated place for all federal resources on risk
communication, social marketing, etc.

Dr. Mollica noted that the media have significant impact on children,
and asked if there were any national guidelines. All the bad health news
gets out on CNN, but there is nothing to help children. Dr. Mickalade
explained that the media have to make public service announcements. Dr.
Reissman noted that CDC already has a public health hotline with this
information, plus a clinicians' network available through ListServe.

Regarding Recommendation #18 and the announcements about duct tape and
plastic, Dr. Jones was concerned about significant health issues and the
necessity of coordination with homeland security and other agencies.

**Public Comment**.

Drew Bernstein, ASTO, Senior Director for Preparedness and Bioterrorism,
wanted to speak about BTAP (Bioterrorism Accountability Indicators
Project). He could not share results yet, but children and terrorism was
discussed intensely by the working group. That assessment was left out
of BTAP because many issues needed to be addressed from a clinical
standards perspective, but would not measure capacity and preparedness.
He cautioned that from a state perspective, there are a number of
unfunded mandates in the recommendations. Everyone agrees on the
concepts, but need financial support to implement them.

Dr. Ellen Garrity, Senior Policy Advisor for the National Center for
Child Traumatic Stress, told the Committee that she was part of the
discussions on Capitol Hill setting up this committee and felt that
committees members had the power and freedom to speak the truth. You can
say what is really going on and what is really needed. There are two
charged issues on the Hill: children and terrorism. You can talk about
children, health and mental health in unprecedented ways and you can
talk about money as well. Take advantage of this historical opportunity.

**Next steps:**

> Timeline:

-   Revised recommendations by May 27^th^, Tuesday.

-   Refining and incorporating suggestions from today.

-   Executive summary by May 30^th^.

-   Final changes by June 3^rd^.

-   Conference call June 5^th^ to finalize and approve.

-   Send supporting materials by June 6^th\ (reports)^

-   Revised materials by June 16^th^

-   Final supporting materials by June 20^th^.

Dr. Rumm expressed appreciation for Victor Balaban's work.

Dr. Redlener announced that results of the Consensus Conference last
February would be released soon. He would like to be able to reference
work with this committee.

Dr. Wright had a question about style, i.e., should the Committee say
things politely and softly, or just directly speak to the issue?

Dr. Kessel commented that the issue was not to put receivers of
information on the defensive, but to get their attention. It would be
better to point out solutions and not dwell on the problems.

Dr. Mollica thought the recommendations should to be crystal clear, not
just bullets, but policymakers don't want to get into minutia.

Dr. Cono pointed out that as a panel of experts, Committee members don't
share the same terminology, so someone should review the document for
jargon.

Dr. Balaban informed that consultants would help with format and visual
presentation.

Dr. Redlener commented that policy makers need to hear briefly and
explicitly what is really doable within a defined period of time. There
will be a list of three or four things that can be accomplished for
children.

Dr. Rumm added that recommendations should have specific action items,
perhaps prioritizing the most time-sensitive items, but keep them all as
they stand.

Mr. Dinnen wondered about having the Secretary's office respond to the
report. Dr.

Redlener added that it was not unusual for this type of committee to
make a formal presentation to the Secretary. All of the recommendations
are important, but some of the most important recommendations aren't the
most doable.

Dr. Chemtob pointed out that many constituencies will read this
document. Sub-groups will seize issues/recommendations and advocate for
them. Dr. Jones added this is an action-oriented administration and
Secretary. Some things can be done today, but are two or three years
down the road because of funding and legislation. People will be
reminding the secretary, so refine the recommendations to be clear
action steps, not starting with 'provide funding for."

Dr. Kelter commented that too many priorities is no priority. Clarity
begins at home. We don't have to have eleven categories; there are lots
of overlaps, synergy and density.

Dr. Rumm said that the overarching action items are the ones that will
be acted on.

It was noted that there was a wealth of information that needed to be
organized in such a way that the most issues are affected with the
greatest economy of words. What one thing would leverage all the others?
What would make us a bold advocate for children? What's critical for
children and no one else is contemplating it?

Dr. Kolbe suggested that the Committee members look at all their
recommendations, clean them up so they are precise with no jargon,
precise, and keep them with modifications. Then take one action item
from each of reports generated and try to merge some of them.

Dr. Kelter pointed out that this was an opportunity to step up to the
plate and take a swing against World Series pitching. The first page is
the only page that counts. Let the hard work and findings be reflected
in the larger document.

Mr. Dinnen felt that some components in this report would attract
private sector cooperation.

After some additional discussion about process, Dr. Diaz thanked all
those present for their hard word and adjourned the meeting at 4:45 pm.