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The Honorable Tommy G. Thompson June 12, 2003

Secretary of Health and Human Services

U.S. Department of Health and Human Services

Dear Mr. Secretary,

On behalf of the National Advisory Committee on Children and Terrorism
(NACCT), I am pleased to present our recommendations to you. In
accordance with the objectives specified in the Public Health Security
and Bioterrorism Preparedness and Response Act of 2002, the goal of our
recommendations is to assist you in identifying and preparing a
comprehensive public health strategy to ensure the safety of America's
children and to meet their physical, medical, psychological and social
needs in the face of the threat of terrorism. Such a strategy should
comprehensively address all phases of preparation, response and recovery
from terror events.

There are more than 70 million children under the age of 18 in the
United States today, and more than 22 million are ages five and younger.
In the event of a terrorist attack, these children would be among the
most vulnerable populations in our society. Protecting children and
families should be at least as important as protecting bridges and
buildings. Yet, while significant resources have been dedicated to the
protection of bridges, national monuments and other physical assets,
comparatively little has been done to safeguard the health and
well-being of children. As recently as 1997, data collected by FEMA
showed that no state disaster plans had pediatric components. A recent
study showed that only about 20% of hospitals have access to pediatric
emergency physicians, and the majority of emergency personnel have
little pediatric training or experience.

While the Department of Health and Human Services (DHHS) and other
federal agencies have responded to the September 11 attacks with a
number of excellent efforts and initiatives, a great deal more must be
done to help the United States be fully prepared to protect its children
in the event of terrorist attacks. The unique needs and vulnerabilities
of children must be incorporated into disaster plans at every stage of
preparation, planning and response in order to facilitate family and
community resilience before, during and after terror attacks. Federal,
state, and local agencies should immediately initiate programs to
enhance the safety and security of children during disasters and terror
events, and DHHS should develop mechanisms to support international
collaborations to increase our nation's access to lessons learned by
other nations with experience with terrorism.

The NACCT has reached remarkable consensus that 1) a comprehensive
public health strategy to meet the needs of children in planning and
responding to terrorism will require review of all current DHHS programs
and guidance to require that a specific focus be placed on meeting the
needs of children and families, 2) funding decisions for
terrorism-related programs and initiatives should be linked to
confirmation that children's needs have been specifically accounted for,
3) structures within DHHS should be created to ensure continued
oversight and adequate response to the needs of children and families in
DHHS programs and initiatives, 4) significant new pediatric and
psychosocial initiatives are needed to address the needs of the nation's
children and families in light of the continued threat of terror events,
and 5) addressing the needs of children and families in the face of
terrorism should be recognized to be an essential part of America's
national security response to terrorism.   

Your leadership to our Nation during these challenging times has been
exemplary. It is our hope that these recommendations will assist you in
preparing and initiating new strategies as well as continuing and
following up on the excellent work already being done to ensure the
public health of America's children by meeting the physical, medical,
psychological and social needs of infants, children, adolescents and
families in all phases of preparation and response to conventional,
chemical, biological, radiological and nuclear terrorism. We are
confident, given your long record of passion and support for children
and families that the challenge of addressing the needs of children in
the event of terrorist attacks is in good hands. The Committee looks
forward to working with you and your staff on an ongoing basis as you
move forward in carrying out these recommendations. We will provide
whatever assistance and expertise is necessary in order to ensure that
these recommendations are pursued and that sufficient resources are
devoted to this most important of tasks, safeguarding our nation's
children from terrorism.

Sincerely,

Angela Diaz, MD, MPH FAAP

Chair, National Advisory Committee on Children and Terrorism

Jean C and James W Crystal Professor of Pediatrics and Community
Medicine

Mount Sinai School of Medicine

Director, Mount Sinai Adolescent Health Center

**Table of Contents**

Executive Summary i

Statement of Principles 1

Recommendations

Federal Responsibilities 2

Schools and Other Child Congregate Care Settings 4

Mental Health and Psychosocial Support 6

Primary Care Pediatric Providers 10

Pre-Hospital and Hospital Care 11

Community Involvement 13

Training 15

Health Intelligence 17

Risk Communication and Public Education 19

Emergency Medical Service Systems and Protocols 21

Strategic National Stockpile 23

Appendices

Appendix 1 -- NACCT Membership, Advisors and Consultants 25

Appendix 2 -- Selected DHHS Accomplishments and Current Initiatives
Related to Children and Terrorism 27

**[Executive Summary]{.smallcaps}**

This document represents the consensus recommendations of the National
Advisory Committee on Children and Terrorism (NACCT), a committee
composed of a variety of experts and professional organizations from the
fields of public health, education, pediatrics, psychiatry, child
development, emergency management, disaster planning and child advocacy
(see Appendix 1).

The NACCT was established on June 12, 2002, in accordance with the
Federal Advisory Committee Act (FACA), for the purpose of making
consensus recommendations to the Secretary of the Department of Health
and Human Services (DHHS) on matters related to terrorism and its impact
on children. The objective of the NACCT, as specified in the Public
Health Security and Bioterrorism Preparedness and Response Act of 2002,
was to provide, within one year, a report to the Secretary that would
assess and provide recommendations regarding:

A)  **The preparedness of the healthcare system to respond to terrorism
    as it relates to children**[^1]

B)  **Needed changes to the healthcare and emergency medical service
    systems and emergency medical services protocols to meet the special
    needs of children**

**C) Changes, if necessary, to the National Strategic Stockpile under
Section 121 of the Public Health Security and Bioterrorism Preparedness
and Response Act of 2002 to meet the emergency health security of
children.**

The Department of Health and Human Services is uniquely positioned to
provide leadership, planning and a wide range of services to help
America's children prepare for and respond to terrorist events. DHHS and
other federal agencies responded to the September 11 attacks with
excellent efforts and initiatives (some of which are described in
Appendix 2). The recommendations contained in this report are designed
to further strengthen our nation's resiliency in coping with any major
event directly or indirectly affecting the well being of children and
families.

The NACCT has reached remarkable consensus that 1) a comprehensive
public health strategy to meet the needs of children in planning and
responding to terrorism will require review of all current DHHS programs
and guidance to assertively require that a specific focus be placed on
meeting the needs of children and families, 2) funding decisions for
terrorism-related programs and initiatives should be linked to
confirmation that children's needs have been specifically accounted for,
3) structures within DHHS should be created to ensure continued
oversight and adequate response to the needs of children and families in
DHHS programs and initiatives, 4) significant new pediatric and
psychosocial initiatives are needed to address the needs of the nation's
children and families in light of the continued threat of terror events,
and 5) addressing the needs of children and families in the face of
terrorism should be recognized to be an essential part of America's
national security response to terrorism.[^2]  

![](media/image2.png){width="2.0in" height="1.6111111111111112in"} 

At the outset, it is important to recognize that the means through which
the effects of terrorism are propagated are largely psychological.
Terrorism seeks to create fear and insecurity, and includes the aim of
creating internal divisions within society over the long term. Moreover,
we would stress it will generally be the *terror generated by* a major
event, not the *event* itself, that will have the greatest long-term
negative impact on children and families throughout the nation. These
recommendations are designed to assist in preparing and initiating
strategies to ensure the public health of America's children by meeting
the physical, medical, psychological and social needs of infants,
children, adolescents and families in all phases of preparation and
response to conventional, chemical, biological, radiological and nuclear
terrorism.

It is essential that the needs of America's children be made a priority
in planning for future disasters and terrorist attacks, and yet the
majority of disaster plans and guidelines do not take into account the
unique needs and vulnerabilities of children and adolescents. Federal,
state, and local agencies immediately should put the safety, security,
and well-being of children and adolescents first and should not wait
until later stages of the planning that currently is taking place to
prepare for terrorism.

Ensuring that the United States is prepared to protect the physical and
mental health of children and families in the event of a terrorist
attack is an immense task. At the very least, the NACCT recommends that
effective disaster planning for children must:

a)  Address the physical and mental health needs of newborns, infants,
    children and adolescents and include pediatric experts in all stages
    of the development of child-specific response plans, training and
    drills.

b)  Prepare to meet the needs of children in schools and other
    congregate care settings where children are normally gathered such
    as child-care facilities, summer camps, juvenile justice facilities,
    in transit between these places and home, or any number of other
    settings.

c\) Ensure coordination and integration of response efforts of Federal,
state and local agencies with hospitals, relevant professional
organizations, community organizations, and non-traditional first
responders such as clergy and teachers.

d\) Prioritize returning children to normal routines with appropriate
supports as soon as possible after a disaster as a way to promote family
and community resilience.

In accordance with the NACCT Charter, three public meetings were held on
March 6, April 30 and May 21, 2003, where the members of the NACCT, as
well as federal advisors and outside consultants, gave presentations and
held discussions to review existing data and response plans. These
meetings provided an interactive forum for the Committee to develop
consensus recommendations for the Secretary. The Committee members,
advisors and consultants were all individuals with nationally and
internationally recognized expertise and experience in relevant subject
areas including pediatric healthcare, disaster planning, emergency
medicine, child development, public health, education, nursing and
pediatric mental health.

Minutes of the NACCT meetings and information about its objectives are
available to the public on the NACCT website
(www.bt.cdc.gov/children/index.asp). Input from the public was solicited
at the meetings, and via an e-mail account created especially for that
purpose on the NACCT website.

In order to best position the Secretary and DHHS to take action and
adequately address the special needs of children before, during and
after terror events, the physical and mental health effects of terrorism
on infants, children and adolescents were assessed by the NACCT, and
recommendations made, in the following eleven areas:

**Objective A of the NACCT: The preparedness of the healthcare system to
respond to terrorism as it relates to children.**

1.  Federal Responsibilities

2.  Schools and Other Child Congregate Care Settings

3.  Mental Health and Psychosocial Support

4.  Primary Care Pediatric Providers

5.  Pre-Hospital and Hospital Care

6.  Community Involvement

7.  Training

8.  Health Intelligence

9.  Risk Communication and Public Education

**Objective B of the NACCT: Needed changes to the healthcare and
emergency medical service systems and emergency medical services
protocols to meet the special needs of children**

10. Emergency Medical Service Systems and Protocols

**Objective C of the NACCT: Changes, if necessary, to the National
Strategic Stockpile under Section 121 of the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002 to meet the emergency
health security of children.**

11. Strategic National Stockpile

Below are the Committee's recommendations from each of the eleven
subject areas assessed by the NACCT. These recommendations are described
in more detail in the "Recommendations" section, along with specific
actions that can be taken to make these recommendations a reality.

**NACCT OBJECTIVE A: The preparedness of the healthcare system to
respond to terrorism as it relates to children.**

##### 1 -- Federal Responsibilities

1.  Formally recognize the unique needs of children in terror events and
    similar emergencies by 1) the permanent addition of relevant child
    emergency public health preparedness subject matter experts to the
    Secretary's Council on Emergency Public Health Preparedness, and 2)
    by creating a working group on children and emergency public health
    preparedness comprised of relevant subject matter experts and
    federal officials under the auspices of the Secretary's Council on
    Emergency Public Health Preparedness with a charge to ensure that
    the issues and proposals raised by the National Advisory Committee
    on Children and Terrorism (NACCT) are carried out.

2.  Assure that the unique physical and mental health needs of children
    are recognized and resources provided for in all DHHS terrorism
    preparedness and response funding initiatives, strategic plans and
    priority setting activities; and include relevant pediatric experts
    in children's physical and mental health in the development of all
    such initiatives, plans and activities.

3.  Conduct a national survey of Federal, state and local terrorism and
    disaster plans that includes a specific assessment of preparedness
    and training for the medical and psychological effects of terrorism
    on children, to provide feedback for implementing changes as part of
    a continuous improvement strategy for disaster planning.

4.  Convene an ongoing series of meetings with stakeholders and relevant
    experts to define needs and core competencies necessary for
    appropriate training, protection and response in relationship to
    children and terrorism.

5.  Continue to ensure that the needs of children and families are
    included in all federal disaster response plans by establishing
    explicit agreements with the Departments of Homeland Security,
    Defense, Justice, Energy and other appropriate agencies to include
    provisions for addressing the physical and mental health need of
    children in all federal terrorism and disaster response plans.

6.  Expand the State Children\'s Health Insurance Program (SCHIP) to
    provide financial mechanisms for States to support post-disaster
    physical and mental healthcare to all children affected by disasters
    and terror attacks, regardless of insurance coverage or pre-existing
    conditions.

**2 -- Schools and Other Child Congregate Care Settings**

1.  Ensure that every major DHHS-funded terrorism initiative, and other
    federal terrorism initiatives, appropriately addresses the role and
    needs of schools and other child congregate care settings by
    providing regulatory requirements, oversight and funding to result
    in effective linkages between state and local education agencies,
    schools, public health agencies and other emergency preparedness
    entities.

2.  Collaborate with the Secretary of Education to formalize
    partnerships at the Federal, state and local levels, and coordinate
    activities to ensure that schools are fully integrated into
    preparedness, response, recovery, and mitigation efforts.

**3 -- Mental Health and Psychosocial Support**

1.  Conduct research relating to identifying patterns of child trauma,
    resilience, coping and recovery in the aftermath of disasters and
    terrorism, and the development of relevant public health tools and
    instruments including simple, reliable and valid measures of
    children's physical and mental health outcomes.

2.  Support activities related to the development of infrastructure and
    capacity for effective surveillance, monitoring and evaluation of
    children's post-disaster physical and psychosocial intervention
    outcomes.

3.  Support the development of a national set of principles and best
    practices for children's post-disaster psychological and social
    intervention. This should include development of training and
    evidence-based practices for primary healthcare providers, police,
    firefighters, emergency medical technicians, municipal leaders,
    schools, clergy and families. Disseminate these principles and best
    practices widely at the state and local levels.

4.  Ensure inclusion of child and adolescent mental health specialists
    in terror and disaster planning, preparation and response at the
    Federal, state and local levels as part of a DHHS-wide plan to
    address psychosocial preparedness and recovery for children within
    major DHHS initiatives and Agencies.

**4 --Primary Care Pediatric Providers**

1.  Assess the central capacity of the public health and healthcare
    systems to ensure that it is sufficiently equipped to adequately
    prepare and train Primary Care Pediatric Providers (PCPPs) to plan
    for and respond to terrorism and disasters.

2.  Evaluate the success of the New York City Medicaid initiative
    post-September 11, 2001 and consider this as a temporary measure
    while working to develop a mechanism for providing post-disaster
    healthcare access for children.

3.  Involve PCPPs in all stages of preparation and response to disaster:
    from planning to evaluation, case identification and treatment of
    children, to ongoing care to families and community healing.

**5 -- Pre-Hospital and Hospital Care of Children**

1.  Ensure that all hospital preparedness programs supported by DHHS
    include provisions for preparing to care for children in the event
    of a disaster or terrorist act.

2.  Support and enhance existing DHHS programs involving communication
    and information management systems between hospitals, local health
    agencies and emergency responders used during a disaster or
    terrorist event.

**6 -- Community Involvement**

1.  Initiate strategies to assist families, faith- and community-based
    organizations, childcare facilities and other child-serving systems
    to increase their capacity to respond to terror events.

2.  Develop and support a multi-site initiative, involving at least six
    demonstration projects, to identify and implement best practices for
    integration of Federal, state and local responders with faith- and
    community-based organizations in emergency management planning,
    training and the building of community resilience related to
    children and families.

**7 -- Training**

1.  Develop training programs to prepare a pediatric healthcare
    workforce to gain the knowledge, skills and abilities to address the
    special needs of children and that can be readily integrated into
    the public health network.

2.  Develop pediatric training programs related to the physical and
    mental health effects of disasters and terrorism on children that
    include continuing education to health professionals already in
    practice; and provide incentives for curricular reform in health
    professions schools and training programs.

3.  Include a specific pediatric training component in all disaster and
    terrorism response plans at the Federal, state and local levels, and
    support sustained training and evaluation by funding ongoing
    pediatric disaster and terrorism drills for first responders,
    healthcare workers, and other relevant professionals and trainees.

4.  Support a comprehensive approach to pediatric training on terrorism
    and children, involving relevant organizations and partnerships.

**8 -- Health Intelligence**

1.  Develop linkages necessary to ensure that the Federal, state and
    local health intelligence systems support emergency planning,
    response, and recovery and are competent in the area of health
    intelligence data related to children\'s physical and mental health
    needs related to an act of terror.

2.  Ensure that the emergency response systems utilized to support
    emergency planning, response, and recovery at Federal, state and
    local levels fully include trained scientific and epidemiological
    professionals with expertise in children's health.

**9 -- Risk Communication and Public Education**

1.  Implement risk communication strategies to positively affect the
    nation as a whole during times of elevated threat levels and actual
    terrorist events, in light of the special effects these threats and
    events have on children.

2.  Develop clear, concise and situation-specific guidance for parents,
    caregivers and teachers concerning helping children to cope with
    terrorism and disasters, and ensure that consistent information is
    disseminated by all DHHS agencies.

3.  Develop and support a translational research initiative to develop
    more effective methods of communicating to the public and to health
    and human services professionals that recognize the special needs of
    children and families.

4.  Maintain a national toll-free number for public information
    pertaining to children and conventional, chemical, biological,
    radiological and nuclear events.

**NACCT OBJECTIVE B: Needed changes to the healthcare and emergency
medical service systems and emergency medical services protocols to meet
the special needs of children.**

**10 -- Emergency Medical Service Systems and Protocols**

1.  Support and enhance existing DHHS programs related to EMS to ensure
    that the physical and mental health needs of children are met and
    that all first responders and EMS personnel receive training in
    post-disaster physical and mental health needs of children.

2.  Working with the Secretary of Homeland Security, create Pediatric
    Specialty Teams for the existing Disaster Medical Assistance Team
    (DMAT) Program. Specifically, create one Pediatric Specialty Team
    per Region, in addition to providing each regular DMAT Team with a
    pediatric component including trained providers, equipment and
    pharmaceuticals.

3.  Conduct research on EMS pediatric emergency and terrorism
    preparedness and response.

**NACCT OBJECTIVE C: Changes, if necessary, to the National Strategic
Stockpile under Section 121 of the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002 to meet the emergency
health security of children.**

**11 -- Strategic National Stockpile**

1.  Establish an annual Pediatric Subject Matter Expert (SME) review
    process of the SNS program's pediatric capacity by relevant
    pediatric subject matter experts to recommend pediatric formulary
    additions or modifications in order to ensure continued and enhanced
    pediatric capability and capacity of the SNS program.

2.  Establish a process to determine prioritization of recommended
    pediatric formulary additions or modifications to the SNS to
    maintain and enhance pediatric capability and capacity of the SNS
    program.

**Conclusion**

Successful responses to terrorism will depend on effective planning and
coordination across a variety of government and community resources
involved in disaster response. These resources must work together on an
ongoing basis to assess and meet the needs of America's children in the
event of terror attacks. Enduring protection will require a variety of
sustained, committed efforts that apply preventive and long-term
consequence management measures. To this point, it is essential that the
issues and proposals raised by the National Advisory Committee on
Children and Terrorism continue to be developed. The Committee looks
forward to working with the Secretary of the Department of Health and
Human Services and his staff to act on these recommendations, and to
ensure that sufficient resources are devoted to this most important of
tasks, safeguarding our nation's children from terrorism.

## [Statement of Principles]{.smallcaps}

![](media/image3.png){width="2.125in" height="1.59375in"}Terrorism, and
the stress associated with terror alerts, can have devastating effects
on children and families. The physical and emotional consequences of
experiencing or witnessing terror attacks can continue long after the
initial event and affect many children who are not in the immediate
vicinity at the time of the event. Children's immature abilities to
understand and process the immediate and long term effects of disasters
and terrorist attacks -- their own injuries, traumatized or injured
parents, loss of loved ones, the disruptions of daily routines,
frightening images around them and in the media -- make children among
the most vulnerable members of affected communities. For example, an
extensive mental health survey of over 8,000 New York City public school
children conducted six months after the World Trade Center attacks found
that a majority of children continued to be affected by the terror
attacks, and that the responses were not limited to children who had
been near Ground Zero, but were in fact found in children throughout all
five boroughs[^3]. Early and well-organized intervention is the key to
promoting resilience in these children and families, and to preventing
the development of problems in the future.

Lack of comprehensive planning for the needs of children in the event of
terrorist attacks is a flaw in America's defenses that must be remedied
immediately. For example, in the recent TOPOFF 2 exercises, a five-day,
full-scale simulation of how the nation would respond in the event of a
weapon of mass destruction attack, Chicago used a vacant school as a
medical center for plague victims, and Seattle conducted drills, such as
sheltering-in-place, after schools hours. Although school officials were
involved in the planning and enactment of the drills, many questions
were not considered during the planning and evaluation phases of the
exercises, including: Can classes continue to be held? Are school and
community plans well-integrated, or in conflict with one another? How
would parents, students, and staff respond to the idea that their
building was being used to triage or treat infected people? How could
authorities and emergency responders let parents, students, and staff
know whether or not the disease or condition was not one that spreads
person-to-person? How would the medical needs of children with chronic
or disabling conditions be met? How would parents, students, and staff
be given assurance that they could safely return to the school building?
How would students be returned to their normal routine as quickly as
possible?

**Snapshot -- On the morning of September 11, 2001, approximately 1.2
million children were enrolled in the New York City public schools.
Approximately 750,000 of them took public transportation to school every
morning, including subways, buses and boats, passing through tunnels and
going over bridges. Hundreds of thousands of other children were at
home, in day care, or in juvenile justice facilities. In the immediate
vicinity of Ground Zero, more than six thousand children were in 7
elementary, middle and high schools, as well as in 28 licensed child
care centers, 58 family child care and group homes, and 14 school age
child care sites, including one childcare center in the Twin Towers.**

Traditionally, most disaster and emergency response plans have taken
into account only the needs of adults. As recently as 1997, data
collected by FEMA showed that no state disaster plans had pediatric
components. A recent study showed that only about 20% of hospitals have
access to pediatric emergency physicians, and the majority of emergency
personnel have little pediatric training or experience. Children, if
they are mentioned at all in emergency plans, are generally assumed to
be "small adults".

Children are not simply small adults. Children breathe faster and have
faster heart rates than adults, making them more vulnerable to
aerosolized biological and chemical agents. Children metabolize drugs
differently, requiring different dosages of drugs and different
antidotes to many agents, as well as specially sized equipment to
administer many treatments. Because of their small size, children have
less fluid reserve and smaller circulating blood volumes, and so are
more vulnerable to the dehydrating effects of vomiting and diarrhea and
go into shock more quickly. Ill and injured children react differently
than adults to stress, and their psychological vulnerabilities in the
aftermath of disasters and emergencies are still only imperfectly
understood. On every level, physical, medical, psychological, emotional
and social, children have unique needs and vulnerabilities that must be
taken into account if America as a nation is to be properly prepared to
protect our children from terrorism.

**[Recommendations]{.smallcaps}**

###### NACCT Objective A -- The preparedness of the healthcare system to respond to terrorism as it relates to children.

#### [1 -- Federal Responsibilities]{.smallcaps}

![](media/image4.wmf){width="1.5215277777777778in"
height="2.3583333333333334in"}Public health programs and agencies, at
Federal, state and local levels, have planned and prepared responses to
many of the health consequences associated with terrorist events for
many years. In doing so, public health has a mandate to protect not only
the individual, but also the general health of the population in active
collaboration with community organizations, universities, hospitals and
clinics, providers and professional associations. Public health and its
partners must lead efforts to assess, assure access to care and provide
credible information about appropriate treatments for children and
families. Most importantly, they must continue to shape policies that
will ensure that all children are protected to the greatest amount
possible from the effects of terrorism. Public health today faces many
competing challenges in the area of children and terrorism that include
inadequate infrastructure, training of public health professionals and,
most importantly, funding.

With this in mind, the Department of Health and Human Services (DHHS)
should be commended for including relevant language in the 2003-2004
Requests for Proposals (RFPs) for Bio-terrorism and Chemical
Preparedness. This will help states, territories and local entities,
where the actual public health measures need to be applied. Some
important language specific to addressing children's needs was added to
the HRSA National Bioterrorism Hospital Preparedness Program Cooperative
Agreement Guidance with input from other federal agencies including the
CDC. DHHS should also be commended for including strong language to
promote mental health needs -- which should also help prepare for the
needs of children. However, such language may not go far enough to
ensure that comprehensive action is taken to prepare for both the
physical and mental health needs of children in events of terrorism.

It is crucial therefore, that DHHS 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 current and future RFPs.

**1.1**

**Formally recognize the unique needs of children in terror events and
similar emergencies by 1) the permanent addition of relevant child
emergency public health preparedness subject matter experts to the
Secretary's Council on Emergency Public Health Preparedness, and 2) by
creating a working group on children and emergency public health
preparedness comprised of relevant subject matter experts and federal
officials under the auspices of the Secretary's Council on Emergency
Public Health Preparedness with a charge to ensure that the issues and
proposals raised by the National Advisory Committee on Children and
Terrorism (NACCT) are carried out.**

-   Successful responses to terrorism will depend on effective planning
    and coordination across a variety of government and community
    resources involved in disaster response. These resources must work
    together on an ongoing basis to assess and meet the needs of
    America's children in the event of terror attacks. Enduring
    protection will require a variety of sustained, committed efforts
    that apply preventive and long-term consequence management measures.
    To this point, it is essential that the issues and proposals raised
    by the National Advisory Committee on Children and Terrorism
    continue to be developed.

**1.2**

**Assure that the unique physical and mental health needs of children
are recognized and resources provided for in all DHHS terrorism
preparedness and response funding initiatives, strategic plans and
priority setting activities; and include relevant pediatric experts in
children's physical and mental health in the development of all such
initiatives, plans and activities. Adequate assurance must be provided
that the following components are integrated into all stages to
terrorism and disaster planning, preparation and response:**

-   Plans for meeting the physical and mental health needs of children
    during and after disasters and terror events;

-   Plans for the coordination and integration of response efforts of
    federal state and local agencies with hospitals, relevant
    professional organizations, community organizations, and
    non-traditional first responders such as clergy and teachers;

-   Plans for integration of training specifically related to the needs
    of children and families in terror and disaster planning,
    preparation and response; and

-   Specific plans for the roles and needs of schools and other child
    congregate care settings, including, but not limited to, day care
    programs, hospitals, after school programs, houses of worship,
    community centers, summer camps and juvenile justice facilities

**1.3**

**Conduct a national survey of Federal, state and local terrorism and
disaster plans that includes a specific assessment of preparedness and
training for the medical and psychological effects of terrorism on
children, to provide feedback for implementing changes as part of a
continuous improvement strategy for disaster planning.**

-   There has been no large-scale survey of terrorism preparedness. The
    CDC, working with the Association of State and Territorial Health
    Officials (ASTHO), the National Association of County and City
    Health Officials (NACCHO) and other relevant organizations, should
    be provided with specific funding and resources to develop an
    assessment tool that studies state and local preparedness and
    training for the effects of terrorism (both mental and physical) on
    the children under their auspices, and to conduct a national
    evaluation using that instrument.

### 1.4

**Convene an ongoing series of meetings with stakeholders and relevant
experts to define needs and core competencies necessary for appropriate
training, protection and response in relationship to children and
terrorism. Meeting topics should include:**

-   Defining the roles and interactions of DHHS and other Federal
    agencies with state and local public health departments in training,
    protection and response in relationship to children and terrorism.
    Meeting participants should include the Association of State and
    Territorial Health Officials (ASTHO), the National Association of
    County and City Health Officials (NACCHO) and other state
    governmental associations;

-   Developing standards of evidence-based best practices for physical
    and mental health interventions for teachers, school counselors,
    school nurses, primary care providers, and families;

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

-   Developing clear, concise, consistent, evidence-based and
    situation-specific guidance for parents and teachers concerning
    helping children to cope with terrorism and disasters;

-   Meeting with 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; and

-   Identifying core competencies, analyzing current practices and
    identifying ways to ensure national consistency on issues such as:

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-   adequate first responder training to care appropriately for children
    exposed to disaster or terrorist attack;

-   quarantine of children;

-   planning for special needs children;

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

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-   development of pediatric training guidelines for communities.

### 1.5

**Continue to ensure that the needs of children and families are
included in all federal disaster response plans by establishing explicit
agreements with the Departments of Homeland Security, Defense, Justice,
Energy and other appropriate agencies to include provisions for
addressing the physical and mental health need of children in all
federal terrorism and disaster response plans.**

### 1.6

**Expand the State Children\'s Health Insurance Program (SCHIP) to
provide financial mechanisms for States to support post-disaster
physical and mental healthcare to all children affected by disasters and
terror attacks, regardless of insurance coverage or pre-existing
conditions.**

**2 -- Schools and Other Child Congregate Care Settings**

Every day 53 million young people attend more than 119,000 public and
private schools where 6 million adults work as teachers or staff.
Counting students and staff, on any given weekday more than one-fifth of
the U.S. population can be found in schools. Children also congregate in
other settings including child care programs, after-school programs,
youth organizations, summer camps, and juvenile justice facilities.

Schools and other congregate care settings may or may not be the direct
targets of terrorism, but they are certain to be affected by terrorism,
whether directly or indirectly. In times of crisis, schools are often
called upon to act as shelters, community meeting places, and even
command centers. Communities can place extra, unfunded burdens on
schools in this situation.

In order to adequately address the special needs of children, public and
mental health agencies, and other emergency responders, must involve
education agencies and schools in their planning processes. Local level
coordination is essential, but a good deal of planning occurs at the
state and national levels. Collaboration at these levels is also
necessary. The best way to address the needs of schools and other child
congregate care settings is through collaboration between public health,
mental health, medical care, education, emergency management, law
enforcement, fire, homeland security and transportation.

####### 2.1

![](media/image5.png){width="3.25in"
height="2.2666666666666666in"}**Ensure that every major DHHS-funded
terrorism initiative, and other federal terrorism initiatives,
appropriately addresses the role and needs of schools and other child
congregate care settings by providing regulatory requirements, oversight
and funding to result in effective linkages between state and local
education agencies, schools, public health agencies and other emergency
preparedness entities.**

-   Expand CDC's School Health Program by supporting a high-level staff
    position in every state education agency and health department to
    coordinate policies and programs focused on the physical and mental
    health needs of students. As a central part of their mission, these
    staff should collaborate to ensure that schools are prepared to
    protect the lives and health of students and staff in emergencies.
    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.

-   Revise the Federal Response Plan, DHHS/CDC Public Health
    Preparedness and Response for Bioterrorism Continuing Grant
    Guidance, DHHS/HRSA National Bioterrorism Hospital Preparedness
    Program Cooperative Agreement Guidance, and other funded programs to
    ensure that schools, other child congregate care settings and
    education agencies are an integral part of preparedness, response,
    recovery, and mitigation efforts.

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-   Develop and disseminate information and measurement instruments to
    assess and improve the capacity of schools and other congregate care
    settings to prepare for and respond to conventional, chemical,
    biological, radiological, nuclear and mass trauma (physical and
    psychological) terrorism.

-   Ensure that DHHS conduct and support new research that can improve
    the preparedness and capacity of schools and other congregate care
    settings to respond to terrorism with emphasis especially 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 conventional,
    chemical, biological, radiological, nuclear or mass trauma events,
    as well as the terror generated before, during and after an event;
    the ability of school and other child congregate care setting 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.

**2.2**

**Collaborate with the Secretary of Education to formalize partnerships
at the Federal, state and local levels, and coordinate activities to
ensure that schools are fully integrated into preparedness, response,
recovery, and mitigation efforts.**

Specific activities on which DHHS and ED can work together include:

-   Adding 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.

-   Funding demonstration projects that evaluate the effectiveness of
    school-based responses to past emergencies (e.g. Columbine high
    school shootings, September 11^th^) and expand and evaluate existing
    emergency planning and response models (e.g., New York City, Los
    Angeles) for involving education agencies and schools in a
    coordinated system of response and recovery.

-   Ensuring 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.

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

-   Developing additional collaborative efforts built upon the May 2002
    teleconference developed by the Department of Education (ED),
    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 the agents of terrorism,
    provide technical assistance on school and community preparedness
    and response, and serve as a model for state-based collaborations.

-   Ensuring that schools are part of community-based planning and
    training as both community resources and as places where large
    numbers of children and adolescents are congregated.

-   Developing and disseminating guidance for school officials
    recommending that, in the context of Presidentially declared
    disasters, school-based screening to identify children and youth
    with continuing psychological problems be conducted without active
    parent consent. In such circumstances, parents should be offered the
    option to opt their child out of the screening by contacting the
    school or health authority conducting the screening.

**[3 -- Mental Health and Psychosocial Support]{.smallcaps}**

Children exposed to terrorist events and disasters are at risk for
developing emotional and psychological reactions. In situations of
terrorism involving mass casualties and related threats, the mental
health and psychosocial needs of children should be assessed as soon as
possible in order to promote psychological resiliency in children and
families. Pediatric mental health services will best be provided, not
only in the form of direct clinical interaction with children and
families, but also by the approaches of a range of law enforcement,
emergency responders and community providers with whom children will
have contact. Therefore, pediatric mental health training is necessary
both for existing emergency responders and for persons in the current
local \"de facto\" child and family mental health system that includes
primary care providers, school counselors and nurses, clergy, law
enforcement and family members.

While there is a tremendous need for basic knowledge about appropriate
treatments and interventions that support psychological and social
resilience in children and families in order to reduce the risks for
later disorders and/or disabilities, all available data point to the
importance of early intervention in promoting post-disaster resilience
in children and families. Better post-disaster psychological and
emotional functioning of parents and caretakers has been shown to
predict better outcomes in children, pointing to the importance of
post-disaster family interventions. In addition, physical symptoms and
injuries in children can often be the result of emotional distress, and
so provide an important method to assess the post-disaster
vulnerabilities of children. Therefore, valid, reliable measures of
emotional distress and psychological factors must be integrated into all
post-disaster medical evaluations of children and families.

![](media/image6.wmf){width="3.25in" height="2.15in"}Early
identification and intervention for emotional distress must take into
account the different needs and vulnerabilities of pre-schoolers,
children and adolescents and be sensitive to the differing
manifestations of mental health problems (i.e. physical and emotional
symptoms, behaviors and functioning) in culturally diverse communities.
Effective post-disaster surveillance and monitoring of the physical,
emotional and psychological needs of children and families and
evaluation of the effectiveness of services and interventions are
necessary in order to direct resources and identify individuals and
groups in need of assistance.

## 3.1

**Conduct research relating to identifying patterns of child trauma,
resilience, coping and recovery in the aftermath of disasters and
terrorism, and the development of relevant public health tools and
instruments including simple, reliable and valid measures of children's
physical and mental health outcomes.**

## 3.2

Support activities relating to the development of infrastructure and
capacity for effective surveillance, monitoring and evaluation of
children's post-disaster physical and psychosocial intervention
outcomes.

-   Require the development of cross-Agency collaborative RFP's to
    address the development of translational research related to
    psychosocial preparedness and recovery including, but not limited
    to:

    -   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; and

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

        -   Provide the DHHS mental health research agencies (e.g. NIH,
            CDC and SAMHSA) with substantial funding to develop
            initiatives related to the psychosocial aspects of the
            effects of terrorism on children and families. These efforts
            will close knowledge gaps, guide public policy, and inform
            national and local efforts to promote resilience in children
            and families. Topics to be funded include, but are not
            limited to:

            -   an integrated three-tier strategy for 1) monitoring
                children's reactions to national distress and
                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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        -   development of standards of evidence-based best practices of
            post-disaster interventions;

        -   epidemiology of post-disaster pediatric exposure and mental
            health and psychosocial reactions.

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

        -   assessment of effectiveness of training on pediatric
            providers and their patients/clients including objective
            changes in provider behavior, mental health outcomes for
            children and families and sustainability over time.

            -   Fund programs such as those at the CDC and at the
                National Child Traumatic Stress Network (NCTSN) 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.

            -   Support the CDC to enhance the School Health Policies
                and Programs Study (SHPPS) to collect detailed
                information on school, district, and state education
                agency policies and activities to prepare for, respond
                to, recover from, and mitigate future terrorist attacks
                and other disasters, and to translate this information
                into program development.

            -   Increase funding for efforts currently under way by
                relevant DHHS agencies (e.g. NIH, CDC and SAMHSA) and by
                programs such as the 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.

            -   Develop and fund mechanisms to support systematic
                cross-national collaborations between our country and
                other nations with significant experience responding to
                terrorism. The Secretary should consider collaborations
                with the State Department (Fogarty Center) and the
                Department of Homeland Security in furthering this aim.

            -   The September 11 terror attacks, the later release of
                anthrax and the Washington DC sniper attacks all
                demonstrated that the effects of terrorism on the
                general population reach well beyond traditional mental
                health concerns with psychological disorders. In
                addition, 9/11 demonstrated the need for improved
                inter-operability between designated first responders as
                well non-traditional first-responders such as teachers,
                volunteer organizations, clergy, and others. Moreover,
                these events demonstrated the need to develop methods to
                \"inoculate\" the population against the psychological
                and emotional effects of terrorism. To increase our
                nation\'s ability to be more resilient in the face of
                attack, the Committee recommends funding
                comprehensive demonstration projects in at least two
                high-risk cities, New York City and Washington DC. These
                demonstration projects should bring together all
                relevant stakeholders in the lives of children to
                identify methods to increase system coordination and
                population resilience, and to systematically implement
                and evaluate the proposed methods.

## 3.3

**Support the development of a national set of principles and best
practices for children's post-disaster psychological and social
intervention. This should include development of training and
evidence-based practices for primary healthcare providers, police,
firefighters, emergency medical technicians, municipal leaders, schools,
clergy and families. Disseminate these principles and best practices
widely at the state and local levels.**

-   The Committee has determined that the full range of response to
    children's psychosocial needs, in all stages of disaster
    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 between all child serving systems, ranging
    from first responders (police, firefighters, EMS) to education
    authorities and health authorities, specifically including
    behavioral health specialists. As described below, significant gaps
    exist in the nation\'s capacity to mount this type of response. The
    Committee recommends the following actions to address these gaps.

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-   Convening an inter-departmental task force to increase basic
    competence in responding to child needs across responder systems by
    reviewing training systems across education, EMS, fire departments,
    justice, and homeland security to identify and remedy gaps in
    preparedness and response capacities that address children's needs.

-   The Secretary should create incentives for cooperative activity
    including service co-location between education, primary healthcare
    and mental health response systems. To further this goal, the
    Secretary should develop a series of demonstration projects within
    these systems to develop improved methods of integrating
    psychosocial response that can then be disseminated.

    -   Provide increased funding 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.

    -   Incorporate disaster mental health into the clinical training of
        all pediatric and mental health disciplines.

## 3.4

Ensure inclusion of child and adolescent mental health specialists in
terror and disaster planning, preparation and response at the Federal,
state and local levels as part of a DHHS-wide plan to address
psychosocial preparedness and recovery for children and adolescents
within major DHHS initiatives and Agencies.

-   The best response to a crisis is often a local response. Identify
    national experts who can provide consultation to local providers
    regarding optimal post-event care. Provide funding 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 providers, and families. Preparation
    should also include establishing protocols for collaborating with
    local responses and groups, and building capacity to accept into
    treatment children and adolescents with serious terrorism related
    mental illness.

-   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 families but by the
    approaches of a range of emergency responders and community
    providers with whom children will have contact. Therefore, provide
    increased funding to develop mental health resources for pediatric
    mental health training both for existing emergency responders and
    persons in the current local \"de facto\" mental health system which
    includes primary care providers, school counselors and nurses,
    clergy law enforcement and family members. In order to maximize
    their acute response effectiveness, acute response providers will
    need:

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

    -   Familiarization 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. 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 particularly in vetting
        professionals before they become involved in the aftermath of an
        event.

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    -   Collaborations among emergency responders and community
        providers should include:

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-   Training of best practices into 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, firefighters, EMS, state and municipal emergency planners,
    public health officials, 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 networks of mental health providers at state and local
    levels who will be part of the first response team in a terror
    event;

-   Mapping 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.);

-   Identifying desired additional collaborative relationships;
    explaining them to relevant stakeholders (i.e., existing members of
    the state, regional and local emergency response teams); assigning
    responsibilities for developing and reporting on new collaborative
    efforts in training and planning of integrated services;

-   Practicing communication and mobilization of response team members
    using simulation scenarios;

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

-   Developing 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. (Additional information specific to
    the nature of attack can be added at the time of the event.)

    -   Conduct at least six demonstration projects to implement
        comprehensive psychosocial preparedness and recovery projects
        aimed at children and families to demonstrate different models
        of preparedness and to promote the comparison of such different
        models with the aim of identifying the best models of
        psychosocial preparation.

**[4 -- Primary Care Pediatric Providers]{.smallcaps}**

![](media/image7.png){width="1.875in" height="1.875in"}One of the
lessons learned from September 11 is that children exhibit fewer lasting
effects of trauma when their parents receive the necessary support and
reassurance to return quickly to a stable routine. In preparing for,
responding to, and recovering from potential terrorism involving
children and adolescents, Primary Care Pediatric Providers (PCPPs) are
quite literally the first line of defense and treatment (as they are for
other age groups, as our experience with anthrax in 2001 taught us). For
children, the presence of a trusted, accessible, regular source of
primary care, who knows the child and his or her family, is as
indispensable in responding to real or threatened terrorism as in the
management of other complex problems. In turn, we also learned that
Primary Care Pediatric Providers can be highly effective in addressing
the needs of anxious and distressed parents. They are well placed to
identify children in need of services. These skills have been key
components of their residency training and are easily transferable to
disaster response.

### 4.1

**Assess the central capacity of the public health and healthcare
systems to ensure that it is sufficiently equipped to adequately prepare
and train Primary Care Pediatric Providers (PCPPs) to plan for and
respond to terrorism and disasters.**

##### 4.2

**Evaluate the success of the New York City Medicaid initiative post
September 11, 2001 and consider this as a temporary measure while
working to develop a mechanism for providing post-disaster healthcare
access for children**.

##### 4.3

**Involve PCPPs in all stages of preparation and response to disaster:
from planning to evaluation, case identification and treatment of
children, to ongoing care to families and community healing.**

-   Maximize the health of children and adolescents through immunization
    and health/mental health education and primary prevention so that
    children have greater resilience to mitigate the effects of
    terrorism.

-   Enhance the PCPP's ability to provide services in a
    bio-psycho-social and culturally competent manner -- differentially
    assessing the needs of children and adolescents and ensuring all
    these needs are addressed in a holistic manner. This should include
    enhancing the capacity of PCPPs to screen and treat children at
    psychological risk for traumatic exposure and loss.

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-   Enhance capacity of PCPPs to screen and treat children at
    psychological risk for traumatic exposure and loss. Ensure the PCPP
    is cognizant of developmental differences between children and
    adolescents vis-à-vis impact of trauma, its expression and treatment
    needs.

-   Conduct training and research on best practices to meet the needs of
    children.

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

-   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 PCPPs' capacity to be the conduit for informing and updating
    the public via mass media, web sites and educational materials.

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

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

##### [5 -- Pre-Hospital and Hospital Care of Children]{.smallcaps}

In many parts of the United States, the number of providers trained and
equipped to handle children is extremely limited. Many areas of the
country also lack specialized children's medical facilities. Community
and general hospitals, while in most cases having pediatricians on
staff, do not have the number, depth or specialty pediatric resources
which would be needed in times of disasters. Even those regions with a
children's hospital usually have only one such hospital which could
easily have its resources exhausted or may be unavailable due to being
affected by the event or due to the need for isolation.

Compounding these limitations, the majority of the nation's children's
hospitals, and the pediatric departments of general hospitals, have done
little if any specific planning around managing widespread chemical,
biological, radiological or nuclear exposure among children and youth.
While coordination among Federal, state and local officials was good in
response to the September 11 attacks in New York City, the secondary
coordination with local hospitals was not optimal; nor were any plans in
place to involve pediatric institutions or providers in specific
disaster preparedness planning for on-going acts of terrorism or
disasters.

All hospitals should be prepared to care for children in the event of a
disaster or terrorist act. Even if the hospital does not focus on the
care of children as its regular business, it may find itself in the role
of providing care to children if is the closest provider, or if other
pediatric institutions in the area are overwhelmed.

![](media/image8.wmf){width="3.25in" height="2.1416666666666666in"}The
Committee recommends that the Secretary support and improve upon the
existing DHHS programs that incorporate children in hospital
preparedness response to a disaster or terrorist act. Programs which
incorporate children into their pre-hospital and hospital preparedness
plan should be encouraged, and expanded in two key areas: 1) adequate
preparation of all hospitals in the event they have to care for
children; and 2) communication between hospitals, and with disaster
management resources (DMAT teams, other children's hospitals), the
community, and the media.

### 5.1

Ensure that all hospital preparedness programs supported by DHHS include
provisions for preparing to care for children in the event of a disaster
or terrorist act.

-   Review existing hospital and pre-hospital preparedness plans for
    specific inclusion of the care of children and adolescents. This
    includes Federal, state, and local plans. As a condition of funding,
    require to inclusion of experts in the medical and psychosocial
    needs of children and families in both plan development and
    implementation.

-   Increase funding to HRSA's Bioterrorism Hospital Preparedness
    Program to improve the capacity of the Nation's hospitals and
    emergency departments to respond to specific pediatric needs during
    biological terrorist attacks and large scale epidemics. It is
    important to evaluate the management of surge capacity. Examples
    include analysis from the SARS epidemic regarding ER capacity,
    quarantine requirements outside and inside the hospital, the
    complexity of separating parents (including employees) from their
    children, and the need to maintain clinical staffing requirements
    over several days or weeks. In an era of clinical care giver
    shortage (nurses, therapists), it will be difficult to maintain
    crisis level staffing for more than a few days without a larger
    logistical plan for rotating help from outside communities.

-   The Committee recognizes that many children may be separated from a
    parent during the initial hours of triage and stabilization. An
    alternate system of designating a temporary responsible adult to
    accompany each and every child through the system is required.
    Community volunteers (teachers, faith-community members, retired
    people, etc.) will be needed in this role as the medical community
    may be overwhelmed taking care of the direct medical needs. A
    definition of community resiliency should include an assessment of
    the community's preparedness to take over the care of its children
    until they can be restored to their families.

-   Conduct research to better understand the most effective
    methodologies for developing pediatric preparedness. Develop a
    programmatic RFP to designate New York City and Washington DC, and
    perhaps eight other cities, as demonstration projects for pediatric
    medical and psychosocial preparedness.

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-   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 insufficient effort has been devoted to psychosocial
    response. In the care of children and families, the psychosocial
    component becomes an even more important element. The Initiative
    should solicit and maximize the development and evaluation of
    innovative models and alternative approaches to permit the eventual
    dissemination of effective models.

    -   Develop a set of pediatric algorithms for the most common
        conditions, and make them available to every hospital and
        location that cares for children.

    -   Expand the ATSDR-supported 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.

### 5.2

**Support and enhance existing DHHS programs involving communication and
information management systems between hospitals, local health agencies
and emergency responders** **used during a disaster or terrorist
event.**

-   Continue to include and expand pediatric demographics and pediatric
    disease presentations in CDC's terrorism surveillance, detection and
    notification systems.

-   Ensure that CDC functions as a hub for providing reliable and timely
    medical information to hospital and pre-hospital teams. This may
    include a satellite based communication center, website or other
    wireless developments.

-   Improvements must be made in communications within hospitals,
    between the field and hospitals, and from hospital-to-hospital. This
    includes telephones, radios and computers. In addition, we encourage
    the use of amateur (HAM) radios to communicate in the event of
    telephone failure, as well as the use of satellite technology.

-   Develop information systems to ensure communication between
    hospitals, schools, child care facilities, faith based community
    resources, Primary Care Pediatric Providers, public health
    departments, pediatric mental health providers, all hospital
    healthcare employees, local officials and the media.

-   Work with the National Association of Children\'s Hospitals and
    Related Institutions (NACHRI) to organize a Children's Disaster
    Network. This network would coordinate the provision of pediatric
    expertise to the disaster or epidemic sites. In addition the network
    would serve as a means of handling surge capacity issues --
    identifying available beds, transportation, clinicians and
    equipment. This network would facilitate communication links between
    the hospital and children's specialty care hospital -- while freeing
    affected locales to focus time and attention on public safety and
    further harm reduction.

**[6 -- Community Involvement]{.smallcaps}**

Nontraditional first responders such as the faith community and members
of volunteer organizations are often first on the scene of a disaster
and the first resource families turn to in times of disaster. Yet they
are rarely included in disaster response plans, and many have
insufficient training to handle the needs of children and families in
emergencies. The Department of Health and Human Services is uniquely
positioned to identify best practices that enhance child, family and
community resiliency*.* The Committee recommends that the Secretary
initiate strategies to assist families, community and faith-based
organizations, and childcare facilities in responding to the threat of a
major terrorist event.

![](media/image9.wmf){width="2.125in"
height="1.4166666666666667in"}Historically, while there has been
considerable emphasis on designated traditional first-responders, a very
significant proportion of the services for recovery from major events
are in fact provided by non-traditional responders from social service,
faith-based, and community organizations. The opportunity to more
effectively engage the vast nation-wide resources of such organizations
in our fight against terrorism is evidenced through accounts of such
organizations responding to community needs in times of crisis. The
engagement of armies of compassion, represented by an array of faith and
community-based organizations, can and should be an integral part of the
fight against the effects of terrorism on our children and families.

### 6.1

**Initiate strategies to assist families, faith- and community-based
organizations, childcare facilities and other child-serving systems to
increase their capacity to respond to terror events.**

-   Convene a summit of community based organizations, including child
    and family serving systems, with experience in emergency management
    planning and response to review existing strategies and common
    practices utilized to build community resilience.

-   Provide funding and technical assistance to enable licensing
    authorities through state child welfare agencies and other state
    licensing authorities to develop emergency response plans and to
    provide related training to respond to disaster and terror events.
    State child care licensing bodies should be requested to include
    major event planning in their standards of care for such facilities.

-   Provide funding for Child Protective Service agencies to develop
    written plans and procedures for responding to a circumstance that
    would create a large number of homeless or orphaned children.
    Service delivery systems capable of meeting the needs of large
    numbers of bereaved children could be developed.

-   Recommend that local emergency management official encourage their
    faith community to participate in emergency response planning and
    training (such as completing the National Voluntary Organizations
    Active in Disasters (NVOAD) training for clergy).

-   Develop communication-related initiatives to increase the
    availability of communication within communities. For example, a
    pamphlet or web-based document should be designed and written to
    assist childcare facilities in planning for a major event. Training
    kits for childcare facilities and staff should be developed to
    facilitate enhanced preparedness.

-   Post the recommendations on family preparedness on the DHHS web site
    and launch a communication effort through national media to promote
    the availability of the information. This effort should be closely
    coordinated with the other federal agencies including the Department
    of Homeland Security.

-   Expand small-grant and outreach programs to provide networking
    opportunities and foster interaction between Primary Care Pediatric
    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 supported 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.

-   Provide mechanisms to develop regional response networks or centers
    to increase cooperation and resource sharing. In addition, identify
    and develop a mechanism to establish a network of National Community
    Response Support Teams comprised of specially trained members of the
    faith community, mental health providers, and social service
    professionals equipped to support the leadership of local
    faith-based organizations, social service organizations, and
    municipalities affected by a major event.

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

### 6.2

**Develop and support a multi-site initiative, involving at least six
demonstration projects, to identify and implement best practices for
integration of Federal, state and local responders with faith- and
community-based organizations in emergency management planning, training
and the building of community resilience related to children and
families.**

-   Include as key elements in the demonstration projects:

    -   methods and procedures used to integrate social service and
        volunteer organizations within the local emergency management
        plan;

    -   methods and procedures used to integrate the faith community
        within the local emergency management plan;

    -   identification of the processes and procedures used to mitigate,
        prepare for, respond to and recover from the effects of a major
        event;

    -   methods used to develop coordination across major response
        systems including health, emergency, education, and faith
        community; and

    -   study and presentation of strategies utilized to develop and
        evaluate methods of creating and sustaining community
        resilience.

-   Evaluate and disseminate nationally the best practices identified in
    this initiative, in collaboration with the Department of Homeland
    Security.

[7 -- Training]{.smallcaps}

![](media/image10.png){width="3.25in" height="2.0347222222222223in"}

Training and drills are essential components of any successful disaster
or terrorism response plan, but the training components of existing
disaster and terrorism response plans make little or no provision for
the unique needs and vulnerabilities of children. Because children
respond differently from adults when they are exposed to a terrorist
attack, they will require special interventions, which in turn
necessitate special training for all responders, whether Federal, state
and local governments or community and volunteer organizations.

It is essential that the United States develop and train an
interdisciplinary workforce of pediatric healthcare personnel to prepare
for and respond to a terrorist attack as well as to address the crucial
need for integration of healthcare professionals into the public health
network.

7.1

**Develop training programs to prepare a pediatric healthcare workforce
to gain the knowledge, skills and abilities to address the special needs
of children and that can be readily integrated into the public health
network. Training should include:**

-   recognizing indications of a terrorist event in their infant, child
    and adolescent patients;

-   treating infant, child and adolescent patients in a safe and
    appropriate manner; and

-   rapidly and effectively alerting the public health system of such an
    event at the community, state and national level.

7.2

Develop pediatric training programs related to the physical and mental
health effects of disasters and terrorism on children that includes
continuing education to health professionals already in practice; and
provide incentives for curricular reform in health professions schools
and training programs.

7.3

**Include a specific pediatric training component in all disaster and
terrorism response plans at the Federal, state and local level, and
support sustained training and evaluation by funding ongoing pediatric
disaster and terrorism drills for first responders, healthcare workers
and other relevant professionals and trainees. Recommendations
include:**

-   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) in real
    disaster drills.

-   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 Federal, state and local
    systems' capacity for pediatric patients.

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

-   Ensure that simulation software as developed for disaster and
    terrorism planning accounts for events with pediatric patients in
    proportion to their existence in the population. Events may
    disproportionately affect children, including having children as a
    majority of the victims. Simulation software and drill design must
    also 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". In
    addition, simulation software should account for the existence of
    children with special healthcare needs**.**

-   Involve children with special healthcare needs as part of the pool
    of victims in disaster and terrorism drills.

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

-   Support 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.

7.4

**Support a comprehensive approach to pediatric training on terrorism
and children, involving relevant organizations and partnerships.**

-   Initiate Request for Proposals (RFPs) for pediatric training to be
    conducted by relevant organizations, such as the American Public
    Health Association (APHA), National Association of City and County
    Health Officials (NACCHO), American Red Cross (ARC), and Association
    of State and Territorial Health Officials (ASTHO), to enhance the
    reach of terrorism training related to children.

-   Ensure that pediatric training is provided to relevant
    nontraditional first responders (e.g. clergy, school staff, members
    of social and volunteer organizations, parents, etc.)

**[8 -- Health Intelligence]{.smallcaps}**

![](media/image11.png){width="3.25in" height="2.1284722222222223in"}

Health Intelligence, the monitoring of the nation's health status, is a
crucial element in protecting America's children from terrorism. In
order for a disaster health intelligence system to be in a constant
state of maintenance and readiness, it must be the same system that is
used for day-to-day public health and emergency medical systems,
employing real-time networks that are fully supported and improved to
serve the jurisdiction\'s physical and mental health needs of children.

Local and state public health agencies must have the capacity to analyze
and report on patterns of pediatric 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, and
schools. Venues where children and families would likely be sheltered in
emergencies must have the capacity to report physical and mental health
needs that occur. This would include, but not be limited to, schools,
nursing homes, large employers, etc.

Merely having data is not enough. It must be analyzed and reported in
real time. Our current system of monitoring population health status is
not sensitive to children\'s propensity for adverse outcomes related to
civil disturbance that occur apart from their own direct injuries. Our
current methods of analysis would identify no pediatric-specific
patterns of symptoms or signs (\"surveillance definitions\") as needing
a public health response. We do not even require, let alone support,
that emergency response procedures include the scientific staffing and
analysis to design and set up research studies in the context of an
emergency response for children. But this is exactly what is needed if
future emergencies are to be met with more effective planning and
responses to meet the physical and mental health needs of children.

## 8.1

**Develop linkages necessary to ensure that the Federal, state and local
health intelligence systems support emergency planning, response, and
recovery and are competent in the area of health intelligence data
related to children\'s physical and mental health needs related to an
act of terror. This can be accomplished, at least in part, by:**

-   funding to allow DHHS, 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
    for children;

-   doubling the size of the current Epidemic Intelligence Service
    (EIS), recruiting more pediatricians and pediatric health
    specialists into it, and assigning at least one terrorism-specific
    EIS Fellow to each state and each local public health jurisdiction
    with a Metropolitan Medical Response Team;

-   doubling the size of the Global EIS program to assure, among other
    goals, that lessons learned abroad can be applied to the U.S.; and

-   funding 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), to create specific
    pediatric components to both programs.

## 8.2

**Ensure that the emergency response systems utilized to support
emergency planning, response, and recovery at Federal, state and local
levels fully include trained scientific and epidemiological
professionals with expertise in children's health. This should allow
emergency response systems to:**

-   Provide real-time analysis and pattern interpretation of children's
    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 children adversely affected
    by the emergency. Even if the children are not directly injured,
    their family members, neighbors, caretakers or co-workers may be;

-   Design and conduct intermediate- and long-term epidemiological
    studies and analyses of patterns of children's 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.

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-   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 include:

    -   coordination of all scientific studies of the effects of the
        emergency be by the emergency response epidemiologists;

    -   processing of all requests for data be through the emergency
        response epidemiologists who would then make a single request
        for all the needed data from participating institutions; and

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

**[9 -- Risk Communication and Public Education]{.smallcaps}**

![](media/image12.png){width="3.25in" height="2.347916666666667in"}

In the wake of disasters and terrorist attacks and alerts, families need
current, accurate information about ongoing events and on talking about
them to their children. Enhanced communication abilities during times of
crisis serve to enhance resilience and mitigate the detrimental impact
of a major event on the emotional and mental health of children and
families, including those communities not experiencing the direct
effects of a terror event or disaster. It is essential to recognize that
efforts to enhance child, family and community resiliency in times of
national emergency must include working through the vast communication
resources of the media. Although the media hold special independence in
the United States, developing appropriate cooperative communication
methodologies can ensure effective information dissemination in times of
crisis. A major outcome of poor communication is the potential for
undercutting public trust and future willingness to listen and adhere to
subsequent warnings and directions.

The information available on websites from federal agencies such as the
CDC, NIH, SAMHSA and FEMA, as well as relevant professional
organizations such as the American Academy of Pediatrics (AAP), the
American Psychological Association (APA) and the American College of
Emergency Physicians (ACEP), contains many consistent themes in
materials on risk communication to parents, including: maintain daily
routines, avoid exposure to the media, and anticipate children's
questions. However, much of the other content varies a great deal:
different sites give widely differing advice on how much information to
give children, nor is much of the material presented in ways that
relates to children's age level and maturity.

The importance of health-risk communications prior to and following
warning of potential exposures as well as actual disasters has been
underestimated. Few of the currently available materials are based on
research, and almost no guidance exists on how to disseminate
information to parents or on which messages have most relevance and
clarity. Research and experience with health risk communications,
informed by basic processes involved in forming and shaping attitudes,
affect, and behavior can help to shape communications.

### 9.1

**Implement risk communication strategies to positively affect the
nation as a whole during times of elevated threat levels and actual
terrorist events, in light of the special effects these threats and
events have on children.**

-   Identify broadly credible spokespeople who can address the nation
    with advice on how families can cope with the mental and emotional
    effects of a major event. The spokespeople should have the support
    of appropriate qualified personnel to formulate advice and
    recommendations for children and families. (First Lady Bush was
    highly effective in delivering advice to parents post-9/11.)

-   Expand initiatives such as the DHHS Number range CHAPTERpartnering
    with Sesame Street 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.

**9.2**

**Develop clear, concise and situation-specific guidance for parents,
caregivers and teachers concerning helping children to cope with
terrorism and disasters, and ensure that consistent information is
disseminated by all DHHS agencies.**

-   Convene a meeting of representatives of government agencies,
    national media sources, educators 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 pediatric mental health
    professionals during times of crisis.

-   Establish a *National Mental Health Preparedness and Communication
    Network*, a web-based information system accessible by community
    mental health providers and organizations, in which DHHS 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.

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-   Distribute widely basic information about appropriate preparation
    for disaster to all potential congregate settings for children. 
    Delineate mechanisms for identifying such settings and
    ensuring appropriate distribution.

**9.3**

**Develop and support a translational research initiative to develop
more effective methods of communicating to the public and to health and
human services professionals that recognize the special needs of
children and families.**

-   Develop RFPs to allow federal agencies to develop clear, concise,
    consistent, evidence-based and situation-specific guidance for
    parents, teachers and other relevant care providers on helping
    children to cope with terrorism and disasters.

-   Expand existing DHHS research and programs that are developing
    messages for parents and caretakers based on what is known about
    decision-making behavior, and for Centers for Public Health
    Preparedness (CPHP) to establish systems to inform parents and
    caregivers what systems are in place in schools, healthcare
    facilities and communities to deal with terrorism threats

-   Create a mechanism to enact systematic multi-national collaboration
    to share information and methodologies utilized to prepare for,
    mitigate, and respond to the impact of terror on children, families
    and communities.

-   Provide funding to DHHS mental health research agencies (NIH, CDC
    and SAMHSA) to conduct a translational research 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:

    -   communicating effectively about 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 that prevents
        negative consequences (e.g., panic, stigma, blaming, requests
        for unnecessary or inappropriate services) and promotes adaptive
        and responsible behavior to minimize risk and injury;

    -   potential scenarios for the use of biological agents, and the
        appropriate health-related behavior or response;

    -   information the public needs to form a realistic appraisal of
        personal risk and 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.

    -   perceptions of trustworthy spokespeople best suited to
        communicate risk messages; which messages are most effective,
        are sensitive to different values, raise or lead to ethical
        questions, etc.; and

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

**9.4**

Maintain a national toll-free number for public information pertaining
to children and conventional, chemical, biological, radiological and
nuclear events.

-   Broaden the missions of the CDC/ATSDR 24-hour hotline and emergency
    response teams and the Poison Control Centers (PCC), and integrate
    them to create a national toll-free number to serve as a national
    source of public information for chemical, biological, radiological
    and nuclear events. The CDC/ATSDR 24-hour hotline and emergency
    response team is already 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. Together with the Poison Control Centers (PCC), the
    hotline can become an integral and vital part of the health system
    and part of the continuum of necessary emergency services,
    particularly in light of chemical, biological, radiological and
    nuclear terrorism threats.

**NACCT Objective B -- Needed changes to the healthcare and emergency
medical service systems and emergency medical services to meet the
special needs of children.**

**[10 -- Emergency Medical Service Systems and Protocols]{.smallcaps}**

While preparation for terrorism is important, the general approach to
emergency response and management cannot be forgotten. Terrorism
response is a subset, which requires a valid public health structure,
health system, medical system, emergency medical system, and overall
approach to disaster preparedness.

Children's unique health and mental health needs require special
consideration in the area of emergency preparedness for terrorism.
However, many facilities lack the specialized equipment needed to care
for children, and many emergency personnel have not been provided with
the necessary education or training to provide optimal care to children.
Increased funding should be provided to programs such as the Emergency
Medical Services for Children (EMSC) grant program in order to assist
local communities in providing the best emergency care to children in
the event of terrorist attacks.

## 10.1

Support and enhance existing DHHS programs related to EMS to ensure that
the physical and mental health needs of children are met and that all
first responders and EMS personnel receive training in post-disaster
physical and mental health needs of children. 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 programs 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; and

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

![](media/image13.wmf){width="3.25in" height="2.1277777777777778in"}

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

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

-   Provision of increased funding 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.

## 10.2

**Working with the Secretary of Homeland Security, create Pediatric
Specialty Teams for the existing Disaster Medical Assistance Team (DMAT)
Program**. **Specifically, create one Pediatric Specialty Team per
Region, in addition to providing each regular DMAT Team with a pediatric
component including trained providers, equipment and pharmaceuticals**

-   Pediatric Specialty Teams within the DMAT program will provide this
    nation with a constant source of pediatric trained providers and
    equipment to supplement local resources in times of terrorism or
    natural disaster. While many DMAT teams do have some pediatric
    providers and some equipment, there is not a clear focus to address
    the needs of children in all responses and to provide a uniquely
    pediatric capable response when required.

## 10.3

**Conduct research on EMS pediatric emergency and terrorism preparedness
and response. This can be accomplished through:**

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

-   Establishing in the form of RFP and RFA from NIH research funding
    for studies related to EMS and Pediatric Emergency and Terrorism
    Preparedness including triage, assessment, treatment and mental
    health.

-   Creating mechanisms for Pediatric Emergency and Terrorism
    Preparedness research gaps identified by the EMSC program to be
    funded.

######  

###### 

###### NACCT Objective C -- Changes, if necessary to the National Pharmaceutical Stockpile under section 121 of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 to meet the emergency health security of children.

**[11 -- Strategic National Stockpile (SNS)]{.smallcaps}**

![](media/image14.wmf){width="2.125in" height="1.586111111111111in"}The
Strategic National Stockpile (SNS) was established in 1999 to assist
state and local governments in the delivery of essential medical
materials during an emergency. The mission of the SNS program is to
deliver pharmaceuticals and other medical materiel to the site of a
national emergency. The SNS program comprises pharmaceuticals, vaccines,
medical supplies and medical equipment that exist to augment depleted
state and local reserves for responding to terrorist attacks or other
emergencies. These supplies are stored in strategic locations around the
U.S. to ensure rapid delivery anywhere in the country. The SNS program
may deliver a 12-hr Push Package when the threat is unknown and a broad
medical response is needed. Alternatively, Vendor Managed Inventory
(VMI) shipments can be tailored to respond to a defined threat and
provide medical products specific to the suspected or confirmed threat.

The SNS stands ready for deployment to any US location within 12 hours,
and on September 11, 2001 the SNS program delivered fifty tons of
medical supplies to New York City within seven hours of the World Trade
Center attacks. Between October 15 and November 29, 2001, 3.75 million
doses of antibiotics for preventative post-anthrax exposure treatment
were delivered to postal workers, mail handlers and occupants of
affected buildings.

The SNS program has established significant buying power and rapid
purchasing capability through the Department of Veterans Affairs
National Acquisition Center. Through this mechanism, medical supplies
that are not part of the formulary and have adequate market availability
may be procured and rapidly delivered to areas of need without the
direct stockpiling of these products.

The SNS program's intent is to provide medical supplies and material
that meet the needs of all populations including children. The current
formulary provides pediatric specific medical equipment including
intravenous catheters, airway management equipment, suction and feeding
catheters, and antibiotic formulations. A review by the National
Advisory Committee on Children and Terrorism strongly supports the
addition of pharmaceuticals and medical supplies as identified by the
SNS pediatric gap analysis and SNS burn/blast and radiation review.

## 11.1

**Establish an annual Pediatric Subject Matter Expert (SME) review
process of the SNS program's pediatric capacity by relevant pediatric
subject matter experts to recommend pediatric formulary additions or
modifications in order to ensure continued and enhanced pediatric
capability and capacity of the SNS program.**

## 11.2

**Establish a process to determine prioritization of recommended
pediatric formulary additions or modifications to the SNS to maintain
and enhance pediatric capability and capacity of the SNS program.**

**General SNS Recommendations**

-   Establish a working group to review pediatric treatment protocols
    for events involving biological, chemical, or radiological agents.
    The primary goal is achievement of a national standard for treatment
    protocols.

-   Establish a working group to develop a list of emergency use
    Investigational New Drugs (INDs) needed for treatment of pediatric
    population in for events involving biological, chemical, or
    radiological agents.

-   Review all state and local communities' distribution plans for
    pediatric specific equipment.

-   Increase the visibility of the pediatric capabilities of the SNS
    program.

-   Evaluating purchasing mechanisms for pediatric specific equipment.

-   Ensure that state and local communities evaluate their pediatric
    equipment and medical inventories and capacities to treat pediatric
    patients and coordinates this assessment with neighboring states.

-   Ensure state and local communities dedicate time and staff resources
    for distribution and administration of pediatric resources.

-   Currently the Strategic National Stockpile (SNS) utilizes 2000 U.S.
    Census data for use in calculating equipment and pharmaceutical
    needs. The Committee recommends that specific data for pediatric
    population be obtained through future research on the impact of
    disaster on the pediatric population and more specific population
    demographics of communities.

-   Include tetanus toxoid for emergency use in the strategic planning
    of the National Immunization Stockpile.

**Formulary Specific SNS Recommendations**

-   The Committee recommends that SNS program use 9 years of age as the
    cutoff age for determining the requirements for antibiotic
    suspensions. The Committee favors antibiotic suspension formulations
    over chewable tablets.

-   The Committee recommends that the 12-hr Push Package be designed to
    have a pediatric specific container/s. This will assist in the
    distribution of pediatric supplies.

-   The Committee recommends review of Epogen for treatment of anemia
    secondary to trauma to reduce the need for blood transfusions.

-   The Committee recommends the inclusion of cytokines for treatment of
    radiation induced neutropenia.

-   The Committee recommends that sufficient quantities of thiosulfate
    for the treatment of 1000 pediatric patients be added to the
    formulary.

-   The Committee recommends that there is an emergency use IND
    developed for Mark 1 Jr Kits.

-   The Committee strongly recommends that future SNS formulary
    additions include assets to treat burn/blast and radiation injuries.
    At a minimum that these additions be sufficient to treat 2500
    pediatric patients.

-   The Committee strongly supports the addition of the following
    pharmaceuticals and medical supplies as identified by SNS pediatric
    gap analysis, and SNS burn/blast and radiation review.

    -   Additional airway management equipment

    -   Medication Delivery Systems such as spacers and masks

    -   Additional ancillary supplies for IM administration of
        medications

    -   Alternative sedatives and analgesics

    -   Additional IV antibiotics

    -   Alternative concentrations of intravenous antibiotic solutions

#### [Appendix 1 -- NACCT Membership]{.smallcaps}

# 

# CHAIR

Diaz, Angela, MD, MPH FAAP

Jean C and James W Crystal Professor of Pediatrics and Community
Medicine

Mount Sinai School of Medicine

Director, Mount Sinai Adolescent Health Center

# EXECUTIVE SECRETARY

Henderson, Joseph

Associate Director of Terrorism Preparedness and Emergency Response

Office of Terrorism Preparedness & Emergency Response

Centers for Disease Control and Prevention

# MEMBERSHIP

Dinnin, Kevin C., CFRE

President and Chief Executive Officer

Baptist Child and Family Services

Greene, Brenda Z.

Director, School Health Programs

National School Boards Association

Kelter, Alexander, MD

Chief, Epidemiology and Prevention for Injury Control Branch

Chronic Disease & Injury Control Division

California Department of Health Services

Maniece-Harrison, Bobbie, EdD

Adjunct Associate Professor

Department of Health Studies

New York University

Marans, Steven R., PhD

Director, National Center for Children Exposed to Violence

Harris Associate Professor of Child Psychoanalysis and Psychiatry, Yale
University School of Medicine

Mickalide, Angela Denise, PhD CHES

Program Director, National SAFE KIDS Campaign

Mollica, Richard F., MD, MAR

Professor of Psychiatry, Harvard Medical School

Director, Harvard Program in Refugee Trauma

Massachusetts General Hospital

Ricciardi, Richard, MS

Chief, Primary Care Nursing

Kimbrough Ambulatory Care Center

Assistant Professor of Nursing, Uniformed Services University

Rumm, Peter D, MD, MPH

Chief Medical Officer

Division of Public Health

Wisconsin Department of Health & Family Services

Wright, Jean A, MD, MBA

Executive Director

Backus Children's Hospital

**CONSULTANTS**

Chemtob, Claude, PhD

Clinical Professor of Psychiatry and Pediatrics

Mount Sinai School of Medicine

Cieslak, Colonel Theodore J., MD, FAAP

Chairman, San Antonio Military Pediatric Center

Consultant, Biodefense Issues, Office of the Army Surgeon General

Cooper, Louis Z, MD, FAAP

Professor of Pediatrics, Columbia University

Immediate Past President, American Academy of Pediatrics

Chair-Emeritus, Department of Pediatrics, St. Luke's-Roosevelt Hospital
Center

Henretig, Fred M., MD, FAAP, FACMT

Medical Director, Poison Control Center

Children's Hospital of Philadelphia

Professor of Pediatrics and Emergency Medicine

University of Pennsylvania School of Medicine

Holbrook, Peter R., MD, FAAP, FCCM

Chief Medical Officer, Children's National Medical Center

Professor of Pediatrics and Anesthesiology, George Washington University
School of Medicine

Markenson, David, MD, EMT-P, FAAP

Director, Program for Pediatric Preparedness\
National Center for Disaster Preparedness\
Mailman School of Public Health

Assistant Professor of Pediatrics, Columbia University College of
Physicians and Surgeons

Pfefferbaum, Betty, MD, JD

Paul and Ruth Jonas Chair

Professor and Chairman,

Department of Psychiatry and Behavioral Sciences

College of Medicine, University of Oklahoma Health Sciences Center

Redlener, Irwin, MD, FAAP

Director, National Center for Disaster Preparedness

Associate Dean, Columbia University Mailman School of Public Health

**FEDERAL ADVISORS**

Amler, Robert W., MD, MS, FAAP, FACPM

Chief Medical Officer

Agency for Toxic Substances and Disease Registry

Cono, Joanne, MD, ScM

Medical Epidemiologist

Bioterrorism Preparedness and Response Program

Centers for Disease Control and Prevention

Feerick, Margaret, PhD

Program Director, Child Development and Behavior Branch

National Institute of Child Health and Human Development

National Institutes of Health

Jones, Wanda K., DrPH

Deputy Assistant Secretary for Health (Women\'s Health)

Department of Health and Human Services

Office on Women\'s Health

Kessel, Woodie, MD, MPH, FAAP

Senior Child Health Science Advisor

Department of Health and Human Services**\
**Office of Public Health and Science, Office of the Secretary

Office of Disease Prevention and Health Promotion

Kolbe, Lloyd J., PhD

Director, Division of Adolescent & School Health

National Center for Chronic Disease Prevention and Control

Centers for Disease Control and Prevention

Modzeleski, William, MPA

Associate Deputy Under Secretary

Office of Safe and Drug-Free Schools

U.S. Department of Education

Pesik, Nicki, MD

Senior Medical Consultant to Strategic National Stockpile

Strategic National Stockpile Program

Pickering, Larry, MD FAAP

Senior Advisor to the Director

National Immunization Program

Centers for Disease Control and Prevention

Reissman, Dori B., MD, MPH

Senior Advisor for Disasters, Terrorism and Mental Health

National Center for Injury prevention and Control

Centers for Disease Control and Prevention

Rivera-Casale, Cecilia, PhD

Senior Project Officer

Substance Abuse and Mental Health Services Administration

Emergency Services and Disaster Relief

Roberts, Rosemary, MD FAAP

Deputy Director, Office of Counter-Terrorism and Pediatric Drug
Development

Center for Drug Evaluation and Research

Food and Drug Administration

Shaffer, Cyndi, MPH

Emergency response Coordinator

Office of Chemical and Radiological Terrorism Preparedness and Response

National Center for Environmental Health

Centers for Disease Control and Prevention

Smith, Richard J, MS

Chief, Injury/Emergency Medical Services Branch

Maternal and Child Health Bureau

Health Resources and Services Administration

Tuma, Farris, ScD

Chief, Traumatic Stress Program & Disruptive Behaviors Disorders
Programs

National Institute of Mental Health

National Institutes of Health

Yeskey, Kevin S., MD (invited)

Chief Medical Officer

Department of Health and Human Services

Office of Public Health Science

Office of Emergency Preparedness

Office of Homeland Security

**COMMITTEE STAFF**

Balaban, Victor, PhD

NACCT Report Coordinator

Division of Unintentional Injuries Prevention

(Detail to Office of Terrorism Preparedness and Emergency Response)

Centers for Disease Control & Prevention

Loy, Amy

NACCT Project Manager

Office of Terrorism Preparedness and Emergency Response, Office of the
Director

Centers for Disease Control & Prevention

**Appendix 2 -- Selected DHHS Accomplishments and Current Initiatives
Relating to Children and Terrorism**

The gaps in America's preparedness for the effects of terrorism on
children identified in these NACCT recommendations should not obscure
the fact that DHHS has responded to the crisis with a wide array of
important programs and initiatives including:

Agency for Healthcare Research and Quality (AHRQ)

-   In February 2003, AHRQ and HRSA's EMSC program provided funding for
    the National Pediatric Disaster Preparedness and Response Consensus
    Meeting to develop consensus recommendations, delineate research
    methodologies and define a research on the needs of children in
    disasters. The conference report has been published and distributed.

**Agency for Toxic Substances and Disease Registry (ATSDR)**

-   ATSDR actively supports and maintains a national network of
    Pediatric Environmental Health Specialty Units (PEHSUs) that provide
    expert consultation, training, and public education on chemical
    exposures in infants and children. Co-funded by the Environmental
    Protection Agency (EPA), these PEHSUs are a valuable asset in the
    all-hazards approach to preparedness and disaster planning, and
    proved instrumental after the terrorist attacks in 2001**.** Each
    PEHSU encompasses, in one regional facility, a multidisciplinary
    complement of specialists from critical fields of expertise. They
    are actively training clinicians 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.

-   ATSDR publishes and disseminates extensive informational resources
    in clinical toxicology with specific sections dealing with health
    issues affecting infants and children. The *ATSDR Toxicological
    Profiles*, *Tox FAQs*, and *Medical Management Guidelines* account
    for the special vulnerabilties of children to acute and long-term
    chemical exposures.

**Centers for Disease Control and Prevention (CDC)**

-   The CDC has responded to public health emergencies for decades, and
    has been preparing for bioterrorism since 1998. The nature of public
    health is such that many activities are designed to benefit the
    health and well being of entire communities, including children,
    even when they are not specifically designated as recipients. The
    CDC has responded to the special needs of children and terrorism by
    using existing resources, modifying existing programs and
    initiatives, providing technical assistance, and whenever possible
    initiating new projects, to assess and respond to the unique needs
    and vulnerabilities of children in the aftermath of terrorism and
    disasters. There is a great deal more that could be accomplished
    with resources specifically designated for the emergency public
    health preparedness of children. Among the many new and ongoing CDC
    efforts to prepare children and families for potential terrorism:

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-   CDC's Office of Terrorism Preparedness and Emergency Response (newly
    created in December 2002) provided all management, resources and
    staffing for the research and writing of these recommendations of
    the National Advisory Committee on Children and Terrorism.

-   CDC Preparedness Grants: Through the states, the CDC last year
    disseminated approximately \$918,000,000 dollars to improve national
    state and local health preparedness.

-   The Strategic National Stockpile (SNS) delivers antibiotics,
    vaccines and pediatric equipment and pharmaceuticals designed for
    children anywhere in the United States within 12 hours of a federal
    decision to deploy. (This has now been transferred to the Department
    of Homeland Security but the CDC will interact with states to order
    deployment in an emergency).

-   Information and fact sheets on children and terrorism are being made
    available on the CDC web site.

-   The National Center for Injury Prevention and Control (NCIPC) is
    developing guidelines and assessment tools for rapid assessment of
    injuries and mental health, for children and adults, in the
    immediate aftermath of terror attacks, large-scale disasters and
    emergencies. NCIPC is also conducting an investigation into the
    behavioral and psychological responses to the sniper attacks in the
    Washington, D.C. metropolitan area which includes an assessment of
    effects on children and families, and is supporting projects
    assessing adolescent and adult exposure and reactions to the
    September 11 World Trade Center attacks.

-   A study of the World Trade Center evacuation is being conducted by
    the CDC, under NCIPC leadership, in coordination with a study by the
    National Institute for Standards and Technology. These studies
    together are expected to yield information that will enhance the
    safety of occupants in tall buildings by improving understanding of
    human behavior, and emergency response, as well as enabling
    improvements in US building and fire codes, standards and practices.

-   The CDC gave technical assistance to a survey commissioned and
    sponsored by the New York City Board of Education that assessed the
    mental health effects of the September 11 attacks on over 8,000
    school children in New York City public schools. The Department of
    Education\'s School Emergency Response to Violence (SERV) Project
    also provided funds to the New York City Department of Education for
    the data collection portion of the investigation.

-   CDCs Epidemic Intelligence Service Officers were deployed
    immediately after the World Trade Center attacks. One hundred thirty
    six CDC EIS officers have been deployed to assist state and local
    public health agencies since September 11, 2001. Many others were
    assigned to monitor for signs of bioterrorism-related illnesses in
    New York, Florida, New Jersey, Washington, D.C. and Connecticut in
    response to the 2001 anthrax release.

-   The National Center for Environmental Health has proposed a
    chemical/radiological illness surveillance initiative to ensure
    early detection of a release of a biological, chemical, or
    radiological agent. This will include preparing for post-event
    surveillance, initiation of a data-sharing system among
    laboratorians, epidemiologists, and health departments, and the
    deployment of response teams.

-   In May 2002, , the CDC, the Department of Education, the Federal
    Emergency Management Agency (FEMA) and the Federal Bureau of
    Investigation (FBI) collaborated to host a teleconference to provide
    state and local education, 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.

**Food and Drug Administration (FDA)**

-   FDA has a public health mandate to facilitate the availability of
    safe and effective drugs, vaccines, and medical devices for
    individuals exposed to a biological, chemical, radiological or
    nuclear agent. The agency is working to get medical countermeasures
    off investigative status and approved with appropriate use
    information including for special populations such as children. In
    particular, the Center for Drug Evaluation and Research (CDER)
    contains an office devoted to Counter-Terrorism and Pediatric Drug
    Development.

**Health Resources and Services Administrations (HRSA)**

-   HRSA manages two programs which directly focus on bioterrorism and
    other public health emergencies and three programs which to varying
    degrees have significant common interest with terrorism and other
    public health emergencies.

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-   The Bioterrorism Hospital Preparedness Program strives to improve
    the capacity of the Nation's hospitals and emergency departments to
    respond to biological, chemical, radiological, and explosion events
    of terrorism or other public health emergencies. The program allows
    for State and regional planning among local hospitals, EMS systems,
    community health centers, poison control centers, and other
    healthcare facilities to improve their preparedness to work together
    to combat terrorist attacks.

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-   The goal of the Bioterrorism Curriculum Development and Training
    Program is the development of a healthcare workforce that possesses
    the knowledge, skills and abilities to (1) recognize indications of
    a terrorist event in their patients; (2) treat their patients in a
    safe and appropriate manner; and (3) rapidly and effectively alert
    the public health system of such an event at the community, State
    and national level.

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-   The Emergency Medical Services for Children (EMSC) Program assists
    States to improve emergency care for children, as well as enable
    States to continue to promote regionalized care.

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-   With funding provided by the EMSC Program and the Agency for
    Healthcare Research and Quality, Children\'s Hospital at Montefiore
    convened the *Pediatric Preparedness for Disasters and Terrorism: A
    National Consensus Meeting* in Washington, DC in 2003.

-   The EMSC initiative for Enhancing Pediatric Patient Safety (EPPS) is
    a demonstration project 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.

-   With an EMSC grant, the Children\'s Hospital of Philadelphia (CHOP)
    studied the mental health impact of emergencies on children and
    supported the development of the \"After the emergency is over:
    post-traumatic stress disorder in children and youth\" fact sheet.

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

-   EMSC Program funding was utilized to develop a training video for
    the JumpSTART pediatric multi-causality triage protocol.

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-   The Poison Control Centers Program assists in stabilizing the
    availability of this 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.

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-   The Trauma/Emergency Medical Services Program goal is to facilitate
    the development of national trauma system infrastructure where each
    State has a legislatively defined trauma system, which coordinates
    regional systems to administer quality, cost effective care at the
    local level.

**National Institutes of Health (NIH)**

**National Institute of Child Health and Human Development (NICHD)**

-   In July of 2002, NICHD hosted a research agenda-building workshop,
    in collaboration with nine other federal agencies including the
    National Institute of Mental Health (NIMH), the National Institute
    on Drug Abuse (NIDA), the Office of Behavioral and Social Sciences
    Research (OBSSR), and the Fogarty International Center (FIC) of the
    National Institutes of Health, the Centers for Disease Control
    (CDC), the Substance Abuse and Mental Health Services Administration
    (SAMHSA), the Office of Special Education Programs of the Department
    of Education, the Office of the Assistant Secretary for Planning and
    Evaluation (ASPE), and the National Institute of Justice (NIJ) in
    the Department of Justice, on Children Exposed to Violence,
    including war and terrorism. Based on this workshop, the NICHD has
    published a program announcement with setaside funds (totaling
    approximately \$3 million per year) on research on children exposed
    to violence, including the epidemiology, identification, and
    assessment of children exposed to war/terrorism, and consequences,
    services, and interventions for these children.

**National Institute of Mental Health (NIMH)**

-   NIMH has been supporting research on the mental and behavioral
    health consequences of mass trauma, including disasters and
    terrorism for many years. Research conducted after various types of
    disasters (Oklahoma City Bombing, Hurricane Andrew; Three Mile
    Island disaster; 1989 San Francisco Bay area earthquake; 1991/92
    Iraqi missile attacks on Israeli civilians; and the terrorist
    attacks on New York City on 9/11/01) has enabled NIMH to provide
    guidance on the magnitude and range of mental and behavioral health
    consequences of mass trauma, what steps can be taken to minimize
    adverse outcomes, and the effectiveness of intervention strategies.
    Shortly after the September 2001 attacks on the Pentagon and World
    Trade Centers, NIMH took steps to fund new research (10 studies) and
    enhance existing data collection (9 studies) specific to the
    attacks. These projects focus on:

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-   Epidemiology of exposure and reactions.

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

-   Mental health impact of bioterrorism.

-   The health impact of chronic threat of terrorism.

-   Psychobiological mechanisms by which trauma infers risk for adverse
    outcomes in children and adults.

-   Interventions (psychotherapy and medication) to reduce the risk of
    disorder and disability.

**Substance Abuse and Mental Health Services Administration (SAMSHA)**

-   SAMSHA is providing funding to the National Center for Child
    Traumatic Stress/Terrorism and Disaster Branch and the broader 37
    site National Child Traumatic Stress Network. This growing program
    has three components: 1) National Center for Child Traumatic
    Stress; 2) Intervention Development and Evaluation Centers; and 3)
    Community Treatment and Service Centers. Each of these are resources
    for both states and local entities to collaborate with on terrorism
    preparedness, and SAMHSA has held a number of training courses for
    public health and private providers.

-   SAMHSA has developed "A Guide for Intermediate and Long-Term Mental
    Health Services After School-Related Violent Events", a guide
    prepared through a Federal inter-agency project with the Department
    of Education Project SERV (School Emergency Response to Violence).
    The guide was prepared as part of a project entitled "The Mental
    Health Component of Project SERV", and it provides guidelines for
    school staff and community mental health personnel to establish and
    maintain immediate, intermediate, and longer-term mental health
    recovery services necessary to restore the social and emotional
    equilibrium and well being of students and staff after violent
    events.

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[^1]: Please note how the following terms have been defined by the
    NACCT. "Healthcare" refers to all aspects of children's physical and
    mental health related to preparedness and response to conventional,
    chemical, biological, radiological and nuclear terrorism.
    "Bioterrorism," with exception to referencing the Public Health
    Security and Bioterrorism Preparedness and Response Act of 2002, is
    hereinafter identified as "terrorism" and includes conventional,
    chemical, biological, radiological and nuclear threats, events and
    effects. Finally, the population of the United States referred to as
    "children" or "pediatric" throughout this document must be
    understood to include newborns, infants, children and adolescents,
    including those with special needs.

    The Committee also noted terrorism-related risks associated with
    pregnancy and childbirth. Pregnant women may be injured or exposed
    to toxic and/or teratogenic agents in the course of terror events,
    and any large scale disaster plan must also take into consideration
    the likelihood of women giving birth during or immediately after a
    terror event. While these considerations are beyond the purview of
    this Committee and the expertise of its members, this is an
    important issue for disaster and terror planning that should be
    explored in the future.

[^2]: A fundamental part of meeting the needs of children in the face of
    the threat of terrorism will be to identify and implement best
    practices relating to children's physical, medical, psychological
    and social needs in all phases of preparation, planning, response
    and recovery from terror events. The consensus reached in these
    NACCT recommendations, together with those in the recently published
    report of the National Pediatric Disaster Preparedness and Response
    Consensus Meeting, both carried out with DHHS funding, are
    significant steps in that process.

[^3]: The role of DHHS in conducting this survey should be noted. The
    Centers for Disease Control and Prevention (CDC) gave technical
    assistance in the design and implementation of the survey,
    commissioned and sponsored by the New York City Board of Education.
    The Department of Education\'s School Emergency Response to Violence
    (SERV) Project also provided funds to the New York City Department
    of Education for the data collection portion of the investigation.