NATIONAL COMMISSION

ON

Children and Disasters

INTERIM REPORT

october 14, 2009

NATIONAL COMMISSION ON CHILDREN AND DISASTERS

NATIONAL COMMISSION ON CHILDREN AND DISASTERS

1250 Maryland Avenue, SW

Portals 8th Floor East

Washington, DC 20447

NATIONAL COMMISSION ON CHILDREN AND DISASTERS INTERIM REPORT OCTOBER 14, 2009


Foreword

Mr. President and Members of Congress:

We are pleased to deliver the Interim Report of the National Commission on Children and 

Disasters, which summarizes our work over the past twelve months.

Children comprise nearly 25 percent of the U.S. population. They represent the promise of 

our nation. We are confident most Americans in the face of a disaster would place the lives 

and well-being of children above all else. Yet it is sobering to inform you that when it comes 

to disaster planning and management across our great nation, children are not placed on par 

with adults. In fact, state and local emergency managers are required by federal law to meet 

the needs of pets in their disaster plans, but not children.

Rather, children are considered an “at risk,” “vulnerable” or “special needs” population 

and subsequently grouped among the elderly, persons with disabilities, the medicallydependent, and persons with special transportation needs or limited English proficiency. 

In general, children do not fit into these broad categories. Among so many competing 

concerns, children are given less attention than necessary when disaster plans are written and 

exercised, equipment and supplies are purchased and disaster response and recovery efforts 

are activated. All 74 million children in this country must be considered and planned for as 

children. And while, for example, children with disabilities may require distinct planning and 

assistance in disasters, all children should be considered an integral part of, and many times 

an asset to, the general population. 

Throughout this Interim Report, the Commission cites instances of what we characterize as 

“benign neglect” of children. The consequences of the benign neglect become magnified 

when children are disproportionately affected by disasters. For example, in April 2009, 

the H1N1 flu outbreak quickly illustrated this point when it was clear that children were 

disproportionately affected.1

 Despite extensive planning for a much larger flu pandemic 

affecting the general population, the public health concerns of children created by the H1N1 

outbreak prompted school and day care closings, creating challenges for accurate and timely 

communication to school administrators, child care operators, and parents, and economic 

consequences for families, small businesses and communities. H1N1 serves as a stark 

reminder of the central position children hold in the family and community. 

Making children an immediate priority in disaster planning and management instills public 

confidence and creates greater stability to help families and communities recover faster. 

Federal Emergency Management Agency (FEMA) Administrator Craig Fugate invokes an 

ideal metaphor from his experiences in managing disasters in Florida, stating that there is 

no stronger indicator of hope and optimism to a disaster-affected community than to see a 

yellow school bus making its way down a neighborhood street. 

1 U.S. Centers for Disease Control and Prevention, “2009 Pandemic Influenza A (H1N1) Virus Infections,” Morbidity and Mortality Weekly Report 58, no. 33 

(2009), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5833a1.htm.

ii NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
We recognize tangible examples of progress to prepare for and respond effectively to 

children, and we are encouraged by the enthusiasm of partners and stakeholders to engage 

the Commission in its work. Repeatedly, we have been told that yes, children should and must 

be a priority. However, much more needs to be done to bring about a sweeping change in 

disaster planning and management culture that currently favors able-bodied adults with better 

means to survive and fully recover from disasters. 

This Interim Report is a prelude to a more extensive body of work that will be presented 

in the Commission’s Final Report , due in October 2010. Over the next twelve months, we 

will dedicate our energies to closely monitoring the implementation of recommendations 

contained in the Interim Report and other initiatives, while simultaneously focusing our 

research more intensively on program evaluation, best practices, the examination of emerging 

issues and development of clear, actionable recommendations. 

Given the rise in the number of disasters over the past two decades and the emergence of 

H1N1, the work of this Commission is certainly as timely as it is essential. With your support 

and assistance, we must inspire a national movement that marks the beginning of the end to 

the cycle of benign neglect. 

Thank you for the opportunity to serve. We look forward to working with you in this most 

important endeavor. 

Respectfully submitted, 

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT iii
Acknowledgements 

The Commissioners wish to thank the following individuals for their dedication, 

commitment and professionalism in researching, drafting and editing the Interim 

Report: Christopher J. Revere, MPA, Executive Director and Co-Editor, CAPT 

Roberta Lavin, Ph.D., APRN-BC, USPHS, Designated Federal Official and CoEditor, Tener Goodwin Veenema, Ph.D., MPH, MS, FNAP, Lead Writer and 

Expert Consultant in Disaster Management to the Commission, Victoria A. 

Johnson, MS, Policy Director, and Randall Gnatt, J.D., Policy Specialist. Special 

thanks are also given to CMDR Stephanie Bardack, USPHS, for conducting an 

extensive literature review and creating our research database, and Frank 

Valliere, MA, for his fact checking and citation work. The Commissioners also 

extend their appreciation to the National Coalition on Children and Disasters and 

many others who testified at public meetings, field hearings, participated as 

members of subcommittees and who contributed white papers, letters and emails 

to inform the public debate on the wide array of issues within the scope of the 

Commission's work. The Commissioners also thank Vinicia Mascarenhas, 

Communications Director, Matthew Seney, Communications Specialist, and 

Jacqueline Haye, Executive Assistant for their untiring efforts in assisting the 

Commissioners and making the work of the Commission accessible to the public 

and stakeholders. And finally the Commissioners greatly thank the U.S. 

Department of Health and Human Services, Administration for Children and 

Families, especially Deputy Assistant Secretary Curtis Coy, Carol Apelt and the 

Office of Human Services Emergency Preparedness and Response for their 

unwavering operational and logistical support.
Contents 

Abbreviations vi 

Background vii 

Executive Summary viii 

Introduction xii 

 1. Disaster Management and Recovery 1 

 2. Mental Health 7 

 3. Child Physical Health and Trauma. 13 

 4. Emergency Medical Services and Pediatric Transport 23 

 5. Disaster Case Management. 29 

 6. Child Care 33 

 7. Elementary and Secondary Education 29 

 8. Child Welfare and Juvenile Justice 45 

 9. Sheltering Standards, Services and Supplies 51 

 10. Housing 55 

 11. Evacuation 61 

Appendices 67

 A Literature Collection Methodology 69 

 B Standards and Indicators for Disaster Shelter Care for Children 70 

 C Supplies for Infants and Toddlers in Mass Care Shelters and Emergency Congregate Care Facilities 73 

 D Subcommittee Members and Other Contributors 79 

 E Stakeholder Outreach. 82 

 F Commissioner Biographies 84 

 G Commission Staff 87 

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT | v 
vi NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

AHRQ Agency for Healthcare Research and Quality

ALS Advanced Life Support

ARC American Red Cross

ASPR HHS Office of the Assistant Secretary for Preparedness and Response

BLS Basic Life Support

CBRNE Chemical, Biological, Radiological, Nuclear and Explosive

CCDBG Child Care and Development Block Grant Act of 1990

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare and Medicaid Services

CONOPS Concept of Operations

DHS Department of Homeland Security

DMAT Disaster Medical Assistance Team

DoEd Department of Education

EMS Emergency Medical Services

EMSC Emergency Medical Services for Children

ESF Emergency Support Function

EUA Emergency Use Authorization

FDA Food and Drug Administration 

FEMA Federal Emergency Management Agency

FETIG Federal Education and Training Interagency Group for Public Health and 

Medical Disaster Preparedness and Response

GAO Government Accountability Office

HHS Department of Health and Human Services

IOM Institute of Medicine

NDMS National Disaster Medical System

NIH National Institutes of Health

NRF National Response Framework

PHEMCE Public Health Emergency Medical Countermeasures Enterprise 

PKEMRA Post Katrina Emergency Management Reform Act of 2006

PST Pediatric Subspecialty Team

REMS Readiness and Emergency Management for Schools

SEA State Education Agency

SNS Strategic National Stockpile

Abbreviations
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT vii

Background

The National Commission on Children and Disasters (“the Commission”) was established 

pursuant to the Kids in Disasters Well-being, Safety and Health Act of 2007 as provided in 

Division G, Title VI of the Consolidated Appropriations Act of 2008.2

 The Commission’s status 

as an independent Federal Advisory Committee was clarified in Division A, Section 157 (b) of 

the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act of 2009.3

The Commission shall conduct a comprehensive study to independently examine and 

assess the needs of children (0-18 years of age) in relation to the preparation for, response 

to and recovery from all-hazards, including major disasters and emergencies, by building 

upon the evaluations of other entities and avoiding unnecessary duplication by reviewing 

the findings, conclusions and recommendations of these entities. In addition to this Interim 

Report, the Commission will submit a Final Report to the President and Congress no later 

than October 14, 2010. 

The Commission shall report specific findings, conclusions and recommendations relating 

to: 1) child physical health, mental health and trauma; 2) child care in all settings; child 

welfare; 3) elementary and secondary education; 4) sheltering, temporary housing and 

affordable housing; 5) transportation; 6) juvenile justice; 7) evacuation; 8) relevant activities in 

emergency management; and 9) the need for planning and establishing a national resource 

center on children and disasters. The Commission shall also report on coordination of 

resources and services, administrative actions, policies, regulations and legislative changes as 

the Commission considers appropriate.4

The Commission is bipartisan, consisting of ten members appointed by the President and 

Congressional leaders. Commission members represent a variety of disciplines, including 

pediatrics, state and local emergency management, emergency medical services, nongovernmental organizations dedicated to children and state elected office. The Commission 

organized four subcommittees comprised of Commissioners, and federal and nonfederal representatives: 1) Education, Child Welfare and Juvenile Justice; 2) Evacuation, 

Transportation and Housing; 3) Human Services Recovery; and 4) Pediatric Medical Care. 

The Commission meets publicly on a quarterly basis and subcommittees meet monthly to 

address their specific focus areas.

2 Public Law (P.L.) 110-161 (2008).

3 P.L. 110-329 (2009).

4 P.L. 110-161 (2008).
viii NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

Executive Summary

The National Commission on Children and Disasters was created by Congress to 1) conduct 

a comprehensive study that examines and assesses the needs of children as they relate to 

preparation for, response to and recovery from all hazards, including major disasters and 

emergencies; and 2) submit a report to the President and Congress on the Commission's 

specific findings, conclusions and recommendations. 

The recommendations contained in this Interim Report fall within the following categories: 1) 

Disaster Management and Recovery; 2) Mental Health; 3) Child Physical Health and Trauma; 

4) Emergency Medical Services and Pediatric Transport; 5) Disaster Case Management; 6) 

Child Care; 7) Elementary and Secondary Education; 8) Child Welfare and Juvenile Justice; 9) 

Sheltering Standards, Services and Supplies; 10) Housing; and 11) Evacuation.

1. DISASTER MANAGEMENT AND RECOVERY

1.1: Distinguish and comprehensively integrate the needs of children across all interand intra-governmental disaster planning activities and operations.

•	 Establish a focus on children and disasters within the Federal Emergency Management Agency 

(FEMA) and the White House, supported by policy and operational expertise from across the 

federal government, non-federal partners and relevant non-governmental organizations.

•	 Incorporate meeting the needs of children as a distinct priority throughout base disaster 

planning documents and relevant grant programs. 

•	 Include children in relevant target capabilities, preparedness training and exercises, with 

specific target outcomes and performance measures.

1.2: Accelerate the development of a National Disaster Recovery Strategy with an 

explicit emphasis on addressing the immediate and long-term physical and mental 

health, educational, housing and human services recovery needs of children. 

2. MENTAL HEALTH

2.1: Integrate mental and behavioral health for children into all public health and 

medical preparedness and response activities.

2.2: Enhance the research agenda for children’s disaster mental and behavioral health, 

including psychological first aid, cognitive-behavioral interventions, social support 

interventions and bereavement counseling and support.

2.3: Enhance pediatric disaster mental and behavioral health training for professionals and 

paraprofessionals, including psychological first aid, cognitive-behavioral interventions, 

social support interventions and bereavement counseling and support.
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT ix

3. CHILD PHYSICAL HEALTH AND TRAUMA

3.1: Ensure availability and access to pediatric medical countermeasures at the federal, 

state and local level for chemical, biological, radiological, nuclear and explosive 

(CBRNE) threats.

•	 Provide funding for the development, acquisition and stockpiling of medical countermeasures 

specifically for children for inclusion in the Strategic National Stockpile (SNS) and all other 

federally funded caches. 

•	 Form a standing advisory body of federal partners and external experts to advise the 

Department of Health and Human Services (HHS) Secretary on issues pertaining specifically 

to pediatric emergency medical countermeasures. 

•	 Include pediatric expertise on all relevant committees and working groups addressing issues 

pertaining to medical countermeasures. 

3.2: Expand the medical capabilities of all federally funded response teams through the 

comprehensive integration of pediatric-specific training, guidance, exercises, supplies 

and personnel.

•	 Designate or establish a Pediatric Health Care Coordinator on each federally funded medical response 

team and develop strategies to recruit and retain team members with pediatric medical expertise.

•	 Establish an Associate Chief Medical Officer for Pediatric Care in the office of National 

Disaster Medical System (NDMS). 

•	 Develop pediatric capabilities within each NDMS region to ensure robust pediatric disaster 

response and enhanced surge capacity. 

3.3: Ensure that all health care professionals who may treat children during an 

emergency have adequate pediatric disaster clinical training specific to their role.

•	 Form a Pediatric Disaster Clinical Education and Training Working Group to establish core 

clinical competencies and a standard, modular pediatric disaster health care education and 

training curriculum. 

3.4: Provide funding for a formal regionalized pediatric system of care for disasters.

•	 Build upon the foundational role of children’s hospitals in strengthening and expanding a 

regionalized network for pediatric care.

•	 Ensure that all hospital emergency departments stand ready to care for ill or injured children 

of all ages through the adoption of disaster preparedness guidelines jointly developed by 

the American Academy of Pediatrics, American College of Emergency Physicians and the 

Emergency Nurses Association.

3.5: Ensure access to physical and mental health services for all children during 

recovery from disaster.
x NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

4. EMERGENCY MEDICAL SERVICES AND PEDIATRIC TRANSPORT 

4.1: Improve the capability of Emergency Medical Services (EMS) to transport pediatric 

patients and provide comprehensive pre-hospital pediatric care during daily operations 

and disasters.

•	 Establish a dedicated federal grant program for pre-hospital EMS. 

•	 Provide additional funding to the Emergency Medical Services for Children (EMSC) program 

to ensure all states and territories meet targets and achieve progress in the EMSC performance 

measures for grantees, and to support development of a research portfolio.

•	 As an eligibility guideline for Centers for Medicare and Medicaid Services (CMS) reimbursement, 

require first response and emergency medical response vehicles to acquire and maintain pediatric 

equipment and supplies in accordance with the national guidelines for equipment for Basic Life 

Support (BLS) and Advanced Life Support (ALS) vehicles.

5. DISASTER CASE MANAGEMENT

5.1: Establish a holistic federal disaster case management program with an emphasis 

on achieving tangible positive outcomes for all children and families within a 

Presidentially-declared disaster area. 

6. CHILD CARE

6.1: Require disaster planning capabilities for child care providers.

•	 Require state child care regulatory agencies to include disaster planning, training and 

exercising requirements within the scope of the state’s minimum health and safety standards 

for child care licensure or registration. 

•	 Require state child care administrators to develop statewide child care plans in coordination 

with state and local emergency managers, public health, child care regulatory agencies and 

child care resource and referral agencies. 

6.2: Improve capacity to provide child care services in the immediate aftermath of and 

recovery from a disaster.

•	 Include the provision of child care as a human service activity within the National Response 

Framework (NRF). 

•	 Provide reimbursement under the Stafford Act, amending the Act as necessary, to support 

child care services to displaced families, establishment of temporary disaster child care and 

the repair or reconstruction of child care facilities. 

7. ELEMENTARY AND SECONDARY EDUCATION

7.1: Establish a school disaster preparedness program and appropriate funds to the U.S.

Department of Education (DoEd) for a dedicated and sustained funding stream to all 

state education agencies (SEAs). Funding should be used for state- and district-level 

disaster response planning, training, exercises and evaluation that are coordinated with 

state and local plans and activities.
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT xi

7.2: Enhance the ability of school personnel to support children who are traumatized, 

grieving or otherwise recovering from a disaster.

•	 Encourage initiatives that support and promote training of teachers and other school 

staff in basic skills in providing support to grieving students and students in crisis through 

requirements for accreditation, licensure and recertification/license renewal.

8. CHILD WELFARE AND JUVENILE JUSTICE

8.1: Provide guidance, technical assistance and model plans to assist state and local child 

welfare agencies in meeting current applicable disaster planning requirements and 

further require collaboration with state and local emergency management, courts and 

other key stakeholders.

8.2: Conduct a national assessment of disaster planning and preparedness among 

state and local juvenile justice systems to inform the development of comprehensive 

disaster plans. 

9. SHELTERING STANDARDS, SERVICES AND SUPPLIES

9.1: Provide a safe and secure mass care shelter environment for children, including 

appropriate access to essential services and supplies.

•	 Develop and implement national standards and indicators for mass care shelters that are 

specific and responsive to children.

•	 Develop a list of essential age-appropriate shelter supplies for infants and children and fund the 

addition of child-specific supplies to caches for immediate deployment to support shelter operations.

•	 Ensure the implementation of standards and training to mitigate risks unique to children in 

shelters including child abduction and sex offenders.

•	 Ensure all shelter operators have access to a fast, accurate and low-cost system for conducting 

national fingerprint-based criminal history background checks for shelter workers and volunteers.

10. HOUSING

10.1: Prioritize families with children for disaster housing assistance and expedited 

transition into permanent housing, especially families with children who have 

disabilities or other special health, mental health or educational needs.

•	 Within the Implementation Plan of the National Disaster Housing Strategy, delineate roles 

and responsibilities of federal, state, local and non-governmental agencies and emphasize the 

delivery of social services and improvement of the living environment for children throughout 

all phases of disaster housing assistance.

11. EVACUATION 

11.1: Develop a standardized, interoperable national evacuee tracking and family 

reunification system that ensures the safety and well-being of children.
xii NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

Introduction

Children constitute nearly 25 percent of our population5 and in most cases their needs 

occupy the center of family and community. Logically, disaster planning should place an 

immediate priority on addressing the needs of children. In reality, children are given a 

passing mention in disaster plans and strategies or relegated to separate annexes in the back 

of planning documents, which emergency managers may not have the time or resources to 

address. In reality, the needs of children are often overlooked and misunderstood. 

The consequences of such “benign neglect” may be devastating for children affected by 

disasters, given their unique health, behavioral and psychosocial needs. Terrorist events such 

as the 1995 Oklahoma City bombing and the unprecedented nature of the September 11, 

2001 attacks signaled a new era in global and domestic terrorism, which deeply affected 

children.6, 7, 8, 9, 10, 11 In the wake of Hurricanes Katrina and Rita, thousands of children were 

separated from their families, and months later, some still remained unaccounted for. Mental 

health distress and disability remain prevalent in Gulf Coast children who experienced 

displacement, long after the storms passed through.12 Wildfires in California, flooding in the 

Midwest and tornadoes touch the lives of children with increasing frequency,13 challenging 

the capability and capacity to respond to frequent local and regional disasters, let alone an 

event of catastrophic proportions.

Catastrophic or “mega” disasters, whether acts of terror or acts of nature, magnify the 

weaknesses of our nation’s daily disaster “state of readiness” for children, whether in 

schools, child care centers, pre-hospital Emergency Medical Services (EMS), hospitals, 

juvenile detention facilities or families.14 Moreover, inadequacies for children exist in: 

emergency equipment and medications; essential supplies and services in mass care 

shelters; reunification systems; pediatric training of first responders; capacity of EMS and 

hospital systems to provide acute care; and mental health services across the continuum of 

disaster management. 

5 U.S. Bureau of the Census, “USA QuickFacts from the US Census Bureau,” http://quickfacts.census.gov/qfd/states/00000.html.

6 Robin H. Gurwitch, Michelle Kees, Steven M. Becker, Merritt Schreiber, Betty Pfefferbaum, and Dickson Diamond, “When Disaster Strikes: Responding to the 

Needs of Children.” Prehospital and Disaster Medicine 19, no. 1 (2004): 22, http://pdm.medicine.wisc.edu/19-1%20pdfs/Gurwitch.pdf.

7 Betty Pfefferbaum, Sara J. Nixon, Ronald S. Krug, Rick D. Tivis, Vern L. Moore, Janice M. Brown, Robert S. Pynoos, David Foy, and Robin H. Gurwitch, “Clinical 

Needs Assessment of Middle and High School Students Following the 1995 Oklahoma City Bombing.” American Journal of Psychiatry 156, no. 7 (1999): 1069-74, 

http://ajp.psychiatryonline.org/cgi/reprint/156/7/1069.

8 Gerry Fairbrother, Jennifer Stuber, Sandro Galea, Betty Pfefferbaum, and Alan R. Fleischman, “Unmet Need for Counseling Services by Children in New York 

City Following the September 11th Attacks on the World Trade Center: Implications for Pediatricians,” Pediatrics 113, no. 5 (2004): 1367-74, http://pediatrics.

aappublications.org/cgi/reprint/113/5/1367.

9 David J. Schonfeld, “Are We Ready and Willing to Address the Mental Health Needs of Children?: Implications from September 11th,” Pediatrics 113, no. 5 (2004): 

1400, http://pediatrics.aappublications.org/cgi/reprint/113/5/1400.

10 Mark A. Schuster, Bradley D. Stein, Lisa H. Jaycox, Rebecca L. Collins, Grant N. Marshall, Marc N. Elliott, Annie J. Zhou, David E. Kanouse, Janina L. Morrison, 

and Sandra H. Berry, “A National Survey of Stress Reactions after the September 11, 2001, Terrorist Attacks,” New England Journal of Medicine 345, no. 20 (2001): 

1507-12, http://content.nejm.org/cgi/reprint/345/20/1507.pdf.

11 Christina W. Hoven, Cristiane S. Duarte, Christopher P. Lucas, Ping Wu, Donald J. Mandell, Renee D. Goodwin, Michael Cohen, Victor Balaban, Bradley A. 

Woodruff, Fan Bin, George J. Musa, Lori Mei, Pamela A. Cantor, J. Lawrence Aber, Patricia Cohen, and Ezra Susser, “Psychopathology among New York City Public 

School Children 6 Months after September 11,” Archives of General Psychiatry 62, no. 5 (2005): 545-51, http://archpsyc.ama-assn.org/cgi/content/abstract/62/5/545.

12 David Abramson, Tasha Stehling-Ariza, Richard Garfield, and Irwin Redlener, “Prevalence and Predictors of Mental Health Distress Post-Katrina: Findings from 

the Gulf Coast Child and Family Health Study,” Disaster Medicine and Public Health Preparedness 2, no. 2 (2008): 77-86. http://www.dmphp.org/cgi/rapidpdf/

DMP.0b013e318173a8e7v1.

13 Federal Emergency Management Agency, Annual Major Disaster Declaration Totals, http://www.fema.gov/news/disaster_totals_annual.fema.

14 Andrew L. Garrett, Roy Grant, Paula Madrid, Aarturo Brito, David Abramson, and Irwin Redlener, “Children and Megadisasters: Lessons Learned in the New 

Millennium,” Advances in Pediatrics 54, no. 1 (2007): 209-10.
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT xiii

In disasters, children should neither be grouped with “at-risk,” “special needs” or “vulnerable” 

populations, nor considered “little adults.” Children’s needs are unique, especially when 

prescribing disaster physical and mental health interventions and purchasing equipment 

and supplies. Children with disabilities and chronic health needs become even further 

marginalized in planning when their needs are not distinguished and prioritized.

In order to achieve a more knowledgeable and integrated consideration of children in disaster 

planning and management across our nation, a significant shift in philosophy, culture and 

attitude must occur, one which elevates the needs of children to an immediate priority. 

Institutional change is neither easy nor swift, but in this instance, it is critical. The road to 

ending the cycle of benign neglect began twelve months ago when the Commission held its 

first public meeting and continues with this Interim Report and its formidable, yet actionable, 

recommendations. 

1. DISASTER MANAGEMENT AND RECOVERY

Recommendation 1.1: Distinguish and comprehensively integrate the 

needs of children across all inter- and intra-governmental disaster planning 

activities and operations.

Recommendation 1.2: Accelerate the development of a National Disaster 

Recovery Strategy with an explicit emphasis on addressing the immediate 

and long-term physical and mental health, educational, housing and 

human services recovery needs of children.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 1

1. Disaster Management15 and Recovery

Recommendation 1.1: Distinguish and comprehensively integrate the needs of 

children across all inter- and intra-governmental disaster planning activities and 

operations.

15

•	 Establish a focus on children and disasters within the Federal Emergency Management Agency 

(FEMA) and the White House, supported by policy and operational expertise from across the 

federal government, non-federal partners and relevant non-governmental organizations.

•	 Incorporate meeting the needs of children as a distinct priority throughout base disaster 

planning documents and relevant grant programs. 

•	 Include children in relevant target capabilities, preparedness training and exercises, with 

specific target outcomes and performance measures.

In disaster16 planning and management, children are considered “at risk,” “vulnerable” or “special 

needs” populations, along with several other groups such as the elderly, persons with disabilities, 

the medically-dependent and persons with limited proficiency in English. In general, children do 

not fit into these broad categories, which often are addressed in annexes at the back of planning 

documents. Among so many competing concerns and limited time and resources, children are 

given far less attention than necessary.

FEMA plays a central leadership and coordinating role in supporting disaster planning and 

management for partners,17 communities and citizens. Responding to concerns expressed 

by the Commission, on August 3, 2009, FEMA Administrator Craig Fugate announced the 

creation of a “Children’s Working Group,” which will serve as a centralized platform across 

all FEMA directorates to ensure that the unique needs of children are incorporated into 

all disaster plans.18 The working group is tasked not only with identifying and facilitating 

how best to integrate children into all FEMA planning efforts, but also with improving 

FEMA’s capacity to work collaboratively with its partners and other key non-governmental 

stakeholders. Representatives from virtually all sectors of the agency will serve on the 

Children’s Working Group, and will consult with experts from other federal agencies as well 

as external stakeholder organizations with subject matter expertise. Upon issuing its Final 

Report, the Commission will evaluate the effectiveness of the Children’s Working Group and 

recommend whether it, or an alternative model, should be established in the agency. 

The Commission further recognizes the central leadership and coordinating role of the White 

House in advising the President on matters affecting national security, including disasters. A 

coordinating council composed of senior White House staff, collaborating with the National 

15 Disaster management is the body of policy, administrative decisions and operational activities required to prepare for, mitigate, respond to, and recover from 

the effects of a natural or man-made disaster (as adapted from definitions listed in the U.S. National Library of Medicine from definitions by the United Nations 

Development Programme Disaster Management Training Program and the Federal Enterprise Architecture Program Management Office).

16 Disaster is defined as all-hazards, including major disasters and emergencies as defined by the Robert T. Stafford Disaster Relief and Assistance Act. P.L. 93-

288, as amended, 42 U.S.C. 5121-5207 (1988).

17 FEMA lists as “partners” state and local emergency management agencies, 27 federal agencies and the American Red Cross. U.S. Federal Emergency 

Management Agency, “About FEMA,” http://www.fema.gov/about/#1.

18 Craig Fugate, Testimony before the U.S. Senate, Committee on Homeland Security and Governmental Affairs, Ad Hoc Subcommittee on Disaster Recovery, 

“Focus on Children in Disasters: Evacuation Planning and Mental Health Recovery,” Washington D.C., August 4, 2009, http://hsgac.senate.gov/public/index.

cfm?FuseAction=Files.View&FileStore_id=ac143d9a-c760-47d6-bc46-0a9845b74116.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 3
SECTION 1: DISASTER MANAGEMENT AND RECOVERY

Security Staff19 and relevant subject matter experts from within and outside the federal 

government should be formed to serve as a focal point for Presidential policy development 

specific to children and disasters. This council would encourage cooperation among partners 

and a clearer understanding of roles and responsibilities in meeting the needs of children 

affected by disasters.

Disaster planning must clearly incorporate specific strategies for children into base planning 

documents, such as Comprehensive Preparedness Guide (CPG) 101, rather than separate 

documents, such as CPG 301 (Special Needs Planning) or annexes. Disaster planning must 

include collaboration with administrators, regulators, parents and parent organizations and 

providers of services to children, such as education, child care, child welfare and juvenile 

justice. National disaster planning documents, such as the National Response Framework 

(NRF), which includes the Emergency Support Functions (ESFs), must elevate the needs of 

children as a distinct priority.20

Further, relevant target capabilities and preparedness training and exercises must include 

specific target outcomes and performance measures for children. The Commission is 

monitoring draft revisions to the Target Capabilities List, particularly sections related to 

Mass Care and Weapons of Mass Destruction and Hazardous Materials Rescue, to ensure 

incorporation of measurable target outcomes and resource elements for children, based upon 

the percentage of children in the community.21 All plans should be based upon the specific 

demographics of the child population and their age-based needs. For example, if a target 

capability is to treat a general population of 1,000 people, and children make up 25 percent of 

the community, the target capability should include treatment of 250 children. The Commission 

recommends exercises include objectives that test capacities including, but not limited to, 

pediatric triage, pre-hospital treatment, surge capacity, transport of children and coordination 

with schools, child care providers and child welfare and juvenile justice systems. 

The Commission is collaborating with the Department of Homeland Security (DHS) Grants 

Directorate to strengthen community preparedness planning, training and exercising by 

making children a priority in grants awarded through the Homeland Security Grant Program 

(HSGP). In addition, the Commission recommends critical supply lists and allowable costs 

and expenses include program activities, planning, training, exercising, equipment, food and 

basic medical supplies for children.22, 23 The Commission recommends that DHS require 

grantees to make pediatric capabilities integral to base plans rather than a subset of “special 

needs” populations. The Commission further recommends that HSGP grant guidance 

enhance and expand capabilities for improved preparedness of child congregate care 

systems, providers and facilities, especially school districts and child care providers.

19 President Obama established a “National Security Staff,” which will function under the direction of the National Security Advisor, to support all White House 

policymaking activities related to both national security and homeland security issues. President Barack Obama, Statement by the President on the White House 

Organization for Homeland Security and Counterterrorism, (Washington, DC: The White House, May 26, 2009), http://www.whitehouse.gov/the_press_office/

Statement-by-the-President-on-the-White-House-Organization-for-Homeland-Security-and-Counterterrorism/.

20 Federal Emergency Management Agency, “National Response Framework, Resource Center,” http://www.fema.gov/emergency/nrf/.

21 The Target Capabilities List (TCL) provides a guide for development of a national network of capabilities that will be available when and where they are needed 

to prevent, protect against, respond to and recover from major events. The TCL comprises 37 capabilities that address response capabilities, immediate recovery, 

selected prevention and protection mission capabilities, as well as common capabilities such as planning and communications that support all missions. They 

provide the basis for assessing preparedness and improving decisions related to preparedness investments and strategies. For these capabilities, local jurisdictions 

and States are the lead in conjunction with Federal and private sector support. U.S. Department of Homeland Security, “Target Capabilities List: A Companion to 

the National Preparedness Guidelines,” ed. DHS (Washington DC: 2007), iv, http://www.fema.gov/pdf/government/training/tcl.pdf.

22 Specifically, grants within the Homeland Security Grant Program including the Urban Areas Security Initiative (UASI) and the Metropolitan Medical Response 

System; the Emergency Management Performance Grants; the State Homeland Security Program Tribal; and the UASI Nonprofit Security Grant Program.

23 U.S. Department of Homeland Security, Office of Grants & Training, “Goals,” U.S. Department of Justice, Office of Justice Programs, http://www.ojp.usdoj.gov/

odp/grants_goals.htm. 

4 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 1: DISASTER MANAGEMENT AND RECOVERY

The absence of a National Disaster Recovery Strategy combined with the absence 

of effective support programs in communities places children in persistent jeopardy. 

Recent reports regarding children affected by Hurricane Katrina reflect conditions of 

serious housing instability, poor access to health care and lack of available and adequate 

educational opportunities.28 

The Post Katrina Emergency Management Reform Act of 2006 (PKEMRA)29 requires the 

development of a National Disaster Recovery Strategy to coordinate long-term recovery 

resources following major disasters. Tangible progress is slow in the development of the 

Strategy.30 The Commission strongly urges that FEMA aggressively intensify efforts to 

develop the Strategy by the close of 2009, with the assistance of governmental and nongovernmental stakeholders who provide health, mental health, educational and social 

services to children. 

In addition to DHS, the Commission initiated discussions with the Centers for Disease 

Control and Prevention’s (CDC) Coordinating Office for Terrorism Preparedness and 

Emergency Response to discuss the provision of input to the Public Health Emergency 

Preparedness cooperative agreement to states and local public health departments,24 as 

well as the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR) 

to discuss the integration of children’s unique needs into the Hospital Preparedness 

Program.25 The Commission found that both grant programs require a more focused 

effort to improve the capacities of health departments and hospitals to meet the unique 

needs of children, particularly in light of the current global H1N1 pandemic. Public health 

departments and hospitals will need to improve their ability to handle a surge of pediatric 

patients due to influenza, provide appropriate risk communication and community 

mitigation guidance to schools, child care providers and other child congregate care 

facilities and potentially execute mass vaccinations and mass prophylaxis, with special 

considerations to safely and effectively administer medications and interventions to 

children. Going forward, the Commission will explore opportunities to engage the CDCfunded Advanced Practice Centers26 and the Centers for Public Health Preparedness27 to 

develop child-centric preparedness guidance and planning tools for state and local health 

departments and hospitals. 

24 Coordinating Office for Terrorism Preparedness and Emergency Response, “Funding Guidance and Technical Assistance to States,” Centers for Disease Control 

and Prevention, http://www.bt.cdc.gov/cotper/coopagreement/.

25 Office of the Assistant Secretary for Preparedness and Response, “The Hospital Preparedness Program (HPP),” U.S. Department of Health and Human Services, 

http://www.hhs.gov/aspr/opeo/hpp/.

26 National Association of County and City Health Officials, “Advanced Practice Centers,” http://www.naccho.org/topics/emergency/APC/index.cfm.

27 Coordinating Office for Terrorism Preparedness and Emergency Response, “Centers for Public Health Preparedness (CPHP),” Centers for Disease Control and 

Prevention, http://www.bt.cdc.gov/cotper/cphp/.

28 “Disaster Assistance: Greater Coordination and an Evaluation of Programs' Outcomes Could Improve Disaster Case Management,” GAO-09-561, ed. United 

States Government Accountability Office (Washington, DC: GAO, 2009), http://www.gao.gov/new.items/d09561.pdf.

29 P.L. 109-295; 120 Stat. 1394 (2006).

30 “Actions Taken to Implement the Post-Katrina Emergency Management Reform Act of 2006,” GAO-09-59R, ed. Government Accountability Office 

(Washington, DC: GAO, 2008), http://www.gao.gov/products/GAO-09-59R.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 5

Recommendation 1.2: Accelerate the development of a National Disaster Recovery 

Strategy with an explicit emphasis on addressing the immediate and long-term 

physical and mental health, educational, housing and human services recovery 

needs of children. 
SECTION 1: DISASTER MANAGEMENT AND RECOVERY

6 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

A National Disaster Recovery Strategy that benefits children and families would ensure:

•	 The designation of a specific federal entity with oversight, coordination and guidance 

responsibilities, that will create awareness of all forms of federal assistance to states and 

localities that address the needs of children and families and will activate, mobilize and 

expedite access to such assistance;

•	 The immediate availability and continuity of disaster case management services to families;

•	 Continuous access to a the full spectrum of pediatric medical services, including a medical 

home,31 pediatric specialty services and children’s hospitals;

•	 Federal disaster assistance through grants for all medical facilities damaged or destroyed by a 

disaster, such as primary medical, dental and mental health care practices and clinics;

•	 Access to appropriate crisis, bereavement and mental health services;

•	 Academic continuity and immediate educational access by enrolling and placing disasteraffected children in educational and related services in compliance with the McKinney-Vento 

Homeless Education Assistance Improvements Act;32

•	 Priority for families with children for disaster housing assistance and expedited transition into 

permanent housing, especially for those families with children who have disabilities or special 

health, mental health or educational needs; and 

•	 The provision of child care and developmental and age-appropriate play and recreation 

options, particularly after-school services.

The overarching principle for recovery from disasters must be to create self-sufficient families 

and a “new and improved normalcy” for all children, especially children who are socially 

and economically disadvantaged. The development of a National Disaster Recovery Strategy 

would specify guiding principles for services that must be provided to children affected by 

disasters, such as: safe, stable living environments; physical, mental health and oral health; 

academic continuity and supervised after-school activities; child care; adequate nutrition; 

and disaster case management. The guiding principles would govern the request for and 

provision of federal disaster and recovery funding for these services to ensure the economic 

recovery of communities as a whole. Strategies, roles and responsibilities for recovery 

must be established and emphasized as critical components of federal, state and local 

disaster plans, and should include the roles and contributions of systems responsible for the 

education, care and welfare of children. 

31 A “medical home” is defined as a source of primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and 

culturally effective. Stephen E. Edwards, “Foreword,” Pediatrics: Supplement: The Medical Home 113, no. 5 (2004), 1471.

32 As part of Title X, Part C of the No Child Left Behind Act: P.L. 107-110; 42 U.S.C. §11431 et. seq (2001).
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 7

2. MENTAL HEALTH

Recommendation 2.1: Integrate mental and behavioral health for children 

into all public health and medical preparedness and response activities.

Recommendation 2.2: Enhance the research agenda for children’s disaster 

mental and behavioral health, including psychological first aid, cognitivebehavioral interventions, social support interventions and bereavement 

counseling and support.

Recommendation 2.3: Enhance pediatric disaster mental and behavioral 

health training for professionals and paraprofessionals, including 

psychological first aid, cognitive-behavioral interventions, social support 

interventions and bereavement counseling and support. 
“As a teacher and caregiver I witnessed children becoming 

insecure and struggling in areas they once had mastered. 

Children were having bathroom accidents, stammering 

speech, crying for long periods, becoming aggressive and/

or constantly talking about the flood and their fear of 

the flood.” 

--Christa Fielder, Hiawatha Day School in Cedar Rapids, Iowa
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 9

2. Mental Health

Recommendation 2.1: Integrate mental and behavioral health for children into all 

public health and medical preparedness and response activities.

All disasters have a high likelihood of negatively impacting mental and behavioral health, 

both immediately and long-term. The mental and behavioral health effects undermine 

the efficacy of response efforts, the ability of citizens to comply with public health 

recommendations and the capacity of the communities and states to ensure effective 

recovery. Yet, mental and behavioral health impacts are rarely considered until long after 

the event when it is too late to inform and affect optimal response or even recovery efforts. 

Therefore, mental and behavioral health should be a core component of the planning 

and response efforts for all disasters, requiring its integration within the creation of a new, 

overarching unified concept of operations (CONOPS). 33

Children are particularly vulnerable to the mental health impact of disasters and lack the 

experience, skills and resources to independently meet their mental and behavioral health 

needs.34 It is therefore both surprising and of concern that children’s mental and behavioral 

health needs are virtually ignored across federal and state disaster planning efforts, and 

training exercises neglect to test for pediatric mental health response capacity.

A broad range of pediatric mental health services, including long-term interventions 

when indicated, must become part of disaster mental health response and recovery. The 

Commission supports the recommendations proposed within the report of the Disaster 

Mental Health Subcommittee of the National Biodefense Science Board, with the addition 

of the prioritization of the mental and behavioral needs of children.35 Disaster mental and 

behavioral health response for children can be strengthened from a common operational 

picture which will: enable triggers for mutual aid requests, resource allocation, targeted 

monitoring of population health and the recovery environment; and provide appropriate 

interventions such as psychological first aid, bereavement counseling and support and 

cognitive-behavioral treatments.

The Commission recommends that at the federal level, coordination of mental and 

behavioral health service efforts for children can be accomplished through a unified 

CONOPS that addresses all phases of disaster planning and includes representation of 

pediatric mental and behavioral health functions within operational frameworks across local, 

state and national levels aligned with the National Incident Management System. In addition, 

states can incorporate disaster mental and behavioral health planning and operations for 

children by including language on children’s mental and behavioral health in all appropriate 

legislation, regulations and grants. 

33 CONOPS is defined here as an overarching and standardized operational framework coordinating federal efforts to respond to the emerging disaster needs of 

affected populations.

34 Schonfeld, “Implications from September 11th,” 1400 (see n. 9).

35 Disaster Mental Health Recommendations: Report of the Disaster Mental Health Subcommittee of the National Biodefense Science Board, ed. U.S. Department 

of Health and Human Services, National Biodefense Science Board, Disaster Mental Health Subcommittee, (Washington, DC: HHS, 2008), 6-20, http://www.hhs.

gov/aspr/conferences/nbsb/dmhreport-final.pdf.
SECTION 2: MENTAL HEALTH

Recommendation 2.2: Enhance the research agenda for children’s disaster mental 

and behavioral health, including psychological first aid,36 cognitive-behavioral 

interventions, social support interventions and bereavement counseling and support.

A small amount of research exists evaluating the effectiveness of services and interventions 

to address the full spectrum of children’s mental health needs in the aftermath of a disaster, 

especially outside the area of trauma-related syndromes and symptoms and trauma-focused 

treatments.37 Evidence suggests that some commonly used interventions, such as critical 

incident stress debriefing or management, are not effective and may instead be detrimental, 

especially when used with children.38, 39 A new, expanded national agenda for disaster mental 

health research would prioritize and facilitate exploration of the full spectrum of mental health 

services for children and families that would be necessary for recovery after a disaster. 

The Commission recommends that a working group of children’s disaster mental health and 

pediatric experts be convened to review the research portfolios of relevant agencies that 

fund federal research across the U.S. government. The working group would identify gaps in 

knowledge, areas of recent progress and priorities for research, including disaster mental and 

behavioral health program evaluation, early intervention, treatment for disaster-related problems 

and dissemination of training in disaster mental and behavioral health interventions. The working 

group would also recommend a national research agenda for federal agencies that fund research 

initiatives across the full spectrum of disaster mental health services for children and families, 

including trauma-related syndromes and symptoms, psychological first aid, cognitive-behavioral 

interventions, social support interventions, bereavement counseling and support and approaches 

to promoting resilience in children and communities. 

Recommendation 2.3: Enhance pediatric disaster mental and behavioral health 

training for professionals and paraprofessionals, including psychological first aid, 

cognitive-behavioral interventions, social support interventions and bereavement 

counseling and support.

Limited numbers of pediatric mental health professionals coupled with the limited insurance 

reimbursement for mental and behavioral health services have resulted in a critical gap in 

our ability to provide the necessary mental health care to those that most need it, especially 

if we rely on traditional mental health providers. Children’s limited access to mental 

health services is further exacerbated during and after disasters by issues such as lack of 

transportation, competing family recovery needs and concerns about stigmatization when 

utilizing these services.40, 41 In order to accommodate the surge of demand for mental health 

services and ameliorate the mental health and behavioral health effects that are caused by 

or exacerbated by a disaster, adequate resources for immediate and long-term interventions 

must be appropriate and available to children. Mental health professionals, including those 

who are school-based, need to have adequate training related to disaster mental health care 

for children. 

36 “Psychological first aid” is psychological support that can be provided by non-mental health professionals to children, family, friends and neighbors. It 

incorporates education on issues related to trauma and active listening. Ibid., 12.

37 Ibid., 8-10.

38 Ibid., 9.

39 Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians, ed. George L. Foltin, David J. Schonfeld and Michael W. Shannon, Bioterrorism 

and Other Public Health Emergencies, (Rockville, MD: American Academy of Pediatrics, 2006), 279, http://www.ahrq.gov/RESEARCH/PEDPREP/pedresource.pdf.

40 Schonfeld, “Implications from September 11th,” 1400.

41 “Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them,” 

GAO-09-563, ed. Government Accountability Office (Washington, DC: GAO, 2009), http://www.gao.gov/new.items/d09935t.pdf.

10 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 2: MENTAL HEALTH

Communities rely upon a cadre of non-mental health professionals who routinely 

interact with children, such as school staff, child care providers and pediatric healthcare 

providers,42 to provide basic mental health and bereavement support services and brief 

interventions. Therefore, it is essential that these individuals receive adequate training and 

are knowledgeable about how to identify children who require more advanced care and can 

provide information to their guardians on existing resources.43

Most children who receive mental health services receive them in schools44 and mental 

health professionals working in schools constitute the largest cadre of primary providers of 

mental health services for children.45, 46 According to the National Center for School Crisis 

and Bereavement, teachers and school administrators receive little, if any, training at the preor post-service level around how to support children and staff during and in the aftermath of 

a disaster to promote adjustment and coping. 

In many disasters, children will experience deaths of family members and friends. Such 

losses may have long-term effects on learning and emotional adjustment. Schools provide 

much needed stability for children following a disaster and are a natural place for children to 

receive information and support after such events.47 Bereavement support should therefore 

be viewed as an essential component of disaster mental health services. 

Basic disaster mental health and psychological support training specific to the unique 

needs of children should be extended beyond the traditional mental health disciplines (e.g. 

psychiatry, psychology, counseling, social work and marriage and family therapy) and health 

care professionals (e.g. medicine, pediatrics, nursing and epidemiology) to include the full 

range of emergency responders (e.g. law enforcement, fire service and emergency medical 

responders), faith-based professionals, educators and disaster response leaders (e.g. incident 

commanders, emergency managers and civil service and elected government leaders).

Disaster mental health training, including traditional and just-in-time training, for the various 

professional groups would include psychological first aid, cognitive-behavioral interventions, 

social support interventions and bereavement counseling and support. Minimum training 

standards should be identified and disaster mental health training should be a requirement 

for professional accreditation and licensure where applicable.

42 “The primary medical care system has become the de facto mental health care system for children in the United States. Children are most likely to be evaluated 

for mental and behavioral health problems and to receive treatment, including psychotropic drugs, from pediatricians for symptoms associated with mental 

disorders.” Schonfeld, “Implications from September 11th,” 1400.

43 Lisa H. Jaycox, Lindsey K. Morse, Terri Tanielian, and Bradley D. Stein, How Schools Can Help Students Recover from Traumatic Experiences: A Tool Kit for 

Supporting Long-Term Recovery, (Santa Monica, CA: RAND, 2006), 6-12.

44 Mark D. Weist, Marcia Rubin, Elizabeth Moore, Steven Adelsheim, and Gordon Wrobel, “Mental Health Screening in Schools,” Journal of School Health 77, no. 2 

(2007): 53-8.

45 Bradley D. Stein, Terri L. Tanielian, Mary E Vaiana, Hilary J. Rhodes, and M. Audrey Burnam, “The Role of Schools in Meeting Community Needs During 

Bioterrorism,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 1, no. 4 (2003), 274, http://www.liebertonline.com/doi/pdf/10.1089/1538713

03771861487?.

46 In New York City, more than half of the students who received counseling in the months following the attacks of September 11, 2001, received it through 

services provided at schools. Yet, most children with mental health needs related to the events of September 11th were not identified and the vast majority never 

received any services. Fairbrother et al., “Unmet Need for Counseling Services, 1369 (see n. 8); Schonfeld, “Implications from September 11th,” 1400.

47 Garrett et al., “Children and Megadisasters,” 207-8 (see n. 13).

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 11

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 13

3. CHILD PHYSICAL HEALTH AND TRAUMA

Recommendation 3.1: Ensure availability and access to pediatric medical 

countermeasures at the federal, state and local level for chemical, 

biological, radiological, nuclear and explosive (CBRNE) threats.

Recommendation 3.2: Expand the medical capabilities of all federally 

funded response teams through the comprehensive integration of 

pediatric-specific training, guidance, exercises, supplies and personnel.

Recommendation 3.3: Ensure that all health care professionals who may 

treat children during an emergency have adequate pediatric disaster 

clinical training specific to their role.

Recommendation 3.4: Provide funding for a formal regionalized pediatric 

system of care for disasters.

Recommendation 3.5: Ensure access to physical and mental health services 

for all children during recovery from disaster.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 15

Recommendation 3.1: Ensure availability and access to pediatric medical 

countermeasures at the federal, state and local level for chemical, biological, 

radiological, nuclear and explosive (CBRNE) threats.

•	 Provide funding for the development, acquisition and stockpiling of medical 

countermeasures specifically for children for inclusion in the Strategic National Stockpile 

(SNS) and all other federally funded caches. 

•	 Form a standing advisory body of federal partners and external experts to advise the 

Department of Health and Human Services (HHS) Secretary on issues pertaining 

specifically to pediatric emergency medical countermeasures. 

•	 Include pediatric expertise on all relevant committees and working groups addressing issues 

pertaining to medical countermeasures. 

Children are known to be at greater risk of: 1) exposure to community-dispersed chemical, 

biological, radiological and nuclear terrorist agents; 2) absorption of comparable doses of these 

agents; and 3) mortality and morbidity from comparable doses of the agents that are absorbed.48

However, while medical countermeasures49 for several CBRNE agents are available for use 

in adults and included in the SNS,50 comparable agents for use in children have not yet been 

approved by the Food and Drug Administration (FDA) to the same extent, and therefore are 

not present in the SNS.51 Currently, 50 to 75 percent of all medications administered to children 

have not been tested on pediatric populations and are being used off-label,52 which hinders 

legal stockpiling and deployment of these pediatric medications. However, many unapproved 

or off-label products may be the very best preventative, diagnostic or therapeutic options 

available.53 Moreover, key federal working groups and committees54 across the National 

Institutes of Health (NIH), Public Health Emergency Medical Countermeasures Enterprise 

(PHEMCE) and CDC are establishing research and development priorities for high-risk CBRNE 

threats and the medical countermeasures to combat them. These groups would benefit greatly 

from the inclusion of pediatric subject matter expertise from outside the federal government. 

In certain instances where the HHS Secretary declares an emergency, FDA may issue an 

Emergency Use Authorization (EUA). EUA permits the FDA to approve the emergency use 

of drugs, devices and medical products (including diagnostics) that were not previously 

48 American Academy of Pediatrics, Committee on Environmental Health and Committee on Infectious Diseases “Chemical-Biological Terrorism and Its Impact 

on Children,” Pediatrics 118, no. 3 (2006): 1271, http://pediatrics.aappublications.org/cgi/content/abstract/118/3/1267.

49 Medical countermeasures refer to drugs, biological products, or devices that treat, identify, or prevent harm due to chemical, biological, radiological, nuclear 

and explosive agents.

50 CDC’s SNS has large quantities of medicine and medical supplies to protect the American public if there is a public health emergency severe enough to cause 

local supplies to run out. Once federal and local authorities agree that the SNS is needed, medicines will be delivered to any state in the U.S. within 12 hours. Each 

state has a plan to receive and distribute SNS medications and medical supplies to local health departments as soon as possible. Coordinating Office for Terrorism 

Preparedness and Emergency Response, “Strategic National Stockpile (SNS),” Centers for Disease Control and Prevention, http://www.bt.cdc.gov/stockpile.

51 U.S. Department of Health and Human Services, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human 

Development, Center for Research for Mothers and Children, Obstetric and Pediatric Pharmacology Branch, “Meeting Minutes,” BPCA Biodefense Meeting, 

Rockville, MD, September 8-9 2008, http://bpca.nichd.nih.gov/outreach/upload/Biodefense-09-08.pdf.

52 Cori Vanchieri, Adrienne Stith Butler, and Andrea Knutsen, Addressing the Barriers to Pediatric Drug Development: Workshop Summary, (Washington, DC: 

Institute of Medicine, 2008), 1.

53 Stuart L. Nightingale, Joanna M. Prasher, and Stewart Simonson, “Emergency Use Authorization (EUA) to Enable Use of Needed Products in Civilian and 

Military Emergencies, United States,” Emerging Infectious Diseases 13, no. 7 (2007): 1046.

54  U.S. Department of Health and Human Services (HHS), “Meeting Minutes,” BPCA Biodefense Meeting 

3. Child Physical Health and Trauma
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

approved, cleared or licensed by FDA and the off-label use of approved products in certain 

well-defined emergency situations.55 Based on the circumstances of the emergency, the EUA 

process may take hours or days. Without pre-existing, consensus-derived guidance from 

experts for off-label use of existing drugs, there may not be enough time to develop such 

consensus in the immediate aftermath of an incident. 

Taking into account the small number of FDA-approved medications for children in the SNS 

and other emergency caches and the challenges associated with developing and approving 

medical countermeasures for children and authorizing off-label use under an EUA, the 

Commission recommends the formation of a standing advisory body. This body should 

consist of federal and non-federal partners and experts to advise the HHS Secretary on issues 

pertaining specifically to pediatric emergency medical countermeasures. Liaisons of this body 

will represent children on all relevant NIH, PHEMCE and CDC committees and working groups 

addressing issues pertaining to medical countermeasures. 

The advisory body would:

•	 Assemble and study available data on therapies used as medical countermeasures in the 

pediatric population for high risk CBRNE;

•	 Develop formal consensus-driven recommendations on the emergency use of medications or 

interventions to pre-authorize the use of specific medical countermeasures; 

•	 Develop a proposed research agenda supported by sufficient funding; and

•	 Rapidly and efficiently approve and disseminate updated treatment guidelines to state and 

local jurisdictions.

In 2006, Congress passed the Pandemic and All-Hazards Preparedness Act,56 which provided 

authority for a number of programs related to the development and acquisition of medical 

countermeasures. Chief among these was the establishment of the Office of the Biomedical 

Advanced Research and Development Authority, which manages the PHEMCE. The PHEMCE 

is a coordinated, inter-agency effort to bring about the development and purchase of necessary 

vaccines, drugs, therapies and diagnostic tools for public health emergencies. The PHEMCE’s 

responsibilities include coordinating research, development and procurement of emergency 

medical countermeasures, and setting deployment and use strategies for the countermeasures 

held in the SNS.57

Current PHEMCE policies do not prioritize children in the research and development of medical 

countermeasures. The most recently published version of the PHEMCE Strategy (2007) states 

that “priority will be given to those medical countermeasures that will prevent and treat adverse 

health effects for the greatest number of individuals.”58 Unfortunately for children, pediatric 

indications of medications and their delivery mechanisms tend to be more difficult and expensive 

to test, develop and acquire compared to adults. Pediatric studies involve special considerations 

relative to adult studies, such as stricter safety and quality control measures, and may require the 

product to be developed in an alternative form from the adult dose, such as oral suspension.59

55 Nightingale, Prasher, and Simonson, “Emergency Use Authorization (EUA),” 1046.

56 P.L. 109-417; 120 Stat. 2831 (2006).

57 Office of the Assistant Secretary for Preparedness and Response, “Public Health Emergency Medical Countermeasures (PHEMC) Enterprise,” U.S. Department 

of Health and Human Services, http://www.hhs.gov/aspr/barda/phemce/index.html.

58 Office of the Assistant Secretary for Preparedness and Response, “HHS Public Health Emergency Medical Countermeasures Enterprise Strategy for 

Chemical, Biological, Radiological and Nuclear Threats,” Federal Register 72, no. 53 (2007), 13112, http://www.hhs.gov/aspr/barda/documents/federalreg_

vol72no53_032007notices.pdf.

59 Vanchieri, Stith Butler, and Knutsen, Addressing the Barriers to Pediatric Drug Development, 4.

16 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

The PHEMCE must address these inherent disadvantages and develop strategies to achieve 

parity for children in the research, development and acquisition of medical countermeasures. 

Incentives and requirements should be developed for the conduct of pediatric research 

by pharmaceutical companies that receive federal awards.60 All procurements of 

countermeasures for the SNS under Project Bioshield61 must provide options and significant 

incentives to study and potentially license the countermeasures for pediatric populations. 

Incentives are also needed to encourage testing of older, off-patent drugs.62 A reprioritization 

of funding also is necessary to facilitate the development, acquisition and stockpiling of 

medical countermeasures specifically for children for inclusion in the SNS and other caches.

The public’s will to prioritize the protection of children when faced with resource constraints 

was made clear in the federal government’s public engagement meetings on the prioritization 

of pandemic influenza vaccines.63 Federal agencies and working groups should consider 

public expectations, population demographics and the difference in benefit when using “lifeyears saved” vs. “lives saved” in any cost-benefit analysis64 for decisions concerning the use of 

limited funding and resources. 

Recommendation 3.2: Expand the medical capabilities of all federally funded 

response teams through the comprehensive integration of pediatric-specific 

training, guidance, exercises, supplies and personnel.

•	 Designate or establish a Pediatric Health Care Coordinator on each federally funded 

medical response team and develop strategies to recruit and retain team members with 

pediatric medical expertise.

•	 Establish an Associate Chief Medical Officer for Pediatric Care in the office of National 

Disaster Medical System (NDMS). 

•	 Develop pediatric capabilities within each NDMS region to ensure robust pediatric disaster 

response and enhanced surge capacity. 

The capability of Disaster Medical Assistance Teams (DMATs)65, 66 to meet the care 

requirements of pediatric disaster survivors is limited by deficiencies in the training, clinical 

practice experience, on-going continuing education and composition of its members and 

60 Ibid., 8.

61 On July 21, 2004, President George W. Bush signed the Project BioShield Act of 2004 (Project BioShield) into law as part of a broader strategy to defend 

America against the threat of weapons of mass destruction. The purpose of Project BioShield is to accelerate the research, development, purchase and availability 

of effective medical countermeasures against biological, chemical, radiological and nuclear (CBRN) agents. P.L. 108-276, 118 Stat. 852 (2004). http://www.hhs.gov/

aspr/barda/bioshield/index.html.

62 Vanchieri, Stith Butler, and Knutsen, Addressing the Barriers to Pediatric Drug Development, 9.

63 U.S. Department of Health and Human Services, and U.S. Department of Homeland Security, Guidance on Allocating and Targeting Pandemic Influenza 

Vaccine, (Washington, DC: HHS and DHS, 2008), http://www.flu.gov/vaccine/allocationguidance.pdf.

64 There is long-standing debate whether to count “lives saved” or “life-years saved” when evaluating policies to reduce mortality risk. Historically, the two 

approaches have been applied in different domains. Environmental and transportation policies have often been evaluated using lives saved, while life-years saved 

has been the preferred metric in other areas of public health including medicine, vaccination, anddisease screening. For benefit-cost analysis, the monetary value 

of risk reductions can be calculated either by multiplying expected lives saved by the “value per statistical life” (VSL) or by multiplying expected life-years saved by 

the “value per statistical life-year” (VSLY). James K. Hammitt, “Valuing 'Lives Saved' Vs. 'Life-Years Saved',” Risk in Perspective 16, no. 1 (2008): 1, http://www.hcra.

harvard.edu/rip/rip_Mar_2008.pdf.

65 DMAT is a group of professional and para-professional medical personnel (supported by a cadre of logistical and administrative staff) designed to provide 

medical care during a disaster or other event. DMATs are designed to be a rapid-response element to supplement local medical care until other federal or contract 

resources can be mobilized, or the situation is resolved. National Disaster Medical System, Office of the Assistant Secretary for Preparedness and Response, “What 

Is a Disaster Medical Assistance Team (DMAT)?,” U.S. Department of Health and Human Services, http://www.hhs.gov/aspr/opeo/ndms/teams/dmat.html.

66 DMATs are managed by the NDMS, the primary federal program that supports care and transfer during evacuation of patients. NDMS is a component of HHS 

comprised of over 1,500 volunteer hospitals and over 6,000 intermittent federal employees assigned to approximately 90 general disaster and specialty teams 

geographically dispersed across the U.S. The overall purpose of NDMS is to establish a single integrated national medical response capability or assisting state 

and local authorities with the medical impacts of peacetime disasters and to provide support to the military. Office of the Assistant Secretary for Preparedness and 

Response, “National Disaster Medical System (NDMS),” U.S. Department of Health and Human Services, http://www.hhs.gov/aspr/opeo/ndms/index.html.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 17
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

18 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

their deployed resources.67, 68, 69 Pediatric patients can comprise a significant percentage 

of disaster survivors treated at DMAT field clinics.70 While 68 percent of the clinical 

practitioners comprising DMATs have pediatric-specific training, only 5.6 percent have formal 

subspecialty training in pediatrics (e.g. pediatricians, pediatric nurse practitioners, pediatric 

emergency medicine and pediatric critical care), and 47 percent have formal training specific 

to pregnant women.71, 72 DMAT members who routinely practice in emergency care settings 

such as hospital emergency departments likely have limited exposure to ill and injured 

children: approximately 50 percent of emergency departments in the United States serve 

less than ten children a day.73, 74

The Commission recommends that NDMS increase its pediatric capacity by forming or 

expanding regional capabilities to ensure robust surge capacity and flexible and scalable 

pediatric disaster response. Currently, there are only two Pediatric Subspecialty Teams75

(PSTs) in the U.S.76 PSTs can provide additional support to hospital providers following the 

pre-hospital management phase of the disaster. To initiate this effort, the two existing PSTs 

in Boston and Atlanta could be tested as a pilot for a regional DMAT response capability 

through exercising as an adjunct to other DMAT teams within their regions. In order to 

ensure that the needs of children are met, system planning must include provision of 

pediatric education for DMAT team members and appropriate equipping of the DMAT 

team prior to deployment. Core competencies in pediatric clinical care, evacuation, triage, 

decontamination and administration of pediatric medical countermeasures should be added 

in the NDMS national credentialing standards currently in development. 

All federally funded medical response teams (including, but not limited to, DMATs, Public 

Health Service Commissioned Corps teams, FEMA teams, Department of Defense teams 

and Medical Reserve Corps) should increase the pediatric capabilities, capacities and assets 

of all deployed teams to meet the demand for pediatric care. First, a Pediatric Health Care 

Coordinator should be designated on each federally funded medical response team, and 

an Associate Chief Medical Officer for Pediatric Care should be established in the office of 

NDMS. Strategies must be developed to recruit and retain members with pediatric medical 

expertise. In addition, development of standards for federally funded medical response teams 

is necessary in relation to stockpiling of pediatric equipment and supplies; protocols for the 

67 Sharon E. Mace and Andrew I. Bern, “Needs Assessment: Are Disaster Medical Assistance Teams up for the Challenge of a Pediatric Disaster?,” The American 

Journal of Emergency Medicine 25, no. 7 (2007): 762-9.

68 Katherine A. Gnauck, Kevin E. Nufer, Jonathon M. LaValley, Cameron S. Crandall, Frances W. Craig, and Gina B. Wilson-Ramirez, “Do Pediatric and Adult Disaster 

Victims Differ? A Descriptive Analysis of Clinical Encounters from Four Natural Disaster DMAT Deployments,” Prehospital and Disaster Medicine 22, no. 1 (2007): 

67-73.

69 Allen Dobbs, Chief Medical Officer, National Disaster Medical System, Letter to Michael Anderson, Commissioner, May 31, 2009.

70 Gnauck et al., “Do Pediatric and Adult Disaster Victims Differ?,” 67.

71 Nicole Lurie, Testimony before the U.S. Senate, Committee on Homeland Security and Governmental Affairs, Ad Hoc Subcommittee on Disaster Recovery, 

“Children and Disasters: The Role of HHS in Evacuation Planning and Mental Health Recovery,” Washington, DC, August 4, 2009, http://www.hhs.gov/asl/testify/2009/08/

t20090804a.html.

72 “Pediatric-specific training” refers to the number of boarded or licensed providers who have received formalized training in pediatric care that also includes 

training for other age groups (e.g. Emergency Medicine and Family Medicine). Physician Assistant training programs also have pediatric-specific training as part 

of their curriculum. These groups also receive formalized training in managing the medical care of pregnant women. “Subspecialty training in pediatrics” refers 

to physicians and nurse practitioners who have received formalized training limited to pediatrics. Allen Dobbs, Chief Medical Officer, National Disaster Medical 

System, E-mail to Christopher Revere, August 19, 2009.

73 Marianne Gausche-Hill, Charles Schmitz, and Roger J. Lewis, “Pediatric Preparedness of US Emergency Departments: A 2003 Survey,” Pediatrics 120, no. 6 (2007): 

1232. 

74 Ibid., 1275.

75 PSTs are specialty DMATS developed to serve the unique needs of children during a disaster, composed of “individuals specifically trained in the care of 

children and pediatric-specific equipment, supplies, and pharmaceuticals. PST members include pediatric emergency medicine, pediatric critical care, pediatric 

trauma surgery, general pediatrics, neonatology, anesthesiology, and toxicology physicians and nurses, as well as respiratory therapists and pharmacists.” Debra L. 

Weiner, Shannon F. Manzi, Mark L. Waltzman, Michele Morin, Anne Meginniss and Gary R. Fleisher, “FEMA's Organized Response With a Pediatric Subspecialty 

Team: The National Disaster Medical System Response: A Pediatric Perspective,” Pediatrics 117, no.5 (2006): S406, http://pediatrics.aappublications.org/cgi/

reprint/117/5/S2/S405.

76 Gausche-Hill, Schmitz, and Lewis, “Pediatric Preparedness,” 1275.
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 19

delivery of care and use of pediatric equipment and supplies; and continuing education and 

training for response team members. Pediatric response capabilities could also be increased 

through the development of new strike teams that can respond to catastrophic events 

involving pediatric mass casualties, such as Pediatric Intensive Care Unit and Neonatal 

Intensive Care Unit Teams, General Pediatric Teams, Pediatric Surgical Teams, Pediatric 

Transport Teams and Pediatric Mental Health Teams. 

Recommendation 3.3: Ensure that all health care professionals who may treat 

children during an emergency have adequate pediatric disaster clinical77 training 

specific to their role.

•	 Form a Pediatric Disaster Clinical Education and Training Working Group to establish core 

clinical competencies and a standard, modular pediatric disaster health care education and 

training curriculum. 

Currently, national standards for pediatric disaster education do not exist, and a set of core 

competencies for pediatric responders has yet to be identified.78 In the event of a large-scale 

disaster or pandemic, the appropriate training and utilization of both pediatric and non-pediatric 

health care personnel will be crucial to minimize the morbidity and mortality of the pediatric 

population. The Pediatric Disaster Clinical Education and Training Working Group would serve 

as an oversight body that would establish a national curriculum as well as provide appropriate 

peer review and quality control over the development and distribution of competency-based 

pediatric disaster training materials. 

The working group would establish core competencies and guidelines for a standard, 

modular pediatric disaster clinical training curriculum. The curriculum would be applied 

across a spectrum of professions from basic training of non-medical emergency responders 

and volunteers to advanced training for DMAT members, pre-hospital and hospital-based 

EMS providers and Medical Reserve Corps volunteers, among others. The scope of practice 

capabilities for pediatric response must be defined for each discipline-specific responder 

and include the identification of core competencies and the articulation of a minimum taskspecific skill-set for pediatric response. For example, continuing education becomes critically 

important for EMS providers as they rarely treat a sufficient number of pediatric patients 

to develop and maintain skills. The Commission supports the adoption of requirements by 

states and territories for pediatric emergency education for the licensure/certification renewal 

of Basic Life Support (BLS) and Advanced Life Support (ALS) providers.79

For disaster response, some professionals such as emergency medical technicians will require 

basic education and training while other responders, such as DMAT members will require 

advanced training. Key elements of the standardized curriculum and training program would 

include the development of core competencies, pediatric-specific severity criteria and treatment 

guidelines and clinical practice guidelines for triage and treatment. The curriculum should also 

provide guidance for professionals in EMS, hospitals, emergency management, fire and law 

enforcement on the incorporation of pediatric-related objectives into routine drills and exercises.

77 “Clinical” refers to medicine, nursing and all allied health care disciplines.

78 Elizabeth Ablah, Annie M. Tinius, and Kurt Konda, “Pediatric Emergency Preparedness Training: Are We on a Path toward National Dissemination?,” The 

Journal of Trauma 67, no. 2 (2009): S156, http://journals.lww.com/jtrauma/Fulltext/2009/08001/Pediatric_Emergency_Preparedness_Training__Are_We.21.aspx.

79 EMSC National Resource Center, EMSC Performance Measures: Implementation Manual for State Partnership Grantees (Draft Edition), (Washington, DC: EMSC 

National Resource Center, Child Health Advocacy Institute, Children's National Medical Center, 2009), http://childrensnational.org/files/PDF/EMSC/ForGrantees/

Implementation_Manual_2009-2010_Draft.pdf.
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

20 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

The objectives of the working group are separate from, yet complementary to, the 

Federal Education and Training Interagency Group for Public Health and Medical Disaster 

Preparedness and Response (FETIG). The expertise and scope of the FETIG is very broad,80

therefore a federally funded pediatric-focused working group that includes external 

stakeholders is necessary to ensure adequate pediatric professional and academic expertise 

for the task of developing core competencies. This working group would collaborate with 

and have representation on the FETIG.

Efforts to develop consensus-based guidelines for altered standards of care and interventions 

for use in disasters must include pediatric medical experts, as children have different 

standards of care than those of adults.81 While altering care for any patient is challenging, 

it may prove nearly impossible to do so for children during a disaster without clear 

recommendations and methodologies. This situation is the result of multiple factors, 

including “the societal expectation for care of children, the emotional burden of potentially 

limiting or withholding care from a child, and the unique barriers faced when trying to 

provide care for children.”82

Recommendation 3.4: Provide funding for a formal regionalized pediatric system of 

care for disasters.

•	 Build upon the foundational role of children’s hospitals in strengthening and expanding a 

regionalized network for pediatric care.

•	 Ensure that all hospital emergency departments stand ready to care for ill or injured children 

of all ages through the adoption of disaster preparedness guidelines jointly developed by 

the American Academy of Pediatrics, American College of Emergency Physicians and the 

Emergency Nurses Association.

Pediatric surge capacity and capability must be assessed beyond the scope of individual 

institutions and in a coordinated manner on local, regional and national levels. Additional funding 

for the HHS Hospital Preparedness Program can assist states in developing and implementing 

comprehensive state and regional plans for pediatric patient surge capacity in conjunction with 

hospitals, EMS and emergency management agencies. In addition, local, regional and national 

disaster response plans must anticipate need and fully integrate trauma systems, children’s 

hospitals, EMS and other institutions with pediatric critical care and pediatric medical and 

surgical subspecialty care capabilities. 

All health care facilities, not simply children’s hospitals, must be prepared for a surge of 

critically ill children. Although EMS field efforts will attempt to match the survivors' needs 

with the nearest appropriate hospital, the most recent disaster literature suggests that up to 

50 percent of survivors arriving at a hospital in a surge (mass casualty) scenario will arrive 

by other means. In order to accommodate a surge of pediatric patients, all hospitals should 

ensure that adequate, up-to-date stocks of pediatric supplies are onsite. Pediatric hospital 

preparedness can be optimized by accommodating pediatric considerations in planning and 

utilizing the guidelines outlined by the American Academy of Pediatrics, American College 

80 Federal Education and Training Interagency Group for Public Health and Medical Disaster Preparedness and Response, “Charter,” U.S. Department of Health 

and Human Services, http://www.hhs.gov/aspr/conferences/nbsb/nbsb-fetig-080328.pdf.

81 ASPR recently sponsored a one-day workshop with the IOM on establishing standards of care in emergency situations. No pediatricians or pediatric-specific 

topics were included in the panel presentations. Workshop on Guidance for Establishing Standards of Care for Use in Disaster Situations, Washington, DC, 

September 2, 2009, http://www.iom.edu/CMS/3740/72417/72451.aspx.

82 David Markenson, “Developing Consensus on Appropriate Standards of Hospital Disaster Care: Ensuring That the Needs of Children Are Addressed,” Disaster 

Medicine and Public Health Preparedness 3, no. 1 (2009): 5.
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 21

of Emergency Physicians and Emergency Nurses Association.83 All hospitals should diligently 

practice disaster drills that include scenarios with sufficient pediatric survivors to test their 

pediatric surge capacity.  These activities should also include all staff who may be called 

upon to deliver care to children. 

Currently, the United States has fewer than 300 children’s hospitals, a fraction of all hospitals 

(five percent), and only 40 percent of hospital emergency departments have procedures 

regarding pediatric transfers. A surge of ill children may present considerable staffing 

challenges to non-pediatric designated hospitals. These hospitals should develop databases 

with the contact information of locally available pediatricians, pediatric nurses and other 

personnel with pediatric experience who can provide assistance in the event of a surge.84

During a biological event, children may not be well suited for transfer and may therefore 

have to remain in the receiving facility.85 The transfer of children to a local or regional 

pediatric referral center may be impaired by factors limiting patient transport (e.g. disaster 

conditions, weather, transport system availability), or the availability, level of function, or 

capacity of the tertiary center (e.g. facility operations and patient saturation). All hospitals 

must be prepared to provide care for children under such circumstances. 

Children’s hospitals can play a critical leadership role in expanding a network of regional 

pediatric care. Going forward, the Commission will collaborate with stakeholder 

organizations to explore innovative ways to expand regionalization of pediatric care.

Recommendation 3.5: Ensure access to physical and mental health services for all 

children during recovery from disaster.

Access to comprehensive primary care, including vaccines, physical, dental and mental health 

screening following a disaster is essential for children. A “medical home,” defined as a source 

of primary care that is accessible, continuous, comprehensive, family-centered, coordinated, 

compassionate and culturally effective,86 is a vital resource for children and families recovering 

from disasters. 

The Commission recommends the development of programs based on a model of care 

consistent with the concept of an enhanced “medical home” that includes preventive care, 

health education, timely diagnosis and treatment of acute illness, management of chronic 

conditions, coordination of specialty care needs and availability of urgent and emergent 

response. Ideally, following a disaster each child would be assigned to a “medical home 

provider” who would provide comprehensive physical, mental and oral health care and 

assessments consistent with the model as described above. Access to medications, specialty 

health care services and other special needs would be assured, and comprehensive medical 

records, preferably on an electronic health record system, would be maintained for every 

child receiving care under this program. 

The ability of physical and mental health care entities, such as clinics and providers, to 

recover from a disaster quickly is essential to assisting children in their recovery. The 

Commission recommends an examination of all federal programs utilized to reestablish 

83 Committee on Pediatric Emergency Medicine American Academy of Pediatrics, Pediatric Committee American College of Emergency Physicians, and Emergency 

Nurses Association, Pediatric Committee, “Joint Policy Statement: Guidelines for Care in the Emergency Department,” Pediatrics 124, no. 4 (2009): in press.

84 Edward W. Boyer, James Fitch, and Michael Shannon, Pediatric Hospital Surge Capacity in Public Health Emergencies. (Prepared under Contract No. 290-00-

0020), ed. Agency for Healthcare Research and Quality, (Rockville, MD: AHRQ, 2009), 16.

85 Ibid., 16-17.

86 Edwards, “Foreword,” 1471 (see n. 30).
SECTION 3: CHILD PHYSICAL HEALTH AND TRAUMA

22 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

vital entities in disaster-affected communities including those provided by the Small 

Business Administration and under the Robert T. Stafford Disaster Relief and Emergency 

Assistance Act87 (“Stafford Act”). Experience along the Gulf Coast following Hurricane 

Katrina illustrated that the convergence of the cost of rebuilding, an unpredictable patient 

base and other economic hardships created difficulties for practices to reestablish 

themselves only with loan programs.

87 P.L. 93-288, as amended, 42 U.S.C. 5121-5207 (1988).
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 23

4. EMERGENCY MEDICAL SERVICES AND 

PEDIATRIC TRANSPORT 

Recommendation 4.1: Improve the capability of Emergency Medical 

Services (EMS) to transport pediatric patients and provide comprehensive 

pre-hospital pediatric care during daily operations and disasters.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 25

4. Emergency Medical Services and Pediatric Transport 

Recommendation 4.1: Improve the capability of Emergency Medical Services (EMS) 

to transport pediatric patients and provide comprehensive pre-hospital pediatric 

care during daily operations and disasters.

•	 Establish a dedicated federal grant program for pre-hospital EMS. 

•	 Provide additional funding to the Emergency Medical Services for Children (EMSC) 

program to ensure all states and territories meet targets and achieve progress in the EMSC 

performance measures for grantees, and to support development of a research portfolio.

•	 As an eligibility guideline for Centers for Medicare and Medicaid Services (CMS) 

reimbursement, require first response and emergency medical response vehicles to acquire 

and maintain pediatric equipment and supplies in accordance with the national guidelines 

for equipment for Basic Life Support (BLS) and Advanced Life Support (ALS) vehicles.88

EMS is a system of public and private entities providing treatment and transportation of 

patients to available emergency medical care. According to a 2006 Institute of Medicine 

(IOM) report, the quality of EMS services varies widely among localities, regions and states. 

Accordingly, EMS is not well prepared to handle the consequences of a disaster, whether 

natural or man-made.89

The majority of EMS systems in the nation do not receive federal grant support for disaster 

preparedness and response, unlike other first responder agencies including emergency 

management, law enforcement, fire, public health and hospitals.90 For example, the American 

Recovery and Reinvestment Act of 200991 did not authorize funds for EMS organizations. In the 

absence of adequate funding to support appropriate staffing on a daily basis, the ability to expand 

surge capacity during a disaster is unrealistic. The DHS Homeland Security Grant Program 

requires states and local governments to include EMS in their homeland security plans, however, 

“...if no state or local funding is provided to EMS, the state should be prepared to demonstrate 

that related target capabilities have been met or identify more significant priorities.”92 A dedicated 

federal grant program for EMS would support state-level coordination and disaster planning, fieldlevel staffing, pediatric supply and equipment needs, and pediatric-specific training and exercises. 

Currently, the EMSC program, based at the Health Resources and Services Administration, 

is the one federal program that provides funding to states and territories to improve the EMS 

infrastructure for day-to-day pediatric emergency preparedness. A dedicated federal grant 

program that is specific to disaster preparedness for EMS could help ensure that EMS systems 

are meeting the pediatric-specific performance measures established by the EMSC program.

88 American College of Surgeons Committee on Trauma, American College of Emergency Physicians, National Association of EMS Physicians Pediatric Equipment 

Guidelines Committee, Emergency Medical Services for Children Partnership for Children Stakeholder Group, and American Academy of Pediatrics, Equipment for 

Ambulances, (Washington, DC: Children's National Medical Center, 2009), http://www.childrensnational.org/files/PDF/EMSC/PubRes/Equipment_for_ambulances_

FINAL.pdf.

89 Committee on the Future of Emergency Care in the United States Health System, Board on Health Care Services, Emergency Care for Children: Growing 

Pains. Executive Summary, ed. Institute of Medicine, (Washington, DC: National Academies Press, 2007), xiii, http://www.nap.edu/nap-cgi/report.cgi?record_

id=11655&type=pdfxsum.

90 National Association of State Emergency Medical Services Officials, State EMS Office Involvement in Domestic Preparedness Efforts: NASEMSO 2008 

Addendum, (Falls Church, VA: NASEMSO, 2008), 5, http://www.nasemso.org/Projects/DomesticPreparedness/documents/08DPAddendumReport-2.pdf.

91 P.L.111-5 (2009).

92 This is problematic because states are not assessed by DHS on their performance in meeting Target Capabilities; this work is self-reported. “Fiscal Year 2009 

Homeland Security Grant Program Guidance and Application Kit,” ed. U.S. Department of Homeland Security (Washington, DC: FEMA, 2008), 11, http://www.

fema.gov/pdf/government/grant/hsgp/fy09_hsgp_guidance.pdf.
SECTION 4: EMERGENCY MEDICAL SERVICES AND PEDIATRIC TRANSPORT

The 2006 IOM report supported the EMSC program citing its many accomplishments 

including the delivery of thousands of hours of pediatric-specific training for emergency 

medical providers, the implementation of injury prevention programs and the establishment 

of a pediatric research network, despite limited funding growth over the history of the 

program.93 IOM recommended that funding for the EMSC program be increased to $37.5 

million per year for five years. Forty-eight stakeholder organizations signed a July 14, 2009 

letter to the Chairmen of the House and Senate Appropriations Subcommittees on Labor, 

Health and Human Services, Education and Related Agencies advocating for an increase 

above the current $20 million appropriation to the EMSC program, citing the fact that death 

rates due to pediatric injury have dropped by 40 percent since the EMSC program was 

established.94, 95 Despite this progress, the gap between adult and pediatric emergency care 

on not only a day-to-day, but also a disaster basis, is sufficiently large as to require substantial 

increases in funding for EMSC beyond the amount recommended by the IOM. A significant 

amount of improvement must still be made to ensure that the emergency care system is 

prepared for the care of children in both everyday emergencies and disasters, and the work 

of the EMSC is instrumental in achieving a higher level of preparedness. 

The Commission recommends that additional funding be provided to the EMSC program as a 

means to boost pediatric preparedness in EMS systems throughout the nation. With additional 

funding, the EMSC program would support the establishment and maintenance of a full-time 

EMSC administrator in every state and territory to ensure the ongoing needs of children are 

met in state disaster planning and response. Assurance that pediatric needs will be met in the 

pre-hospital system is an ongoing process that requires a state-level champion who is solely 

dedicated to ensuring that children are not forgotten during disaster planning and response. 

EMSC would provide additional funding for research to build an evidence base for the 

development of standardized pre-hospital pediatric disaster care practices and protocols. 

The EMSC State Partnership Grant Program has a set of comprehensive performance 

measures that serve to establish an ongoing, systematic process for tracking progress 

towards meeting the goals of the EMSC program and allow for continuous monitoring of 

the effectiveness of key program activities.96 The Commission supports the use of these 

performance measures in determining the extent to which grantees are meeting established 

targets and recommends that the proposed federal funding stream for EMS provide sufficient 

support to ensure that all states integrate the EMSC priorities97 into existing state and territory 

requirements by 2014.98 With additional funding, EMSC could publish an annual report card 

on each state’s performance in providing EMS to children, which would provide incentives 

for progress and public transparency in the use of the funds.

93 Committee on the Future of Emergency Care in the United States Health System, Emergency Care for Children, 13-14.

94 Coalition for American Trauma Care Advisory Council et al., Letter to Representative David Obey, July 14, 2009, http://www.nasemsd.org/Advocacy/

PositionsResolutions/documents/07-14-09EMSCAppropsltrObey.pdf.

95 Coalition for American Trauma Care Advisory Council et al., Letter to Senator Tom Harkin, July 14, 2009, http://www.nasemsd.org/Advocacy/

PositionsResolutions/documents/07-14-09EMSCAppropsltrHarkin.pdf.

96 EMSC National Resource Center, EMSC Performance Measures: Implementation Manual, 3.

97 The priorities summarized are:

1. Pre-hospital provider agencies have on-line and off-line pediatric medical direction at the scene of an emergency for BLS and ALS providers.

2. BLS and ALS patient care units in the state/territory have the essential pediatric equipment and supplies.

3. The existence of a statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric medical 

emergencies and trauma.

4. Hospitals in the state/territory have written pediatric inter-facility transfer guidelines with specific components.

5. Hospitals in the state/territory have written pediatric inter-facility transfer agreements.

6. The adoption of requirements by the state/territory for pediatric emergency education for the licensure/certification renewal of BLS and ALS providers.

7. A full-time EMSC manager within the state system to ensure and maintain the operational infrastructure to provide optimal pre-hospital care to children.

98 EMSC National Resource Center, EMSC Performance Measures: Implementation Manual, 102-4.

26 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 4: EMERGENCY MEDICAL SERVICES AND PEDIATRIC TRANSPORT

Over the next year, the Commission will be closely reviewing issues concerning the 

lack of surge capacity for critical care transport of children. One of EMSC’s prioritized 

performance measures is the establishment of statewide, territorial or regional standardized 

systems that recognize hospitals that are able to stabilize or manage pediatric medical 

emergencies and trauma. The existence of a statewide recognition system has been shown 

to increase the number of hospital emergency departments that are capable of providing 

pediatric emergency care.99 Another priority is the establishment of written pediatric interfacility transfer agreements. A categorization process and inter-facility transfer guidelines 

help facilitate EMS transfer of children to appropriate levels of resources. Although 19 

states have such a system in place for trauma, only eight states have a categorization 

system for medical emergencies. 

Since pre-hospital EMS providers generally do not treat a sufficient number of pediatric 

patients to develop and maintain clinical skills,100 continuing education is critically important. 

There is a pressing need for a new approach to pediatric training and education for 

professionals in EMS. It is necessary to expand and create a comprehensive pediatric training 

program into the initial and recertification process for EMS practitioners.101 The Commission 

supports the adoption of requirements by states and territories for pediatric emergency 

education for the licensure and certification renewal of BLS and ALS providers. 

The Commission also recommends that eligibility guidelines for CMS reimbursement should, 

at a minimum, require first response and emergency medical response vehicles to acquire 

and maintain pediatric equipment and supplies in accordance with the national guidelines 

for equipment for BLS and ALS vehicles.102 Such action would provide a strong incentive to 

help ensure that all BLS and ALS vehicles meet a baseline level of pediatric preparedness. 

99 Ibid., 42-4.

100 Ibid., 71.

101 U.S. National Highway Traffic Safety Administration, “National EMS Education Standards and Instructional Guidelines,” http://www.ems.gov/portal/site/ems/

menuitem.5149822b03938f65a8de25f076ac8789/?vgnextoid=409589ff3091f110VgnVCM1000002fd17898RCRD.

102 American College of Surgeons Committee on Trauma et al., Equipment for Ambulances.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 27

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 29

5. DISASTER CASE MANAGEMENT

Recommendation 5.1: Establish a holistic federal disaster case management 

program with an emphasis on achieving tangible positive outcomes for all 

children and families within a Presidentially-declared disaster area.
“Often after a disaster like Hurricane Ike, survivors are 

overwhelmed by all the losses and devastation in their 

lives – home, vehicles, jobs, personal belongings and even 

the deaths or injuries of family and friends. As a result, 

they often have trouble figuring out where to even begin 

the process of rebuilding homes and lives.” 

--Mark Minick, Lutheran Social Services
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 31

5. Disaster Case Management

Recommendation 5.1: Establish a holistic federal disaster case management program 

with an emphasis on achieving tangible positive outcomes for all children and 

families within a Presidentially-declared disaster area. 

Following Hurricanes Katrina and Rita, the federal government provided at least $209 million 

for disaster case management103 services to assist survivors in coping with the devastation 

and rebuilding their lives, yet deficiencies existed that resulted in poor outcomes for these 

programs and illuminated the need for greater coordination and program evaluation in the 

provision of disaster case management services.104

Confusion regarding roles and responsibilities across federal agencies compounded by 

the expiration of federally funded disaster case management programs initiated after the 

storms led to breaks in funding that adversely affected case management agencies and 

may have left survivors most in need of assistance without access to case management 

services.105, 106 For example, as the first federally funded case management program, 

Katrina Aid Today drew to a close in March 2008 and some case management providers 

shut down their operations. Cases were closed, not because the client’s needs had 

been met, but simply because the funding for the program was coming to an end. FEMA 

provided funds for additional services, but due to budget negotiations, the program’s 

continuation in Mississippi was delayed several months while the program in Louisiana 

was not implemented.107

The Commission recognizes that FEMA is evaluating four pilot disaster case management 

programs authorized following Hurricanes Gustav and Ike in 2008. However, the Commission 

recommends that FEMA move aggressively to determine a preferred program by the end 

of 2009. The Commission will collaborate with FEMA as appropriate to develop expert 

consensus around a disaster case management program, with specific parameters and 

elements as indicated below. 

The Commission supports the recommendation of the U.S. Government Accountability 

Office (GAO) for the development of a federal disaster case management program108

and suggests that it be holistic in scope, flexible and sensitive to cultural and economic 

differences in communities, while placing a priority on serving the needs of families with 

103 Disaster case management is the process of organizing and providing a timely, coordinated approach to assess disaster-related needs as well as existing 

healthcare, mental health and human services needs that may adversely impact an individual’s recovery if not addressed. The objective of disaster case 

management is to rapidly return children and families who have survived a disaster to a state of self-sufficiency. This is accomplished by ensuring that each child/

family has access to a case manager who will capture information about the child/family’s situation and then serve as their advocate and help them organize and 

access disaster-related resources. “Disaster Case Management Implementation Guide,” ed. U.S. Department of Health and Human Services Administration for 

Children and Families (Washington, DC: HHS, 2008), 62. 

104 “Greater Coordination and Evaluation of Programs,” ed. GAO, 7 (see n. 27).

105 The federal role for funding and coordinating disaster case management was not explicitly defined until the passage of PKEMRA. The Stafford Act, as 

amended, is the primary authority under which the federal government provides major disaster and emergency assistance to states, local governments, tribal 

nations, individuals and qualified private, nonprofit organizations. FEMA is responsible for administering the provisions of the Stafford Act. At the time of Hurricanes 

Katrina and Rita, the Stafford Act contained no explicit authority to fund disaster case management services. The Post-Katrina Act amended the Stafford Act and, 

among other things, granted the President the authority to provide financial assistance for case management services to victims of major disasters. P.L. 109-295, title 

VI, §689f, codified at 42 U.S.C. §5189d (2006). The Post-Katrina Act was passed in October 2006.

106 “Disaster Assistance: Greater Coordination and an Evaluation of Programs' Outcomes Could Improve Disaster Case Management,” GAO-09-561, ed. United 

States Government Accountability Office (Washington, DC: GAO, 2009), 13.

107 Ibid.

108 Ibid., 36.
SECTION 5: DISASTER CASE MANAGEMENT

children. Disaster case management should be led by a single federal agency that will 

coordinate, among all relevant agencies and organizations, disaster case management and 

ensure there is: 

•	 Adequate understanding of the health, nutrition, education and human services needs of 

children and families;

•	 Involvement of voluntary agencies that provide disaster case management; and

•	 Access to funding that supports all aspects of disaster case management, including direct 

services. 

Disaster preparedness funding must be provided for infrastructure and capacity building to 

support a case management program, in advance, and to contract for the rapid deployment 

of case managers into disaster-affected areas.

The purpose of disaster case management is to rapidly return children and families who have 

survived a disaster to a state of self-sufficiency. The program should develop a consistent 

set of comprehensive program evaluation tools that regularly measure and monitor success 

based upon tangible positive outcomes for families, especially those most in need, rather 

than case managers simply making referrals. The program evaluation should also include 

guidelines for assessing and monitoring recovery milestones for children. 

The Commission further recommends a national contract to ensure rapid deployment of case 

managers, funding and transition to service providers in the local community. The contractor 

would be required to pre-identify state and local subcontracting agencies and prepare a 

roster of disaster case managers from professional organizations that can provide surge 

capacity following a disaster. 

Following Hurricanes Katrina and Rita, difficulties in coordination resulted in limited 

monitoring and program oversight and a lack of accurate and timely information sharing 

between federal agencies and case management providers.109 These difficulties, in 

conjunction with current privacy policies, have created barriers to the provision of disaster 

case management services.110 According to the GAO report, state and local agencies 

responsible for providing federally funded disaster case management services following 

the hurricanes faced consistent difficulty obtaining timely and accurate information from 

the federal agencies overseeing the programs.111 As a result of FEMA’s interpretation 

of information sharing and privacy requirements under the Privacy Act,112 some case 

management providers in Louisiana and Mississippi were unable to obtain critical information 

that inhibited the coordination of service delivery and prevented eligible hurricane survivors 

from receiving services.113 The Commission recommends a review and modification of 

current privacy policies and laws as necessary to permit the timely sharing of relevant 

disaster victim information among federal, state, local, tribal and non-governmental agencies 

and organizations engaged in supporting children and families affected by disasters.

109 Ibid., 15-20.

110 Ibid., 19-20. 

111 Ibid., 19-20

112 P.L. 93-579; 5 U.S.C. § 552a (1974).

113 “Disaster Assistance: Greater Coordination and an Evaluation of Programs' Outcomes Could Improve Disaster Case Management,” GAO-09-561, ed. United 

States Government Accountability Office (Washington, DC: GAO, 2009), 19-20.

32 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 33

6. CHILD CARE

Recommendation 6.1: Require disaster planning capabilities for child 

care providers.

Recommendation 6.2: Improve capacity to provide child care services in 

the immediate aftermath of and recovery from a disaster.
“It is an immediate concern of parents to have a safe and 

healthy environment for the care of their children. These 

parents cannot successfully return to work or focus on 

work issues when there is no child care available.” 

--Mississippi Governor Haley Barbour 
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 35

6. Child Care

Recommendation 6.1: Require disaster planning capabilities for child care providers.

•	 Require state child care regulatory agencies to include disaster planning, training and 

exercising requirements within the scope of the state’s minimum health and safety standards 

for child care licensure or registration. 

•	 Require state child care administrators114 to develop statewide child care plans in coordination 

with state and local emergency managers, public health, child care regulatory agencies and 

child care resource and referral agencies. 

Disaster planning for child care providers is crucial because young children, many of whom 

are immobile and unable to communicate basic identifying information to a rescuer, are 

particularly vulnerable in the face of danger when away from their families.115 There are 

nearly 12 million children under the age of five in child care each week.116 Child care 

providers must be prepared for disasters, not only to ensure children’s safety and mental 

well-being in the face of danger, but also to facilitate recovery by providing support services 

to parents, guardians, employees and employers in the aftermath of a disaster.117 

However, a lack of basic disaster preparedness requirements for child care providers is 

commonplace in states throughout our nation. In June 2009, Save the Children released a 

report, “The Disaster Decade,” which contained a report card on child care disaster planning 

requirements across 50 states and the District of Columbia.118 Among the key findings were: 

•	 Only seven states have laws or regulations requiring licensed child care providers to 

have basic written emergency plans in place addressing evacuation, reunification and 

accommodating children with special needs;

•	 Only 21 states require licensed child care facilities to have a designated site and evacuation 

route in the event of a disaster; and

•	 Only 15 states require licensed child care facilities to have a reunification plan for children and 

families in the event they become separated during an emergency.119

State child care regulatory agencies should include disaster planning, training and exercising 

requirements within the scope of the state’s minimum health and safety standards for child 

care licensure or registration. Disaster plans for child care providers must, at a minimum, 

incorporate specific measurable capabilities for shelter-in-place, evacuation, relocation, 

family reunification, staff training, continuity of operations and accommodation of children 

with disabilities and chronic health needs. State and local emergency management planning 

114 State child care administrators refers to lead agencies at the state level responsible for developing child care programs and administering federal funding 

received through the Child Care Development Fund (CCDF). Child Care and Development Fund, Code of Federal Regulations, 45 CFR § 98.1 (2007) 547-8, http://

www.acf.hhs.gov/programs/ccb/law/finalrul/ccdf_regulations_oct_2007.pdf.

115 National Association of Child Care Resource & Referral Agencies, Keeping Children Safe: A Policy Agenda for Child Care in Emergencies, (Arlington, VA: 

NACCRRA, 2008), 3.

116 Ibid., 3.

117 Ibid., 9.

118 Save the Children, The Disaster Decade: Lessons Unlearned for the U.S., (Westport, CT: Save the Children U.S. Programs, 2009), 4, http://www.

savethechildren.org/publications/usa/disaster-decade-lessons.pdf.

119 Ibid.
SECTION 6: CHILD CARE

activities must be expanded to include participation of child care administrators, child care 

regulatory agencies and child care resource and referral agencies. Similarly, state child 

care administrators must develop statewide child care disaster plans in coordination with 

emergency managers, child care regulatory agencies and child care resource and referral 

agencies. Model plans, guidance and technical assistance will aid disaster planning, training 

and exercising efforts of individual child care providers and encourage state and local 

planning collaborations.

States must develop child care disaster plans that establish guidelines for recovery after 

a disaster addressing the continuation of child care services and provision of temporary 

child care services. Child care is a critical component of recovery efforts.120, 121 Provision 

of child care services to accommodate families who need temporary relief during recovery 

efforts can mitigate a wide variety of economic, mental health and social problems after a 

disaster.122, 123 Child care is also essential to first responders, emergency managers and critical 

personnel who work around the clock. 

In the aftermath of a disaster, temporary child care facilities may be set up near large 

employers and temporary housing sites to support parents, guardians, employees and 

employers and provide children with appropriate care, adequate nutrition and recreational 

opportunities.124 However, those providing temporary child care services in non-permanent 

facilities often encounter regulatory hurdles that can obstruct their efforts to serve children 

and families.125 While it is critical that providers of temporary disaster child care services 

preserve the highest possible standards of care, states must appreciate the difficulties 

associated with providing care in a potentially devastated post-disaster environment and 

must be prepared to accommodate the provision of temporary child care in a variety of 

settings including shelters and non-permanent facilities.126 Establishing temporary child 

care services in the aftermath of a disaster may require exemptions from certain ordinary 

state child care licensing requirements that best serve needs of children in normal times.127 

Accordingly, states must develop temporary disaster child care operating standards that 

permit the provision of disaster child care in non-traditional settings and modify, and when 

necessary waive, requirements that may be impractical in the aftermath of a disaster while 

continuing to ensure the health, safety, nutritional status and overall well-being of children.128

The pending reauthorization of the Child Care and Development Block Grant Act of 1990 

(CCDBG)129 provides Congress the opportunity to improve the disaster planning capabilities 

of child care providers. The CCDBG, which provides formula grants to states, territories 

and tribes to assist low-income families in the purchase of child care services, also requires 

states to establish baseline health and safety standards for child care providers supported 

by CCDBG.130, 131 In the CCDBG’s reauthorization, Congress should require state child 

120 “ESF-6 Disaster Response Recommendation to FEMA: Reimbursement for Child Care Assistance,” ed. U.S. Department of Health and Human Services, 

Administration for Children and Families (Washington, DC: HHS, 2007), 1. 

121 Lenore T. Ealy and Paige Ellison-Smith, To Hold Safe: Framing a New Era of Disaster Child Care, (Carmel, IN: Project K.I.D., 2007), 9.

122 “ESF-6 Disaster Response Recommendation” ed. U.S. Administration for Children and Families, 1.

123 Ealy and Ellison-Smith, To Hold Safe, 9.

124 Ibid., 15.

125 Ibid., 18.

126 Ibid.

127 Ibid.

128 Ibid.

129 P.L. 101-58, as amended; 42 U.S.C. 9859, et seq. 

130 Ibid. 

131 “ESF-6 Disaster Response Recommendation” ed. U.S. Administration for Children and Families, 2-3.

36 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 6: CHILD CARE

care regulatory agencies to include disaster planning, training and exercising for child 

care providers, whether or not they receive CCDBG funds, within the scope of the state’s 

regulatory requirements for child care providers. In addition, state child care administrators 

should be required to develop disaster plans that include guidelines for recovery, including 

temporary operating standards to be used in the aftermath of disasters.

Recommendation 6.2: Improve capacity to provide child care services in the 

immediate aftermath of and recovery from a disaster.

•	 Include the provision of child care as a human service activity within the National Response 

Framework (NRF). 

•	 Provide reimbursement under the Stafford Act, amending the Act as necessary, to support 

child care services to displaced families, establishment of temporary disaster child care and 

the repair or reconstruction of child care facilities. 

Following a disaster, child care is an essential human service necessary to protect the safety 

of children and support the stabilization of families.132 Child care helps expedite recovery 

efforts by ensuring that children are safe while parents visit damaged property, access 

public benefits, search for employment and housing and make other efforts to rebuild their 

lives.133, 134 Moreover, child care recovery supports a community's economic recovery. If 

a community does not have access to child care for its youngest children, families can 

not return to work and the community can not recover economically.135 Finally, research 

indicates that consistent, high-quality early education and child care improve the health and 

promote the cognitive development of young children,136 both of which can be negatively 

affected by a disaster.137

The need for child care as a “supportive service” to survivors is clear when states and 

localities experience an overwhelming demand for child care assistance, including assistance 

through the CCDBG program.138 The addition of child care as an essential service along 

with a definition of “emergency child care” to the NRF under ESF 6 and in the development 

of a National Disaster Recovery Strategy will serve to formalize child care as a necessary 

component of disaster preparedness and recovery across all levels of government.

Following a disaster, states and localities may be faced with a surge of families with young 

children seeking child care assistance and may lack resources to meet the increased 

demand.139 After Hurricane Katrina, Mississippi funded the provision of child care services 

for displaced families, many of whom would not have otherwise been eligible for benefits 

due to residency, income or work requirements, with the expectation that the state could be 

reimbursed.140 Mississippi’s Office of Children and Youth provided 60-day emergency child 

care certificates to displaced families without regard to income or employment, waiving 

132 Ibid., 1.

133 Ibid.

134 National Association of Child Care Resource & Referral Agencies, Keeping Children Safe, 9.

135 Ibid.

136 American Academy of Pediatrics, “Policy Statement,” Pediatrics 115, no. 1 (2005), 187, http://aappolicy.aappublications.org/cgi/reprint/pediatrics;115/1/187.pdf.

137 Lori Peek, “Children and Disasters: Understanding Vulnerability, Developing Capacities, and Promoting Resilience - an Introduction,” Children, Youth and 

Environments 18, no. 1 (2008), 4.

138 “ESF-6 Disaster Response Recommendation” ed. U.S. Administration for Children and Families, 2-3.

139 Ibid., 2. 

140 Ibid., 1.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 37
SECTION 6: CHILD CARE

38 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

the co-payment fee for parents.141 Mississippi served over 2,700 evacuee children at an 

approximate cost of $1.65 million.142 However, it was denied reimbursement from FEMA 

which determined that emergency child care services did not qualify as an eligible Category 

B Emergency Protective Measure.143 

The CCDBG program is not suited to accommodate increased demand for child care services 

resulting from a disaster since the program’s finite resources are allocated to states based on 

statutorily required formulas and cannot be awarded to states impacted by a disaster on a 

targeted basis.144 FEMA could act preemptively to ensure that states that support child care 

services for disaster survivors have a mechanism to receive reimbursement under the Stafford 

Act for the expenses they incur in serving these families. Additionally, the creation of an 

emergency contingency fund through the CCDBG program to support states on a targeted 

basis after a federally declared disaster would allow states to receive reimbursement when 

subsidizing child care services for displaced families. States would be able to serve disaster 

survivors without depleting their already committed CCDBG funds that provide needed child 

care services to working low-income families. 

Funding and support for the repair and reconstruction of child care infrastructure is crucial to 

restoring child care services as quickly as possible. In New Orleans before Hurricanes Katrina 

and Rita, the city had 15,731 day care slots at 266 licensed centers.145 Nearly a year after 

the storms, 80 percent of those centers and 75 percent of the slots were still gone.146 In St. 

Bernard Parish in Louisiana, the number of child care centers dropped from 26 before Katrina 

to only two by 2007.147 Between 62 to 94 percent of the licensed child care slots were “lost or 

potentially lost” in the three coastal Mississippi counties hit hardest by Hurricanes Katrina and 

Rita.148 Without repairing, rebuilding and reopening child care facilities that are damaged in 

disasters, communities may lose their capacity to provide child care services, which can stymie 

recovery by limiting the ability of parents to return to work and the ability of families to return 

to communities. Furthermore, research indicates that investment in the child care sector is 

effective in spurring economic development in both the short and long-term.149, 150

Certain private non-profit child care facilities may be eligible for reimbursement for 

repairs and reconstruction under the Stafford Act, if they fail to qualify for disaster loans 

administered by the Small Business Administration. However, according to the National 

Association of Child Care Resource and Referral Agencies, many, if not most, child care 

services are provided by private businesses that operate for profit, thus precluding them from 

receiving Stafford Act funds. Child care providers, regardless of their tax status, should be 

eligible to receive federal reimbursement for the repair and reconstruction of their facilities. 

141 Ibid.

142 Ibid.

143 Ibid.

144 Ibid., 2.

145 Elizabeth F. Shores, Cathy Grace, Erin Barbaro, Michael Barbaro, and Jenifer Moore, Orleans Parish, Louisiana, Child Care Assessment; Executive Summary, 

(Mississippi State: Mississippi State University Early Childhood Institute, 2006), 3, http://www.earlychildhood.msstate.edu/orleans-summary/orleans-exec-summ.pdf.

146 Ibid., 3.

147 U.S. Senator Mary L. Landrieu, Committee on Homeland Security and Governmental Affairs, Ad Hoc Subcommittee on Disaster Recovery, Focusing on 

Children in Disasters: Evacuation Planning and Mental Health Recovery, August 4, 2009, http://www.senate.gov/fplayers/I2009/urlPlayer.cfm?fn=govtaff080409&st

=0&dur=6090.

148 Mississippi State University Early Childhood Institute, After Katrina: Rebuilding Mississippi's Early Childhood Infrastructure; the First Six Months, Early Childhood 

Report no. 1, (Mississippi State: Mississippi State University Early Childhood Institute, 2006), 5, http://www.earlychildhood.msstate.edu/katrina-report.pdf.

149 Mildred E. Warner and Zhilin Liu, “Economic Development Policy and Local Services: The Case of Child Care,” International Journal of Economic 

Development Vol. 7, no. 1 (2005): 25-64. 

150 Mildred E. Warner, “Putting Child Care in the Regional Economy: Empirical and Conceptual Challenges and Economic Development Prospects,” Community 

Development: Journal of the Community Development Society 37, no. 2 (2006): 7, http://government.cce.cornell.edu/doc/pdf/7-22%20warner.pdf.
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 39

7. ELEMENTARY AND SECONDARY EDUCATION

Recommendation 7.1: Establish a school disaster preparedness program 

and appropriate funds to the U.S. Department of Education (DoEd) for a 

dedicated and sustained funding stream to all state education agencies 

(SEAs). Funding should be used for state- and district-level disaster response 

planning, training, exercises and evaluation that are coordinated with state 

and local plans and activities.

Recommendation 7.2: Enhance the ability of school personnel to support 

children who are traumatized, grieving or otherwise recovering from a disaster.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 41

Recommendation 7.1: Establish a school disaster preparedness program and 

appropriate funds to the U.S. Department of Education (DoEd) for a dedicated and 

sustained funding stream to all state education agencies (SEAs).

151 Funding should 

be used for state- and district-level disaster response planning, training, exercises 

and evaluation that are coordinated with state and local plans and activities.

Most schools and school districts have developed emergency management plans to address 

“multiple hazards,”152 however very few of these plans are comprehensive enough to 

address disasters such as pandemics and radiological events.153 School districts currently 

lack integration with the planning efforts of SEAs and would benefit from community-wide 

coordination with local heads of government, local public health and emergency response 

officials and parents.154 In a 2007 GAO report, school officials from 62 percent of all school 

districts included in the study identified challenges to implementing emergency management 

programs, including lack of equipment, training for staff and lack of personnel with expertise 

in the area of emergency planning.155 While most school districts practice their emergency 

management plans annually within the school community, the GAO estimates “over one 

quarter of school districts have never trained with first responders and over two thirds of 

school districts do not regularly train with community partners on how to implement their 

school district emergency management plans.”156

The Commission recommends authorizing legislation and appropriations to the DoEd for 

a dedicated and sustained federal funding stream to all SEAs for state- and district-level 

school disaster response planning and evaluation. Existing federal funding for school districts, 

such as the DoEd’s Readiness and Emergency Management for Schools (REMS) program, 

has provided much-needed support to help a number of school districts revise emergency 

management plans, provide training and develop systems to sustain project activities. REMS 

should receive continued support since it is a mechanism that can yield model programs and 

test various cost- and time-effective approaches to improving school preparedness. However, 

REMS is a competitive grant program with a very limited budget that is able to fund a select 

number of school districts, thus leaving the majority of school districts in this country less 

than optimally prepared.157 The establishment of a federal funding stream to all SEAs would 

facilitate coordinated disaster planning and exercising activities in school districts throughout 

the country. For example, federal funding would support: 

151 SEAs include tribal nations and territories.

152 “Emergency Management: Status of School Districts’ Planning and Preparedness,” GAO-07-821T, ed. Government Accountability Office (Washington, DC: 

GAO, 2007), http://www.gao.gov/products/GAO-07-821T. 

153 “Emergency Management: Most School Districts Have Developed Emergency Management Plans, but Would Benefit from Additional Federal Guidance,” 

GAO-07-609, ed. Government Accountability Office (Washington, DC: GAO, 2007), 5, http://www.gao.gov/new.items/d07609.pdf.

154 Ibid.

155 Ibid., 6.

156 Ibid.

157 Since 2003, the REMS program has distributed 714 grants to 661 Local Education Agencies, serving a small proportion of the 14,200 public school districts 

nationwide. Readiness and Emergency Management for Schools Technical Assistance Center, “FY2009 REMS Grantees,” U.S. Department of Education, http://rems.

ed.gov/index.cfm?event=grantees2009. 

7. Elementary and Secondary Education
SECTION 7: ELEMENTARY AND SECONDARY EDUCATION

•	 School districts via the SEA to support the development of comprehensive school district 

disaster plans at the local level;

•	 The equitable participation of non-public schools;

•	 Coordination with existing school-based programs and networks for disaster-displaced 

children, specifically the Education for Homeless Children and Youth Program under the 

McKinney-Vento Act;

•	 Provision of in-service training to teachers and school staff on important aspects of disaster 

planning and management and disaster mental health; 

•	 Execution of regular disaster preparedness exercises and drills that involve local emergency 

management, school personnel and other stakeholders; 

•	 Development of state, regional and local school district continuity of operations plans to 

ensure academic continuity for all students affected by a disaster; and

•	 Effective dissemination of guidance, best practices and technical assistance building upon the 

work of the REMS Technical Assistance Center.

DHS provides funding to state emergency management agencies for emergency 

preparedness initiatives, with grant guidance that allows the inclusion of school-related 

activities such as security training for school bus drivers and physical hardening of school 

buildings.158 Yet very few states provide DHS funding directly to school districts even though 

school districts are eligible to receive the funds.159

Guidance from a new dedicated funding stream to school districts via SEAs could require 

state-level collaboration among SEAs and state emergency management agencies to better 

leverage federal emergency management funds. State and school district performance 

measures and benchmarks must be established and disseminated with federal funding 

for emergency preparedness activities, and regular evaluations should be conducted to 

assess progress and accountability for federal funding to both SEAs and state emergency 

management agencies.

A current and comprehensive national assessment is needed to inform the development 

of realistic performance measures and benchmarks that would allow school districts to 

show progress in disaster preparedness. An assessment of these plans would update and 

expand upon findings from the 2007 GAO report “Status of School Districts’ Planning and 

Preparedness.”160 A more accurate snapshot of the current state of readiness within schools 

and school districts, including information regarding their capacity to respond to children 

with disabilities and special needs would also serve to identify continuing gaps requiring 

targeted federal and state guidance and technical assistance. 

158 U.S. Department of Homeland Security, “School Safety,” http://www.dhs.gov/files/programs/gc_1183486267373.shtm.

159 GAO reported “Five states—Florida, Hawaii, Michigan, Mississippi, and Wyoming—reported that they provided approximately $14 million in DHS funding 

directly to school districts in these states during fiscal years 2003–2006.” “Most School Districts Have Developed Emergency Management Plans,” ed. GAO, 60.

160 “Status of School Districts’ Planning and Preparedness,” ed. GAO. 

42 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 7: ELEMENTARY AND SECONDARY EDUCATION

Recommendation 7.2: Enhance the ability of school personnel to support children 

who are traumatized, grieving or otherwise recovering from a disaster.

Encourage initiatives that support and promote training of teachers and other school staff 

in basic skills in providing support to grieving students and students in crisis through 

requirements for accreditation, licensure and recertification/license renewal.

Federal and state guidance must enhance the ability of school personnel to support children 

who are traumatized, grieving or recovering from crisis situations. Most children who 

receive mental health services receive them in schools.161 However, without proper planning 

and training, school personnel can be unsure about their role with children following a 

disaster.162 Teachers, school administrators and other school personnel should be trained 

to understand the impact of trauma and loss and to provide basic supportive services and 

basic bereavement support following a disaster. According to school personnel interviewed 

following Hurricanes Katrina and Rita, the greatest barriers to helping students following the 

storms were not knowing what mental health programs they should use and the shortage of 

trained staff to implement these types of programs.163

Initiatives that both support and promote emergency preparedness and crisis response 

training for teachers and other school staff should be encouraged through requirements 

for accreditation and licensure. The National Center for School Crisis and Bereavement 

has recommended that concerted efforts be made to ensure that basic knowledge about 

the impact of bereavement and crisis on children is covered within pre-service training of 

teachers. In addition, basic skills in providing support to students grieving or in crisis should 

be assessed in licensure and accreditation examinations of new teachers. This provision is 

consistent with recent recommendations by the Disaster Mental Health Subcommittee of the 

National Biodefense Science Board.164

The pandemic outbreak of H1N1 influenza is an ongoing concern for schools and 

communities. A January 2009 report to the Homeland Security Council found that many 

state governments deferred pandemic influenza planning responsibilities, such as school 

closure decisions, to their local educational or governing entities.165 The report noted “it is 

neither likely that [school districts] would have the capacity to operate with equal levels 

of ability, nor is it likely that the [SEA] would be comfortable deferring all responsibility 

to [school districts] with no oversight or coordination. Furthermore, a lack of coordinated 

state response could potentially compromise the state’s ability to successfully mitigate 

the virus’ transmission.”166 A dedicated funding stream to SEAs could improve state and 

regional coordination of school closures and dissemination of federal and state guidance 

and emergency information to school districts, and improve disaster planning and response 

efforts at the local level. 

161 Weist et al. “Mental Health Screening in Schools,” 54 (see n. 43).

162 Claude M. Chemtob, Joanne P. Nakashima, and Roger S. Hamada, “Psychosocial Intervention for Postdisaster Trauma Symptoms in Elementary School 

Children: A Controlled Community Field Study,” Archives of Pediatric and Adolescent Medicine 156, no. 3 (2002): 211-16, http://archpedi.ama-assn.org/cgi/content/

abstract/156/3/211.

163 Jaycox et al., How Schools Can Help, 10-12 (see n. 42).

164 Disaster Mental Health Recommendations, ed. HHS, 11-14 (see n. 34).

165 “Assessment of States' Operating Plans to Combat Pandemic Influenza: Report to Homeland Security Council,” ed. U.S. Department of Health and Human 

Services (Washington, DC: HHS, 2009), http://pandemicflu.gov/professional/states/state_assessment.html. 

166 Ibid., 25.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 43

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 45

8. CHILD WELFARE AND JUVENILE JUSTICE

Recommendation 8.1: Provide guidance, technical assistance and 

model plans to assist state and local child welfare agencies in meeting 

current applicable disaster planning requirements and further require 

collaboration with state and local emergency management, courts and 

other key stakeholders.

Recommendation 8.2: Conduct a national assessment of disaster planning 

and preparedness among state and local juvenile justice systems to inform 

the development of comprehensive disaster plans. 
“We had human feces floating around us in the water ... 

we was forced to survive in for 3 days. I still have little 

sores on my skin. I can’t seem to get that smell out of my 

skin. ... Maybe it’s all in my head but that smell will be 

with me, and be in my head for a very long time.” 

--C.S., a 15-year-old boy sheltered in Orleans Parish Prison during 

Hurricane Katrina 
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 47

8. Child Welfare and Juvenile Justice

Recommendation 8.1: Provide guidance, technical assistance and model plans to 

assist state and local child welfare agencies in meeting current applicable disaster 

planning requirements and further require collaboration with state and local 

emergency management, courts and other key stakeholders.

Although state child welfare agencies are required to have disaster plans, additional measures 

may be required to enable child welfare programs to maintain services and adequately 

respond to disasters. In addition to challenging a child welfare agency’s ability to handle 

existing cases, a disaster may also create a higher level of demand on referrals for children 

in need of child welfare services, including children who are separated from their parents, 

injured or orphaned. 

In 2006, Congress passed the Child and Family Services Improvement Act, adding a 

requirement that state child welfare agencies have procedures in place to do the following: 

•	 Identify, locate and continue availability of services for children under state care or supervision 

who are displaced or adversely affected by a disaster;

•	 Respond to new child welfare cases in areas adversely affected by a disaster, and provide services;

•	 Remain in communication with caseworkers and other essential child welfare personnel who 

are displaced because of a disaster;

•	 Preserve essential program records; and

•	 Coordinate services and share information with other states.167

Prior to the passage of the Act, the majority of states did not have written child welfare 

disaster plans, and the plans that were in place failed to adequately address tracking children 

and families and managing the ongoing needs of the system in the wake of a disaster.168 In 

2006, the GAO surveyed foster care disaster planning in states to evaluate their plans to 

continue an operational foster care system during a disaster and found that only three states 

had comprehensive child welfare plans addressing all of the vital components of planning 

included when the Act became law.169 

Although plans had to be submitted to HHS by September 28, 2007, the requirement was not 

tied to any additional funding to aid states in creating or implementing a plan and states may 

have had inadequate funding or guidance to engage in comprehensive, meaningful planning 

activities. Additionally, the Act neither requires states to coordinate their child welfare plans 

with other disaster relief efforts in the state nor utilize the expertise of emergency 

167 P.L. 109-288; 120 Stat. 1233 (2006).

168 “Child Welfare: Federal Action Needed to Ensure States Have Plans to Safeguard Children in the Child Welfare System Displaced by Disasters,” GAO-06-944, 

ed. Government Accountability Office (Washington, DC: GAO, 2006), 3, http://www.gao.gov/new.items/d06944.pdf.

169 Ibid., 16.
SECTION 8: CHILD WELFARE AND JUVENILE JUSTICE

management agencies to help them develop better plans. Furthermore, the plans do not 

require training, exercises or the identification of personnel to implement the plans at the 

local level.170 Consequently, many of the state plans, which were deficient or nonexistent 

prior to the Act, may still be lacking.171

In addition, the Act does not require state child welfare agencies to collaborate with courts 

and other key stakeholders within the child welfare arena in the formulation of plans. 

Today’s child welfare system is a “large and interconnected web” that is the product of 

contributions from various stakeholders from the judicial and executive branches and the 

public and private sectors.172 In a disaster, in order to identify, locate and continue available 

services to families who have children under state care or supervision who are displaced or 

adversely affected by a disaster, the child welfare agency, courts and other stakeholders such 

as lawyers, advocates for foster children, youth and parents, public and private providers 

of services such as health, mental health, developmental and substance abuse services and 

foster and biological families must all work together in a collaborative effort.173 

In a recent review of specific state child welfare plans, the National Council of Juvenile 

and Family Court Judges found that state plans often contained only general statements 

addressing the five areas of planning required by the Child and Family Services Improvement 

Act, and had no directives concerning how information would be shared with the courts 

that make vital decisions affecting the lives of children and families in the child welfare 

system.174 To the extent that a court has a duty to ensure that children in the state’s custody 

are receiving proper care, it is imperative for that court to know whether the children under 

its jurisdiction are physically and emotionally healthy.175 In addition to having their own 

continuity of operations plans, courts must be involved in the planning efforts of state and 

local child welfare agencies. A coordinated planning effort would help reconvene separated 

foster families, attorneys, social workers, court-appointed special advocates, children’s 

relatives and parents for timely processing of open cases. 

If a disaster forces a mass evacuation, biological parents may have difficulty reuniting with 

their children in foster care at the time of the evacuation, resulting in children remaining in 

foster care for extended time periods. Without proper procedures to locate children and 

families in their systems, preserve essential program records and remain in communication 

with caseworkers, courts and other key personnel and stakeholders, states will be unable to 

continue processing cases and providing much-needed services. In addition, child welfare 

systems and courts in areas that were not directly affected by a disaster should be prepared 

to effectively respond to an influx of new child welfare cases emanating from the disaster 

area or emerging as a result of the disaster itself. 

170 Gerald F. Glynn, “Foster Care: Disasters Complicate an Already Bad Situation” In Children, Law and Disasters: What We Have Learned from Katrina and 

the Hurricanes of 2005, ed. American Bar Association Center on Children and the Law, University of Houston Law Center and Center for Children Law and Policy 

(Houston: ABA Center on Children and the Law, 2009), 33.

171 Ibid., 34.

172 Karen Gottlieb and Susan Jennen Larson, “How Should the Best Interests of the Child Be Balanced against the Need for Confidentiality of Records in Times of 

Emergency?,” In Emergency Preparedness in Dependency Courts: Ten Questions That Courts Serving Abused and Neglected Children Must Address, ed. Victor E. 

Flango (Williamsburg, VA: National Center for State Courts) Chapter 7, http://www.icmeducation.org/katrina/chapter7.html.

173 Ibid.

174 Lisa Portune and Sophia I. Gatowski, Ensuring the Unique Needs of Dependency Courts Are Met in Disaster Planning Efforts: Dependency Court Planning 

Templates for Continuity of Operations Plans, (Reno, NV: National Council of Juvenile and Family Court Judges, Permanency Planning for Children Department, 

2008), 67.

175 Victor E. Flango, “Why Must the Needs of Children Come First” In Emergency Preparedness in Dependency Courts: Ten Questions That Courts Serving 

Abused and Neglected Children Must Address ed. Victor E. Flango (Williamsburg, VA: National Center for State Courts), Chapter 1, http://www.icmeducation.org/

katrina/chapter1.html.

48 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 8: CHILD WELFARE AND JUVENILE JUSTICE

Recommendation 8.2: Conduct a national assessment of disaster planning and 

preparedness among state and local juvenile justice systems176 to inform the 

development of comprehensive disaster plans. 

Each year, more than 140,000 juveniles are placed in residential, correctional and detention 

facilities, foster homes and group homes nationwide.177   The experience of approximately 150 

residents of juvenile detention centers run by the City of New Orleans during Hurricane Katrina 

provides an illustration of the importance of having and effectively implementing such plans in 

a disaster.178 

While state-run juvenile facilities in New Orleans evacuated inmates to Baton Rouge in 

advance of the hurricane, the residents of city-operated juvenile detention centers remained 

trapped in their facilities until shortly before the storm made landfall when they were moved 

to Orleans Parish Prison, which predominantly housed adult male inmates, for several 

days following the storm.179 As floodwaters inundated the city and the prison itself, “these 

children – a substantial percentage of whom had only just been arrested and not adjudicated 

of any crime – would endure flooding, exposure to toxins, food deprivation, water 

deprivation, medical care deprivation, heat exposure, violence and significant psychological 

stress.”180 Once the juveniles were finally evacuated to a Baton Rouge facility several days 

after the storm, officials had difficulty locating families of several of the New Orleans 

youth.181  In addition, the juvenile records of the detainees were left behind in the floodravaged city, which stalled officials’ efforts to determine who could be released to family 

and who needed to remain in custody.182 About 50 youths had been admitted to detention 

centers shortly before the storm, and had to wait weeks for their initial court hearings.183        

The Orleans Parish Juvenile Court, which moved operations to Baton Rouge and recruited 

public defenders and assistant district attorneys to hold hearings and conduct trials, was 

able to hold its first post-storm hearing just over three weeks after the storm.184 Within 

two months, every eligible juvenile inmate had been released, placed on probation or 

sentenced.185 While the Court’s effort in reestablishing operations in the storm’s aftermath 

is commendable, the horrors experienced by the juveniles while detained at Orleans Parish 

Prison, along with some of the difficulties they encountered thereafter, could have been 

avoided with better planning and preparation. It is therefore critical that state juvenile justice 

systems ensure that all residential treatment, correctional and detention facilities that house 

juveniles via court-ordered placements have comprehensive disaster plans.

176 State and local juvenile justice systems include juvenile justice agencies, courts, probation services and public and private residential treatment, correctional 

and detention facilities.

177 Charles Puzzanchera, and Melissa Sickmund, Juvenile Court Statistics, (Pittsburgh, PA: National Center for Juvenile Justice, 2008), 50, http://www.ncjrs.gov/

pdffiles1/ojjdp/224619.pdf.

178 Juvenile Justice Project of Louisiana (JJPL), Treated Like Trash: Juvenile Detention in New Orleans before, during, and after Hurricane Katrina, (New Orleans, 

LA: JJPL, 2006), 3, http://www.jjpl.org/PDF/treated_like_trash.pdf.

179 Ibid., 5.

180 Ibid.

181 Allen Powell II, “State Searching for Families of Some Youth Detention Center Residents,” Times-Picayune, September 15, 2005, Hurricane Katrina: Special 

Coverage Section.

182 Ibid.

183 Ibid.

184 Richard A. Webster, “Not Child's Play,” New Orleans CityBusiness, May 8, 2006, http://www.neworleanscitybusiness.com/viewStory.cfm?recID=15477.

185 Ibid.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 49
SECTION 8: CHILD WELFARE AND JUVENILE JUSTICE

50 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

Although a baseline level of disaster planning is required for state child welfare agencies, 

there is currently no parallel federal law requiring state juvenile justice systems to have 

comprehensive disaster plans in place.  In addition, little information is available regarding the 

level of disaster preparedness among state juvenile justice systems and residential, correctional 

and detention facilities.  

Accordingly, the Commission recommends that a working group be formed by the Office 

of Juvenile Justice and Delinquency Prevention (OJJDP) within the Department of Justice 

to include members from relevant federal, state and local agencies and non-governmental 

stakeholders with expertise in managing and providing services within juvenile justice 

systems, including courts, as well as members with disaster management experience. The 

working group would:

•	 Identify common gaps and shortcomings in state disaster planning, and best practices; 

•	 Develop and disseminate guidance and model disaster plans for state juvenile justice systems;

•	 Provide technical assistance and training to states; and

•	 Encourage state juvenile justice systems to develop or update disaster plans in coordination 

with state emergency management and key stakeholders including juvenile courts, residential 

treatment, correctional and detention facilities that house juveniles via court-ordered 

placements, and social services agencies. 

The Commission met with the OJJDP to discuss creative ways to support state planning 

activities and bring state juvenile justice disaster planning to the forefront of the agenda.  

The Commission will collaborate with the OJJDP to identify mechanisms to support the 

efforts of state agencies and to elevate the importance of juvenile justice disaster planning.  

The Commission envisions the recommended working group playing an integral role in 

facilitating this effort and increasing the disaster preparedness of juvenile justice systems 

across the nation.  An ultimate goal of this partnership is to support the development and 

implementation of disaster plans that minimize long-term displacement of children housed in 

residential, correctional and detention facilities from their families and support networks. 
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 51

9. SHELTERING STANDARDS, SERVICES 

AND SUPPLIES

Recommendation 9.1: Provide a safe and secure mass care shelter 

environment for children, including appropriate access to essential services 

and supplies.
”Within hours of Hurricane Ike’s landfall in Texas, San 

Antonio officials had compiled precise statistics bout 

their evacuee situation. They knew the city would need to 

care for 5,303 people (561 of whom had special medical 

needs) and 642 pets. ... But there was one key group for 

which they had no figures: children.” 

--Newsweek, “Overlooked: The Littlest Evacuees” (October 6, 2008)
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 53

9. Sheltering Standards, Services and Supplies

Recommendation 9.1: Provide a safe and secure mass care shelter environment for 

children, including appropriate access to essential services and supplies.

•	 Develop and implement national standards and indicators for mass care shelters that are 

specific and responsive to children.

•	 Develop a list of essential age-appropriate shelter supplies for infants and children and 

fund the addition of child-specific supplies to caches for immediate deployment to support 

shelter operations.

•	 Ensure the implementation of standards and training to mitigate risks unique to children in 

shelters including child abduction and sex offenders.

•	 Ensure all shelter operators have access to a fast, accurate and low-cost system for 

conducting national fingerprint-based criminal history background checks for shelter 

workers and volunteers.

Sheltering services in disasters typically are provided by a core group of National Voluntary 

Organizations Active in Disasters. These core agencies operate under agreed upon standards 

and protocols, including basic care of children. The Commission determined that a more 

comprehensive body of information is necessary to provide guidance about children to local 

emergency planners, shelter managers and staff. 

The Commission facilitated the development and dissemination of a draft document, 

Standards and Indicators for Disaster Shelter Care for Children (Appendix B). The document 

is being piloted in the field by the American Red Cross (ARC) and selected state and local 

emergency agencies during the 2009 hurricane season. At the request of the Commission, 

the availability of services and supplies relevant to infants and children also will be included 

in federal shelter assessment tools in the field. The standards and indicators will be evaluated 

and revised as necessary and incorporated into comprehensive documents that provide 

general shelter guidelines and training for shelter managers and staff.186 In addition, the 

Commission has engaged the U.S. Department of Justice to address the needs of children 

with disabilities and chronic health needs in shelters, including the needs of children who 

have parents with disabilities or chronic health needs.

The Commission also facilitated the development of a list of age-appropriate shelter supplies 

for infants and toddlers (Appendix C). Based upon this list, federal, state and local disaster 

supply caches can be created or expanded to support shelter managers with essential and 

cost-reimbursable supplies (e.g. formula, food, diapers, etc.) prior to the opening of shelters. 

186 For example, they can be incorporated into the Common Standards of Care for Domestic Disaster Response in development by the coalition group National 

Voluntary Organizations Active in Disasters.
SECTION 9: SHELTERING STANDARDS, SERVICES AND SUPPLIES

The Commission recommends that all shelter operators establish protocols to ensure the 

safety and security of children. A fast, accurate and low-cost system for conducting national 

fingerprint-based criminal history background checks for shelter workers and volunteers 

would help prevent sex offenders from entering shelters and coming in contact with children. 

At a minimum, all shelter workers and volunteers should be trained to identify and address 

suspicious and inappropriate activity.

Systems must also be in place to allow for appropriate tracking of children and families in 

shelters and to share appropriate information for the purpose of family unification. Protocols 

should prevent families from being separated during evacuations and ensure they are 

sheltered together. Staff must be aware of protocols to manage unaccompanied minors, 

homeless youth or self-evacuated youth that present at shelters. Staff must also plan to 

accommodate children with disabilities and chronic health needs. Additional protocols 

may be required to ensure the rapid reunification of children separated from their families. 

Shelter operators should coordinate shelter planning and operations with government 

agencies and non-governmental organizations that have responsibility for providing services 

to children, such as medical and educational services, including school enrollment and 

child protective services. 

Development of an electronic database and records management system would facilitate 

an accurate daily count of children in shelters, identified by age and need, and would assist 

with locating children residing in shelters. Demographic information would be useful to 

shelter managers and entities in the community that coordinate and provide for the medical, 

behavioral, academic, mental health and basic daily needs of children. The current version 

of the National Shelter System is owned and maintained by the ARC and does not collect 

demographic information on children. The system relies upon self-reported aggregate 

information from shelter managers based on the daily number of occupied beds. FEMA has 

also developed its own version of the National Shelter System187 and is working with the 

ARC to achieve integration of the two systems via automatic electronic updates by early 

2010.188 The Commission recommends that integration include demographic and needs data 

on children.

Recognizing the strong bonds between children and their pets, the Commission also 

recommends guidance and planning be provided for the location of pet shelters in close 

proximity to shelters, whenever possible.

187 The National Shelter System (NSS) is a comprehensive, web-based data system created to support agencies (government and non-government) responsible for 

elements of shelter management. The NSS allows users to identify, track, analyze and report on shelter data in a consistent and reliable manner. The NSS supports 

Emergency Support Function (ESF 6) - Mass Care, Housing, and Human Services. U.S. Department of Homeland Security, “National Shelter System,” Federal 

Emergency Management Agency, http://www.fema.gov/about/regions/regioni/bridge8-3.shtm.

188 Personal communication to Tener Veenema from Scott Richardson, FEMA National Shelter System Point of Contact, August 20, 2009.

54 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 55

10. HOUSING

Recommendation 10.1: Prioritize families with children for disaster housing 

assistance and expedited transition into permanent housing, especially 

families with children who have disabilities or other special health, mental 

health or educational needs.
“Homelessness for a child is more than loss of a house. 

It disrupts every aspect of life. It separates children 

from their belongings, beloved pets, reassuring routines, 

friends and community. At a time when children should 

be developing a sense of safety and security ... they are 

severely challenged and limited by unpredictability, 

dislocation and chaos.” 

--Ellen Bassuk, MD, Harvard Medical School 
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 57

10. Housing

Recommendation 10.1: Prioritize families with children for disaster housing assistance 

and expedited transition into permanent housing, especially families with children 

who have disabilities or other special health, mental health or educational needs.

Within the Implementation Plan of the National Disaster Housing Strategy, delineate roles 

and responsibilities of federal, state, local and non-governmental agencies and emphasize 

the delivery of social services and improvement of the living environment for children 

throughout all phases of disaster housing assistance.

When forced to move several times or relocate to unfamiliar communities or temporary 

housing following a disaster, children may suffer emotional stress as a result of separation 

from family, friends and social networks and exposure to unfamiliar geographic and cultural 

environments.189 Children displaced following Hurricane Katrina experienced an average 

of three moves per child.190 It is generally believed that a child requires between four to 

six months for academic recovery following a move that results in a change in schools.191 

In addition, children living in FEMA-subsidized community sites192 following Hurricanes 

Katrina and Rita faced a variety of medical, physical and social hazards.193, 194 Six months 

after Hurricane Katrina, 34 percent of children living in community sites had at least one 

diagnosed chronic medical health condition.195

Access to adequate housing is a precondition for many other elements of a family’s recovery 

following a disaster, including returning children to schools and child care, returning parents 

to work and reconnecting children with their medical care providers. To help create a stable 

environment and minimize the harmful effects that can occur when children’s lives are 

disrupted by a disaster, housing recovery plans should facilitate quick and seamless transitions 

from emergency shelters to temporary housing to permanent housing. Lessons learned from 

previous disasters suggest that the goal for post-disaster housing should be to keep children and 

families linked to the support networks within their communities by enabling them to remain 

in or return to their homes as quickly as possible, reducing the need for shelters and temporary 

housing options and preventing minor damage from developing into major damage.196 Families 

who are unable to return to their own homes should be provided with safe, healthy, stable, 

adequate and affordable housing in their home communities whenever possible. Throughout 

the trajectory of emergency sheltering to interim and permanent housing, the safety and 

physical, mental and behavioral well-being of children must be prioritized.

189  Lori Peek, “Children and Disasters,” 4-7 (see n. 136).

190  Anne Westbrook Lauten and Kimberly Leitz, “A Look at the Standards Gap: Comparing Child Protection Responses in the Aftermath of Hurricane Katrina and 

the Indian Ocean Tsunami,” Children, Youth and Environments 18, no. 1 (2008), 187.

191  Laurene M. Heyback and Patricia Nix-Hodes, “Reducing Mobility: Good for Kids, Good for Schools,” The Beam: The Newsletter for the National Association 

for the Education of Homeless Children and Youth 9, no. 1 (1999), 5.

192  Commonly referred to as “temporary housing camps” or “trailer camps.”

193  Shane Townsend and Nathalie Dajko, Rapid Assessments of Temporary Housing Camps for Hurricane-Displaced Children and Families, (Westport, CT: Save 

the Children, 2006), 1-2.

194  David Abramson and Richard Garfield, On the Edge: Children and Families Displaced by Hurricanes Katrina and Rita Face a Looming Medical and Mental 

Health Crisis, (New York: National Center for Disaster Preparedness and Operation Assist, Mailman School of Public Health, Columbia University, 2006), 13-19, 

http://www.preventionweb.net/files/2958_On20the20Edge20LCAFH20Final20ReportColumbia20University.pdf.

195 Ibid., 1.

196 Habitat for Humanity, Letter to the Commission, June 8, 2009.
SECTION 10: HOUSING

In the aftermath of an event where the severity and magnitude warrants a disaster declaration 

by the President, the 2009 National Disaster Housing Strategy articulates FEMA’s initial 

actions that focus on supporting state efforts to ensure that all disaster survivors are sheltered 

safely and securely, with access to food and other necessary life-sustaining commodities and 

resources.197 The Commission supports the six goals for disaster housing assistance addressed 

in the National Disaster Housing Strategy198 and recommends integration of child-specific 

priorities throughout the forthcoming Implementation Plan. 

In addition, the Commission recommends that representation on both the National Disaster 

Housing Task Force, and its complementary state task forces, include persons with subject 

matter expertise related to children and the programs that serve their health, mental health, 

nutrition, educational and social services needs. Working groups should be formed to 

specifically address these needs. 

The Commission also supports FEMA’s strategy that community sites of factory-built 

housing units be used only as “an option of last resort.”199 However, when community 

sites are erected in situations where all other options have been exhausted, it is essential 

that these sites be designed and built to better meet the needs of children and families. In 

the community sites constructed in the wake of Hurricane Katrina, children were put at 

risk as a result of overcrowding, unsafe environments and alienation from surrounding 

communities.200 To improve community site operations that were deleterious to children’s 

health, safety and well-being, PKEMRA required a plan for the operation of community sites, 

including access to public services, site management, security and site density.201 

FEMA recognizes that access to educational institutions, places of employment and essential 

social services such as public transportation, emergency services and healthcare facilities, 

must be considered during the process of planning and designing a community site.202

Although FEMA states that the availability of these and other wrap-around services203

should be considered during the community site design process, it also acknowledges that 

positioning a community site in close proximity to these services is not always possible. In 

addition, FEMA maintains that the Stafford Act provides no specific authorities to FEMA for 

these temporary augmentations to community sites, such as child care, playground facilities 

and other services for children.204

To address the social service needs of people living in interim housing, FEMA intends 

to rely on community groups, such as faith-based and volunteer organizations, and 

municipal organizations, such as local housing authorities.205 In its forthcoming 

Implementation Plan, FEMA must clearly delineate the roles and responsibilities of all 

197  “National Disaster Housing Strategy,” ed. Federal Emergency Management Agency (Washington, DC: FEMA, 2009), 88-90, http://www.fema.gov/pdf/

emergency/disasterhousing/NDHS-core.pdf.

198  National Goals: 1) Support individuals, households, and communities in returning to self-sufficiency as quickly as possible. 2) Affirm and fulfill fundamental 

disaster housing responsibilities and roles. 3) Increase our collective understanding and ability to meet the needs of disaster victims and affected communities. 4) 

Build capabilities to provide a broad range of flexible housing options, including sheltering, interim housing, and permanent housing. 5) Better integrate disaster 

housing assistance with related community support services and long-term recovery efforts. 6) Improve disaster housing planning to better recover from disasters, 

including catastrophic events. Ibid., 4-5.

199  “National Disaster Housing Strategy: Annexes,” ed. Federal Emergency Management Agency (Washington, DC: FEMA, 2009), 99, http://www.fema.gov/pdf/

emergency/disasterhousing/AnnexesAll.pdf.

200  Townsend and Dajko, Rapid Assessments of Temporary Housing, 3.

201  P.L. 109-295; 120 Stat. 1394.

202  “National Disaster Housing Strategy,” ed. FEMA, 52.

203  “The term �

that go beyond a physical need for housing.” “National Disaster Housing Strategy: Annexes,” ed. FEMA, 109.

204  Ibid., 109-10

205  “National Disaster Housing Strategy,” ed. FEMA, 52.

58 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 10: HOUSING

stakeholders involved in community site design and operations and establish a clear plan 

to better facilitate the delivery of social services and improve the living environment for 

children and families in community sites. As recommended in a 2006 Save the Children 

report,206 the Implementation Plan must address how FEMA will support its partner 

agencies in recovery to: 

•	 Provide access to basic services including, but not limited to, transportation, emergency 

services, education, healthcare facilities, food shopping, laundry facilities and child care;

•	 Link residents with state and local resources; 

•	 Facilitate integration into local communities; 

•	 Improve school integration;

•	 Improve the physical environment to include playgrounds, lighting, ramps, signage for children, etc.;

•	 Create a communal space for children and parents; and

•	 Ensure the provision of basic activities such as child play207 and social activities. 

According to a recent report from the Ad Hoc Subcommittee on Disaster Recovery of the 

U. S. Senate Committee on Homeland Security and Governmental Affairs, FEMA’s heavy 

reliance on trailers in recent disasters has “proved less healthy, cost effective, livable, or 

humane” for families than rental housing would have been for intermediate and long-term 

housing recovery needs.208 PKEMRA established a rental repair pilot program, which was 

implemented in two disasters of different incident types until the program’s expiration on 

December 31, 2008.209 The pilot program provided adequate, cost-effective temporary 

housing to individuals and households by funding repairs to existing multi-family rental 

housing units. An expanded rental repair program has the potential not only to facilitate 

recovery by increasing rental stock and affordable housing in disaster stricken areas, but also 

to help prevent children and families from exposure to many of the well-documented dangers 

associated with living in manufactured housing and community sites. Furthermore, FEMA 

estimated that the cost of providing housing via its rental repair pilot program in one pilot 

site was 83 percent less than the cost of providing manufactured housing, and 66 percent 

less in the other.210 Any pilot or permanent rental repair program established to expand 

affordable housing options in disaster-affected jurisdictions should prioritize assistance to 

families with children.

Townsend and Dajko, Rapid Assessments of Temporary Housing, 3.

207  “Play is at the heart of what it means to be a kid,” and is critical to their mental well-being. It is imperative that following a disaster, children are provided 

protective, restorative environments where they can return to being a kid as soon as possible. In this pursuit, Project K.I.D. established PlayCare disaster child care 

sites across coastal Mississippi, Alabama and Louisiana, and worked on-the-ground with over 5,000 children in storm devastated areas in the aftermath Hurricane 

Katrina. Ealy and Ellison-Smith, To Hold Safe, 2 (see n. 120).

208  “Far from Home: Deficiencies in Federal Disaster Housing Assistance after Hurricanes Katrina and Rita and Recommendations for Improvement,” ed. U.S. 

Senate Committee on Homeland Security and Governmental Affairs (Washington, DC: U.S. Government Printing Office, 2009), 274, http://www.gpoaccess.gov/

congress/index.html.

209 

1-2.

210  Ibid., 4.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 59

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 61

11. EVACUATION

Recommendation 11.1: Develop a standardized, interoperable national 

evacuee tracking and family reunification system that ensures the safety and 

well-being of children.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 63

11. Evacuation

Recommendation 11.1: Develop a standardized, interoperable national evacuee tracking 

and family reunification system that ensures the safety and well-being of children.

Hurricane Katrina provided a graphic illustration of the challenges in our national disaster 

response capacity regarding evacuation, tracking and family reunification. Parents and 

guardians were separated from their children, as far as hundreds of miles apart. Downed 

communication lines, the lack of centralized record keeping and the absence of a tracking 

system logging evacuees’ movements hampered survivors’ abilities to locate family members.211

Following Hurricanes Katrina and Rita, the National Center for Missing and Exploited Children 

received over 34,000 calls on the hotline they established and devoted specifically to reuniting 

children missing as a result of the two storms, with greater than 5,000 children separated from 

their families.212 Three months after the storms, 4,371 children had been reunited with their 

families, but 740 children remained separated from their parents or guardians.213 After six 

months of separation, the last missing child was reunited with her family.214

Depending on their stage of development, children may be unable to provide their name, 

address or phone number, or may be too frightened to give any information to aid in reunification 

efforts. 215 The rapid identification, protection and reunification of separated children with their 

guardians can help to minimize secondary injuries such as physical and sexual abuse, neglect 

and abduction.216 The separation of children from their guardians also affects the psychological 

responses of children after a disaster and places them at greater risk for injury.217

Following the Indian Ocean earthquake and resulting tsunami in 2004, the World Health 

Organization issued Guiding Principles for tracking and reunification of families following 

a disaster. These principles state that “[u]naccompanied and separated children should be 

provided with services aimed at reuniting them with their parents or customary care-givers 

as quickly as possible.”218 The principles also state that “[i]nterim care should be consistent 

with the aim of family reunification, and should ensure children’s protection and wellbeing... Identifying, registering and documenting unaccompanied and separated children are 

priorities in any emergency and should be carried out as quickly as possible.”219

211 Daniel D. Broughton, Ernest E. Allen, Robert E. Hannemann, and Joshua E. Petrikin, “Getting 5000 Families Back Together: Reuniting Fractured Families 

after a Disaster: The Role of the National Center for Missing & Exploited Children,” Pediatrics 117, no. 5 (2006): S442-5, http://pediatrics.aappublications.org/cgi/

reprint/117/5/S2/S442.

212 Sarita Chung, and Michael Shannon, “Reuniting Children with Their Families During Disasters: A Proposed Plan for Greater Success,” American Journal of 

Disaster Medicine 2, no. 3 (2007): 114.

213 Ibid., 114.

214 Ibid., 114.

215 Ibid., 116-7.

216 Mark A Brandenburg, Sue M. Watkins, Karin L. Brandenburg, and Christoph Schieche, “Operation Child-ID: Reunifying Children with Their Legal Guardians 

after Hurricane Katrina,” Disasters 31, no. 3 (2007): 277-87.

217 Ibid.

218 World Health Organization, Unaccompanied and Separated Children in the Tsunami-Affected Countries, (Maldives: WHO, 2005), http://www.who.org.mv/

EN/Section40/Section41_56.htm.

219 Ibid.
SECTION 11: EVACUATION

PKEMRA authorized the creation of two mechanisms to help locate family members and 

displaced children after a major emergency or disaster. First, the Act established the National 

Emergency Child Locator Center within the National Center for Missing and Exploited Children 

to provide assistance in locating displaced children and reunifying missing children with their 

families. The Act also required the FEMA Administrator to establish the National Emergency 

Family Registry and Locator System to help reunify separated families.220, 221

To date, tracking and family reunification plans have not worked consistently during disasters.222

Although some tracking systems have been developed or are in varying stages of development, 

current systems are not interoperable and no central data repository exists.223 A November 

2008 Congressional Research Service report recommended that Congress consider expanding 

FEMA grants for the research and development of new technologies that could improve 

evacuation planning and operations.224 The American College of Emergency Physicians also 

recommended the investigation of the use of newer technology (such as digital identification) 

that can integrate information from multiple sites for identifying and tracking missing 

individuals, especially children, to assist in the reunification of families.225 While states such as 

Texas and Louisiana have initiated development of state-wide electronic tracking systems, the 

need for a national tracking system is buttressed by the fact that many major evacuations across 

the U.S. result in an average of 3.5 moves per household, often across state lines.226

The Agency for Healthcare Research and Quality (AHRQ) developed recommendations for 

a National Mass Patient and Evacuee Movement, Regulating and Tracking System that could 

be used during a mass casualty or evacuation incident for the purposes of locating, tracking 

and regulating227 patients and evacuees.228 The recommendations for the proposed national 

system, which would also provide decision support to those with responsibility for patient 

and evacuee movement and care, health care and transportation resource allocation and 

incident management, acknowledged various difficulties associated with implementation, 

including legal and privacy issues and challenges with interoperability of data management 

systems.229 The AHRQ proposal recommends that the system obtain much of the data 

needed to track the location and health status of patients and evacuees electronically from 

existing systems at health care facilities, disaster shelters and other locations.230 However, 

the Privacy Act231 and Health Insurance Portability and Accountability Act232 may present 

barriers to the sharing of personal information of evacuees,233 and thus to the effective 

implementation of the system for reunification purposes. 

220 William O. Jenkins Jr., “Emergency Management: Actions to Implement Select Provisions of the Post-Katrina Emergency Management Reform Act,” GAO-09-

433T, ed. Government Accountability Office (Washington, DC: GAO, 2009).

221 P.L. 109-295; 120 Stat. 1394 (2006).

222 Nancy Blake and Kathleen Stevenson, “Reunification: Keeping Families Together in Crisis,” Journal of Trauma: Injury, Infection, and Critical Care 67, no. 2 

(2009): S147.

223 Ibid.

224 Bruce R. Lindsay, “Federal Evacuation Policy: Issues for Congress,” RL34745, ed. Congressional Research Service (Washington, DC: The Library of Congress, 

2008), http://www.fas.org/sgp/crs/homesec/RL34745.pdf.

225 American College of Emergency Physicians, Letter to the Commission, June 8, 2009.

226 Abramson and Garfield, On the Edge, (see n. 193).

227 “Regulating is a process that attempts to ensure that a patient or evacuee is transported on an appropriate vehicle to a location that has the staff, equipment, and 

other supplies that are needed to care for this person.” Regulation of child victims could greatly enhance the success of a regional pediatric disaster response system. 

Tom Rich, Paul Biddinger, Richard Zane, Andrea Hassol, Lucy Savitz, and Margarita Warren, Recommendations for a National Mass Patient and Evacuee Movement, 

Regulating, and Tracking System, ed. Agency for Healthcare Research and Quality, (Rockville, MD: AHRQ, 2009), http://www.ahrq.gov/prep/natlsystem/natlsys.pdf.

228 Ibid.

229 Ibid.

230 Ibid.

231 P.L. 93-579; 5 U.S.C. § 552a (1974).

232 P.L. 104-191; 101 Stat. 1936 (1996).

233 Rich et al., National Mass Patient and Evacuee System, 32, 41-43

64 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
SECTION 11: EVACUATION

A consensus conference on pediatric reunification was hosted by the Pediatric Disaster 

Resource and Training Center, Los Angeles, in June 2008, at which recommendations were 

released across a broad scope of issues.234 The Commission will review and consider these 

recommendations in the coming year and will continue to investigate the feasibility of 

implementing a standardized interoperable national evacuee tracking and family reunification 

system and the barriers associated therewith.

234 Blake and Stevenson, “Keeping Families Together in Crisis,” S147-S51.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 65

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 67

APPENDICES

Appendix A: Literature Collection Methodology 

Appendix B: Standards and Indicators for Disaster Shelter Care for Children

Appendix C: Supplies for Infants and Toddlers in Mass Care Shelters 

and Emergency Congregate Care Facilities

Appendix D: Subcommittee Members and Other Contributors

Appendix E: Stakeholder Outreach

Appendix F: Commissioner Biographies

Appendix G: Commission Staff

NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 69

APPENDIX A: LITERATURE COLLECTION METHODOLOGY

Commission staff explored academic databases and websites to identify existing research, 

reports, policy positions, guidelines, recommendations and identified gaps in the professional 

literature related to children and disasters using the terms and keywords “child*”, “pediatric”, 

“disaster”, “all-hazards”, “emergency”, “policy”, “recommendation” or “guidelines” in the title 

or abstract. These include PubMed, Google Scholar, the Health Services Research Library, and 

the National Child Resource Center from the Child Welfare Information Gateway. 

Federal government websites and related websites, including Thomas.gov, GAO.gov, 

OpenCRS.com, EBSCOhost.com, and GalleryWatch.com were searched for reports, findings 

and recommendation papers either cited in the above searches or containing specific 

wording on “child,” “disaster” and “all-hazards.” 

Websites of professional, advocacy and other non-governmental organizations related to 

children and disasters were reviewed for public documents discussing policy, guidelines, 

recommendations or gaps within the Commission’s scope. 

Citations and sources of relevant articles and reports were reviewed to identify any 

additional papers and reports for acquisition. 

On April 1, 2009 the Commission sent letters requesting information, research articles, 

reports and policy recommendations to 73 non-governmental stakeholder organizations 

conducting policy or academic work relating to children’s health and mental health, 

emergency management, disaster response, human services, housing, children’s education, 

juvenile justice and state and local government and legislatures (Appendix E). The 

Commission received 25 responses. Furthermore, documents from these stakeholder 

organizations and other various entities and individuals have also been submitted in meetings 

and by mail and email throughout the Commission’s tenure. 

All documents within the Commission’s scope, including abstracts where available, were 

entered into an EndNote® X2 database, which serves as the Commission’s library. PDF copies 

of the documents when available were attached to the citations. All documents were scanned 

for relevant information and categorized when possible. As of September 15, 2009, the 

database contained 759 documents.

APPENDIX A: LITERATURE COLLECTION METHODOLOGY
APPENDIX B: STANDARDS AND INDICATORS FOR DISASTER SHELTER CARE FOR CHILDREN

APPENDIX B: STANDARDS AND INDICATORS FOR DISASTER SHELTER 

CARE FOR CHILDREN

Purpose

To provide guidance to shelter managers and staff that ensures children have a safe, secure 

environment during and after a disaster – including appropriate support and access to 

essential resources.

Standards and Indicators for All Shelters

•	 Under most circumstances a parent, guardian or caregiver is expected to be the 

primary resource for their children, age 18 and younger. 

•	 In cases where parents or guardians are not with their children, local law enforcement 

personnel and local child protective/child welfare services must be contacted to assist 

with reunification. 

•	 Children are sheltered together with their families or caregivers.

•	 Every effort is made to designate an area for families away from the general shelter 

population. 

•	 Family areas should have direct access to bathrooms. 

•	 Parents, guardians and caregivers are notified that they are expected to accompany 

their children when they use the bathrooms.

•	 Every effort is made to set aside space for family interaction: 

o This space is free from outside news sources thereby reducing a child’s repeated 

exposure to coverage of the disaster. 

o If age-appropriate toys are available they will be in this space, with play 

supervised by parents, guardians or caregivers. 

•	 Shared environmental surfaces in shelters that are frequently touched by children’s 

hands or other body parts should be cleaned and disinfected on a regular basis. High 

contact areas may include diaper changing surfaces, communal toys, sinks, toilets, 

doorknobs and floors. These surfaces should be cleaned daily with a 1:10 bleach 

solution or a commercial equivalent disinfectant based on the manufacturer’s cleaning 

instructions. Local health department authorities may be consulted for further 

infection control guidance.

•	 When children exhibit signs of illness, staff will refer children to on-site or local health 

services personnel for evaluation and will obtain consent from a parent, guardian or 

caretaker whenever possible.

•	 When children exhibit signs of emotional stress, staff will refer children to on-site or 

local disaster mental health personnel and will obtain consent from a parent, guardian 

or caretaker whenever possible. 

•	 Children in the shelters come in all ages and with unique needs. Age appropriate and 

nutritious food (including baby formula and baby food) and snacks are available, as 

soon as possible after needs are identified. 

70 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 71

APPENDIX B: STANDARDS AND INDICATORS FOR DISASTER SHELTER CARE FOR CHILDREN

•	 Diapers are available for infants and children as soon as possible after needs are 

identified. General guidelines suggest that infants and toddlers need up to 12 diapers a 

day. 

•	 Blankets, for all appropriate ages, are also available. 

•	 A safe space for breastfeeding women is provided so they may have privacy and 

a sense of security and support (this can include a curtained off area or providing 

blankets for privacy).

•	 Basins and supplies for bathing infants are provided as soon as possible after needs 

are identified. 

Standards and Indicators for Temporary Respite Care for Children

Temporary Respite Care for Children provides temporary relief for children, parents, 

guardians or caregivers. It is a secure, supervised and supportive play experience for children 

in a Disaster Recovery Center, assistance center, shelter or other service delivery site. When 

placing their child or children in this area, parents, guardians or caregivers are required to 

stay on-site in the disaster recovery center, assistance center or shelter or designate a person 

to be responsible for their child or children, who shall also be required to stay on-site. 

In cases where temporary respite care for children is provided in a Disaster Recovery Center, 

assistance center, shelter and other service delivery site, the following Standards and Indicators 

shall apply:

•	 Temporary respite care for children is provided in a safe, secure environment following a 

disaster.

•	 Temporary respite care for children is responsive and equitable. Location, hours of 

operation and other information about temporary respite care for children is provided 

and easy for parents, guardians and caregivers to understand. 

•	 All local, state and federal laws, regulations and codes that relate to temporary respite 

care for children are followed.

•	 The temporary respite care for children area is free from significant physical hazards 

and/or architectural barriers and remains fully accessible to all children. 

•	 The temporary respite care for children area has enclosures or dividers to protect 

children and ensure that children are supervised in a secure environment.

•	 The temporary respite care for children area is placed close to restrooms and a 

drinking water source; hand washing and or hand sanitizer stations are available in the 

temporary respite care for children area. 

•	 Procedures are in place to sign children in and out of the temporary respite care for 

children area and to ensure children are only released to the parent(s), guardian(s), 

caregiver(s) or designee(s) listed on the registration form.

•	 All documents---such as attendance records and registration forms (which include 

identifying information, parent, guardian or caregiver names and contact information), 

information about allergies and other special needs, injury and/or incident report 

forms---are provided, maintained, and available to staff at all times. 

•	 Toys and materials in the temporary respite area are safe and age appropriate.
72 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX B: STANDARDS AND INDICATORS FOR DISASTER SHELTER CARE FOR CHILDREN

•	 Prior to working in the temporary respite care for children area, all shelter staff 

members must receive training and orientation. In addition, such staff must 

successfully complete a criminal and sexual offender background check. Spontaneous 

volunteers are not permitted. When inside the temporary respite area, staff shall 

visibly display proper credentials above the waist at all times. 

•	 When children are present, at least two adults are to be present at all times. No child 

should be left alone with one adult who is not their parent, guardian or caregiver. 

•	 All staff members must be 18 years or older. Supervision of the temporary respite care 

for children area is provided by a staff person at least 21 years of age. 

•	 An evacuation plan will be developed with a designated meeting place outside 

the center. The evacuation plan will be posted and communicated to parent(s), 

caregiver(s), and guardian(s) when registering their child. 

•	 The child to staff ratio is appropriate to the space available and to the ages and needs 

of the children in the temporary respite care for children area at any time.
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 73

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE 

SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

This document was facilitated by the National Commission on Children and Disasters with 

guidance from subject matter experts in emergency management and pediatric care. The 

document identifies basic supplies necessary to sustain and support 10 infants and children up 

to 3 years of age for a 24 hour period. The guidance is “scalable” to accommodate 10 or more 

children over a longer period of time.

The National Commission on Children and Disasters recommends state and local 

jurisdictions provide caches of supplies to support the care of children in mass care shelters 

and emergency congregate care facilities for a minimum of 72 hours. The amount of supplies 

cached in an area should be based upon the potential number of children up to 3 years of 

age that could be populating the local shelters and facilities for a minimum of 72 hours, as 

determined by an assessment of current demographic data for the jurisdiction. 

Depending on the nature of the event, a 24-72 hour supply of essential child-specific supplies 

should be on site prior to the opening of a shelter or facility. However, in situations where this 

is not possible, supplies should still be available for immediate deployment and delivered on 

site within 3 hours. 

Such a level of preparedness is critical due to the high vulnerability of this population.

(Guidance begins on next page.)
74 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

REQUIRED PERISHABLE SUPPLIES

Quantity Description Comment

40 Jars Baby Food - Stage 2 (jar size is 3.5 - 4 oz) Combination of vegetables, fruits, 

cereals, meats

1 box 

(16oz)

Cereal - single grain cereal preferred (e.g. 

rice, barley, oatmeal)

Rice, barley, oatmeal or a 

combination of these grains

See Note Diaper wipes - fragrance free 

(hypoallergenic) Minimum of 200 wipes

40 Diapers - Size 1 (up to 14 lbs.)

Initial supply should include one 

package of each size, with no less 

than 40 count of each size diaper

40 Diapers - Size 2 (12 - 18 lbs.)

40 Diapers - Size 3 (16 - 28 lbs.)

40 Diapers - Size 4 (22 - 37 lbs.)

40 Diapers - Size 5 (27 lbs. +)

40 Pull Ups 4T - 5T (38 lbs. +)

320oz Formula, milk-based, ready to feed 

(already mixed with water) ++

Breastfeeding is the best nutritional 

option for children and should be 

strongly encouraged.

64oz 

Formula, hypoallergenic-hydrolyzed 

protein, ready to feed (already mixed 

with water) ++

320oz Formula, soy-based, ready to feed 

(already mixed with water) ++

1 Quart

Oral Electrolyte solution for children, 

ready-to-use, unflavored (e.g. Pedialyte) 

- Dispensed by medical/health 

authority in shelter ++

Do not use sports drinks. The exact 

amount to be given, and for how 

long, should be determined by 

an appropriate medical authority 

(doctor or nurse). To be used in the 

event an infant/child experiences 

vomiting or diarrhea, and the degree 

of dehydration.

See Note

Nutritional Supplement Drinks for Kids/

Children, ready-to-drink 

(e.g., Pediasure, Kids Essential/Kids 

Boost) - Dispensed by medical/health 

authority in shelter

** Not for infants under 12 

months of age ** Requirement is a 

total of 40-120 fl. oz per day; in no 

larger than 8 oz bottles.

Note: See “Supplemental Information” for additional information regarding the items followed by “++.”
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 75

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

REQUIRED NON-PERISHABLE SUPPLIES & EQUIPMENT

Quantity Description Comment

25 Infant feeding bottles (plastic only) ++ 4 - 6 oz. size preferred (to address 

lack of refrigeration)

30 Infant Feeding Spoons ++

Specifically designed for feeding 

infants with a soft tip and small 

width. Can be used for younger 

children as well.

50 Nipples for Baby Bottles (non-latex 

standard) ++ 2 per bottle

25 Diaper Rash Ointment (petroleum jelly, 

or zinc oxide based) Small bottles or tubes

100 pads Disposable Changing Pads

At least 13x18 in size. Quantity is 

based on 8-10 diaper changes per 

infant per day

10 Infant bathing basin Thick plastic non-foldable basin. 

Basin should be at least 12” x10” x 4”

See Note Infant wash, hypoallergenic

Either bottle(s) of baby wash 

(minimum 100 oz.), which can be 

“dosed out” in a disposable cup (1/8 

cup per day per child) or 1 travel size 

(2oz) bottle to last ~48 hrs per child.

10 Wash cloths Terry cloth/cotton - at least one per 

child to last the 72 hr period

10 Towels (for drying after bathing) Terry cloth/cotton - at least one per 

child to last the 72 hr period

2 sets Infant hat and booties ++ Issued by medical/health authority in 

shelter

10 Lightweight Blankets (to avoid 

suffocation risk)

Should be hypoallergenic, (e.g., cotton, 

cotton flannel, or polyester fleece)

5 Portable Crib

To provide safe sleeping 

environments for infants up to 12 

months of age

2 Toddler potty seat

That can be placed on the seat of an 

adult toilet, with handles for support. 

One each should be located in both 

a Men's and Women's restroom

1 pack Electrical Receptacle Covers

Minimum 30 (Note: Prioritize 

covering outlets in areas where 

children and families congregate 

(family sleeping area, children’s 

areas, etc.)

Note: See “Supplemental Information” for additional information regarding the items followed by “++.”
76 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

RECOMMENDED PERISHABLE SUPPLIES

Quantity Description Comment

Baby Food – Stage 1 (jar size ~ 2.5 oz) Combination of vegetables, 

fruits, cereals, meats

Baby Food - Stage 3 (jar size ~ 6 oz) Combination of vegetables, 

fruits, cereals, meats

Diapers - Preemie Size (up to 6 lbs.) As needed for shelter population

Healthy snacks that are safe to eat 

and do not pose a choking hazard 

(intended for children 2 years and 

older)

Should be low sugar, low 

sodium: yogurt, applesauce, 

fruit dices (soft) (e.g., peaches, 

pears, bananas), veggie dices 

(soft) (e.g., carrots), 100% real 

fruit bite-sized snacks, real fruit 

bars (soft), low sugar/whole grain 

breakfast cereals and/or cereal 

bars, crackers (e.g., whole grain, 

“oyster”/mini)

RECOMMENDED NON-PERISHABLE SUPPLIES & EQUIPMENT

Quantity Description Comment

Sip Cups (support for toddlers) ++

Note: See “Supplemental Information” for additional information regarding the items followed by “++.”
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 77

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

SUPPLEMENTAL INFORMATION

Description Supplemental Notes

Formula

Use of a powered formula is at the discretion 

of the jurisdiction or shelter operator. If using 

powdered preparation of the formula should 

be conducted by appropriately trained food 

preparation workers. Water used should be 

from an identified potable water source (bottled 

water should be used if there is any concern 

about the quality of tap or well water). 

Hypoallergenic hydrolyzed formula can be 

provided in powdered form—(1) 400 gram 

can—but only if potable water is accessible. 

Infant Feeding Bottles and Nipples 

Each time nutritional fluids, formula and/

or other infant feeding measures (including 

breast milk in a bottle) are distributed by 

trained, designated shelter staff and/or medical 

professionals, clean, sterilized bottles and 

nipples must be used. Note: After use, bottles 

are to be returned to the designated location 

for appropriate sterilization (and/or disposal). 

Bottle feeding for infants and children is a 

24/7 operation and considerations must be 

in place to provide bottle feeding as needed 

(On average, infants eat at minimum 5-8 times 

daily). 

Note to staff: Sterilizing and cleaning 

Sterilize bottles and nipples before you use them 

for the first time by putting them in boiling water 

for 5 minutes. Nipples and bottles should be 

cleaned and sterilized before each feeding. If 

disposable bottles and nipples are not available 

and more durable bottles and nipples will be 

re-used they must be fully sterilized before each 

feeding. To the greatest extent possible bottles 

and nipples should be used by only one child. 

In the event parents want to use their own 

bottles and nipples, shelter staff should provide 

support for cleaning these items between 

feedings. Support such as access to appropriate 

facilities for cleaning (not public restrooms).
78 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX C: SUPPLIES FOR INFANTS AND TODDLERS IN MASS CARE SHELTERS AND EMERGENCY CONGREGATE CARE FACILITIES

SUPPLEMENTAL INFORMATION

Description Supplemental Notes

Note regarding all feeding implements for 

Infant/Children

There is a specific concern with cleaning and 

sanitizing of all feeding implements associated 

with infants and children (infant feeding bottles/

nipples, spoons, sip cups, etc.). These items will 

require additional attention by food preparation 

staff to ensure they are sanitary as a means 

of reducing food borne illness. Staff medical/

health staff should be consulted on best means 

of raising awareness among shelter residents 

and enlisting their support for these extra 

sanitary measures.

Feeding implements such as spoons and sip 

cups should be cleaned using hot soapy water 

provided potable water is available. When the 

item is being cleaned to give to another child 

the item must be sterilized. 

For the following items: infant bathing 

basin, lightweight blankets, diaper rash 

ointment, wash cloths, and towels

Consider pre-packaging the listed items together 

and providing one package to each family with 

children. Note: additional blankets and towels 

will be necessary for families with more than 

one child. 

(continued)
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 79

APPENDIX D: SUBCOMMITTEE MEMBERS AND OTHER CONTRIBUTORS

APPENDIX D: SUBCOMMITTEE MEMBERS AND OTHER CONTRIBUTORS

The Commission would like to thank the following agencies that have met with the 

Commission and have provided information used in the preparation of the Interim Report: 

Corporation for National and Community Service

Department of Health and Human Services

Department of Homeland Security

Department of Education

Department of Justice

Department of Housing and Urban Development

National Council on Disability 

U.S. Access Board

The Commission would also like to thank those who participated on the Subcommittees and/

or substantially contributed to the Interim Report:

HUMAN SERVICES RECOVERY SUBCOMMITTEE 

Federal Representatives:

Roberta Lavin, Department of Health and Human Services

Laura McClure, Department of Homeland Security

Non-federal Representatives:

David Abramson, National Center for Disaster Preparedness

Nell Bolton, Episcopal Diocese of Louisiana

Kim Burgo, Catholic Charities USA

Sue Catchings, Health Care Centers in Schools

Robin Gurwitch, National Center for Child Traumatic Stress

Cheryl Peterson, American Nurses Association

Augustina Reyes, University of Houston

Monteic Sizer, Louisiana Family Recovery Corps

Linda Smith, National Association of Child Care Resource & Referral Agencies
80 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX D: SUBCOMMITTEE MEMBERS AND OTHER CONTRIBUTORS

EVACUATION, TRANSPORTATION AND HOUSING SUBCOMMITTEE 

Federal Representatives:

Martin Gould, National Council on Disability 

Sophia Hsu, Department of Health and Human Services

Marsha Mazz, U.S. Access Board

Mark Tinsman, Department of Homeland Security

Non-federal Representatives:

Judy Bezon, Brethren Disaster Ministries, Children’s Disaster Services

Jeanne Aimee DeMarrais, Save the Children

Andrew Garrett, National Center for Disaster Preparedness

Kathleen Henning, International Association of Emergency Managers

David Lurie, National Association of County & City Health Officials

Richard Muth, National Emergency Management Association

Trevor Riggen, American Red Cross

Diana Rothe-Smith, National Voluntary Organization Active in Disasters

Shirley Schantz, National Association of School Nurses

Donna Swarts, Southern Baptist Disaster Ministries

JR Thomas, formerly of Save the Children

PEDIATRIC MEDICAL CARE SUBCOMMITTEE

Federal Representatives:

Sally Phillips, Department of Health and Human Services

David Siegel, Department of Health and Human Services

Tasmeen Singh Weik, Department of Health and Human Services

Non-federal Representatives:

Susan Dull, National Association of Children’s Hospitals and Related Institutions

Andrew Garrett, National Center for Disaster Preparedness

Linda Juszczak, National Association for Pediatric Nurse Practitioners

Steve Krug, Children’s Memorial Hospital, Chicago

Sharon Mace, American College for Emergency Physicians 

Cindy Pellegrini, American Academy of Pediatrics

Jeffrey Upperman, Childrens Hospital Los Angeles
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 81

APPENDIX D: SUBCOMMITTEE MEMBERS AND OTHER CONTRIBUTORS

EDUCATION, CHILD WELFARE AND JUVENILE JUSTICE 

SUBCOMMITTEE 

Federal Representatives:

Bill Modzeleski, Department of Education

Non-federal Representatives:

Kay Aaby, National Association of County & City Health Officials

Pat Cooper, Early Childhood and Family Learning Foundation

Patrick Chaulk, Annie E. Casey Foundation

Howard Davidson, American Bar Association Center on Children and the Law

Barbara Duffield, National Association for the Education of Homeless Children and Youth 

Vincent Giordano, formerly of the New York Academy of Medicine, 

Office of School Health Programs

Gina S. Kahn, Hampden-Wilbraham Regional School District (MA)

Ned Loughran, Council of Juvenile Correctional Administrators

Pegi McEvoy, Seattle Public Schools (WA)

Michael Nash, National Council of Juvenile and Family Court Judges

MaryEllen Salamone, Families of September 11th

Carole Shauffer, Youth Law Center

Lisa Soronen, National School Boards Association

Gregory A. Thomas, National Center for Disaster Preparedness

Marleen Wong, LAUSD/RAND/UCLA Trauma Services 

Adaptation Center for Schools and Communities

Also, the Commissioners wish to thank the following for their significant contributions:

Terry Adirim, Department of Homeland Security

Cheryl Vincent, Department of Health and Human Services

Kate Dischino, Save the Children

Gina Lagarde, Member, American Academy of Pediatrics

Sara Hoverter and Melanie MacLean, Harrison Institute for Public Law, 

Georgetown University Law Center
82 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX E: STAKEHOLDER OUTREACH

APPENDIX E: STAKEHOLDER OUTREACH

The National Commission on Children and Disasters requested information, reports, research 

findings and policy recommendations from the following non-governmental organizations:

American Academy of Family Physicians

American Academy of Pediatrics†*§ 

American Bar Association Center on Children and the Law†* 

American Association of School Administrators

American College of Emergency Physicians†* 

American College of Nurse-Midwives

American Federation of Teachers*

American Medical Association

American Nurses Association†

American Public Health Association

American Red Cross†*

America's Promise

Annie E. Casey Foundation† 

Association of Maternal and Child Health Programs*§

Association of State and Territorial Health Officials§

Association of the Schools of Public Health, Centers for Public Health Preparedness 

Association of Women's Health, Obstetric & Neonatal Nurses

Brethren Disaster Ministries, Children's Disaster Services†

Catholic Charities U.S.A.†

Center for Education Reform

Children & Family Futures

Children's Defense Fund

Children's National Medical Center

Church World Service

CityMatch

Coalition for Global School Safety

Congressional Research Service§

Council of Juvenile Correctional Administrators† 

Council of State Governments

Early Childhood and Family Learning Foundation† 

Education Commission of the States

Emergency Management Assistance Compact Advisory Group§

Episcopal Diocese of Louisiana† 

Families of September 11th † 

Feeding America*

First Star

Food Research and Action Center§

Habitat for Humanity*

Health Care Centers in Schools†

Home Safety Council

Institute of Women's Policy Research

International Association of Chiefs of Police

International Association of Emergency Managers†*

International Association of Emergency Medical Services Chiefs

International Association of Fire Chiefs*

International City/County Management Association

LAUSD/RAND/UCLA Trauma Services Adaptation Center for Schools and Communities† 

Louisiana Family Recovery Corps†*
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 83

APPENDIX E: STAKEHOLDER OUTREACH

March of Dimes

Mississippi Coast Interfaith Disaster Task Force

National Assembly on School-Based Health Care*

National Association for the Education of Homeless Children & Youth†*

National Association of Child Care Resource & Referral Agencies†* 

National Association of Children's Hospitals

National Association of Children’s Hospitals and Related Institutions†

National Association of Counties§

National Association of County and City Health Officials†*§

National Association of Emergency Medical Technicians*

National Association of Pediatric Nurse Practitioners†*

National Association of School Nurses†

National Association of School Psychologists

National Association of State Boards of Education

National Association of State EMS Officials§

National Center for Child Traumatic Stress† 

National Center for Disaster Preparedness at Columbia University†

National Center for Missing and Exploited Children†*

National Center for School Crisis and Bereavement* 

National Child Traumatic Stress Network

National Coalition on Children and Disasters§

National Conference of State Legislatures§

National Council of Juvenile and Family Court Judges†

National Education Association*

National Emergency Management Association†*§

National Emergency Medical Services Association

National Governor's Association§

National Homeland Security Consortium§

National League of Cities*§

National School Boards Association†* 

National Voluntary Organizations Active in Disaster†

Poverty & Race Research Action Council

Project KID, Inc*

Ready Communities Partnership

Ready Moms Alliance*

Rebuilding Together

Salvation Army

Save the Children†§

Southern Baptist Disaster Ministries†

The Children's Health Fund

Trust for America's Health*

United States Breastfeeding Committee§

U.S. Conference of Mayors

White Ribbon Alliance for Safe Motherhood*

Youth Law Center†

† Provided representation to one of the Commission’s four subcommittees

* Provided a formal response to the Commission’s April 1 outreach letter

§ Held an in-person meeting with the Commission
84 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX F: COMMISSIONER BIOGRAPHIES

APPENDIX F: COMMISSIONER BIOGRAPHIES

Ernest “Ernie” E. Allen, J.D.

Appointed to the Commission by Senate Minority Leader Mitch McConnell, Mr. Allen is 

Co-Founder, President and CEO of the National Center for Missing and Exploited Children 

(NCMEC). He guided NCMEC’s role in the recovery of 140,000 children, with NCMEC’s 

recovery rate climbing from 62% in 1990 to 97% today. Mr. Allen also built a global missing 

children’s network that includes 17 nations. He came to NCMEC after serving as Chief 

Administrative Officer of Jefferson County, Director of Public Health and Safety for the City 

of Louisville, and Director of the Louisville-Jefferson County Crime Commission. He is a 

graduate of the Louis D. Brandeis School of Law. 

Michael R. Anderson, M.D., FAAP

Vice-Chairperson 

Appointed to the Commission by President George W. Bush, Dr. Anderson is the Interim 

Senior Vice President and Chief Medical Officer at University Hospitals. As a pediatric 

specialist, Dr. Anderson has been active at the local, state and national level in pediatric 

disaster readiness and response. Currently he is pooling the talent of Ohio’s six children’s 

hospitals to form a disaster response team to serve as a state and federal asset in the wake 

of future disasters. His research and clinical interests include national physician workforce, 

pediatric critical care transport and national health policy issues for children. 

Merry Carlson, MPP

Appointed to the Commission by Senate Minority Leader Mitch McConnell, Ms. Carlson is 

the Preparedness Chief for the Division of Homeland Security and Emergency Management 

for the State of Alaska, where she helps provide critical services to the State to protect lives 

and property from terrorism and other hazards, as well as to provide rapid recovery from 

disasters. Ms. Carlson has served as Alaska’s Suicide Prevention Council Coordinator, and 

as Deputy Director for Behavioral Health for the North Slope Borough Health Department 

in Barrow, Alaska, where she both provided direct service and administered agencies in the 

areas of mental health, substance abuse, fetal alcohol, children and youth, developmental 

disabilities and infant learning. 

Honorable Sheila Leslie

Appointed to the Commission by Senate Majority Leader Harry Reid, Ms. Leslie is a 

Member of the Nevada General Assembly and the Specialty Courts Coordinator for the 

2nd Judicial District Court, running the criminal, family and juvenile drug courts and the 

state’s first mental health court. Ms. Leslie has worked on behalf of Nevada children, youth, 

and families for over 25 years. She served as Executive Director of the Children’s Cabinet, 

where she created innovative, award-winning programs including Family Preservation, the 

Child Care Resource Council, Homeless Youth Advocacy, Parent Education Network, and 

Nevada’s first comprehensive Adolescent Health Care program. She was also founding 

director of the Food Bank of Northern Nevada. As owner of a small consulting business, Ms. 

Leslie provided comprehensive consulting services through contracts with public and private 

non-profit human service organizations, specializing in developing and implementing public/

private partnerships addressing the needs of children and their families. 
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 85

APPENDIX F: COMMISSIONER BIOGRAPHIES

Bruce A. Lockwood, CEM

Appointed to the Commission by Speaker Nancy Pelosi, Mr. Lockwood is the Public Health 

Emergency Response Coordinator for the Bristol-Burlington Health District. Mr. Lockwood 

has 28 years experience in emergency management, emergency medical services and 

public safety, with extensive planning at the local, regional and state levels for children’s 

needs in disaster situations. He served as the Canton Schools All Hazard Planning Chair, 

and as a member of the Governor’s Prevention Partnership School Safety Portal Committee 

and the Child Safety and Crisis Response, State of Connecticut, Daycare and Child Care 

Subcommittee; he also served on the Connecticut Public Health Emergency Preparedness 

Advisory Committee. 

Graydon “Gregg” Lord, MS, NREMT-P

Appointed to the Commission by President Bush, Chief Lord is Associate Director of the 

National EMS Preparedness Initiative and Senior Policy Analyst at the Office of Homeland 

Security at George Washington University Medical Center. His career in Public Safety 

spans over 25 years and encompasses roles in rural and urban jurisdictions. He became a 

paramedic in the early 1980’s, subsequently achieving promotion to EMS Operations Chief 

of the second largest EMS system in New England at Worcester Emergency Medical Services. 

Chief Lord lectures nationally and internationally on EMS systems management, leadership 

and operations. He is an adjunct faculty member for various institutions and agencies, 

including Institute for International Disaster Emergency Medicine, Texas A&M University, 

U.S. Department of Justice and the Copenhagen Fire Department. Prior to his role at George 

Washington University Medical Center, Chief Lord served as Division Chief of Emergency 

Medical Services for Cherokee County Fire Department in Cherokee County, Georgia.

Irwin Redlener, M.D., FAAP

Appointed to the Commission by Speaker Nancy Pelosi, Dr. Redlener is President and cofounder of The Children’s Health Fund; he is also Director of the National Center for Disaster 

Preparedness at Columbia University’s Mailman School of Public Health. Dr. Redlener 

worked extensively in the Gulf region following Hurricane Katrina where he helped establish 

ongoing medical and public health programs. He also organized medical response teams 

in the immediate aftermath of the World Trade Center attacks in 2001 and has national and 

international disaster management leadership experience. Dr. Redlener served as Director 

of Grants and Medical Director of USA for Africa and Hands Across America; he also 

developed one of the country’s largest health care programs for homeless children and their 

families, the nationally acclaimed New York Children’s Health Project, now a model for 

several health care projects in The Children’s Health Fund’s network of programs. 

David J. Schonfeld, M.D., FAAP

Appointed to the Commission by House Minority Leader John Boehner, Dr. Schonfeld, FAAP 

is a developmental-behavioral pediatrician and the Thelma and Jack Rubinstein Professor 

of Pediatrics, Director of the Division of Developmental and Behavioral Pediatrics, and 

Director of the National Center for School Crisis and Bereavement at Cincinnati Children’s 

Hospital Medical Center; he is Professor Adjunct of Pediatrics at Yale University School of 

Medicine. Dr. Schonfeld is a member of the Disaster Mental Health Subcommittee of the 

National Biodefense Science Board Federal Advisory Committee and the American Academy 

of Pediatrics Disaster Preparedness Advisory Council; he is a Past President of the Society for 
86 NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT

APPENDIX F: COMMISSIONER BIOGRAPHIES

Developmental and Behavioral Pediatrics. For over two decades, he has provided consultation 

and training on school crisis and pediatric bereavement in the aftermath of a number of school 

crises (e.g., school shootings) and disasters within the United States and abroad, including 

flooding from Hurricane Katrina in New Orleans and Hurricane Ike in Galveston and the 2008 

earthquake in Sichuan, China. He coordinated the training of school crisis teams for New York 

City Public Schools after 9/11. Dr. Schonfeld is actively engaged in school-based research 

involving children’s understanding of an adjustment to serious illness and death and schoolbased interventions to promote adjustment and risk prevention.

Honorable Mark K. Shriver, MPA

Chairperson 

Appointed to the Commission by Senate Majority Leader Harry Reid, Mr. Shriver is Vice 

President and Managing Director for U.S. Programs at Save the Children. Before joining Save 

the Children, Mr. Shriver served as a Member of the Maryland House of Delegates. Among 

his many leadership roles as an elected official, he served as Maryland’s first-ever Chair 

of the Joint Committee on Children, Youth and Families, where he spearheaded an early 

childhood education initiative resulting in over 37 million new dollars for early education. 

Before being elected, Mr. Shriver created and was Executive Director of the innovative 

Choice Program, a public/private partnership serving at-risk youth through intensive, 

community-based counseling and job training services. The Choice Program has expanded 

to include The Choice Jobs Program and The Choice Middle School Program, and has been 

replicated nationwide. Mr. Shriver served on the Board of Directors of the Maryland Special 

Olympics and of the Montgomery County Court Appointed Special Advocates. He was a 

member of the Governor’s Juvenile Justice Advisory Council and the Governor’s Task Force 

on Alternative Sanctions to Incarceration. 

Lawrence E. Tan, J.D., NREMT-P

Appointed to the Commission by House Minority Leader John Boehner, Mr. Tan is Chief of 

Emergency Medical Services at the New Castle County Department of Public Safety. He 

started his career as a volunteer firefighter/EMT during high school, and has served as a 

paramedic, EMS Lieutenant, Emergency Services Assistant Manager, Assistant Chief and 

Deputy Chief. Mr. Tan’s assignments have included commander of both the Administrative 

and Operations components of the service, in addition to a special Homeland Operations 

detail within the Office of the County Executive. Mr. Tan was a member of the National 

Faculty for the Counter Narcotics and Terrorism Operations Medical Support Program 

conducted by the Department of Defense Uniformed Services University of the Health 

Sciences, Department of Homeland Security Federal Protective Service and United States 

Park Police. He also serves on the Federal inter-agency Board for Equipment Standardization 

and Interoperability as a member of the Medical subgroup, and serves on the executive 

committee of the FEMA Region III Regional Advisory Council. 
NATIONAL COMMISSION ON CHILDREN AND DISASTERS: INTERIM REPORT 87

APPENDIX G: COMMISSION STAFF

APPENDIX G: COMMISSION STAFF

Christopher J. Revere, MPA 

Executive Director, Co-Editor

Victoria Johnson, MS

Policy Director

Vinicia Mascarenhas 

Communications Director

Randall Gnatt, J.D. 

Policy Specialist

Frank Valliere, MA

Policy Specialist

Matthew Seney

Communications Specialist

Stacey Broadwater

Executive Assistant

Jacqueline Haye

Executive Assistant

Rhonda Davis-Dorsey

Executive Assistant

CAPT Roberta Lavin, PhD, APRN-BC, USPHS 

Designated Federal Official, Co-Editor

Carol Apelt

Alternate Designated Federal Official

Tener Goodwin Veenema, PhD, MPH, MS, FNAP

Lead Writer and Expert Consultant in Disaster 

Management to the Commission