Children’s Hospital & Research Center Oakland

1. Children’s Hospital & Research Center Oakland

2. Children’s Hospital & Research Center Oakland How Prepared Are YOU? Safety Information Youcame into this room -did you size up? • Exit Points, Fire Extinguishers,1st Aid and Defibrillators locations, and Assembly Area Do you sponsor a culture resiliency?

3. CERT: Children in Disaster OUTLINE • Presentation and discussion format • Case study and interactive tabletop

4. CERT: Children in Disaster Why do the training? • Initiative—thank you! • Take it a step further (CERT: Pediatric Triage—August; CERT: Pediatric Patient Packaging and Movement—September) • Focus on social-emotional development of young children • Opportunity to reflect and learn from others

5. Triage System Perimeter Perimeter Expectant/ Morgue Treatment Leader EXIT Control Point RED: Immediate ENTRY Control Point Transportation Unit Group Medical Branch Director YELLOW: Delayed Medical Supply Coordinator GREEN: Minor Perimeter Perimeter

6. CERT: Children in Disaster HYGEINE • Wash hands frequently (40-60 seconds) • Or use alcohol-based hand sanitizer (20-30 seconds) • Wear non-latex exam gloves • Wear N95 mask and goggles • Keep dressings sterile • Avoid contact with body fluids • “If it is warm, wet, and not yours, don’t touch it!”

7. CERT: Children in Disaster Carry Types • Single carry • Pack-strap carry • Double carry • Blanket carry

8. CERT: Children in Disaster Pack-strap carry

9. CERT: Children in Disaster Blanket carry

10. CERT: Children in Disaster Pedi Transport • Send/Receive info • Reassure/Review • Car seats • Keep warm • ZERO rx • No feeding • Transport in position of comfort

11. Child Life Suggestions for Pain Management/Relaxation Techniques Deep breathing- -‘Smelling flower, blowing bubble’ -Count 1-4 Distraction for pain/discomfort- -Calm steady voice -Soft touch -Singing -Comfort Item -Conversation Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

12. CERT: Children in Disaster OBJECTIVES • Develop a clear definition for traumatic events. • Recognize the stages of grief. • Common reactions children experience when dealing with trauma. • Working with Children • Expand resources for helping children after a traumatic event.

13. CERT: Children in Disaster Pair Share • 9/11 • Loma Prieta • Oakland Hills Fire • Newtown School Emotional adjectives

14. CERT: Children in Disaster Traumatic vs. Stressful Events Points to consider: • Types of care • Types of “events” • Impacts on mental health of child • Impacts on CERT team members

15. CERT: Children in Disaster GRIEF, TRAUMA and LOSS Four Myths of Grief • An active child is not a grieving child • Infants & Toddlers are too young to grieve • Children need to “get over” their grief • Children are better off not attending funerals

16. CERT: Children in Disaster

17. Stress & Brain Development • Stress can impact a child’s brain development & chemistry. • Early childhood trauma has been associated with reduced size of the brain cortex, impaired ability to regulate emotions, & intelligence. • Many factors affect a child’s development! Please note!!! No credible scientific evidence that supports the conclusion that young children who have been exposed to significant early stresses will always develop stress-related disorders. • National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Retrieved from www.developingchild.harvard.edu

18. Need 2 Volunteers to participate in demonstration!!!

20. For the Purpose of rest of this Presentation…. • ‘Children’ will be referred to as pediatric population of 0-18years old • Provides generalized overview • Special Populations & Teens

21. CERT Team • Can provide emotional support to children/families • “Psychological First Aid” Pfefferbaum, B., Shaw, J. & AACAP, & CQI. (2013). Practive Parameter on Disaster Preparedness. Journal of the American Academy of Chlid & Adolescent Psychiatry, 52(11), 1224-1238. Mental Health Professionals • May use different types of Triage/Rapid Assessment • Ex) PsySTART Rapid Mental Health Triage Center for Disaster Medical Science- Univeristy of California. The PsychSTART Mental Health Triage & Incident Management System. http://www.cdms.uci.edu/PDF/PsySTART-cdms02142012.pdf Accessed December8, 2013

22. Children’s Experience & Coping In Disasters • Biological & Developmental Age of Child • Direct Exposure to Event • Grief/Loss • Ongoing Stress From Secondary Effects of Disaster • Other Considerations: Special Needs Cultural Differences Language Barriers (American Red Cross: http://www.redcross.org Accessed December 8, 2013. )

23. Infants (0-12months) Gets Information through senses Development of trust Primary Caregiver Bond Minimal Language Meet basic physical needs Possible Disaster Stressors Sensory Experience / Injury Possible Separation from Caregiver Impaired basic needs Stranger anxiety Behaviors You May See (Coping Behaviors) Crying Hand & mouth activity Interventions Safety Talk before touch Singing/holding Decrease # of caregivers if possible Avoid hunger if possible Child Development, Possible Disaster Stressors, and InterventionsDevelopmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of OrangeCounty. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,2013.

24. Seeks independence Developing language Process of learning new skills (walking & toilet training) Routine is everything! Short attention span Possible Disaster Stressors Sensory Experience / Injury Separation from caregiver/ Fear of abandonment Stranger anxiety New Environment Loss of independence & mobility Changes in routine Back-laying position frightens toddlers Scared of sudden movements or loud noises Behaviors You May See (Coping Behaviors) Regression of recently learned skills Clinging to people Temper tantrums Interventions Safety Allow to move around as able Offer choices Expect treatment to be resisted Provide simple explanations Singing/encouraging statements, toys Toddlers (1-3yrs)Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of OrangeCounty. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,2013.

25. Belief they are ‘center of world’ Limited language skills Fantasy & magical thinking Fear of dark Limited concept of time May view disaster as punishment Learn best by doing Does not understand death as final Possible Disaster Stressors Sensory Experience / Injury Separation from caregiver Heightened fears (pain, strangers, etc) Loss of protection & sense of abandonment Confusion about events Confusion between fantasy vs. reality Behaviors You Might See (Coping behaviors) Regression (act younger than age) Temper tantrums Aggression/anger Guilt Fantasy Interventions Safety Give Choices & reinforce positive behavior Expression of feelings through play/verbalizing Child participation in care Be realistic & truthful Comfort Encouraging statements, singing Preschoolers (3-5yrs)Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of OrangeCounty. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,2013. Child coloring picture at Shelter in Haiti

26. Friendships are important Develops concrete thinking Active learners Increased participation in self care Continued language skills developed Concerns about body image Possible Disaster Stressors Sensory Experience/Injury Separation from caregiver Loss of bodily control Enforced dependence Loss of competence Fears body harm, pain, or death Behaviors You Might See (Coping behaviors) Guilt Acting out/regression/depression/withdrawal Separation Anxiety Mirror Caregiver/Adult response Interventions Safety Give Choices Teach coping strategies that teach mastery Encourage participation in their care Give child tasks to help Correct misconceptions Respect child’s modesty Comfort, humor, encouragement, etc School age (6-12yrs)Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of OrangeCounty. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,2013. Children after Tornado destroyed school in Oklahoma (NY Daily News)

27. Socialization is important Changing body image Body image relates to self esteem Need for privacy Increasing independence & responsibility Struggle to develop self-identity Use of deductive reasoning & abstract thought Possible Disaster Stressors Sensory Experience / Injury Lack of trust Loss of independence & control Threat of change in body image/harm Restriction of physical activities Loss of peer acceptance & fear of rejection Threat of bodily competence or future Fear of death Behaviors You May See (Coping Behaviors) Defense mechanisms Intellectualizations Conformity Uncooperative behavior Interventions Safety Respect & maintain privacy Involve in care & decisions Peers Communicate honestly Discuss potential psych & physical changes Comfort Jokes, music, encouraging, deep breathing, imagery. Adolescent 13-18yrsDevelopmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of OrangeCounty. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,2013.

28. YOU make a difference!!! -SAFETY- Injuries, potential danger & harm -Calming emotions -Helping to decrease sensory stimulation -Basic needs YOU ARE CREATING A POWERFUL MEMORY OF STRENGTH & HELPING WITHIN THIS EVENT!!!

29. Working With Children • Use age appropriate simple language. • Use child’s name. • Get down at the child’s level.

31. Communication • Encouragement & Praise • Be direct. State what you want them to do (not what you don’t want).

32. Avoid euphemisms!!! Use concrete terms. • Letting them know their feelings are normal. It is ok to feel ________. • Crying is ok! (don’t tell boys of any age to be tough or brave)

33. Being honest about what happened & that they are safe. • Reassuring the child the event was not their fault.

34. Avoid talking about children as if they are not there!! • Children hear & understand more than we think. • Misconceptions & fears may arise from fragments of information that were overheard & not explained.

35. Every Child is different! • Children react differently to stress. Some may not appear to react at all. • Prepare children on what is happening or going to happen. (Ex: Going into a shelter or triage) • If you do not know the answer to a child’s question, it is ok to say that you do not know.

36. After The DisasterAfter The Disaster. American Red Cross. http://www.ready.gov/coping-with-disaster Accessed December 8, 2013. Common Reactions to Disaster by Age • Birth through 2 years. • Are pre-verbal but can retain sensory memories • May be irritable & wanting to be held more. • Respond to caregivers coping • Preschool - 3 through 6 years. • Feelings of helplessness, fear, & insecure. • Fear of separation from caregiver • Does not understand that death is permanent • May use repetitious play to reenact incident • School age - 7 through 10 years.  • May become preoccupied with event & want to talk about. • Has ability to understand permanence of death/loss. • Problems at school or concentration. • May have variety of emotions related to disaster (fear it may happen again, anger it happened, guilt it was their fault) • Pre-adolescence to adolescence - 11 through 18 years. • May become involved in risk-taking behaviors • May be fearful of leaving home • May change world view (feel unsafe) • May have variety of emotions related to disaster (yet may feel unable to discuss them with others

37. What Adults Can Do To Help ChildrenThe National Child Traumatic Stress Network (NCTSN). www.nctsnet.org Accessed December 8, 2013. • Help to role model positive coping skills. • Monitor adult conversations. • Limit media exposure. • Reassure children that they are safe. • Tell children about community recovery. • Review the family preparedness plan. • Maintain regular daily life & routines. • Maintain expectations. • Encourage children to help. • Do not criticize your children for changes in behavior. • Be extra patient as your children return to school. • Give support at bedtime. • Help with boredom. • Keep things hopeful. Even in the most difficult situation, your positive outlook on the future will help your children see good things in the world around them, helping them through challenging times. • Seek professional help if your child still has difficulties more than six weeks after the earthquake.

38. Children may grieve in spurts & can re-grieve at new developmental stages as their understanding of death & perceptions of the world change. • The National Child Traumatic Stress Network (NCTSN). www.nctsnet.org Accessed December 8, 2013.

39. Resources- Disaster Preparedness Federal Emergency Management Agency (FEMA). www.ready.gov/kids Accessed December 8, 2013. American Red Cross: http://www.redcross.org/prepare/location/home-family/children Accessed December 8, 2013. Let’s Get Ready. Sesame Street. http://www.sesamestreet.org/ parents/topicsandactivities/toolkits/ready Accessed December 8, 2013. The National Child Traumatic Stress Network (NCTSN). www.nctsnet.org Accessed December 8, 2013.

40. After The Disaster After The Disaster. American Red Cross. http://www.ready.gov/coping-with-disaster Accessed December 8, 2013. • ‘Disaster Distress Hotline’ (Substance Abuse & Mental Health Services Administration-US Dept of Health & Human Services). http://disasterdistress.samhsa.gov Accessed December 8, 2013. • (Hotlines supports Survivors, Disaster Workers) • Natural Disasters. The National Child Traumatic Stress Network. http://www.nctsn.org/trauma-types/natural-disastersAccessed December 8, 2013. (General Information, Online Training, Online Children’s book on Earthquakes) • Talking To Children After Disaster. Substance Abuse & Mental Health Services Adminstration- United States Department of Health & Human Services. http://disasterdistress.samhsa.gov/media/796/tips_talking_to_children_after_disaster.pdfAccessed December 8, 2013. • Talking To ChildrenAbout Disasters. American Academy of Pediatrics. http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Talking-to-Children-About-Disasters.aspx Accessed December 8, 2013.

41. Other Resources A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8, 2013. Center for Disaster Medical Science- Univeristy of California. The PsychSTART Mental Health Triage & Incident Management System. http://www.cdms.uci.edu/PDF/PsySTART-cdms02142012.pdf Accessed December 8, 2013 National Child Life Council www.childlife.org National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Retrieved from www.developingchild.harvard.edu Pfefferbaum, B., Shaw, J. & AACAP, & CQI. (2013). Practice Parameter on Disaster Preparedness. Journal of the American Academy of Child & Adolescent Psychiatry, 52(11),1224-1238.

42. Breathe….. (Smell the flower….blow the bubble)

43. “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” -Margaret Mead

44. Children’s Hospital & Research Center at Oakland • Additional References: • Community Emergency Response Basic Training Powerpoints. FEMA. Web. 8 September 2013. <https://www.fema.gov/media-library/assets/documents/27669?id=6191> • Mass casualty triage: An evaluation of the data and development of a proposed national guideline. Disaster Med and Public Health Preparedness, 2008;2(Suppl 1):S25-S34. [PubMed Citation] • SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008 Dec;2(4):245-6. [PubMed Citation] • The Pediatric Assessment Triangle: Accuracy of Its Application by Nurses in the Triage of Children.Journal of Emergency Nursing. 2013 March;Volume 39, Issue 2, Pages 182-189 Timothy Horeczko, Brianna Enriquez, Nancy E. McGrath, Marianne Gausche-Hill, Roger J. Lewis • Newton, C., Heckle, M. (2013-07-30). Mass Casualty Incidents: Pediatrics.Children’s Hospital & Research Center Grand Rounds. Lecture conducted from Children’s Hospital & Research Center at Oakland, Oakland, California.

45. Questions? • Christy Johnson, CCLS, MSW • chrjohnson@mail.cho.org • James Betts, MD • jbetts@mail.cho.org Michelle D. Heckle, CHEP • Emergency Management • Children’s Hospital & Research Center Oakland • 747 52nd Street • Oakland, CA 94609 • 510.428.3371 • mheckle@mail.cho.org