children’s hospital & research center oakland

Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

Children’s Hospital & Research Center Oakland


Children’s Hospital & Research Center Oakland

How Prepared Are YOU?

Safety Information

You came 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?


CERT: Children in Disaster

OUTLINE• Presentation and discussion format• Case study and interactive tabletop



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


Triage System

RED: Immediate

YELLOW:Delayed

GREEN:Minor

Expectant/Morgue

Treatment Leader

Medical Branch Director

Medical Supply

Coordinator

Perim

eter

Perimeter

Perim

eter

Perimeter

ENTRY Control Point

EXIT Control Point

Transportation Unit

Group



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!”



Carry Types• Single carry• Pack-strap carry• Double carry• Blanket carry



Pack-strap carry



Blanket carry



Pedi Transport• Send/Receive info• Reassure/Review• Car seats• Keep warm• ZERO rx• No feeding• Transport in position

of comfort

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, MSWMD Heckle, Emergency Management




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.



Pair Share• 9/11• Loma Prieta• Oakland Hills Fire• Newtown School

Emotional adjectives



Traumatic vs. Stressful Events

Points to consider: • Types of care• Types of “events”• Impacts on mental health of child• Impacts on CERT team members


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

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


• Need 2 Volunteers to participate in demonstration!!!


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


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 TriageCenter 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

http://www.cdms.uci.edu/PDF/PsySTART-cdms02142012.pdf

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. )


http://www.redcross.org/

Child Development, Possible Disaster Stressors, and Interventions

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.

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


http://www.childlife.org/files/CaregiverInterventions.pdf

Toddlers (1-3yrs) Developmental Information from 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.

• 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



Preschoolers (3-5yrs)Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange


• 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

Child coloring picture at Shelter in Haiti


School age (6-12yrs)Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange


• 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 responseInterventions• 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

Children after Tornado destroyed school in Oklahoma (NY Daily News)


Adolescent 13-18yrsDevelopmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange


• 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.


YOU make a difference!!!-SAFETY- Injuries, potential danger &

harm-Calming emotions-Helping to decrease sensory

stimulation -Basic needsYOU ARE CREATING A POWERFUL

MEMORY OF STRENGTH & HELPING WITHIN THIS EVENT!!!


Working With Children• Use age appropriate simple language.

• Use child’s name.

• Get down at the child’s level.


Communication• Encouragement &

Praise

• Be direct. State what you want them to do (not what you don’t want).


• 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)


• Being honest about what happened & that they are safe.

• Reassuring the child the event was not their fault.


• 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.


• 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.

Every Child is different!


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


http://www.ready.gov/coping-with-disaster

What Adults Can Do To Help Children

The 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.

http://www.nctsnet.org/

• 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.



Resources-

Disaster Preparedness

Federal Emergency Management Agency (FEMA). www.ready.gov/kids


American Red Cross: http://www.redcross.org/prepare/location/home-family/children


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.


http://www.ready.gov/kids

http://www.redcross.org/prepare/location/home-family/children

http://www.sesamestreet.org/parents/topicsandactivities/toolkits/ready


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-disasters Accessed 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.pdf Accessed December 8, 2013.

• Talking To Children About 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.

http://www.ready.gov/coping-with-disaster

http://disasterdistress.samhsa.gov/

http://disasterdistress.samhsa.gov/

http://www.nctsn.org/trauma-types/natural-disasters

http://disasterdistress.samhsa.gov/media/796/tips_talking_to_children_after_disaster.pdf

http://disasterdistress.samhsa.gov/media/796/tips_talking_to_children_after_disaster.pdf

http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Talking-to-Children-About-Disasters.aspx

http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Talking-to-Children-About-Disasters.aspx

Other Resources

A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of OrangeCounty. 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). ExcessiveStress Disrupts the Architecture of the Developing Brain: Working PaperNo. 3. Retrieved from www.developingchild.harvard.edu

Pfefferbaum, B., Shaw, J. & AACAP, & CQI. (2013). Practice Parameter onDisaster Preparedness. Journal of the American Academy of Child &Adolescent Psychiatry, 52(11),1224-1238.



http://www.cdms.uci.edu/PDF/PsySTART-cdms02142012.pdf

http://www.childlife.org/

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


“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



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.

https://www.fema.gov/media-library/assets/documents/27669?id=6191

http://www.ncbi.nlm.nih.gov/pubmed/18769263







Questions?

Michelle D. Heckle, CHEP• Emergency Management• Children’s Hospital &

Research Center Oakland

• 747 52nd Street• Oakland, CA 94609• 510.428.3371• [email protected]

Christy Johnson, CCLS, MSW

• [email protected]

James Betts, MD

• [email protected]

children’s hospital & research center oakland

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