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Children’s Hospital & Research Center Oakland

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1 Children’s Hospital & Research Center Oakland
Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

2 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? Components of the fire triangle: Ignition sources Fuel sources Oxidizers Which are all present during surgical procedures. The program will identify strategies to prevent fires, as well as to manage a fire should one occur. It's important to remember that operating room fires are 100 percent preventable Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

3 CERT: Children in Disaster
OUTLINE Presentation and discussion format Case study and interactive tabletop Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 QUICK review of triage (August) and patient packaging and movement (September). Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

5 Medical Branch Director Medical Supply Coordinator
Perimeter Triage System 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 Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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!” Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

7 CERT: Children in Disaster
Carry Types Single carry Pack-strap carry Double carry Blanket carry Reassure child, hold close. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

8 CERT: Children in Disaster
Pack-strap carry Child in bag—NOT pack-strap carry Correct: photo with man and child on his back Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

9 CERT: Children in Disaster
Blanket carry Use what you have with safety in mind. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 Send / Receive Contact Info (Name, phone # of contact, patient name, age and birth date, any allergies, last time they ate or drank, care rendered at the scene and who gave it, etc/ which hospital are they expected to go to) Reassure and Review Keep the victim calm and as comfortable as possible,(don't let them keep picking at their wound); let them know the plan. Person to accompany victim to keep them calm and give info. *(at the discretion of the ambulance crew) Car Seats if they have it, use it (if the injury permits) Keep them warm (especially if they had a burn that was cooled off with water) Do not give them any medicines that they don't normally take Do not feed them if they are going to need a procedure done at the hospital Transport in Position of Comfort (if the injury permits) For injuries with deformities, splint the limb how you find it (don't straighten it) For injuries without deformities, splint in the position of function. (No pointed toes or fully extended arms or legs). Elevate just to level of heart. If they need to keep their necks immobilized, remember that their level of anxiety may be heightened because of their now limited field of vision, therefore keep them appraised of what is happening around them. Defer to the EMT that respond to your location. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 Begin exercise—ask Susan “I Spy” Concept ‘Good Luck’/special Item (rock, whatever you have) 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. •Encourage participants to be active learners; acknowledge the wealth of expertise they can contribute to the group. •The most important item to remember is that this training is to be used as a framework for helping the children they may encounter. •Responsibility: children in their care Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

13 CERT: Children in Disaster
Pair Share 9/11 Loma Prieta Oakland Hills Fire Newtown School Emotional adjectives Collect emotional adjectives: two to three Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 •Consider the various types of child care & different scenarios. •Consider traumatic & stressful events that can have a negative impact on the mental health of children. •Types of disasters include: man-made (bombing, acts of terrorism); health crises (epidemic, famine);technological disasters (nuclear reactor spills, oil spills); international crises (wars, accidental missile launch); natural disasters (weather or environmental-related); and acts of violence (gangs, domestic violence) Key idea: Participants will gain a better understanding of HOW to help children cope with trauma and develop resources that will help them in preparing for traumatic events. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 •An active child is not a grieving child: • Don’t expect children to mourn in the same way you do. Some may cry or say they are sad, some may appear not to be feeling anything; and others may show anger and hurt. All of these reactions need to be accepted. • Remember, a child can work out feelings best through play. What may appear to be a frivolous play activity to us may well be an important part of the child’s mourning process. •Infants & Toddler are too young to grieve: • Any child who is old enough to love is old enough to mourn. • Certainly infants and toddlers are capable of giving and receiving love, yet we often hear they are too young to understand. Children need to “get over” their grief: • Children and adults are often told that they “should be over it by now—it’s been almost a year.” Adults who believe this myth deny children the patience to live with and to work with their grief. Children are better off not attending funerals: • Not allowing children to attend funerals creates an environment of denial that does not allow them to actively participate in the grieving process. The funeral provides a structure for the child to see how people comfort each other openly, mourn a loved one, and honor his or her life. Children learn the ways we say goodbye to the remains of the person who died and how we show respect for the deceased.

16 CERT: Children in Disaster
•An active child is not a grieving child: • Don’t expect children to mourn in the same way you do. Some may cry or say they are sad, some may appear not to be feeling anything; and others may show anger and hurt. All of these reactions need to be accepted. • Remember, a child can work out feelings best through play. What may appear to be a frivolous play activity to us may well be an important part of the child’s mourning process. •Infants & Toddler are too young to grieve: • Any child who is old enough to love is old enough to mourn. • Certainly infants and toddlers are capable of giving and receiving love, yet we often hear they are too young to understand. Children need to “get over” their grief: • Children and adults are often told that they “should be over it by now—it’s been almost a year.” Adults who believe this myth deny children the patience to live with and to work with their grief. Children are better off not attending funerals: • Not allowing children to attend funerals creates an environment of denial that does not allow them to actively participate in the grieving process. The funeral provides a structure for the child to see how people comfort each other openly, mourn a loved one, and honor his or her life. Children learn the ways we say goodbye to the remains of the person who died and how we show respect for the deceased. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 Brain cortex: responsiblle for COMPLEX functions: memory, attention, perceptual awareness, thinking, language, and consciousness May become more fearful, not feel safe or protected Why does 2 children who have been through the same trauma have different outcomes??? 1---- recovers, 2--- longterm effects??? Many factors, some known & some unkown Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

18 Need 2 Volunteers to participate in demonstration!!!
Will involve 1 volunteer (CHO staff member or audience volunteer to be “CHILD” & will sit in ) First CHILD will just sit & observe –2 audience volunteers put on gloves & they will have on 2 different types of shirts or vests & put on gloves - They will take out a few items out of bag Whole time they will talk only to each other in gibberish & only insert CHILD’s name occasionally Second CHILD volunteer will ask to close his/her eyes (optional) audience volunteers will: Use sound toys to make noises in various locations around CHILD A 3rd person will join conversation -A feather will tickle arm of CHILD Can put an alcohol wipe under CHILD nose? Blanket wrapped around child. END OF EXERCISE– Will question CHILD volunteer what experience was like (what was it like not knowing what outfits for, gloves for, items out of bag, conversations, sounds, sensations, scents, blanket coming, etc. EXPLAIN extreme example & none of us would treat child like this but this mimics how a child might not have the words or awareness of what meaning behind even simple events….a surprise of a blanket, what certain outfits mean, how a conversation we have/unfamiliar terms /talking like child is not there might sound so scary, not knowing what a smell means, sensations, certain item/tools are for, etc Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

19 Christy Johnson, CCLS, MSW MD Heckle, Emergency Management
WHAT SENSORY THINGS MIGHT KIDS/TEENS EXPERIENCE???? Smell- of gas, fire, chemicals, dust Hearing-Sound of tornado siren, ambulance, helicopter (media/rescue), crying, yelling, rumbling, megaphone, objects falling, gunfire? Feel- Shake of earthquake (shaking, bam), warm, injury, wet, cold, hot, wind, weather, Sight- PEOPLE (CERT green shirts/vests), police/SWAT, fire, hazmat, red cross, masks, helmets, Rubble, buildings, fire, smoke, injured people/dead, Taste-smoke, chemical, Pictures are of: Child after Batrop Wildfires getting breathing treatment by respiratory therapist/volunteer (American Red Cross Photo) Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 Every individual & situation is unique!!!! Teens- Involve in choices in care if able, seek autonomy, Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

21 Mental Health Professionals
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), 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. Accessed December8, 2013 After additional trained professionals (mental health, crisis counselors, etc)– may use different assessment tools Can vary depending on who’s in command/city/agency, current research/practice at time One example is PsySTART Rapid Mental Health Triage- Rapid mental health triage particularly for high surge population Considered a national model for children Uses a Triage Tag Scale (School staff/health care/self can fill out) to help Works well w/ incident command / Helps pre event linkage btwn key health/mental health & disaster response sysetms Compliance w/ varied state/national policy directives Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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: Accessed December 8, ) Bio- # of years alive Dev- intellectual/emotional age Direct exposure- life in danger, others?, someone hurt/killed, observed, saw on news? Grief/Loss- Loss of life (family, pet, neighbor), witnessed?, home, belongings, etc Ex) Hurricane Katrina Evacuee Child- Bear Example to Secondary Effects of Disaster- clean-up?, shelter, financial, lost family, school, medications, Hurricane Katrina----Supposed to have an end: still going on, ‘disaster scene’ still present, people not returned, ongoing stories on news Financial, relationships (FEMA/government?), Special needs- Health, developmental, mental health issues previously Cultural-religious, spiritual, tribal, refugee, immigration status, can it affect healthcare, evacuation, death practices, idea of home, leaving belongs, Language- speak same language? Deaf/hard of hearing, Past traumas Teens- Involve in choices in care if able, seek autonomy, Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

23 Child Development, Possible Disaster Stressors, and Interventions Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. 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 Let’s Talk About Working With Kids ……. Many of You may have experience already….. Just a Review or reminder of disaster scenerios Many of these stressors, behaviors, & interventions can be seen or used across all age groups (including adults!!!) These are just ones that are commonly seen in these certain groups! Sometimes things must be done STAT or urgently----safety is #1 above all else! Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

24 Toddlers (1-3yrs) Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. 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 Toddler- in healthcare laying on back & lack of control sometimes upsets more than anything Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

25 Preschoolers (3-5yrs) Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. Accessed December 8, 2013. 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

26 School age (6-12yrs) Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. Accessed December 8, 2013. 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 Children after Tornado destroyed school in Oklahoma (NY Daily News)

27 Adolescent 13-18yrs Developmental Information from A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. Accessed December 8, 2013. 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.

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!!! How do you work with kids in these extreme scenerios? What do I say? YOU can help decrease trauma, fear, & traumatic moments by helping to promote sense of safety, Sometimes even first responders help decrease incidence of PTSD by helping to limit exposure to dead body, arrest, down at level & helping child feel safe DANGER & SAFETY EMOTIONS & EMOTION REGULATION HELPING RELATIONSHIP SENSORY CREATING A POWERFUL MEMORY OF STRENGTH/HELPING WITHIN THIS TRAUMA/DISASTER Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

29 Working With Children Use age appropriate simple language.
Use child’s name. Get down at the child’s level. Power of Language!!! Ex: Hospital words: CAT Scan- Is a cat there? Is it going to scratch me? IV: A plant? What is it? Transfering to the floor: Why are they going to put me on the floor? Ex: CERT words: Triage We are going to a “tree”? CERT - Hurt? Candy? Command? Aftershock- Is it going to shock/electrocute me? “Hi Johnny. My name is Christy. I am a helper & we wear the green shirts. I am helping people who are hurt / who are looking for their family / go to a safe place Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

30 Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

31 Communication Encouragement & Praise
Be direct. State what you want them to do (not what you don’t want). Example: “Please sit down on your bottom.” Instead of “Don’t stand up on the chair! I don’t want you to fall!” Example: First ______, then ______. (First take off jacket, then we will color). Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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) Example: “Gone to a better place” It’s ok to feel mad or sad or happy. Even all at the same time! Crying is ok! Crying is a coping tool & way to express emotion. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

33 Being honest about what happened & that they are safe.
Reassuring the child the event was not their fault. Do not ask children to talk about event (unless you need to for information) CERT TEAM MEMBERS ROLE IS FIRST AID PSYCH Trained mental health professionals will provide crisis counseling/assessment/etc. However if a child wants to talk/begins provide active listening/reflect back what you hear. Share w/ professional so further support can be given to child. Safety- We are going to a place where there is food & water. Other people are going there to rest & we will see if your family is there. Sometimes after an earthquake (when ground is shaking), the ground might shake again. We are all here to help take care of you & help keep you safe. (if appropiate!!!) NOT THEIR FAULT-----Nothing they did, They were not bad– did not cause earthquake etc Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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. Example: Death at FD, 3 children did not realize that mother passed Do not make comments about the child’s parent/family choices during the disaster or living conditions. Be careful not to unintentionally make the child feel they may be “forever damaged” because of the incident. (Talking to another CERT member, I don’t know how he will get through this with what he saw!) Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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. Prepare- What they will see, why, we are going to take care of you & are looking for your family, Safety is KEY!!! (Ex: Is another earthquake going to happen? I don’t know but we are going to take care of each other and figure out what to do next/ go to another place that is not having earthquakes/ . Explain what is being done to help keep people/them safe. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

36 Common Reactions to Disaster by Age
After The Disaster After The Disaster. American Red Cross 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 Ex) Increased sensitivity to aftershocks, creaking sounds, things falling or crashing, buildings swaying slightly in the wind, or trembling that occurs when a big truck drives by Changes in sleep patterns Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

37 What Adults Can Do To Help Children The National Child Traumatic Stress Network (NCTSN). 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. Be a role model. Try to remain calm so that you can teach your child how to handle stressful situations. Monitor adult conversations. Be aware of what adults are saying about the earthquake or the damage. Children listen to adults' conversations and may misinterpret what they hear, becoming unnecessarily frightened. Limit media exposure. Protect your child from too many images and descriptions of the earthquake, including those on television, on the Internet, on radio, and in the newspaper. Reassure children that they are safe. You may need to repeat this frequently even after the earthquake passes. Spend extra time with them, playing games outside, reading together indoors, or just cuddling. Be sure to tell them you love them. Replace lost or damaged toys as soon as you are able. Calm worries about their friends' safety. Even though phones may not be working, reassure your children that their friends' parents are taking care of them, just the way you are taking care of your children. Tell children about community recovery. Reassure them that the government is working hard to restore electricity, phones, water, and gas. Tell them that the town or city will be removing debris and helping families find housing. Take care of your children's health. Help them get enough rest, exercise, and healthy food and water. Give them both quiet and physical activities. Review the family preparedness plan. Some children will fear another earthquake, particularly when there are aftershocks, so practicing the plan can help increase their sense of safety. Maintain regular daily life. In the midst of disruption and change, children feel more secure with structure and routine. As much as possible, have regular mealtimes and bedtimes. Maintain expectations. Stick to your family rules about good behavior and respect for others. Continue family chores, but keep in mind that children may need more reminding than usual. Encourage children to help. Children cope better and recover sooner when they help others. Give them small cleanup tasks or other ways to contribute. Afterward, provide activities unrelated to the earthquake, such as playing cards or reading. Do not criticize your children for changes in behavior, such as clinging to parents, acting out the earthquake in play, or seeking reassurance frequently. Be extra patient as your children return to school. They may be more distracted and need extra help with homework for a while. Give support at bedtime. Children may be more anxious when separating from parents. Spend a little more time than usual talking, cuddling, or reading. Start the bedtime routine earlier so children get the sleep they need. If younger children need to sleep with you, let them know it is a temporary plan, and that soon they will go back to sleeping in their own beds. Help with boredom. The earthquake may have disrupted the family's daily activities (watching television, playing on the computer, and having friends over) or caused the suspension of extracurricular activities (sports, youth groups, dances, or classes). Help children think of alternative activities, such as board games, card games, and arts and crafts. Try to find community programs (at the library, a park program, or a local YMCA) with child-friendly activities. 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). Accessed December 8, 2013. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

39 Disaster Preparedness
Resources- Disaster Preparedness Federal Emergency Management Agency (FEMA). Accessed December 8, 2013. American Red Cross: Let’s Get Ready. Sesame Street. parents/topicsandactivities/toolkits/ready Accessed December 8, 2013. The National Child Traumatic Stress Network (NCTSN). Accessed December 8, 2013. Resources for all mixed together---- Good to know resources for family, can be helpful to know tools that are out there for them & helpful tools in how to work with kids Also professional resources on sites, online trainings, articles FEMA- great resources for both kids/grownups (Information for families/kids/educators/workers- Games, family communication plan, information) American Red cross- always great resources, teamed with Disney in Sept for Mickey themed Sesame Street- geared toward younger children, creative tools (Disaster Information for families & Disaster workers, Disney Mickey & Friends Disaster Preparedness Activity Book) (Disaster Information for families- Family Emergency Plan, Emergency Kit, Know Your/Parents Name, Activities) Nationals Child Traumatic Stress Network (Preparedness & After The Disaster) Brochures, suggests videos, printable children’s book about earthquakes, hurricane, (multiple languages), dealing with anniversaries, various types of trauma Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

40 After The Disaster Accessed December 8, 2013.
After The Disaster. American Red Cross. Accessed December 8, 2013. ‘Disaster Distress Hotline’ (Substance Abuse & Mental Health Services Administration-US Dept of Health & Human Services). Accessed December 8, 2013. (Hotlines supports Survivors, Disaster Workers) Natural Disasters. The National Child Traumatic Stress Network. 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. Accessed December 8, 2013. Talking To Children About Disasters. American Academy of Pediatrics. Accessed December 8, 2013.

41 Other Resources A Guide for the caregiver of the Hospitalized Child. Children’s Hospital of Orange County. Accessed December 8, 2013. Center for Disaster Medical Science- Univeristy of California. The PsychSTART Mental Health Triage & Incident Management System. Accessed December 8, 2013 National Child Life Council 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), Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

42 Breathe….. (Smell the flower….blow the bubble)
This is heavy material!!! Be sure to take care of yourself, each other, de-brief/destress, & enjoy each moment! Breathe….. (Smell the flower….blow the bubble) Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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 THANK YOU FOR WHAT YOU DO!!!!! From a recent conference reminded of a quote by social anthropologist Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

44 Children’s Hospital & Research Center at Oakland
Additional References: Community Emergency Response Basic Training Powerpoints. FEMA. Web. 8 September <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 Dec;2(4): [PubMed Citation] The Pediatric Assessment Triangle: Accuracy of Its Application by Nurses in the Triage of Children. Journal of Emergency Nursing March; Volume 39, Issue 2, Pages Timothy Horeczko, Brianna Enriquez, Nancy E. McGrath, Marianne Gausche-Hill, Roger J. Lewis Newton, C., Heckle, M. ( ). Mass Casualty Incidents: Pediatrics. Children’s Hospital & Research Center Grand Rounds. Lecture conducted from Children’s Hospital & Research Center at Oakland, Oakland, California. Christy Johnson, CCLS, MSW MD Heckle, Emergency Management

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


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