Children’s Hospital & Research Center Oakland
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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?
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
CERT:
Children in Disaster
OUTLINE
• Presentation and discussion format
• Case study and interactive tabletop
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Perimeter
Triage System
Expectant/
Morgue
Treatment Leader
RED:
Immediate
ENTRY Control Point
Medical Branch Director
Medical
Supply
Coordinator
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
YELLOW:
Delayed
GREEN:
Minor
EXIT Control Point
Transportation
Unit
Group
CERT:
Children in Disaster
HYGEINE
• Wash hands frequently (40-60 seconds)
– Or use alcohol-based hand sanitizer (20-30 seconds)
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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
CERT:
Children in Disaster
Carry Types
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Single carry
Pack-strap carry
Double carry
Blanket carry
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
CERT:
Children in Disaster
Pack-strap carry
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
CERT:
Children in Disaster
Blanket carry
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
CERT:
Children in Disaster
Pedi Transport
• Send/Receive info
• Reassure/Review
• Car seats
• Keep warm
• ZERO rx
• No feeding
• Transport in position
of comfort
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
-Conversation
-Comfort Item
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
CERT:
Children in Disaster
Pair Share
• 9/11
• Loma Prieta
• Oakland Hills Fire
• Newtown School
Emotional adjectives
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
CERT:
Children in Disaster
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
Christy Johnson, CCLS, MSW MD
Heckle, Emergency Management
• Need 2 Volunteers to participate in
demonstration!!!
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
Children’s Experience & Coping In
Disasters
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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. )
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,
2013.
Infants (012months)
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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
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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.
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Seeks independence
Developing language
Process of learning new skills (walking
& toilet training)
Routine is everything!
Short attention span
Possible Disaster Stressors
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Sensory Experience / Injury
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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
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Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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
County. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,
2013.
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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
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Sensory Experience / Injury
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Separation from caregiver
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Heightened fears (pain, strangers, etc)
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Loss of protection & sense of abandonment
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Confusion about events
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Confusion between fantasy vs. reality
Behaviors You Might See (Coping behaviors)
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Regression (act younger than age)
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Temper tantrums
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Aggression/anger
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Guilt
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Fantasy
Interventions
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Safety
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Give Choices & reinforce positive behavior
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Expression of feelings through
play/verbalizing
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Child participation in care
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Be realistic & truthful
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Comfort
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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
County. www.childlife.org/files/CaregiverInterventions.pdf Accessed December 8,
2013.
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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)
Adolescent 13-18yrs
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.
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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 needs
YOU ARE CREATING A POWERFUL
MEMORY OF STRENGTH &
HELPING WITHIN THIS EVENT!!!
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Working With Children
• Use age appropriate simple language.
• Use child’s name.
• Get down at the child’s level.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Communication
• Encouragement &
Praise
• Be direct. State
what you want
them to do (not
what you don’t
want).
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
• 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)
Christy Johnson, CCLS, MSW MD
Heckle, Emergency Management
• Being honest about
what happened &
that they are safe.
• Reassuring the
child the event was
not their fault.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
• 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.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
After The Disaster
After The Disaster. American Red Cross. http://www.ready.gov/coping-with-disaster
Accessed December 8, 2013.
Common Reactions to Disaster by Age
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Birth through 2 years.
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Are pre-verbal but can retain sensory memories
May be irritable & wanting to be held more.
Respond to caregivers coping
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Preschool - 3 through 6 years.
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Feelings of helplessness, fear, & insecure.
Fear of separation from caregiver
Does not understand that death is permanent
May use repetitious play to reenact incident
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School age - 7 through 10 years.
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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)
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Pre-adolescence to adolescence - 11 through 18 years.
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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
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
What Adults Can Do To
Help Children
The National Child Traumatic Stress Network (NCTSN). www.nctsnet.org Accessed December 8, 2013.
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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.
• Children may grieve in spurts &
can re-grieve at new
developmental stages as their
understanding of death &
perceptions of the world change.
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The National Child Traumatic Stress Network (NCTSN). www.nctsnet.org Accessed December 8, 2013.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
ResourcesDisaster 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.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
After The Disaster
After The Disaster. American Red Cross. http://www.ready.gov/coping-with-disaster
Accessed December 8, 2013.
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‘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)
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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)
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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.
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Talking To Children About Disasters. American Academy of Pediatrics.
http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-andDisasters/Pages/Talking-to-Children-About-Disasters.aspx Accessed December 8,
2013.
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.
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Breathe….. (Smell the flower….blow the bubble)
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
“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
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Children’s Hospital & Research Center
at Oakland
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Additional References:
•
Community Emergency Response Basic Training Powerpoints. FEMA. Web. 8
September 2013. <https://www.fema.gov/medialibrary/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.
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Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
Questions?
Christy Johnson, CCLS, MSW Michelle D. Heckle, CHEP
• Emergency Management
[email protected]
• Children’s Hospital &
James Betts, MD
Research Center
Oakland
[email protected]
• 747 52nd Street
• Oakland, CA 94609
• 510.428.3371
• [email protected]
Christy Johnson, CCLS, MSW
MD Heckle, Emergency Management
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