David J. Schonfeld

The pediatrician and disaster preparedness

For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully. This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types of patients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems. New uses of the HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.

Talking with children about death

Nurses are often asked to respond to childrens questions about death and to advise parents and teachers on how to discuss this topic with children. This article reviews the concepts that children must learn to understand and cope with a death. Cognitive limitations of young children that may result in guilt and misinterpretations are reviewed. Advice is provided on how nurses can assist infants, young children, and adolescents in dealing with deaths of significant others or their own impending death. The importance of identifying and addressing the personal needs of the helper are underscored.

The accuracy of children's reports with anatomically correct dolls

The accuracy of childrens reports of alleged sexual abuse during interviews with anatomically correct dolls is the focus of considerable controversy. This study used an analog experience to measure empirically the accuracy of reports in a relevant, but controlled setting: the forensic medical examination for suspected sexual abuse. Twenty-one 3− to 7-year-old children were interviewed about what occurred during previous examinations with open-ended questions, open-ended questions with anatomically correct dolls, and direct questions with the dolls. Children provided significantly more accurate reports and fewer omissions with direct questions using the dolls compared with either of the two open-ended sections, but there was no significant difference in the number of false reports across the three sections of the interview. These results suggest that anatomically correct dolls may bolster the recall of childrens memory in the setting of direct questions without prompting false reports. J Dev Behav Pediatr 16:71–76, 1995. Index terms: anatomically correct dolls, sexual abuse.

The Integration of Mental and Behavioral Health Into Disaster Preparedness, Response, and Recovery

The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health into disaster and emergency preparedness and response activities. One vital opportunity to improve integration is the development of clear and directive national policy to firmly establish the role of mental and behavioral health as part of a unified public health and medical response to disasters. Integration of mental and behavioral health into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services, addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.

A cross-cultural comparison of israeli and american children's death concepts

Abstract Cross-cultural comparisons are a valuable means of exploring the impact of sociocultural and environmental variables on a childs understanding of the concepts related to death. Exploration of an empirical nature has been hampered by the absence of an appropriate instrument in the English literature for quantifying death concepts in the young child. We report our experience utilizing the Smilansky Death Concept Questionnaire, a structured interview for the examination of human and animal death conceptualization of children aged 4–12 years, in our cross-cultural comparison of Israeli and American lower-socioeconomic-class children in prekindergarten through second grade. Significant differences, with Israeli children performing higher than American children, were noted for all grade levels in two factors, that of irreversibility and finality (with the exception of irreversibility for second-grade children) and for total death concept score. No significant differences were noted for the two remaini...

Supporting adolescents in times of national crisis: potential roles for adolescent health care providers

Before I address the topic of how health care providers can help adolescents cope with a national crisis, I would like to acknowledge that we all have been, and many continue to be, affected by the terrorist acts that began on September 11th and the ongoing war. Now that almost 6 months have passed, there is a wide spectrum in the degree to which people are still affected by these events. Some adults and children are still highly affected, whereas others are far less so. For some adolescents, such as those who witnessed firsthand the terrorist attacks or whose parents are in the armed forces, the comments that I make today may be relevant to ongoing attempts to help them adjust to the events of September 11th or ongoing war. For most adolescents, no further specific intervention may be needed; my comments should be seen as relevant to how to address future crises that may occur in their lives. It is also important to realize that although the terrorist attacks in our country are a shared experience at one level, it is fundamentally a very personal experience. The nature and degree of the impact varies individually, and in part, for this reason we will reach our own unique understanding of the events. For some individuals, the tragic, senseless, and random loss of life promotes a sense of carpe diem, a decision to look less to the past or the future, but to invest fully in the present. Other individuals may choose to focus on past events in order to search for ways to prevent similar occurrences. Others may adopt a future orientation to attempt to anticipate and mitigate the likely negative affect of this crisis. These are only a few of the many legitimate, although quite different, reactions that may be seen after a crisis event. Whatever the reaction may have been to date, join with me to look toward the future and to think about ways that we, as health care providers, can provide assistance to adolescents and their families in times of national crisis. I will begin by describing the roles that health care providers can take to help adolescents cope with the past crisis events, as well as future crises, and will point out some of the potential barriers to successfully fulfilling these roles. I will then outline some of the potential symptoms of adjustment reactions to terrorist events that health care providers may see and describe the factors that may adversely affect the nature and degree of reaction to a terrorist event for a particular adolescent. I will then offer more practical advice on how to facilitate discussion with adolescents about these topics in order to promote their adjustment and offer my views on some of the many reasons why these conversations often do not occur. One very important role for health care providers is to continue to do the work that we were doing before the crisis event. Shortly after the terrorist attacks, I again called the mother of a young child who was terminally ill. They live in New York and I had been calling the mother on an ongoing basis over the prior 9 months to offer support and assistance. It wasn’t until I called her for the second time after September 11th that she confided in me her concern From the Yale University School of Medicine and School Crisis Response Initiative, National Center for Children Exposed to Violence, Yale Child Study Center, New Haven, Connecticut Address correspondence to: David J. Schonfeld, M.D., Department of Pediatrics, Yale University School of Medicine, 333 Cedar St., P.O. Box 208064, New Haven, CT 06520-8064. E-mail: david.schonfeld@yale.edu. Portions of this lectureship were presented by the author within a plenary presentation at the 2001 National Conference and Exhibition of the American Academy of Pediatrics, October 22, 2001, San Francisco, California. JOURNAL OF ADOLESCENT HEALTH 2002;30:302–307

Crisis Intervention for Bereavement Support A Model of Intervention in the Children's School

A crisis intervention consultation service to the schools for bereavement support for children is described. Examples are offered of the authors experience in providing this service to children from the pre-kindergarten to senior high level, at private, parochial, and public schools. These requests were generally in response to tragic deaths of fellow students and significant adults, including teachers, parents, and friends. Suggestions are outlined for pediatric and mental health consultants who may wish to offer similar services within their communities, with particular emphasis on issues to address in program planning and implementation.

The impact of school-based education on the young child's understanding of death.

The young childs immature understanding of the concepts related to death serves to heighten anxiety about death and interferes with successful adjustment to loss. This study was a randomized trial of the efficacy of a 3-week school-based educational program in the promotion of the concepts of death in 4-to 8-year-old children (prekindergarten through second grade). The Smilansky Death Concept Questionnaire, a validated and published structured interview, was administered pre- and postintervention phase to all study participants (N = 184). The experimental group received three interventions: (1) a series of six 30 to 45-minute presentations about concepts of death, (2) teacher educational presentation, and (3) parent educational presentation. Significant mean gains were noted for the experimental group as compared to the control group in the total death concept score, the total score for human death, the total score for animal death, and two of the four factors studied, that of causality and that of inevitability and old age. The gain in total death concept score as a result of the 3-week educational program was equivalent to the amount of conceptual development that is seen in one year in the absence of intervention.

Elementary school-age children's developmental understanding of the causes of cancer.

&NA; This study examines childrens conceptual understanding and factual knowledge of the causes of cancer. Using a standardized, developmentally based, semistructured interview (ASK [AIDS (acquired immunodeficiency syndrome) Survey for Kids]), 784 children (43% black, 38% white, and 18% Hispanic; 48% female) in kindergarten through sixth grade attending six public elementary/middle schools in New Haven, Connecticut, were asked open‐ended questions about the causes of cancer and, for comparison, the causes of colds and AIDS. Responses were scored for level of conceptual understanding and coded for factual content and factual accuracy. The level of conceptual understanding for causality of cancer increased consistently as grade level increased. When comparisons were made among the illnesses, childrens level of conceptual understanding was significantly lower for the causes of cancer than for the causes of colds (p < .0001), but not significantly different from that of AIDS. Although the single most frequent cause of cancer mentioned was cigarettes/smoking (24%), more than one in five students stated that casual contact or contagion was a cause of cancer. More children cited casual contact/contagion than cited the following factually accurate or logically contributory causes combined: poor diet, air/water pollution or overexposure to sun, alcohol, and old age. Slightly more than one half of students in kindergarten through sixth grade worried about getting cancer, and the vast majority (80%) knew that cancer could be fatal. Children have a less sophisticated conceptual understanding of cancer than of colds and a very limited factual knowledge base for cancer, and thus they have the capacity to increase both their understanding and knowledge. These results have implications for the creation of developmentally appropriate cancer prevention curricula for elementary school‐age children.