Pediatric Issues in Terrorism
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© Lou Romig MD, 2006. Used with permission.
Guiding Principles
Assuring excellence of pediatric
emergency care on a daily basis
is the best preparedness for
pediatric disaster care.
Preamble
Preparing for the involvement of
children as victims of a terrorist
attack is little different than
preparing for any other kind of
multicasualty disaster.
Guiding Principles
The best approach to disaster
preparedness is to plan for all
pertinent hazards.
Guiding Principles
We don’t need separate disaster
plans for kids but we do need to
focus on their unique needs and
critical differences when it comes
to preparing for any kind of
disaster, including terrorist attacks.
Guiding Principles
We must all be responsible for
our own preparedness and that of
our loved ones.
Pediatric Issues in Terrorism

Children at risk

Assessing your community’s risks

Community preparation issues

Family preparation issues

Psychological issues with children

Resources
“Collateral
damage?”
FEMA Photo Library
Or intentional targets?
When Lee Malvo asked why he planned
to attack children in schools and on
buses, convicted sniper John Mohammed
allegedly replied:
“For the sheer terror of it – the worst
thing you can do to people is aim at
their children.”
(From AP story 5/30/06)
Children at Risk: Targets

Innocent, vulnerable population

Tend to gather in large groups, including
daycare centers at places of business

Natural curiosity

May not be able to rescue themselves

Extreme emotional reaction by rescuers
and public
Children at Risk: Vulnerabilities

Low to ground

Faster respiratory rates

Larger skin surface area to mass ratio

Vulnerable to fluid loss
Children at Risk: Vulnerabilities

More permeable blood-brain barrier

Many rapidly reproducing cells

Unable to escape (longer exposure)

Found in large groups (contagion)
Is your community at risk?
Is your community at risk?

Major trade, banking or retail centers

Historic landmarks

Military installations

Colleges/schools

Manufacturing plants

Chemical storage centers
Is your community at risk?

Government buildings

Major sports, entertainment, and
convention venues and events

Technological research centers

Airports, other transportation centers

Religious centers

Hospitals
Are there children near your
community’s at-risk sites?
Community Preparation
Local emergency management



Assess pediatric venues at risk
Assist local medical services and
agencies in preparing for the needs of
children and families
Involve local child and family
advocate agencies in emergency
planning
Community Preparation
Local emergency management

Community education addressing
children’s issues

Pediatric aspects of shelter
management

CERT programs

Working knowledge of state and
federal response resources
Community Preparation
Schools and Child Care

Disaster plans and exercises including
initial scene assessment, rescue and
triage

Awareness of risk factors in area

Education for teachers, administrators,
parents and children

Reunification/ shelter in place/
evacuation planning
Community Preparation
EMS/Fire

Work to be able to take good care
of kids on a daily basis

Training

Equipment

Quality management
Community Preparation
EMS/Fire

Incorporate children in all MCI
drills and exercises

Knowledge of at-risk groups in
the area

Knowledge of local hospital
pediatric capabilities

Have appropriate protocols/aids
for pediatric WMD/WME care
Community Preparation
Hospitals

Work to be able to take good care of
kids on a daily basis

Training

Equipment

Quality management
Community Preparation
Hospitals

Incorporate the needs of children
and families into all aspects of
disaster planning and preparedness


Acknowledge the likelihood of an
unusual pediatric patient load in the
disaster setting
Be aware of available pediatric
resources
Community Preparation
Hospitals

Incorporate children and families in all
disaster exercises

Work within hospital networks to
identify pediatric resources that might
be tapped in cases of unusual pediatric
load

Prepare for public concerns
Community Preparation
All medical responders/receivers must be
prepared to deal with:
 Pediatric and adult multicasualty triage
 Decontamination issues





Children who are unable to selfdecontaminate
Risk of hypothermia
Post-decon clothing for infants and
children
Keeping family members together
Children’s fear of “monsters” garbed in
protective equipment
Community Preparation
All medical responders/receivers must be prepared
to deal with:

Lack of familiarity with pediatric antidotes and
treatments and lack of pediatric drug
formulations

Unusual pediatric patient loads and acuities

Relative lack of local pediatric specialty
resources due to overwhelming patient volume

Ethical dilemmas in resource-constrained
environments
Family
Preparation Issues
FEMA Photo Library
Family Preparedness for Terrorism
The best family preparedness plan focuses on all
pertinent hazards. The possibility of being affected
by a terrorist attack should be acknowledged and
addressed the same as any other hazard but not
emphasized.
The concept of terrorism is now a part of our
culture. Children must have a context into which
to place information about terrorism.
Children Need to Know

If a parent has a potentially
hazardous occupation, children need
to know

Discuss why parent takes the risk

Talk about general risks to safety;
limit details

Stress safety measures taken; allow
children to become familiar with
protective equipment
Children Need to Know

What to do if they find an
unidentified package or substance

How to find safe places and exits

Not to be scared of rescuers

What potentially dangerous areas are
located near home and/or school
Family Prep: Reunification

Everyone needs to carry ID and an
emergency contact number

Keep current photos of all family
members in a secure place

Family members should have a
general idea of where others in
family are

Appoint one family member to keep
track of family travelers
Family Prep: Reunification

Plan on who will pick up children from
school, etc if necessary in an emergency

Be familiar with school disaster plans
(early pick-up, shelter in place, preplanned evacuation sites)

Plan family rendezvous points


Physical
Central communications point
Family Prep: Talking about
Terrorism
Terrorism is now a part of our culture.
Children need to learn about terrorism
the same way they learn about other
aspects of the world’s cultures, history
and current events.
Talking about Terrorism

<5 yrs of age


Children in this age group have little
concept of the future and will not
understand discussion of something
that might happen.
Be honest about your emotions if an
attack does occur. Tell child that
people were hurt but that he/she and
the family are safe and that you’ll feel
better after awhile.
Talking about Terrorism

5-9 yrs of age

Discuss terrorism when child shows
curiosity because of exposure at school
or in the media.

Ask the child what they’ve heard about
terrorism. Correct misinformation and
misunderstanding.

Emphasize the emotions of terrorism
rather than the politics.
Talking about Terrorism

5-9 yrs of age

Emphasize that many people are
working hard to keep all of us safe.

Discuss who to blame and who not to
blame.

Discuss things the child can do to
stay safe from all kinds of hazards.
Talking about Terrorism

9 yrs and older

Can begin to discuss “politics”,
including why people and countries
may disagree

Talk in general about the different
things terrorists might use as weapons
Emphasize that it is very unlikely that
anyone in the family will be involved
in a terrorist incident
Caution children about rumors


Psychology in the
Aftermath
FEMA Photo Library
Immediately After An Incident

Allow children to watch media but limit
exposure and be present to discuss and
handle children's reactions.

Reassure younger children that they
didn’t cause an event to happen.

Assure children that an event is not
happening again just because they see
pictures over and over on TV.

Set aside a time for family discussion.
Immediately After An Incident

Explain in concrete terms what happened
and answer questions truthfully.

If possible, reassure children that their
loved ones are safe.

If a family member’s status is unknown,
tell children why and what is being done
to find out.
Immediately After An Incident

Children pick up on adults’ emotions.
Don’t hide emotions but try to keep them
under control.

Tell children that it’s OK for them to be
feeling sad, angry, or numb and that not
everyone will be feeling the same way at
the same time.

Maintain family routines.
Expect and
respect fear for
family members
in public service
positions
FEMA Photo Library
As Time Goes On

Supervise media exposure

Expect a greater need for physical
reassurance

Encourage talking and emotional
expression

Emphasize tolerance and unity

Turn thoughts toward recovery
As Time Goes On

Common psychological reactions:








Regressive behaviors
Sleep disturbances
Fatigue
Unusual expressions of anger
Changes in appetite
Mood swings
Lack of ability to experience pleasure
Substance abuse
As Time Goes On

Seek professional assistance if children
have:
 New behaviors that consistently
interfere with activities of daily life
 Suicidal thoughts
 Depression
 Aggressive behavior
 Flashbacks
 Substance abuse
 Chronic physical symptoms
As Time Goes On
Allow
children to
participate in
memorials
and help in
relief efforts
FEMA Photo Library
As Time Goes On
Introduce a family ritual to honor victims
and responders, especially if loved ones
and acquaintances were involved.
FEMA Photo Library

The best preparation for emergency
medical response to children as
victims of terrorism is to be able to
take excellent care of kids every day.

An all-hazards approach to planning
at all levels is probably the most
efficient.
FEMA Photo Library
Summary
Summary

Individuals and families must plan
for the possibility (not probability)
that they will be directly or indirectly
affected by terrorism.

Terrorism should be discussed with
children in appropriate terms.
Help!

Children and families are well represented on
many federal and national planning committees.
Watch for consensus statements and
recommendations.

Broselow/Luten CWIK Response project

Increasing availability of pediatric drug delivery
systems such as Meridian Medical’s Atropen®
autoinjectors

National Disaster Medical System includes two
specialty pediatric teams.
Some Useful Resources

International Critical Incident Stress
Foundation @ www.icisf.org

EMS-C National Resource Center @
www.ems-c.org

American Academy of Pediatrics @
www.aap.org

FEMA @ www.fema.gov (includes
FEMA for Kids)
Some Useful Resources




Centers for Disease Control @
www.cdc.gov
Pediatric Preparedness for Disasters and
Terrorism: A National Consensus
Conference @
http://www.bt.cdc.gov/children/index.asp
JumpSTART Pediatric MCI Triage @
www.jumpstarttriage.com
Chemical Warfare involving Kids
(CWIK) @ http://www.cwikresponse.com