Executive Summary

The President and Congress charged the National Commission on Children and Disasters with carrying out the first-ever comprehensive review of Federal disaster-related laws, regulations, programs, and policies to assess their responsiveness to the needs of children and make recommendations to close critical gaps.

In this Executive Summary, the Commission assembles all the recommendations in this report. As is customary for a Federal advisory body such as the Commission, the recommendations are primarily directed toward the President, Federal agencies, and Congress. However, in order to achieve a coordinated national strategy on children and disasters at all levels of government—including Federal, State, tribal, territorial, and local—the Commission urges non-Federal executive and legislative branches of government to consider and apply the recommendations, as appropriate.

To assist Congress, Federal agencies, and non-Federal partners in quickly identifying recommendations most relevant to them, the Commission provides an index organized by the agency, group, or individual charged with implementing the recommendation (go to Appendix B: Index to Recommendations and Responsible Entities).

1. Disaster Management and Recovery

Recommendation 1.1: Distinguish and comprehensively integrate the needs of children across all inter- and intra-governmental disaster management activities and operations.

• The President should develop a National Strategy for Children and Disasters.
• The Executive Branch, Congress, and non-Federal partners should prioritize children separately from "at-risk" population categories.
• The Executive Branch at all levels of government should establish and maintain permanent focal points of coordination for children and disasters, supported by sufficient authority, funding, and policy expertise. The Federal Emergency Management Agency (FEMA) should establish Children's Integration Specialists at the regional level.
• The Executive Branch and non-Federal partners should incorporate children as a distinct priority in base disaster planning documents and relevant grant programs.
• The Executive Branch and non-Federal partners should incorporate education, child care, juvenile justice, and child welfare systems into disaster planning, training, and exercises.
• The Executive Branch and non-Federal partners should incorporate children as a distinct priority in relevant target capabilities, preparedness training, and exercises, with specific target outcomes and performance measures.
• The Executive Branch and Congress should institute accountability and progress monitoring measures to track implementation of Commission recommendations and capability improvements.

Recommendation 1.2: The President should accelerate the development and implementation of the National Disaster Recovery Framework with an explicit emphasis on addressing the immediate and long-term physical and mental health, educational, housing, and human services recovery needs of children.

Recommendation 1.3: The Department of Homeland Security (DHS)/FEMA should ensure that information required for timely and effective delivery of recovery services to children and families is collected and shared with appropriate entities.

• Government agencies and non-governmental organizations should collect information on children and families necessary to identify and support their immediate and long-term recovery needs.
• DHS/FEMA should expand information sharing with appropriate government agencies and non-governmental organizations to enable the delivery of recovery services.
• DHS/FEMA should pre-identify and credential additional local and out-of-State voluntary and non-governmental organizations and networks that provide disaster assistance to children and families.

Recommendation 1.4: DHS/FEMA should establish interagency agreements to provide disaster preparedness funding, technical assistance, training, and other resources to State and local child serving systems and child congregate care facilities.

2. Mental Health

Recommendation 2.1: HHS should lead efforts to integrate mental and behavioral health for children into public health, medical, and other relevant disaster management activities.

• Congress should direct HHS to lead the development of a disaster mental and behavioral health Concept of Operations (CONOPS) to formalize disaster mental and behavioral health as a core component of disaster preparedness, response, and recovery efforts.

Recommendation 2.2: HHS should enhance the research agenda for children's disaster mental and behavioral health, including psychological first aid, cognitive-behavioral interventions, social support interventions, bereavement counseling and support, and programs intended to enhance children's resilience in the aftermath of a disaster.

• HHS should convene a working group of children's disaster mental health and pediatric experts to review the research portfolios of relevant agencies, identify gaps in knowledge, and recommend a national research agenda across the full spectrum of disaster mental health for children and families.

Recommendation 2.3: Federal agencies and non-Federal partners should enhance predisaster preparedness and just-in-time training in pediatric disaster mental and behavioral health, including psychological first aid, bereavement support, and brief supportive interventions, for mental health professionals and individuals, such as teachers, who work with children.

Recommendation 2.4: DHS/FEMA and the Substance Abuse and Mental Health Services Administration (SAMHSA) should strengthen the Crisis Counseling Assistance and Training Program (CCP) to better meet the mental health needs of children and families.

• Simplify the Immediate Services Program (ISP) grant application to minimize the burden on communities affected by a disaster and facilitate the rapid allocation of funding and initiation of services.
• Establish the position of Children's Disaster Mental Health Coordinator within State level CCPs.
• Formally modify the CCP model to indicate and promote "enhanced services" where the mental health impact is unlikely to be adequately addressed by "typical" CCP services.
• Include bereavement support and education within services typically provided under the CCP.

Recommendation 2.5: Congress should establish a single, flexible grant funding mechanism to specifically support the delivery of mental health treatment services that address the full spectrum of behavioral health needs of children including treatment of disaster-related adjustment difficulties, psychiatric disorders, and substance abuse.

3. Child Physical Health and Trauma

Recommendation 3.1: Congress, HHS, and DHS/FEMA should ensure availability of and access to pediatric medical countermeasures (MCM) at the Federal, State, and local levels for chemical, biological, radiological, nuclear, and explosive threats.

• Provide funding and grant guidance for the development, acquisition, and stockpiling of MCM specifically for children for inclusion in the Strategic National Stockpile (SNS) and all other federally funded caches, including those funded by DHS/FEMA.
• Amend the Emergency Use Authorization to allow the FDA, at the direction of the HHS Secretary, to authorize pediatric indications of MCM for emergency use before an emergency is known or imminent.
• Form a standing advisory body of Federal partners and external experts to advise the HHS Secretary and provide expert consensus on issues pertaining specifically to pediatric emergency MCM.
• Within the HHS Biomedical Advanced Research and Development Authority, designate a pediatric leader and establish a pediatric and obstetric working group to conduct gap analyses and make research recommendations.
• Include pediatric expertise on the HHS Enterprise Governance Board or its successor and all relevant committees and working groups addressing issues pertaining to MCM.
• Establish a partnership between the proposed MCM Development Leader and key pediatric stakeholders both within and outside government.

Recommendation 3.2: HHS and DoD should enhance the pediatric capabilities of their disaster medical response teams through the integration of pediatric-specific training, guidance, exercises, supplies, and personnel.

• HHS should develop pediatric capabilities within each National Disaster Medical System (NDMS) region.
• HHS should establish a "reserve pool" of pediatric health care workers to assist in NDMS disaster response.
• HHS and DoD should establish a Pediatric Health Care Coordinator on each disaster medical response team and develop strategies to recruit and retain team members with pediatric medical expertise.

Recommendation 3.3: HHS should ensure that health professionals who may treat children during a disaster have adequate pediatric disaster clinical training.

• The President should direct the Federal Education and Training Interagency Group for Public Health and Medical Disaster Preparedness and Response (FETIG) to prioritize the development of pediatric core competencies, core curricula, training, and research.
• The FETIG should support the formation of a Pediatric Disaster Clinical Education and Training Working Group to establish core clinical competencies and a standard, modular pediatric disaster health care education and training curriculum.

Recommendation 3.4: The Executive Branch and Congress should provide resources for a formal regionalized pediatric system of care to support pediatric surge capacity during and after disasters.

• HHS should include pediatric surge capacity as a "Required Funding Capability" in the Hospital Preparedness Program.
• States and hospital accrediting bodies should ensure all hospital emergency departments stand ready to care for ill or injured children through the adoption of emergency preparedness guidelines jointly developed by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association.

Recommendation 3.5: Prioritize the recovery of pediatric health and mental health care delivery systems in disaster-affected areas.

• Congress should establish sufficient funding mechanisms to support restoration and continuity of for-profit and non-profit health and mental health services to children.
• The Executive Branch should recognize and support pediatric health and mental health care delivery systems as a planning imperative in the development and implementation of the National Health Security Strategy and National Disaster Recovery Framework.
• HHS should create Medicaid and Children's Health Insurance Program incentive payments for providers in disaster areas.
• The American Medical Association should adopt a new code or code modifier to the Current Procedural Terminology to reflect disaster medical care in order to facilitate tracking of these services and as a means for enhanced reimbursement from public and private payers.

Recommendation 3.6: EPA should engage State and local health officials and non-governmental experts to develop and promote national guidance and best practices on re-occupancy of homes, schools, child care, and other child congregate care facilities in disaster-impacted areas.

• EPA and HHS should expand research on pediatric environmental health risks associated with disasters.

4. Emergency Medical Services and Pediatric Transport

Recommendation 4.1: The President and Congress should clearly designate and appropriately resource a lead Federal agency for emergency medical services (EMS) with primary responsibility for the coordination of grant programs, research, policy, and standards development and implementation.

• Establish a dedicated Federal grant program under a designated lead Federal agency for pre-hospital EMS disaster preparedness, including pediatric equipment and training.

Recommendation 4.2: Improve the capability of emergency medical services (EMS) to transport pediatric patients and provide comprehensive pre-hospital pediatric care during daily operations and disasters.

• Congress should provide full funding to the Emergency Medical Services for Children (EMSC) program to ensure all States and territories meet targets and achieve progress in the EMSC performance measures for grantees, and to support development of a research portfolio.
• As an eligibility guideline for Centers for Medicare & Medicaid Services (CMS) reimbursement, require first response and emergency medical response vehicles to acquire and maintain pediatric equipment and supplies in accordance with the national guidelines for equipment for Basic Life Support and Advanced Life Support vehicles.
• HHS and DHS should establish stronger pediatric EMS performance measures within relevant Federal emergency preparedness grant programs.
• HHS should address the findings of the EMSC 2009 Gap Analysis of EMS Related Research.

Recommendation 4.3: HHS should develop a national strategy to improve Federal pediatric emergency transport and patient care capabilities for disasters.

• Conduct a national review of existing capabilities among relevant government agencies and the private sector for emergency medical transport of children.

5. Disaster Case Management

Recommendation 5.1: Disaster case management programs should be appropriately resourced and should provide consistent holistic services that achieve tangible, positive outcomes for children and families affected by the disaster.

• The Executive Branch and Congress should provide sufficient funds to build, support, and deploy a disaster case management system with nationwide capacity.
• DHS/FEMA should clarify the transition from Federal to State-led disaster case management programs.
• Government agencies and non-governmental organizations should develop voluntary consensus standards on the essential elements and methods of disaster case management, including pre-credentialing of case managers and training that includes focused attention to the needs of children and families.

6. Child Care and Early Education

Recommendation 6.1: Congress and HHS should improve disaster preparedness capabilities for child care.

• Congress and HHS should require States to include disaster planning, training, and exercise requirements within the scope of their minimum health and safety standards for child care licensure or registration.
• Congress should provide HHS the authority to require States to develop statewide child care disaster plans in coordination with State and local emergency managers, public health, State child care administrators and regulatory agencies, and child care resource and referral agencies.

Recommendation 6.2: Congress and Federal agencies should improve capacity to provide child care services in the immediate aftermath of and recovery from a disaster.

• DHS/FEMA should revise its Public Assistance regulations to codify child care as an essential service.
• Congress should codify child care as an "essential service of a governmental nature" in the Stafford Act.
• Federal agencies should incorporate child care as an essential service in the National Response Framework, the National Disaster Recovery Framework, the National Disaster Housing Concept of Operations, and Disaster Housing Practitioners' Guide.
• Congress should authorize a grant funding mechanism, such as an emergency contingency fund, to repair or rebuild private, for-profit child care facilities, support the establishment of temporary child care, and reimburse States for subsidizing child care services to disaster-affected families.

Recommendation 6.3: HHS should require disaster preparedness capabilities for Head Start Centers and basic disaster mental health training for staff.

7. Elementary and Secondary Education

Recommendation 7.1: Congress and Federal agencies should improve the preparedness of schools and school districts by providing additional support to States.

• Congress and the Department of Education (ED) should award disaster preparedness grants to State education agencies to oversee, coordinate, and improve disaster planning, training, and exercises statewide and ensure that all districts within the State meet certain baseline criteria.
• DHS/FEMA should partner with ED to provide funding and other resources to support disaster preparedness efforts of State and local education agencies, including collaborative planning, training, and exercises with emergency management officials.

Recommendation 7.2: Congress and ED should enhance the ability of school personnel to support children who are traumatized, grieving, or otherwise recovering from a disaster.

• Congress and ED should award funds to States to implement and evaluate training and professional development programs in basic skills in providing support to grieving students and students in crisis, and establish statewide requirements related to teacher certification and recertification.

Recommendation 7.3: Ensure that school systems recovering from disasters are provided immediate resources to reopen and restore the learning environment in a timely manner and provide support for displaced students and their host schools.

• Congress should create a permanent funding mechanism to support recovery for schools and students.
• Congress should establish an emergency contingency fund within the Education for Homeless Children and Youth program and expeditiously provide grants to school districts serving an influx of displaced children.
• Congress and ED should support the immediate provision of expert technical assistance and consultation regarding services and interventions to address disaster mental health needs of students and school personnel.
• DHS/FEMA, ED, and other Federal agencies should clarify, consolidate, and publicize information related to the recovery programs, assistance, and services (e.g., transportation to schools) currently available to school systems through the Stafford Act and other Federal sources.

8. Child Welfare and Juvenile Justice

Recommendation 8.1: Ensure that State and local child welfare agencies adequately prepare for disasters.

• Congress should request a national assessment of child welfare disaster planning to determine if significant advances have been made since passage of the Child and Family Services Improvement Act of 2006 (CFSIA):
  • HHS should develop detailed disaster planning criteria by regulation or other formal policy guidance to supplement the basic procedures mandated in CFSIA.
• Within each ACF regional office, child welfare staff and the region's emergency management specialist should collaboratively review and evaluate the State child welfare disaster plans required by CFSIA and assist States in developing comprehensive plans and meeting their statutory obligations.
• DHS/FEMA and HHS should provide funding, guidance, and technical assistance to child welfare agencies and encourage collaboration with emergency management, courts, and other key stakeholders.

Recommendation 8.2: Ensure that State and local juvenile justice agencies and all residential treatment, correctional, and detention facilities that house children adequately prepare for disasters.

• Congress should require State and local juvenile justice agencies and all residential treatment, correctional, and detention facilities that house children to have comprehensive disaster plans in place.
• DHS/FEMA and DOJ should support disaster planning for State and local juvenile justice agencies and residential treatment, correctional, and detention facilities that house children by providing funding, technical assistance, and training.

Recommendation 8.3: HHS and the Department of Justice (DOJ) should ensure that juvenile, dependency, and other courts hearing matters involving children adequately prepare for disasters.

• HHS should include disaster preparedness as a component of the Court Improvement Program for dependency courts.
• DOJ should include disaster preparedness as a component of the proposed National Juvenile Delinquency Court Improvement Program.
• DOJ and the National Council of Juvenile and Family Court Judges should incorporate disaster preparedness into the Model Courts program.

9. Sheltering Standards, Services, and Supplies

Recommendation 9.1: Government agencies and non-governmental organizations should provide a safe and secure mass care shelter environment for children, including access to essential services and supplies.

• Implement national standards and indicators for mass care shelters that are specific and responsive to children.
• Integrate essential age-appropriate shelter supplies for infants and children into shelter planning and fund the addition of child-specific supplies to caches for immediate deployment to support shelter operations.
• Implement common standards and training, including standards for criminal background checks, to mitigate risks unique to children in shelters such as child abduction and sex offenders.

10. Housing

Recommendation 10.1: Prioritize the needs of families with children, especially families with children who have disabilities or chronic health, mental health, or educational needs, within disaster housing assistance programs.

• Government agencies and non-governmental organizations should ensure that families with children in disaster housing, especially community sites, have access to needed services and are provided safe and healthy living environments.
• Congress should authorize DHS/FEMA to reimburse State and local governments for providing wrap-around services to children and families in community sites.
• DHS/FEMA should develop clear written guidance around emergency transportation planning and reimbursement for State and local governments that addresses the recovery needs of children and families.
• Government agencies and non-governmental organizations should identify and promote innovative programs to expedite the transition into permanent housing for families with children.

11. Evacuation

Recommendation 11.1: Congress and Federal agencies should provide sufficient funding to develop and deploy a national information sharing capability to quickly and effectively reunite displaced children with their families, guardians, and caregivers when separated by a disaster.

• DHS should lead the development of a nationwide information technology capability to collect, share, and search data from any patient and evacuee tracking or family reunification system.
• DHS should support the development of voluntary consensus-driven standards for data collection and data sharing through a joint Federal, non-Federal, and private sector process.
• Government agencies should ensure the collection of appropriate data on evacuated children, particularly unaccompanied minors.

Recommendation 11.2: Disaster plans at all levels of government must specifically address the evacuation and transportation needs of children with disabilities and chronic health needs, in coordination with child congregate care facilities such as schools, child care, and health care facilities.

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