Pediatric Disaster Science: Understanding Needs, Highlighting Imperatives, and Leveraging Opportunities

 

ABSTRACT | The National Academies of Sciences, Engineering, and Medicine (NASEM) Symposium on Pediatric Disaster Science, which was led by the Action Collaborative for Disaster Research, was held August 1st and 2nd, 2022, in Washington, DC. The meeting convened a broad representation of subject matter experts, including federal and nonfederal partners, with the goal of presenting the scope of perspectives, information, and scientific needs related to disasters affecting children. Meeting goals were achieved through formal presentations and facilitated discussions that identified high level pediatric disaster research priorities, opportunities for synergistic scientific efforts, and considerations and strategies to effectively advance pediatric disaster science to improve outcomes for children in disasters. This three-part discussion paper is part of the Symposium collection of works as a compilation of perspectives, ideas, and discussions shared during the Symposium, with follow-on considerations for the field. Part 1 focuses on pediatric disaster science throughout the disaster cycle; Part 2 addresses the scope of translational science in pediatric disaster management; and Part 3 addresses opportunities for building the infrastructure and workforce to support current and future pediatric disaster science efforts. Associated articles in this Symposium collection of works were submitted after the meeting by experts in the field; these pieces augment some of the themes and key concepts identified throughout the Symposium.

 

Introduction

Children’s vulnerabilities to, and outcomes from, disasters differ from adults, and the effects of disasters on children profoundly impact society. Numerous disasters have demonstrated that children continue to be at increased risk from all hazard types, including but not limited to geophysical and weather-related natural hazards, infectious diseases, and willful acts of violence such as terrorism and shootings. Disasters have led not only to the premature births, premature deaths, and preventable injuries and illnesses of millions of infants, children, and adolescents, but have also caused short- and long-term emotional distress, disrupted children’s developmental and educational trajectories, and harmed family and peer networks. (Appendix 1 provides a list of events from 1996-2023 to demonstrate the breadth and scale of varied disaster types impacting children; this sample is not all inclusive as multitudinous disasters have been recorded during this period.)

Significant progress has been made to amplify children’s protection during disasters and public health emergencies (PHE) over the past decade. This progress has been made possible through the continued engagement of many, including government and non-government champions passionate about child health and wellbeing, emergency planners and responders, medical and trauma providers, children’s and academic hospitals, behavioral and mental health specialists, social scientists, public health professionals, educators and childcare providers, faith leaders, community members, and parents and youth themselves. All have worked tirelessly to care for, protect, and promote the health of children, in both everyday times and in crisis events. (Appendix 2 summarizes a select sample of recent federal and non-federal activities that support children.)

Building on the urgent need and substantial momentum of these and other activities to prioritize children’s health and protection before, during, and after disasters, a landmark Symposium on Pediatric Disaster Science was hosted August 1st and 2nd, 2022, by the Action Collaborative for Disaster Research under the National Academies of Sciences, Engineering, and Medicine (NASEM) Forum on Medical and Public Health Preparedness for Disasters and Emergencies (NASEM, 2024a; 2024b). The Symposium’s overarching goal was to harmonize the collective understanding of the state of disaster science focused on United States (US) pediatric populations, and to identify gaps, opportunities, and strategies for future scientific endeavors. For the purpose of the Symposium, the term “disaster” included natural and human-induced events, pandemics, and mass casualty incidents that outstrip the capacity of local, health care, community, and/or governmental resources. All efforts were made to consider the diversity of the pediatric population (i.e., individuals below age 21) across all sociodemographic backgrounds; physical and intellectual abilities; access, functional and health care needs; and language literacy and preferences.

This three-part discussion paper provides views and considerations from the Symposium’s presentations and discussions, which involved experts in fields of disaster preparedness, response, recovery, and reunification; pediatrics, emergency medicine, critical care, and infectious disease; mental and behavioral health; environmental and public health; developmental and educational psychology; social and behavioral science; informatics; and pharmacology and therapeutics. It also involved scientists representing national and international networks, centers, and consortia; community-based representatives; childcare providers and advocates; regulatory affairs; applied science and policy; and funding agencies. This discussion paper shares and expands upon Symposium concepts and ideas, highlighting how: science can inform hazards and risks specific to pediatric populations; discovery and testing of evidence-based interventions have the potential to improve outcomes for children at risk of or who have experienced a disaster; scientific approaches and dissemination of effective interventions can increase knowledge and have more equitable reach; and the pediatric disaster science field can synergistically leverage existing infrastructure and resources, and build a more cohesive, equitable, and evidence-based disaster management enterprise. Actionable Themes to advance the field of pediatric disaster science are offered (see Box 1–3). Moreover, since a shared understanding of pediatric disaster science is critically important, a unifying definition for the field is presented, in hopes that it will be used, discussed, and refined over time.

 

Pediatric Disaster Science: A Unifying Definition

Pediatric disaster science is the scientific field that aims to improve outcomes across the disaster management cycle for infants, children, and adolescents at risk of or who have experienced a disaster of any type, utilizing the full spectrum of translational science via a transdisciplinary, integrated, and equitable approach.

 

Part 1: Pediatric Disaster Science Throughout the Disaster Management Cycle

The scientific field pertaining to children and disasters has changed over the decades, as has an increased need for an integrated, transdisciplinary approach to disaster management. Part 1 demonstrates these shifts, as well as the numerous scientific opportunities and imperatives for prioritizing evidence and science throughout the disaster management cycle. Box 1 provides associated Actionable Themes.

 

 

Pediatric Disaster Science and the Disaster Management Cycle

The impact of disasters on children and societies is extensive. Children experience disasters differently from adults and have different outcomes after the same event. Yet, many systems and societies are unable to adequately protect them before, during, and after events.

Children represent approximately 25 percent of the global population (World Bank, 2022). Mortality estimates, however, reveal that children account for 30–50 percent of deaths occurring from natural events that would otherwise cause morbidity in non-emergency situations (UNDRR, 2019; Save the Children, 2007). Due to their biologic differences (anatomic and physiologic variations with age and size), rapid behavioral and socio-emotional development, and differing levels of dependence on adults and autonomy, children are uniquely vulnerable to threats (CDC, 2020b). When disasters and PHE occur, these differences are compounded and lead to disproportionate impacts. This is especially true for the large number of children who live in poorer households or disadvantaged communities, and for those who are members of marginalized groups (such as children with a race/ethnicity other than White, children with disabilities, and others) (US Census Bureau, 2023; Hallegatte et al., 2016). Psychological distress and trauma after disasters is also well-established among children and adolescents, with demonstration of these differing depending on the child’s developmental phase (SAMHSA, 2024). Children have an additional risk of re-traumatization and may experience secondary disasters after events, from interpersonal or gender-based violence (including physical and sexual assault), forced displacement, and human trafficking (Seddighi, 2021; ACF, 2018). Therefore, children are not only affected when a disaster or PHE occurs, but they often suffer short-, medium-, and long-term effects across their health development and learning trajectories, and may be targeted for exploitation in unstable post-disaster settings.

To adequately protect children before, during, and after disasters, it is necessary to plan and ensure the availability of pediatric-specific space, equipment, supplies, and tools. It is also critical that appropriate countermeasures and safety precautions are in place, and that the workforce present have the necessary skills and expertise to attend to children’s needs. At baseline, however, many settings, even hospitals and disaster shelters, are not equipped with the essential child-specific plans, resources, infrastructure, and pediatric-specific workforce competency.

The disaster management cycle, first proposed in 1932 and modified over time, conceptualizes the continuum of disaster management (Carr, 1932). The cycle details the sequence of disaster phases: preparedness, response, recovery, and mitigation and prevention. Similarly, the pandemic management cycle has been mapped onto the disaster management cycle to facilitate conceptualization of the PHE continuum (Fakhruddin et al., 2020). To improve outcomes for child populations, scientific advancement and evidence-based progress must envelop and penetrate all aspects of the disaster management cycle (before, during, and after the event), across all disaster phases and hazards with children’s unique needs remaining central to this work (see Figure 1).

 

 

Disasters are increasing in frequency, complexity, and scope (EM-DAT, 2024; NCEI, 2024; UNDRR, 2022). Moreover, the designation between “human-induced” and “natural disasters” is not straightforward. A marked driver of the current increase in the number of disaster events per year is human-caused global climate change, which has transformed the global risk landscape for hurricanes and other tropical cyclones, severe storms and tornadoes, flooding, wildfires, landslides, infectious disease threats, severe heat and cold events, and droughts (USGCRP, 2024). Aging infrastructure, technological systems, increasing climate risks, and population changes have resulted in more frequent and severe events. Intentional disaster threats, such as incidents of mass violence and conflict, have also increased (Gramlich, 2023; United Nations, 2020). Pediatric populations are a focus of increased risk and concern for all these events, as well those of chemical, biological, radiological, and nuclear (CBRN) incidents, which have exponential risk of harm given the potential for increased pediatric dose exposure and long-term effects of exposure (Chung et al., 2020). This accelerating risk environment demonstrates a pressing need to prioritize investments and strategic interventions for children and an imperative for a rigorous science that yields an evidence base across the disaster cycle.

Pediatric disaster science provides the necessary focus on challenges and solutions for infants, children, and adolescents at risk of or who have experienced a disaster. To enhance the efficiency and effectiveness of programs across the disaster cycle, different sectors, and hazard types, interventions need to be based on evidence and continually evaluated for the focal population(s) and setting(s) of interest. Coordination of these efforts and real-time communication streams of data throughout and between the phases of the disaster management cycle are critical. Additionally, as further described in Part 3, pediatric disaster science is integral to building and sustaining the infrastructure and workforce that unifies the mission and work to accelerate evidence-based progress and optimize outcomes for children during disasters and throughout their lifetimes. In conjunction, the field can foster and support research for workforces critical during disasters, such as pediatric disaster focused professionals, trained volunteers, and those serving children in health care and education. Ensuring that science helps build the evidence of such programs is vital. Importantly, including input from youth themselves, who can and will be responsible to address challenges, will help the field strengthen its evidence base.

 

Pediatric Disaster Science Over the Decades

A growing body of research has focused on children and disasters, most especially in the social and behavioral sciences from 1945–2016. Six major overlapping waves emerged during this period: (1) assessing children’s psychological and behavioral reactions to disaster; (2) understanding children’s exposure and physical health outcomes; (3) characterizing social vulnerability and considering sociodemographic characteristics of children; (4) placing children in broader socioecological context; (5) understanding children’s resilience, strengths, and capacities; and (6) centering on children’s voices, perspectives, actions, and human rights (Peek et al., 2018). Throughout all waves, there has remained a consistent need for increased integration with pediatric disaster science ensuring that the characteristics and qualities of different child subpopulations are considered.

Several scientific domains have also emerged centering on children’s uniqueness and disasters. For example, children are biologically and psychologically vulnerable to environmental stressors and toxins yet have incredible adaptive capacities and resilience. Additionally, the effects and manifestations of stress exposure depend on the age and phase of development during which the child experiences the stress exposure. Children are dependent on the relationships, structures, and systems in their lives, including familial, communal, social, and political relations. Given children’s often limited ability to independently make decisions and buffer stress exposure, individuals, communities, and systems must work on children’s behalf.

Different socioecological models and scientific areas have been utilized over time to better understand the mediators and modifiers that occur in the context of a disaster. These include vulnerability, response and resilience science, evaluating dose-response and dose-dependent models of disasters and outcomes, epigenetic research and later life morbidity, toxic stress exposure, and exposome science.

 

Gaps and Opportunities in Pediatric Disaster Science

Significant gaps and opportunities in pediatric disaster science remain. Though children have been referenced in numerous after-action reports from disasters over the years, and disaster management experts have begun focusing on children across the disaster management continuum, the field has an imperative to now engage a more formalized scientific process within these activities. Pediatric disaster science needs to extend beyond reviews, commentaries, surveys, and case studies to improve and increase the methodologic rigor of the field. Such research will propel the field beyond anecdotal recommendations to more systematic impact, most especially if evidence is operationalized across local, state, national, tribal, and territorial levels.

As an example, preliminary results from a recent disaster-cycle based review of US pediatric disaster literature from 2000–2022 revealed over 700 relevant articles. Increases in publications were observed after large-scale natural disasters (specifically, Hurricane Katrina and Hurricane Ike), major acts of violence such as mass shootings and terrorist attacks, and more recently, the COVID-19 pandemic. The majority of articles were epidemiologic, descriptive, or qualitative in nature, with few prospective studies. Most articles focused on initial disaster management cycle phases (preparedness and response); few centered on recovery, mitigation, or prevention. Significant opportunity exists to expand on the continuity of pediatric disaster science over time and the breadth of research addressing all hazards across the full disaster management cycle. Furthermore, prospective and interventional science is needed and can increase the quality, rigor, and fidelity of this research.

There is also a paucity of research to understand the range of impacts on and outcomes for children who have experienced one or more disasters. Trauma, illness, and psychosocial stress symptoms expressed emotionally and physically after disasters have been reported but scope and detail are limited by data collection challenges. Additionally, evidence-based interventions and validated measures and methodologies to capture and assess the full spectrum of disaster management are yet to be envisaged. Recognizing the importance of studying the prevalence and impact of trauma and other symptoms expressed after disasters, and the need for advancing the full spectrum of interventions and measures, the field is poised to develop and embrace a more holistic research agenda.

Population and individual level research opportunities additionally exist to ensure equity of initiatives and resources. These should be guided by a diverse and inclusive engagement that identifies and meets the needs of all individuals and populations to better understand and ultimately impact short- and long-term disaster outcomes, while also evaluating for intended and unintended consequences. Some examples include evaluation of access; the use of and treatment provided in care facilities; psychological first aid; and supportive services for children and families from historically underserved and marginalized groups. Once effective interventions for these populations are identified, systemic research must drive best practices to ensure that they are equitably disseminated and implemented across individuals and populations.

Moreover, science can discover effective support interventions for not only parents and other caregivers, but for trained volunteers, educators and school staff, and pediatric health care providers. For example, organizations such as the American Red Cross respond to over 60,000 disasters every year with 95 percent of these relief workers being volunteers (American Red Cross, 2023). The Red Cross supports preparedness initiatives, such as the Pillowcase Project, and offers emergency response and relief provisions, mental health services, and longer-term community recovery support. Similarly, the health care and education workforce are often stretched beyond capacity during everyday times, and their jobs expand significantly in the context of a PHE or disaster. This was most dramatically witnessed during and following the COVID-19 pandemic. Disaster science has the potential to understand the critical development, support, and sustaining of these volunteers and health care and education professionals who will continue to care for young people for generations to come.

 

Prioritizing Science Throughout the Disaster Management Cycle

Emergency Planning Research to Equitably Identify and Prepare for Hazards

Emergency planning research, or preparedness science, is a field that aims to understand how to effectively prepare for or better protect against disasters before an event occurs. This type of scientific endeavor must identify and offer insights to equitably prepare for all hazards. Emergency preparedness research should transcend “random acts of preparedness” to a strategically coordinated and consistently funded preparedness agenda based on evidence that advances the discipline. Hypothesis-driven science must guide the next generation of this work. For preparedness to be effective, evidence should support best community-informed and community-based practices such as family disaster planning, school preparedness, public drills, and relocation and unification plans. Such practices should also inform health system management including triage, decontamination, countermeasures, and patient distribution.

Pediatric-focused perspectives must be woven into the fabric of emergency planning and preparedness science, including within the social service emergency management community. The individual, pre-disaster conditions and available resources within communities and households supporting children significantly influence their ability to manage disaster shocks, recover, and thrive. Disaster science must consider and inform human service coordination of efforts to prevent additional destabilization of socially vulnerable children and families who rely on these human services. Commitment to equity, the understanding of disparities and challenges, and representation for those affected by a disaster must be at the heart of this scientific work.

Adopting a person-centered approach to pediatric disaster science will help researchers better understand the complex elements that frame the research question in preparedness and response activities and potential actions needed to address desired population-level outcomes. On a personal and family preparedness level, research that informs best practices for preparedness, and that engages children, families, schools and the public at the respective value-level from planning through implementation, will have the greatest impact.

 

Trauma and Medical Preparedness and Response Science for Better Outcomes

Research must guide not only how best to prepare and respond to a disaster but also how to help children after a disaster and do so equitably. Emergency care and trauma systems are at the front line of taking care of children in disasters and PHEs. Yet children are especially vulnerable in these systems, particularly with the frequent silos of pediatric and adult health care settings. For example, research has demonstrated that readiness to care for children in emergency departments (EDs) in everyday times correlates with improved short- and long-term survival. Among children with acute injury or medical illness, those who are initially cared for in EDs with the highest pediatric readiness (preparedness) standards are 60 percent and 76 percent less likely to die in the hospital, respectively, as compared to those initially treated in EDs with the lowest pediatric readiness standards (Newgard et al., 2023a). These children also have significantly less risk of death within a year of the initial visit (Newgard et al., 2023a). However, over 80 percent of emergency visits for children in the US occur in general EDs that primarily care for adults, and given their low pediatric volume, these EDs may not be fully prepared to care for children (EIIC, 2023b). Only half of children transported by emergency medical service (EMS) providers are being delivered to EDs prepared to care for them (Newgard et al., 2023b). Moreover, less than 50 percent of US hospitals have pediatric considerations in their disaster plans and even fewer have preparation drills for pediatric patients (NACCD, 2015).

Trauma and medical preparedness and response science must aim for better outcomes for children, both in everyday times and during a crisis. Daily emergency care systems provide a natural laboratory to study disasters through issues such as system strain and capacity constraint, as these systems routinely deal with large increases in volumes, interruptions to flow, staffing shortages, structural and supply inadequacies, communication difficulties, and access challenges. All settings and situations including pre-hospital, hospital, and nonhospital everyday care and surge care sites should be studied in partnership with EMS to facilitate rigorous analysis of everyday and disaster pediatric readiness throughout the medical system. Furthermore, preparedness for children at children’s and adult hospital sites and at nonhospital care sites should engage in regular and measured simulation exercises with consistent validated metrics.

From a health system perspective, regionalized pediatric hospital systems optimize care and outcomes for individual pediatric patients during everyday times. However, regionalized systems, many of which are near, at, or even over capacity during everyday times, get strained beyond capacity, and may not be accessible due to infrastructure damage and disruptions during disasters. This disruption of the well-balanced system can prompt crisis level care—shifting pediatric patients to facilities and providers not prepared to take care of them and their conditions, or worse, leaving children with no place to be seen. Research-informed medical and trauma care must aim to build capacity and systems improvement to ensure crisis level care is available and of high quality for all populations. Disaster science that breaks down silos between adult and pediatric health systems during everyday times can preserve and improve care for children during disasters and PHE responses.

Data science can identify equipment, bed, supply, and countermeasure availability and use; model and evaluate staffing needs prior to events; predict anticipated patient and resource needs; match acuity to level of care; and plan for and strategically utilize capacity resources and initiatives. Ongoing data-driven modifications to the system can meet real-time needs throughout the disaster management cycle. Equity at the health system level must ensure preparation for and provision of everyday and disaster level care in medical homes, EDs, inpatient and rehabilitation settings, and mental health units. These services must be available for all children regardless of their gender, race, ethnicity, geographic location, or economic means.

Technologic interventions and novel solutions should be developed, tested, and implemented to bridge the divide of available and competent pediatric health care workforce. Research must guide health system best practices for every local, regional, and national pre-hospital and hospital community. Science that informs efficacy of deployable response teams, resources, and technologies at ground zero of a disaster and in other crisis settings is needed. Additionally, research that identifies the necessary training and skill sets needed for effective response teams and what designates a pediatric-capable team is warranted.

Response science also needs to consider rigorous tracking of data. Record-keeping is difficult during a disaster, and data collection specifically for research during these events has unique challenges. This work, however, is necessary for better understanding the patterns, mechanisms, and extent of injury, illness, and mental health during and after disasters. Real-time data can inform purposeful measures and actions that are the most effective and efficient for improving immediate and long-term outcomes.

Also important are evidence-based response operations that continue to seek innovation. Ongoing evaluation of response operations for efficacy of these endeavors, as well as the assurance of child safety and security when displacement occurs, is critical. Furthermore, the study of differing organizational models that oversee response at local, state, and national levels is imperative to ensure these are most impactful and equitable across populations.

 

Optimizing Reunification Science to Minimize Child Separation

The separation and reunification of families in the wake of disaster events is another area in which pediatric disaster science can offer evidence-based contributions. Family separation harms children’s health. Article 19 of the United Nations Convention on the Rights of the Child speaks to a child’s right not to be separated from his or her parents (United Nations Human Rights Office of the High Commission, 1989). Thus, the goal in every disaster scenario is to prevent separation of children and families, and if separation does occur, to reunite children with their parents, other family members, or caregivers as quickly and safely as possible.

Current US preparedness strategies for family reunification are variable. Though federal resources for community and family reunification after a disaster exist, most disasters happen locally. Hence when disasters occur, victims look to their local hospitals as trusted sources and visit local health care facilities for care and coordination. As of 2019, however, only 64 percent of hospitals nationwide have a written family reunification plan (Rebmann et al., 2021).

Pediatric disaster science needs to discover, disseminate, and implement best practices for reunification in the event of family separation during disasters. In addition to the use of photographs, videos, and finger/palm recognition software, the development, ethical ramifications, and rigorous evaluation of technologic advances should be considered. Many platforms hold great potential to improve identification of separated children—including the use of social media, artificial intelligence, biometrics, and even DNA biobanking and matching to ensure security, safety, efficiency, and precision in the reunification process. Each of these endeavors, however, must be balanced with the need to protect the rights and dignity of persons, adherence to International Humanitarian Law, and ethical and equitable protocol development for technologies or other approaches. Ethicists, social scientists, and families should be engaged to help identify trust concerns that many caregivers have in sharing their children’s identification via certain channels while avoiding potential re-traumatization or ambiguous loss that many families experience in the event of a missing child. Community and federal reunification plans need to take into consideration the rigorous evaluation of baseline and novel reunification approaches as they are adopted in localities nationally and internationally.

 

Behavioral Interventions and Mental Health Research with a Life Course Lens

Little efficacy research is available for prevention initiatives or early interventions for children impacted or at risk of being impacted by disasters. Moreover, potential unintended consequences of behavioral interventions that are not evidence-based may have detrimental outcomes. A lack of evidence-based practices has the potential to impact children’s short- and long-term mental health.

School shootings are an example. Though most school districts require active shooter drills among other emergency drills and exercises, evidence demonstrating the efficacy of these activities is lacking. Recent research has demonstrated potential harmful consequences of drills among school personnel who completed active shooter training. Specifically, participants of training programs designed to improve decision-making during a crisis may be more likely to misjudge critical actions steps in a drill as compared to untrained staff (Dorn, 2018). Also concerning, children who are taught first aid may remain in harm’s way to care for an injured peer during an active shooter event (Schonfeld et al., 2020). High-intensity drills with predatory and aggressive acting by individuals posing as attackers may have differing effects on children and adults, each with unique personalities, intellectual and functional needs, coping styles, and potential pre-existing mental health conditions or prior histories of trauma. Preparedness and response science needs to strategically evaluate behavioral interventions prior to widespread implementation, ensuring that both intended and unintended consequences are considered. Research is needed to demonstrate the type, extent, and frequency of live exercise interventions effective in preventing and decreasing physical harm while not causing additional burden on vulnerable children.

For natural hazards, such as storms, fires, floods, and earthquakes, and technological or infrastructure disasters, there also remain significant gaps in the science base to demonstrate efficacy of specific population-level, subclinical, preventive interventions. Strengthened science is imperative to help prioritize behavioral health interventions for children and youth aimed at promoting effective coping with disaster-related stress, grieving losses, and managing potentially traumatic exposures. Further, “two-generation” interventions designed to promote healthy family system functioning post-disaster would greatly enhance efforts to prevent clinically significant distress in children.

Mental health research in disasters is multifaceted and must consider not only what happens at the time of the disaster, but also the potential compounding effects of a second or third disaster that may occur during the recovery phase. Additional research that builds upon foundational work and reveals the strength and resilience factors in a person, community, and society is needed (Masten et al., 1990). More work needs to be done to clarify ecological frameworks to identify vulnerabilities and resources in a particular community and how these affect disaster outcomes (Abramson et al., 2010). Performance metrics of scientific endeavors to ensure sustained progress and impact of projects on the intended population is important.

 

Recovery Science and Resilience Building for Stronger Communities

Scaling of research-informed and evidence-based interventions is critical for short- and long-term recovery. Federally supported interventions are being implemented at the local, state, tribal, and territorial levels, and among non-government organizations (NGOs). However, there is a shortfall in research on the effectiveness of these interventions. Pediatric disaster science must prioritize studies that test the efficacy of existent interventions, focused on holistic child outcomes of health, wellbeing, and resilience. Though research may discover novel recovery interventions, partnerships with groups who will potentially fund and deliver these programs need to be considered a priori to ensure that partners can help inform existent feasibility and potential resource constraints prior to the discovery and testing process.

Multi-sectoral systems affect the outcomes of children and youth who have experienced a disaster event. Recovery science must embed interdisciplinary partners and processes at the inception of interventions. Said interventions should take into consideration the dissemination, implementation, and evaluation in public health, behavioral and mental health, clinical and subclinical, and human services sectors. There is a scientific need to ensure that communication in crisis events is effective and averts potential misinformation challenges and disinformation agendas. Taking lessons from prior disasters and the COVID-19 pandemic, science that understands and discovers best communication strategies and appropriate trusted messenger sources during everyday times and crises is especially relevant.

From a longer-term standpoint, recovery science must aim to better understand and reduce disparities, which are often amplified immediately and long after a disaster strikes. Communities and individuals with pre-existing poorer health, economic instability, and fewer resources experience even greater disparities in outcomes, not only immediately but also for many years after a disaster. Research can discover the health care, social, behavioral, and public health interventions that can prepare populations for the immediate and long-term strategies and initiatives for mitigating and recovering from these events.

There is a dearth of research on diverse child populations, and it is important to remember that young people’s lives are marked by differences along lines of race, class, gender, citizenship status, and sexual orientation, among myriad other factors (Peek et al., 2018). For example, there is a shortage of research on how lesbian, gay, bisexual, transgender, queer (or questioning), and other (LGBTQ+) youth are affected by disasters and interventions that can best aid in this population’s recovery. At baseline, LGBTQ+ youth have a greater risk of depression, substance abuse, suicidality, and disconnection from family support systems as compared to their straight and cisgender peers. Disasters have the potential to magnify these risks, not only among LGBTQ+ youth but for all children. Recovery science has the potential to develop and test evidence-based interventions that can improve outcomes for all youth, including those who are socially marginalized along various dimensions.

While the impact of a disaster on a child depends on many factors (e.g., the child’s development, how well the systems around the child are functioning, cultural and historical factors, and more), research has also shown that a child’s functioning and resilience is dynamic (Masten, 2001; Masten et al., 2021). A common list of protective factors has been demonstrated across children, families, schools, and various kinds of organizations. These factors reflect the major drivers of human psychosocial resilience, and three basic strategies are found to support and promote resilience across child and adult populations. These strategies are to: (1) reduce risk and exposure to frightening media or news in the wake of a disaster; (2) boost available resources (such as care provision, technologies, essential supplies) in the event of a disaster; and (3) leverage powerful drivers of resilience including structure and social interactions that reflect psychosocial human adaptive systems at multiple levels. Science that helps to support and build those systems predisaster and to reactivate them after disruption can improve child resilience. Furthermore, it is pertinent to understand that a child’s future resilience depends on how well families, schools, and communities nurture their resilience today.

 

Part 2: Full Spectrum of Translational Science in Pediatric Disaster Management

At the core of every scientific endeavor is the quest for discovery and the need for data and dissemination. As defined by the National Institutes of Health (NIH), “translation is the process of turning observations in the laboratory, clinic, and community into interventions that improve the health of individuals and the public—from diagnostics and therapeutics to medical procedures and behavioral changes. Translational science is the field that generates scientific and operational innovations that transform the way research is done, making it faster, more efficient, and more impactful” (NCATS, 2024). Applied to disaster science, translational science entails principles and practices that span and integrate scientific methodologies ranging from surveillance to basic science, clinical research, social sciences, applied science, implementation science, and more. Whether a scientific endeavor is done on a micro- or macro-scale, pediatric disaster science can leverage translational science principles (see Figure 2) and methodological approaches.

 

 

There is a breadth of translational science methodologies that can be harnessed to increase the rigor, scope, and impact of pediatric disaster science and evidence-based programs and initiatives. Part 2 illustrates many such approaches and endeavors across the translational science spectrum and the disaster management cycle; it also emphasizes the need for a transdisciplinary and integrated approach in pediatric disaster science. Box 2 provides associated Actionable Themes.

 

 

Type 1: Translational Research—From Basic Science to Clinical Effectiveness

 

Cultivating Discovery through Basic, Epidemiologic, and Exposome Science

Pediatric disaster science must leverage basic and clinical discovery because these endeavors often yield results that may not yet be predicted. For example, after the discovery of mRNA in 1960, a rapid process of tissue- and animal-based studies led to eventual human studies. These studies were what allowed for the subsequent readiness to rapidly develop the novel mRNA vaccine after COVID-19 was identified in 2019 and spread globally in 2020. Notably, even after preparatory discovery studies enabled swift COVID-19 vaccine development, pediatric trials of efficacy have been challenging and limited. Albeit barriers to conducting these trials were multifactorial (including but not limited to investigator and regulatory hesitancy), a case in point was that nearly one year elapsed between approval of the COVID-19 vaccine for people aged 16 and older and approval of the vaccine for the youngest age groups.

From a surveillance perspective, several principles of epidemiology can be applied to pediatric disaster science that could further improve outcomes for pediatric populations. Disasters often happen quickly, and diseases can spread from one part of the world to another in less than 24 hours. Surveillance allows for recognition, monitoring, and analysis of hazards threats and emerging risks via data collection. Modeling surveillance data can help investigators better understand impacts and trends, even when datasets are sparse. Effective communication of population health guidance must be understood and fully envisaged. Therapeutic platforms should be developed, tested, and deployed to improve outcomes. Tracking, collaboration, and training within existent groups or networks is necessary to scale impact. Harnessing technology can improve research activities across the translational spectrum.

Exposome science is the study of the exposome, described as “an integrated function of exposure on our body including what we eat and do, our experiences, and where we live and work” (Vermeulen et al., 2020). These exposures, which occur across an individual’s lifespan, are multilayered and can include chemical, biological, and other constructs, that link to health impacts. For example, in addition to well-known vectors such as allergens and infections, exposome science studies how the nutritional, built, social, and natural environments combine to affect health. Exposome science has also been able to correlate structural racism with toxic environments (Mascarenhas et al., 2021). Pediatric disaster science exposomics epitomizes discovery research to better understand the multilayered effects of disasters on child health. While biomarker assays could identify health impacts, including clinical, developmental, or behavioral trajectories of exposures, exposome science also has significant potential to utilize other non-assay-based platforms. For instance, crowdsourcing and wearable devices could provide real-time data to understand geospatial distribution and detect other potential attributable exposures following disasters.

 

Trials and Mechanistic Science to Increase the Rigor of Pediatric Disaster Science

Rigorous trials, whether small or large in scale, can help to advance any given scientific field, including pediatric disaster science. Further, larger sample sizes with diverse patient cohorts across settings, regions, and communities can enhance the reproducibility and generalizability of findings. Networks of institutions, researchers, and practitioners are especially well-suited to conduct large-scale clinical studies including randomized controlled trials.

The Pediatric Emergency Care Applied Research Network (PECARN) is one such large federally funded US network poised to improve the scale and rigor of pediatric disaster science from an emergency care trials and mechanistic standpoint (PECARN, n.d.). With 18 hospitals and three pre-hospital centers, this collective network cares for approximately 1.5 million children annually. Using a disease and candidate investigator agnostic approach, PECARN ensures explicit protocols and uniform standards for all network studies, including having a core social determinants dataset with central Institutional Review Board (IRB) and experience conducting emergency care research using the federal exception from informed consent (EFIC). Disaster science needs to leverage already existent infrastructures, such as PECARN and other specialty networks, to help drive the nimbleness of these groups.

A learning health system (LHS) is defined as a “health system in which internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice” (AHRQ, 2019b). These large multi-specialty systems can further advance the field of pediatric disaster science, leveraging their networks to create real-time peer-to-peer information sharing, as was achieved by Project ECHO during the COVID-19 pandemic (Hunt et al., 2019). They also create a context and collaborative environment for expansive LHS trial designs, which range from N=1 participant to stepped wedge and cluster randomized samples, individual patient-level randomization, pragmatic adaptive trials, and target trial emulations. Importantly, LHS trials can range from simple to complex, and often deconstruct typical parallel work streams of research and clinical care by being embedded into the usual provision of care. With patients and families as active participants, new knowledge becomes an integral byproduct of the care experience. Multispecialty clinical research networks with the infrastructure and interconnectedness to conduct LHS trials, as well as other discovery and implementation science endeavors across health systems and communities, are poised for great impact. One example is PEDSnet, which is a large, national-scale LHS comprised of 11 academic medical centers that includes researchers, clinicians, child patients, and families (PEDSnet, n.d.). This pediatric network, which conducts observation and interventional clinical research across health systems and includes 9 million children in its database, was instrumental to understanding aspects of COVID-19 and vaccine effects on children (Forrest et al., 2022; Rao et al., 2022; Razzaghi et al., 2024). With their economies of scale, this and other rigorous, national/global, multidisciplinary, disease-agnostic LHS networks have the potential to rapidly identify and answer disaster and PHE-relevant questions that are important to the health sector and communities.

Other more recent federally funded entities that could be leveraged are the Health Resources and Services Administration (HRSA) funded Pediatric Pandemic Network (PPN) and the Administration for Strategic Preparedness and Response (ASPR) Pediatric Centers of Excellence. Although conducting research is not their primary mission, with their impressive national children’s hospital and community reach focused on pediatric preparedness and response, both groups could inspire, catalyze, or even carry out research. These entities can also promote science preparedness of organizations and communities for when time-sensitive, urgent scientific inquiries arise. The addition of networks or centers that are dedicated to pediatric disaster science would underpin and drive continued biomedical advancement of the field.

Pharmaceutical development and testing must be an integral part of pediatric preparedness and response science. Although pharmacologic and therapeutic development has been slower for children, in part due to a smaller, less lucrative pediatric market for drugs, the momentum is changing. This shift is critical in drug development for children in routine times and for preparedness to ensure the availability of essential medications and medical countermeasures for children. For example, the Best Pharmaceuticals for Children Act gives pharmaceutical companies six months of exclusivity to conduct pediatric research (BPCA, 2002). This legislation also authorizes the NIH Pediatric Trials Network (PTN) to support and train scientists to conduct off-patent pharmaceuticals for children (PTN, n.d.). Working closely with the US Food and Drug Administration (FDA), the PTN has been successful in helping conduct pharmacokinetic and safety studies on antibiotics, antivirals, anxiolytics, and other medications. It has also helped provide evidence for potential label changes to existing medications to better serve children. The PTN was instrumental in understanding data and safety profiles of off-label medications initially considered for children with COVID-19. It has also studied the impact of personal protective equipment on the performance of emergency pediatric tasks. Such a network, whose scientists work closely with the FDA, could be a tremendous asset for advancing pediatric disaster science within the pharmaceutical and therapeutic realm.

 

Type 2: Translational Research—From Practice to Communities

 

Dissemination, Implementation, and Community-Engaged Research to Broaden Reach and Impact of Evidence-Based Interventions

Community engagement, equitable dissemination of data and findings, and implementation of other best practices in pediatric disaster science endeavors are critical because every community has the right to available, affordable, and effective interventions appropriate for their unique setting. Community input is paramount to understand the needs of at-risk or disaster-affected populations and to ensure they share in developing and equitably benefiting from solutions. Engaging community collaboration early in needs assessments and research processes, including conversations about potential power dynamics involved in control of research design, decision making, oversight, and funding, is essential. Through respectful and reciprocal partnerships with communities, researchers can enhance the rigor and reach of their studies. For example, the COVID-19 pandemic highlighted not only health equity and health outcome concerns for populations but also fears around transparency and trust. The University of Alabama at Birmingham Community Engagement Alliance Against COVID-19 Disparities represents a successful academic–community partnership. The alliance mobilized during the COVID-19 pandemic to discuss vaccine hesitancy within communities while simultaneously partnering with community members in disseminating important information regarding COVID vaccines (UAB, 2024).

Child and youth input can bring about positive bidirectional results in pediatric disaster science. Involving young people in research and applications helps center their lived experiences and their novel ideas, while also developing their skill sets. Research shows that not only do children have important insights to share that can advance the evidence base, but they also have a strong desire to contribute to disaster preparedness, response, and recovery efforts (Fothergill and Peek, 2015). The PPN is one example of a group aiming to embody the community engagement model, including youth engagement, for pediatric crises and disasters (PPN, n.d.). Importantly, not only does the PPN have community and child-centered activities and goals, but its leadership also includes both a community-engaged advisory committee and a youth engagement committee.

When considering children in communities, disaster science must involve childcare centers, schools, and other settings that children regularly frequent. Nearly 90 percent of the world’s primary school-age children attend schools (UNICEF, 2024). In the US, more than 60 percent of children 5 years old and younger attend center-based daycare, preschool, or kindergarten (NCES, 2019). Thus, to improve outcomes for children, these settings must have excellent evidence-based disaster preparedness and response programs. Additionally, since disasters affect children’s physical and mental health, schools and daycare centers are central to youth recovery. After disasters, these settings often provide food, shelter, medical resources, and psychological resources; they also establish normalcy and routines for children and their families, which is recommended by the American Psychological Association.

Barriers to engaging in disaster preparedness efforts or accessing post-disaster programs can often be unsurmountable for many families due to cost, availability, transportation, and other factors. Programs that are offered in educational settings, however, can help youth overcome these barriers. To bridge the disaster equity divide, dissemination and implementation science should, at a minimum, help identify best practices and feasible dissemination of school and childcare center-based services (Lai et al., 2016). More broadly, it should help pediatric disaster scientists to systematically study the translation of evidence-based interventions into intended communities, schools, and health care settings where children live, are educated, and are served.

 

Improvement, Systems, and Applied Sciences for Comprehensive Pediatric Disaster Management Activities and Regulations

Overall, pediatric disaster science is both driven by and can drive system improvements. Whether at the micro or macro level, communities, institutions, health, and public health systems must aim to continue to deliver the highest-level care, while simultaneously assimilating research to best practices.

Nearly all improvement methods, and the overarching health services research field, can be applied to disaster science, as they collectively study data, quality, delivery, organization, financing, and outcomes of services across the disaster management cycle. Further, all tenets of high-reliability organizations can apply to this field of disaster science, as they do within the larger health care ecosystems (AHRQ, 2019a). Such tenets as applied to disaster science include: (1) pre-occupation with failure—research that embraces the notion that disaster management needs improvement, and a continued commitment to finding solutions; (2) reluctance to simplify interpretations—science that continually asks “why” and “how” to leverage new understanding and capabilities to address the complex universe of activities to improve child outcomes in disasters (3) sensitivity to operations—research that drives continued situational awareness with bidirectional knowledge exchange during all cycles of disaster management and with all relevant parties; (4) commitment to resilience—science that commits to quick identification and mitigation of unanticipated issues as they arise, empowering pediatric disaster groups to respond collectively and swiftly; and (5) deference of expertise—research that harnesses experts and communities to inform decision making in pediatric disaster management systems and policies.

To fully envisage applied sciences into pediatric disaster research activities, several operational challenges must be overcome. Research across the translational spectrum (from basic research to preclinical and clinical research to clinical implementation and public health) must take a wider view of the intersectionality of social influences on health at the individual to societal level. It must be built with bottom-up teams focused on community needs. Impact-oriented work must coexist with traditional deterministic research models within organizations, with avenues for sustained career tracks and funding outside of the typical models. Incentive and organizational structures must democratize timely sharing of data, which will require that common data elements (CDE) and standards be agreed upon. Equitable implementation and translation of research to populations is necessary. Priorities related to advocacy, politics, and investment must be better aligned to true community needs—including those of discovery, resources, and evaluation. As an example, through a partnership between Columbia University, Save the Children, Office of Emergency Management, and Child Care Aware of Northwest Arkansas, communities across the region were able to identify unknown deficits and barriers in emergency response for early childcare centers (those serving children ages 6 months to 5 years) and collectively overcome these challenges through shared understanding and communication exchange, tabletop crisis exercises, and community outreach (National Center for Disaster Preparedness, n.d.).

Finally, regulatory processes should exemplify how partnerships with local, state, and federal entities build progress. EFIC processes through the FDA must be more timely and readily achievable for studying interventions for children in crises or emergency situations. Integration of administrative data pre- and post-disaster should be available in near real-time and leveraged to better evaluate the efficacy of interventions. Other publicly available data sets (i.e., weather, environmental, structural, agricultural) should be more widely integrated to offer a more robust understanding of pediatric health outcomes of interest across various geographies.

 

Part 3: The Pediatric Disaster Science Enterprise—Building Infrastructure and Workforce

The pediatric disaster science enterprise will benefit from synergistically leveraging existing infrastructure, developing the workforce, and building sustainable research capacity that supports pediatric disaster science for all hazards, in an integrated and transdisciplinary fashion. This includes foundational work in pediatric-specific disaster science protocols, instruments, processes, and resources; ensuring ethical approaches while operationalizing unique and time-sensitive science; harnessing activities across centers, networks, and consortia to develop and maintain data capacity; strengthening pathways for inclusion and equity among pediatric disaster scientists; and understanding federal funding sources and policy. Consideration of a framework that organizes these entities and activities at the national, state, and local level would be beneficial. Box 3 provides associated Actionable Themes.

 

 

Strengthening the Foundation to Conduct Pediatric Disaster Research

 

Pediatric-Specific Disaster Science Protocols, Instruments, and Common Data Elements

Since children are considered a vulnerable population by IRBs and other entities, balancing the need for pediatric disaster research protections with the potential benefit of participation—especially in the context of rapid response research—can be challenging. Certain unique aspects of pediatric research must be considered, including ethics, consent/assent, pediatric-appropriate protocols and processes, localities where children are (such as health care settings, schools, and childcare centers), assessment tools across the age spectrum, interventions, and evaluation of outcomes.

Many ethical questions and concerns related to conducting research with or on children date back to at least the 1970s—and have since become the foundation for current federal regulations on this population. These concerns continue to be present within the field of pediatric disaster science and must be considered in advance of a disaster. Such considerations include: (1) Parent or guardian permission and age-appropriate child assent are required, counterbalanced by EFIC during emergency or disaster research to facilitate this science. (2) Age and developmentally appropriate tools for assessment, which may not always be developed, available, or suitable to the study question. Further, though tools may exist, there is at times a lack of appropriate expertise in their use. These tools can range from pediatric-specific equipment to pediatric expertise and experience to psychosocial assessments appropriate for the population. (3) Interventions that take into consideration differences in child anatomy and physiology, developmental, and functional capabilities, and psychosocial health. (4) Outcome measures that are relevant to the study question, appropriate and reliable for the age and developmental state of the study participant, and accurately demonstrate the intended result. Since survivability is fortunately common in children, this outcome may be less helpful whereas the development of new morbidities may be a more sensitive tool. For example, the Pediatric Critical Care Research Network developed and validated a Functional Status Scale, which is a well-defined, quantitative, rapid, and reliable measure of functional status used to measure the development of new morbidities (Pollack et al., 2009). Many other validated pediatric tools and measures can be found within the Patient-Reported Outcomes Measurement Information System (PROMIS, 2023). These could be considered for further extrapolation or exploration into the pediatric disaster science field.

Preparation to conduct real-time disaster research in advance of a disaster should include: (1) pre-approved protocols, established sampling frames, validated instruments and measures, and data collection forms to ensure research that adequately characterizes the pediatric experience; and (2) interventions and data acquisition and dissemination protocols that can provide real-time feedback to develop and assess data-driven interventions and initiatives while building trust and individual and societal adoption of recommendations. The standards for CDEs need to be developed and collectively agreed upon in preparation of a scientific endeavor. At their core, CDEs are a set of variables collected in research in response to a precisely defined question paired with a specified set of responses. CDEs allow for increased efficiency and rapid, steady startup once defined. They also promote collaboration and maximize discovery by the creation of standardized data sets which can be compared, contrasted, and combined. If done correctly, CDEs promote better understanding of the population level impact and can advance and scale the rigor of pediatric disaster science. Many avenues to develop CDEs exist. The example of a global expert CDE development for acute respiratory distress syndrome is one that could be leveraged for pediatric disaster science paying attention to lessons learned throughout this robust international process (Ward et al., 2020).

Aspects of post-disaster research need to be considered. From a social sciences and psychosocial lens, pediatric disaster science must take into consideration trauma-informed impacts of disasters on children’s wellbeing and psychological functioning. The impact of children on society should also be noted, as well as the need to foster child and societal pediatric-related resiliency through all aspects of research participation. Ensuring participant welfare and avoidance of re-traumatization of participants involved in or at risk of disaster is important, alongside the understanding that current research among trauma survivors, including children, has demonstrated positive aspects of research participation. Timeliness of post-disaster research is critical to maximize the reliability and fidelity of data, particularly perishable data, which is dependent on participant contextualization and recall (Adams et al., 2023). Counterbalancing this timeliness is unnecessary research or surveying of disaster victims during the impact and recoil phases. To this end, some investigators and institutions have proposed that at least 30 days post-impact recruitment (for mental health-related research) is both ethical and feasible.

The National Institute of Environmental Health Sciences (NIEHS) Disaster Research Response (DR2) Program is a platform for collaboration and shared communities of practice that could be utilized to host tools (such as pre-approved protocols, survey instruments, and CDE dictionaries) for pediatric disaster science (Miller et al., 2016). While not child-focused, the DR2 Program already houses disaster research protocols, training and guidance materials, instruments, data dictionaries, and tools for data privacy and review. Furthermore, it hosts the 2022 NIH COVID-19 Survey Instruments repository tool to address COVID, which includes CDEs for pediatric COVID. The site now is REDCap enabled to access and deploy these items in a rapid fashion. Similarly, the DesignSafe-Cyberinfrastructure, while also not child-focused, is supported by the National Science Foundation (NSF) to serve as a domain-specific data repository for the hazards and disaster field (Rathje et al., 2020). Social science and public health data, research instruments, and protocols can be published via DesignSafe and receive a permanent Digital Object Identifier (DOI), which help ensure future discoverability, data reuse, and replication of instruments across disaster sites. At present, there is a limited number of published and publicly available datasets and instruments on DesignSafe that specifically focus on children and schools in disaster. With the release of federal guidance now requiring the prompt availability of data and findings from federally funded research, further use of such data sharing platforms is vital in the disaster field broadly, and in pediatric disaster science more specifically (Peek et al., 2023).

 

Human Subjects Protections and Rapid Review Considerations in Disasters

The Belmont Report, issued in 1978, laid out basic ethical principles under which human subject research should be conducted. Central to this report is ensuring autonomy, beneficence, and justice. IRBs follow the translated regulatory criteria and common rule from this report and thereby investigators doing research involving human subjects also have to satisfy these rules. IRBs have additional considerations in the setting of emergencies and disasters, including informed consent and whether child assent is necessary; confidentiality and privacy to ensure fair subject section; independent review as protection of human subjects research; and single versus multiple jurisdiction oversight. At times, disasters can impact the IRB infrastructure itself. This was evident most recently during the COVID-19 pandemic, at which time review processes (as well as considerations for new forms of virtual data collection) had to pivot to the virtual space.

Rapidness of review is often a challenge that needs to be considered prior to emergencies. To respond to such time-sensitive review needs, many institutions have set up local Rapid or Emergency Response IRBs (Packenham et al., 2017; 2021). Although different models exist, many use alternate IRB members allowing for a quorum in a relatively short period of time. Through close collaboration with investigators, a thorough prereview of the protocol with the investigator present to answer questions and respond to IRB conditions saves considerable time. IRBs also can be creative. In the context of bio-emergencies and during crisis standards of care, IRBs may need to consider alternate models to streamline other regulatory requirements, such as umbrella applications for single-patient investigational new drug (IND) requests. As an example, Doctors Without Borders (Médecins Sans Frontières), a non-governmental organization that provides humanitarian medical care, has an Ethics Review Board that retains pre-approved generic research templates and procedures (MSF, n.d.).

Models also exist where IRBs have worked closely with large interdisciplinary research teams—spanning multiple academic institutions and the federal government—to establish pre-approved IRB protocols and multi-institution authorization agreements for rapid response disaster research in hurricanes, tornadoes, and other natural hazards (Peek et al., 2021). Such models may be especially important for pediatric disaster scientists to pursue for several reasons, including the special ethical considerations that must be addressed in advance of research and the institutional designation of children as a vulnerable population that can slow the IRB review process.

On the community voice front, IRBs should ensure that there is community representation on existing and emergency IRB committees. Community representation is critical to ensuring the quality of the work, as is having a trusted champion (such as a school administrator, faith leader, or community advocate) to secure confidence between community members and researchers. On a local, state, or national scale, resources that highlight community expectations in research oversight and review will be of great benefit to science related to pediatric disasters or otherwise.

 

Developing and Maintaining a Registry of Networks and Scientists

 

Leveraging Centers, Networks, and Consortia to Deploy and Implement Disaster Science Studies

Engaging with local, state, regional, national, and international entities is critical to pediatric disaster science. In addition to strong community partnerships, the field needs to embed this work into the systems of care that already serve children to streamline real-time research activities across populations and to accelerate the dissemination, implementation and evaluation of evidence-based interventions. The following sample of entities are engaged in activities that could be leveraged to further expand and strengthen institutions and networks in the field of pediatric disaster science.

The HRSA Maternal Child Health Bureau (MCHB) has a mission to improve the health and wellbeing of US mothers, children, and families, with a focus on four major goals: (1) access to high-quality care, (2) equity, (3) workforce capacity, and (4) impact through partnerships and stewardship. MCHB’s Division of Child, Adolescent, and Family Health funds several of the nation’s leading clinical and preventative networks, programs, and initiatives. The PPN aims to coordinate among US children’s hospitals and their communities to prepare and respond to global health threats (MCHB, 2022; PPN, n.d.). The Emergency Medical Services for Children (EMSC) program “expands and improves emergency medical services for children” and includes the PECARN—a high-quality, multicenter research network focused on prevention and management of conditions in children “across the continuum of emergency medicine health care”; the EMSC Innovation and Improvement Center (EIIC), which aims to “improve the clinical care and management of pediatric patients within  the Emergency Medical Services (EMS) system”; and others (PECARN, n.d.; EIIC, 2023a). The Bright Futures Guidelines provides evidence-based guidance for pediatric prevention and health screening (Bright Futures, 2023). The Children’s Safety Network equips “states and jurisdictions to strengthen their capacity, utilize data and implement effective strategies to make reductions in injury-related deaths, hospitalizations, and emergency department visits” (CSN, 2023). The National Center for Fatality Review and Prevention is the “technical support and data center serving US Child Death Review and Fetal and Infant Mortality Review programs” (NCFRP, 2023). The Poison Control Program is the national resource for help during a poisoning emergency (Poison Control, n.d.). These MCHB networks and other endeavors advance health promotion, strengthen injury prevention, and improve and expand emergency medical services and emergency preparedness for children, adolescents, and their families.

The Pediatric Emergency Research Network (PERN) is a global network of pediatric emergency care networks, with a mission to perform meaningful and scientifically rigorous global collaborative research in pediatric emergency care (PERN, 2023). Currently, eight member networks representing 200 hospitals in 35 countries, and four of the six World Health Organization regions, are involved in this entity. Altogether, PERN serves more than five million annual pediatric emergency visits and aims to assess hypotheses that would benefit acutely ill or injured children globally.

PEDSnet is a “pediatric learning health system dedicated to discovering and implementing new ways of providing the best care and improving health care outcomes” for US children (PEDSnet, n.d.). It is open to researchers to conduct prospective studies or scientific inquiries using the robust PEDSnet data repository (PEDSnet, n.d.). The newer ATOMAC+ Pediatric Trauma Research Network is another multicenter collaborative research network, focused on studying high-quality clinical trauma care research (ATOMAC, 2024).

With NSF funding, the social infrastructure for the hazard and disaster research community has grown significantly. The CONVERGE facility, which is housed at the Natural Hazards Center at the University of Colorado Boulder, serves as the lead organization for eight federally funded Extreme Events Research and Reconnaissance (EER) networks (Peek et al., 2020b). This EER ecosystem has helped disciplinary communities to identify and self-organize researchers while also encouraging interdisciplinary collaboration across engineering, the social sciences, public health, and the natural sciences. CONVERGE has free online training modules on topics such as social vulnerability, disaster mental health, reciprocity, ethics, emotionally challenging research, and cultural competence (CONVERGE, n.d.). Further, CONVERGE holds virtual forums, funds teams, and coordinates teams in large-scale disasters (Peek, 2022). In partnership with DesignSafe, CONVERGE has developed a number of data and instrument, publication, and training opportunities for social and behavioral scientists and interdisciplinary scholars (Peek et al., 2023). While these applications are designed for a broader community of disaster researchers, they are applicable to pediatric disaster science as well.

The Social Science Extreme Events Research (SSEER) network was established in 2017 with the support of NSF. It is noteworthy in that it has more than 1,700 members globally and hosts an interactive web map designed in partnership with Esri (Environmental Systems Research Institute), a multinational geographic information system software company. SSEER’s web map allows users to geolocate researchers and to learn more about their expertise. For example, because the map is searchable by keyword, discipline, and disasters studied, it is possible to rapidly identify those with expertise in social sciences pertaining to children and disasters. Further, if a disaster is unfolding in a particular location, the map can be used to identify locally affected researchers (Peek et al., 2020a; SSEER, n.d.). In 2022, the CDC, through support to the NSF, established the Public Health Extreme Events Research (PHEER) network. PHEER members hold expertise in various aspects of public health and medicine and are focused on the systematic collection of perishable data (PHEER, 2023).

The Genomic Information Commons is a multi-institutional pediatric network demonstrative of a model where the field of pediatric disaster science can potentially execute research projects across cohorts, electronic health record data, and genomic data (GIC, 2020). Using advanced and scalable biomedical informatics approaches to engage patients in research, with integration of biologic samples and a wide array of clinical and omics data, this collaborative network transforms research, and the simultaneous care of patients.

Finally, the NIH mission is to “seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability” (NIH, 2015). Several of the 27 NIH Institutes and Centers already fund research pertaining to PHE and disasters. Additionally, multiple NIH-funded networks and centers exist to advance biomedical and behavioral research across fields of science and populations. Given the significant need for increased capacity and rigor within pediatric disaster science, such esteemed networks or centers could be leveraged to scale research for those children at risk of, or who experience disaster.

 

Building a Pipeline of and Capacity for Pediatric Disaster Scientists

Pediatric disaster science is a transdisciplinary field, which can be compared to emergency care research. Starting over a decade ago, funding increased to support emergency care research, training, and early career development. As a result, the field has been able to provide critical networking opportunities, sharing of research perspectives across disciplines and sites, and interdisciplinary mentorship for a significant number of emergency care scientists. An example of success was the former NIH K12 Emergency Care Program, which increased the number and success of emergency care scientists nationally, as well as ensured rigor in training and science (Morris et al., 2022). Similarly, the pediatric disaster science field will grow if there is a strong commitment to training and career development programs that leverage transdisciplinary activities and promote research collaborations.

When considering growth of and capacity for pediatric disaster scientists, funders should also examine and dismantle structural and systemic inequities related to who receives funding (Lai, 2023). A 2011 article examined 80,000 applications to the NIH. Compared to White applicants at that time, Asian and Black or African American applicants were 4 percent and 13 percent less likely, respectively, to receive R01 funding (Ginther et al., 2011). A follow-up article demonstrated that Black applicants were less likely than White applicants to be employed at a top 100 NIH-funded institution (Ginther et al., 2018). Further, the top 10 percent of funded institutions receive 70 percent of the research project grant funding, while the bottom 50 percent of institutions receive less than 5 percent (Lauer, 2021).

At the organizational and leadership level, it should be known and understood that research and institutional successes, whether in the field of pediatric disaster science or otherwise, are built on having diverse staff and scientists. Solutions to inequities that exist in funding and staffing require deliberate action at all levels of organizations and institutions. Networks, centers, and consortia can play a role by ensuring that there is diverse representation among their investigators and deliberately including institutions that are less resourced. Funding agencies should build diversity and inclusion requirements into the framework of funding opportunity announcements and ensure that scientific reviewer experts also represent diversity in people, institutions, and areas of expertise.

 

Leveraging Big Data for Pediatric Populations

 

Real-Time Data Sharing, Technology, and Mathematical Modeling

Real-time data collection and sharing have different meanings depending on the end-user. Capabilities to capture and release real-time data also vary substantially by vendors and platforms. Real-time data tracking has different cadences ranging from on-demand data, to automated 24- hour refresh of data, to slower “when data are available” avenues, which can lead to the release of data over weeks, months, or even years.

Regardless of definition of real-time, data flow can be stratified into overarching streams: (1) essential data tracking; and (2) data pattern recognition and forecasting. Both data streams are relevant and important in disaster surveillance, operations, and rigorous evaluation. Specifically, realtime data recognition of patients, staffing, facility capacity, and population patterns can forecast system strain at the individual, health, and population level in everyday times and during crisis events. It can also identify and inform needs for strategic resources, including supply chain and national stockpile management.

Technological advances such as machine learning models, artificial intelligence, intelligence augmentation, and mathematical modeling are all tools that may enhance (or complicate) data sharing and forecasting. These rapidly evolving technologies have the potential to leverage real-time electronic health record data, make probabilistic assessments, and provide clinical decision support to improve everyday and crisis care. An example is A Randomised, Embedded, Multi-factorial, Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP), which leveraged electronic health data to explore the impacts of COVID-19 on patients (REMAP, n.d.).

The 21st Century Cures Act also has the potential to advance disaster science. This act, signed into law in 2016, is “designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently” (FDA, 2020). More specifically, the associated ONC’s Cures Act Rule, which “supports seamless and secure access, exchange, and use of electronic health information,” aims to give patients and providers “secure access to health information” (ONC, 2024). As of December 2022, Certified Health Information Technology (IT) Developers were required to have “standardization of application programming interfaces (API) for patient and population services” (ONC, 2020). This criterion will allow the health care delivery system to become a more robust tool for public health. With patient privacy and autonomy as a top priority, public health agencies will now have access to aggregate, de-identified, surveillance data that can be manipulated via partial and fully automated processes to better understand population health trends and risks in everyday times and during emergencies.

 

Data Harmonization and Interoperability of Existing Data Repositories

Utilizing existing data resource streams and repositories is important for economies of scale at baseline and in disaster science. Key considerations for connecting diverse data systems include: (1) leveraging existing investments in data repositories, tools, and web services; (2) improving interoperability and connectedness between systems, such as use of common data models; (3) developing human factors-centered design processes and technologies (to connect systems and tools in alignment with needs); and (4) ensuring connectivity and outputs have open (software, data, and metadata) standards. Further, given that there are thousands of data repositories hosted across a range of academic, federal, and other institution types, it is important to clarify where data relevant to pediatric disaster science is housed and how it can be accessed and properly reused (Peek, 2023).

Engagement in such endeavors requires discussions around scope of harmonization, interoperability, and connectivity, as well as ownership, governance, privacy, and security. Other important considerations are content of data, policies specific to special populations, and plans for risk mitigation. To create sustainable data ecosystems for pediatric disaster science, diversity and inclusion of partners is paramount, as are considerations concerning equitable data sharing policies. Convening data scientists, informaticians, researchers, and the community alone is not sufficient; these conversations must also include system engineers, owners of data systems, ethics review boards, and funders.

Several multi data source entities (such as PECARN and PEDSnet) are described in this discussion paper. Another example of an existing model for multi data source harmonization and interoperability is the Gabriella Miller Kids First Data Resource Center (Kids First, 2024). This large-scale database includes “clinical and genetic data from patients with childhood cancers and structural birth defects and their families” (NIH, 2024). Using a cross-disease framework that incorporates varying data types, streams, and cadences, this entity empowers tools and data sources that researchers can input and evaluate to improve child health. To date, 32 studies are included within this resource center portal, representing data from nearly 60,000 participants and families combined. Though this data resource is not focused on pediatric disasters or emergencies, the model could be envisaged for the pediatric disaster science field—essentially building a data resource center whose sum becomes greater than its individual parts.

Administrative data can also be harnessed for pediatric disaster science from local, regional, state, or federal entities, and include but are not limited to data representing health care utilization, operations, reunification, public health, community engagement, hazards, and infrastructure. Both incentivizing contribution to these data sets and mitigating logistic and process challenges for access to this data will strengthen the scientific impact of these data sources.

Pediatric disaster science can drive prioritization of accelerated data sharing via harmonization and interoperability across data sources from multiple sectors, including health care, education, environment, justice, and social services. Challenges to implement, deploy, and support collective translational data frameworks are disease- and event-agnostic. Great promise lies in the pediatric disaster science field’s ability to mandate or leverage a common foundational framework to allow for swift data flow (inputs through outputs), as well as the evaluation of a real-time feedback to impact child health and services before, during, and after disasters.

 

Funding Streams and Regulations to Help Bridge Scientific Gaps

Sustained and coordinated funding streams are necessary to grow and make significant contributions to this burgeoning scientific field. Current funding streams are parsimonious and incongruent among federal and other funders. Traditional boom-and-bust funding models hinder steady progress and prohibit equitable scale out. Research funds that support infrastructure and tools, data collection, evaluation of interventions, technology, career and workforce development, and more will help foster and sustain the field of pediatric disaster science. Improved synergy and coherent strategy across funding agencies and recipients are poised to result in improved science with less redundancy and more possibility for societal impact.

Especially pertinent to disaster science is the need for expedient funding of certain research endeavors. Federal funding agencies that create mechanisms and streamline processes to fund pediatric disaster science are poised to have significant impact on timelines and fidelity of research activities, most critically for those endeavors in which the availability and quality of data is lost. An example of such a funding program has been the NSF Rapid Response Research grants, which support research when the urgency of collecting perishable data and conducting the project is critical (NSF, n.d.). The NIH was also successful at rapid funding of urgent research endeavors during the COVID-19 pandemic, with one example being the Safe Return to School Diagnostic Testing Initiative within the RADx-UP Program, which helped to develop and test COVID-19 diagnostic procedures to safely return children and staff to in-person school settings (RADXUP, n.d.). Another example of rapid federal funding is the CDC’s Public Health Crisis Response Funding mechanism, which allows for quick funding in jurisdictions where a cooperative agreement already exists with the public health entity and the CDC (CDC, 2023).

Growth and maintenance of these and other federal funding sources needed to support rapid research are important to advance pediatric disaster science in an expedient and high-quality manner. Table 1 offers a sample list of agencies supporting funding opportunities for disaster science and other activities, which could be leveraged by the pediatric disaster science field. With each agency having its own priorities, programs, and policies, pediatric disaster scientists are encouraged to research and contact specific agencies relevant to their science. Importantly, the development and funding for dedicated research centers that aim to build and scale this science in a concerted and integrated fashion, across hazards, sectors, and relevant groups, could expedite discovery, implementation, and impact.

 

 

Key also to any research is its ability to share results in meaningful ways. Listening to communities, engaging with partners, and leveraging diverse and respected voices to communicate pediatric disaster science findings to practitioners and policy makers is paramount. There are countless examples of community champions who have successfully advocated for evidence and research-proven interventions to become part of policy. Although many approaches for doing so exist, this element, with a focus on the longer-term audience and potential dissemination strategies and partners, needs to be considered at the outset of a research endeavor. Further, once research is produced, it is critical that data and study findings are shared through various outlets including peer-reviewed publications, trusted pediatric focused organizations such as the American Academy of Pediatrics and the World Health Organization, government agencies worldwide, as well as social media, news media, and other public information platforms. As one example, the Natural Hazards Center at the University of Colorado Boulder partnered with the CDC to develop a special collection of research briefs synthesized from scholarly publications on children and disasters (Breeden et al., 2019). These entries were then published online and in print form and promoted widely via social media and other outlets.

From a pediatric disaster science lens, helping practitioners and policy makers understand and have access to key findings and descriptive statistics that are relatable to the population they serve is vitally important. Powerfully demonstrating changeable factors that are both feasible and demonstrate good stewardship of taxpayer dollars can be persuasive. Providing plans and data on policy evaluation and outcomes of potential interventions can be impactful. Finally, communicating regularly and frequently with legislators, including sharing 1–2-page policy briefs that feature collective information and provide compelling examples or stories is necessary to move the needle.

 

Conclusions

Children are not small adults. They have unique functional and rapidly developing capacities but are also vulnerable and disproportionately affected by the increasing number, severity, and scope of disasters from all hazard types.

Like operational planning, the disaster management cycle can be used when conceptualizing pediatric disaster science. This framework ensures that the field increases research and evidence equitably across all aspects of preparedness, response, recovery, and mitigation priorities and activities. It also fosters the critical integrative and transdisciplinary nature of pediatric disaster science throughout the continuum.

The full spectrum of translational science is necessary to effectively and equitably scale up and increase the rigor and fidelity of pediatric disaster science across all sectors. From discovery science of novel countermeasures, to improving risk and impact surveillance, to developing and testing of interventions with community partnership by rigorous means, to evaluating ongoing or new programs within federal, state, local, tribal, and territorial partners and communities, to increasing applied sciences within and between hospitals, and testing other systems of care—all pediatric disaster scientific approaches must center on children’s strengths, needs, and vulnerabilities.

Growing capacity and support for ethical pediatric disaster science entails leveraging cross-sector collaboration and partnerships; enhancing and building resources including pediatric protocols and ethical review procedures; scaling up the scientific workforce and infrastructure for research before, during, and after disaster events; and a sustaining commitment of scientists, legislators, and funders between events.

If done holistically and in a sustained and integrated manner, pediatric disaster science will provide the necessary long-term focus on challenges and solutions for children at risk of, or who are affected by, disasters. It will enhance the understanding of risk and threats at the local, regional, national, and global level. It will improve efficiency, effectiveness, and equitable delivery of programs for all hazards throughout the full disaster management cycle and across different sectors. It will build, test, and inform evidence-based interventions and continually improve upon these for diverse pediatric population groups. It will foster transdisciplinary and integrated coordination of scientific efforts and real-time data and communication streams throughout and between all phases of the disaster management cycle across sectors. Finally, it will influence infrastructure, capacity, and scalability of a multidisciplinary workforce with a unified mission and work to accelerate evidence-based progress and optimize outcomes for children at baseline and throughout their lifetimes.

Looking forward, it is imperative that subject matter experts; federal, state, and local partners; and other community, parent, and youth parties continue the momentum gained as a result of this Symposium on Pediatric Disaster Science and the many presented perspectives, ideas, and discussions. It is important for all vested parties to consider their individual and collective roles to achieve the Actionable Themes for pediatric disaster science. After all, safeguarding children before, during, and after a disaster and fostering children’s protection and resilience is critical to their short- and longterm wellbeing and can improve societal resilience. Now is the time to work together, building knowledge and capacity in a coordinated, integrated, equitable, and scientific manner across the disaster management cycle for the sake of current and future generations of children.

 

Appendix 1

 

Select sample of disasters affecting children from 1996–2023

• 1996 — Oklahoma City Bombing killed 19 US children and injured many more (Mallonee et al., 1996).
• 1999 — Colorado’s Columbine High School’s deadly mass school shooting event, resulted in the deaths of 12 students and one teacher, and the suicide of the two perpetrators. Countless other students suffered long-term distress from the incident (Brener et al., 2002).
• 2001 — The coordinated attacks on the World Trade Center in New York City, United Flight 93, and Washington, DC on September 11th, resulted in eight child deaths and left a generation of children who grew up without the respective nearly 3,000 adults who died that day, including lost parents, caregivers, friends, and relatives.
• 2004 — The Indian Ocean Earthquake and Tsunami was responsible for an estimated 160,000 deaths with children having some the highest mortality rates. Among children 9–18 years old who survived the event, over 14,000 lost one or both parents (Cas et al., 2014).
• 2005 — Hurricane Katrina devastated an entire region of the US, resulting in relatively few child deaths, yet tens of thousands of children were displaced, often without family and with long-lasting negative health and educational effects (Abramson et al., 2010; Fothergill and Peek, 2015).
• 2007 — The entire town of Greensburg, Kansas was destroyed by a powerful EF5 tornado. Approximately 25 percent of the population were children, and Greenburg’s original school was flattened by the tornado.
• 2009 — The H1N1 pandemic resulted in nearly 1,000 global child deaths and children being hospitalized at approximately 7-fold the previous rates of hospitalization for seasonal flu (Shrestha et al., 2011).
• 2010 — The entire country of Haiti was affected by the 7.0 Mw earthquake and its subsequent aftershocks, resulting in over 200,000 deaths, 10 percent of whom were children and adolescents (Doocy et al., 2013).
• 2012 — The Sandy Hook purposeful mass shooting of elementary school children; with 28 lives lost that day (Shultz et al., 2013).
• 2017 — Hurricane Maria resulted in significant disaster exposure and widespread trauma-related symptoms among children. Large percentages of children had a friend or family member leave the island, experienced damage to their own homes, experienced food, water, and power shortages, and perceived their own lives to be at risk (Orengo-Aguayo et al., 2019).
• 2018 — The Indonesia Earthquake and Tsunami affected more than half a million children with many losing family members, friends, homes, and schools; most were left without access to basic nutrition and health services (UNICEF, 2019).
• 2020–2023 — In the US, children made up less than 1 percent of those who died during the pandemic, although by 2023, COVID-19 had become the eighth most common cause of death among young people aged 0 to 19 (Flaxman et al., 2023). Estimates also suggest 265,000 children in the US lost a parent or caregiver to COVID-19, leaving a generation of children bereaved (NASEM, 2023).

 

Appendix 2

 

Select sample of federal and non-federal activities and support prioritizing children at risk of or who have experienced disaster or emergency events (list presented in domains)

Policy and Advisory Forums

• The National Commission on Children and Disasters 2010 Report to the President and Congress (National Commission on Children and Disasters, 2010).
• Recommendations from the National Commission on Children and Disasters from 2013–2018.
• The 2022–2023 Recommendations from the National Advisory Committee on Children and Disasters (ASPR, n.d.a).
• The Homeland Security for Children Act, signed into law in 2022, ensuring that the needs of children are considered in mission planning and mission execution (Homeland Security for Children Act, 2022).

 

Funding for Readiness of Systems

The Health Resources and Service Administration (HRSA) funding

• Pediatric Pandemic Network which coordinates among US children’s hospitals and their communities to prepare and respond to global health threats (MCHB, 2022; PPN, n.d.).
• Emergency Medical Services for Children (EMSC) program which aims to expand and improve emergency care for children no matter where they live, including the EMSC State Partnership Program which supports 57 states, territories, and jurisdictions in meeting the needs of children within their unique emergency care systems; and the EMSC Innovation and Improvement Center (EIIC) and EMSC Data Center which serve as national resource centers to advance quality improvement (EIIC, 2023a).

 

The Administration for Strategic Preparedness and Response (ASPR) funding of three Pediatric Disaster Care Centers of Excellence to advance the delivery of clinical care during these events (ASPR, 2019; EIIC, 2022).

 

Emergency Operations

• The Administration for Children and Families (ACF) Office of Human Services Emergency Preparedness and Response which “promotes resilience of vulnerable individuals, children, families, and communities impacted by disasters and public health emergencies” (ACF, 2023).
• The Administration for Strategic Preparedness and Response (ASPR) Office of Community Mitigation and Recovery which “advances the nation’s ability to recover from the health and social services impacts of emergencies and disasters, leveraging existing federal health and social services programs and resources to help state and local communities recover from disasters” (ASPR, n.d.b).
• The authorization of a Technical Expert on children in disasters within the Federal Emergency Management Agency (Homeland Security for Children Act, 2022).
• The Centers for Disease Control and Prevention’s Children’s Preparedness Unit within the Office of Readiness and Response serves as the agency’s go-to source for children’s needs in public health emergencies (CDC, 2020a).

 

Interagency Initiatives to Promote Strategic Integration

• The Subcommittee on Climate, Emergencies, and Disasters within the President’s Task Force for Environmental Health Risks and Safety Risks to Children aiming to provide a convening and coordinating role among federal partners focused on addressing gaps and health protection of children within climate, emergencies, and disasters (PTFEHSRC, 2024).

 

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