The effects of armed conflict on children are devastating, with more than 520 million children and adolescents residing in conflict zones worldwide. Armed conflicts not only cause death and destruction but also lead to widespread displacement, exposing children to physical injuries, sexual violence, family separation, food insecurity, and disruption of essential services like education and health care. All pediatricians and health care providers play crucial roles in addressing the complex challenges faced by children in these settings. Pediatric professionals are called to advocate for policy reforms, ensure culturally appropriate, sensitive, and trauma-informed care and community support, and engage in research to mitigate short- and long-term harm and promote resilience. Strategic interventions include ensuring access to health care and mental health services, safeguarding education, and providing bereavement and psychosocial support during and after resettlement. In doing so, pediatricians can help protect children's rights and foster a future where every child, regardless of conflict, has the opportunity to thrive.

Most school-age children experience the death of a close family member or friend. This chapter summarizes the range of common adjustment reactions and the factors that may complicate or prolong children's grief. In addition, this chapter offers practical strategies for school professionals on how to start the conversation with children about primary and secondary losses, adapt academic requirements, develop coping responses when grief responses are activated in the classroom, develop school-based memorial and commemorative activities, conduct outreach to grieving families, and mobilize peer support for the grieving student.

In recent decades, there has been increased advocacy for death education as well as grief literacy. Simultaneously, digital learning has been extensively integrated into higher education, particularly post-COVID-19. The study's aim was to explore the use of digitally-delivered death education training, related to childhood bereavement, to gain insight into participants' learning outcomes and the contribution of the digital platform. Employing a qualitative approach, data collection included open-ended reflections, a focus group, and semi-structured interviews with 32 pre-service teachers (PSTs), all of which were analyzed using inductive thematic analysis. Findings revealed three themes (values, knowledge, skills), each of which was divided into two categories (self-oriented, other-oriented), and nine subthemes denoting PSTs' learning outcomes. The analysis also indicated four aspects of the digital platform that facilitated these learning outcomes. The study provides theoretical insights alongside practical implications of using digitally-delivered death education to teach wide-scale best practices to support grieving children.

The death of someone close to a child often has a profound and lifelong effect on the child and results in a range of both short- and long-term reactions. Pediatricians, within a patient-centered medical home, are in an excellent position to provide guidance to caregivers and to offer assistance and support to grieving children of all ages and their families. This clinical report offers practical suggestions on how to talk with grieving children to help them better understand what has happened and its implications. An understanding of guilt, shame, and other common reactions as well as an appreciation of the role of secondary losses and the unique challenges facing children in communities characterized by chronic trauma and cumulative loss will help the pediatrician to address factors that may impair children's adjustment and to identify complicated mourning and situations when professional counseling is indicated. Advice on how to support children's participation in funerals and other memorial services and to anticipate and address grief triggers and anniversary reactions is provided so that pediatricians are in a better position to advise caregivers and to offer consultation to and collaborate with professionals in schools, early education and child care facilities, and other child congregate care sites. Pediatricians often enter their profession out of a profound desire to minimize the suffering of children and may find it personally challenging to bear witness to the distress of children who are acutely grieving. The importance of professional preparation and self-care is, therefore, emphasized, and resources are recommended.

Pediatric health care providers can provide universal support to children and families to mitigate potential risk factors to adjustment while fostering protective factors to promote resiliency in children and families. They can educate caregivers about ways to enhance recovery of their children by modifying expectations and addressing the special emotional and social needs of their children. Most public health emergencies evolve through stages across an extended time period, often taxing the personal resources of health care providers. This underscores the need for pediatric health care providers to integrate self-care strategies in their personal and professional practice routines.

Background: Grief and loss are common experiences for children and adolescents, particularly during the COVID-19 pandemic. Educators feel unprepared to support grieving students due to lack of training. We studied educator experiences receiving grief-sensitive training as part of the grief-sensitive schools initiative (GSSI), which provides grief-sensitive training, online video-based and print resources, and a financial grant to schools and school districts for use in supporting grieving students.Methods: Fourteen New York and Florida educators who received GSSI training participated in small focus groups or semi-structured interviews on their experiences receiving GSSI training and supporting grieving students during the pandemic. Transcripts were analyzed using grounded-theory analysis.Results: Emergent themes included increased confidence engaging grieving students, the desire for recurring trainings, the value of receiving training from an expert on pediatric grief and loss and the opportunity to ask questions, the need for grief-sensitive training to reflect the cultural diversity of school communities, the unique losses experienced by students during the pandemic, and compassion fatigue and burnout in educators.Implications for School Health Policy, Practice, and Equity: Policymakers should recognize the effects of grief on students' learning and development and collaborate with educators to develop resources.Conclusions: Educators found GSSI training useful in supporting grieving students, particularly during the pandemic.

Supporting grieving students is part of a school nurse's role which can provide meaning or special purpose in their career. This was verified by an online survey completed by 648 school nurse members of the National Association of School Nurses (NASN). A majority of respondents felt personal distress as a result of their work with grieving students which was predicted by a lack of access to work/community resources available and a lower level of educational background of the school nurse. Training to support grieving students and a higher level of educational background of the school nurse, however, appeared to predict a greater level of personal meaning found in school nurses' support of grieving students. Level of support by school leadership provided to school nurses in their support of grieving students was also found to be related to both the personal distress experienced and the personal meaning derived by school nurses.

Adverse Childhood Experiences (ACEs) include various childhood stressors that can negatively impact the health and well-being of children. ACEs are associated with poor academic achievement. Attention is strongly associated with academic achievement, and there is a graded relationship between ACEs exposure and subsequent development of parent-reported ADHD; however, it is unclear whether ADHD symptoms mediate the relationship between ACEs and academic achievement. This study tested a model of mediation by ADHD symptoms between ACEs and academic achievement (measured by reading score). This retrospective cohort analysis utilized data from the Longitudinal Study on Child Abuse and Neglect (LONGSCAN), a data consortium exploring the impact of child maltreatment (n = 494). There were relatively even numbers of male and female child participants, and the majority of caregivers were either non-Hispanic White or Black. Path analyses were modeled for ACEs as a sum score and separately for individual ACE exposures, with number of symptoms of Inattention (IN) and Hyperactivity/Impulsivity (H/I) as mediators, and academic achievement as the outcome, adjusting for covariates. ACEs were highly prevalent in this sample ( M = 5.10, SD = 1.90). After retaining significant covariates, significant direct associations ( P < .05) were seen between ACE sum score and IN (β = .14) and H/I (β = .21), and between H/I and reading score (β=-.14). A higher ACE score was associated with lower reading scores through variation in H/I, but not IN. H/I mediated the relationship between ACEs and reading score in this high-risk population, providing new insight into relationships between ACEs and academic achievement, which can inform interventions.

OBJECTIVE To determine whether the association between ADHD severity and electronic media use was mediated by parental aggravation. METHODS This was a retrospective analysis from the 2016 to 2017 National Survey of Children's Health (NSCH) involving children ages of 3 to 17 years with parent-reported ADHD (n = 5,930). Path analyses were used to model the relationships between ADHD severity with parental aggravation (PA) as a mediator, and electronic device (ED) and television (TV) use as outcomes, controlling for covariates. RESULTS Parental aggravation mediated the relationship between ADHD severity and ED use and TV use (indirect effects: β = .02, p < .001; β = .01, p = .004). When stratified by age, the mediation effect between ADHD and ED use remained significant for adolescents and school-age children, and mediation between ADHD and TV use remained significant only for adolescents. CONCLUSION These findings suggest a need to develop targeted interventions to address PA and manage excessive electronic media use in children with moderate/severe ADHD.

Anticipatory guidance should be provided to families on identifying and addressing common adjustment reactions after a school shooting. Although adjustment difficulties may be related to post-traumatic and grief reactions, many will not be directly attributable to the school shooting. Understanding how to cope with associated worries and reactions can help children better adjust. Pediatricians can assist with guidance about the development of a reasonable timeline for emotional and academic recovery, traumatic stress/loss, coping strategies, support for students with special needs, identification of students most in need of support, identification of staff who are most likely impacted, and appropriate preparedness activities.

BACKGROUND:Children involved with Child Protective Services (CPS) have been shown to have lower academic achievement. It is unclear whether certain qualities of the home environment can optimize academic achievement in this vulnerable population.OBJECTIVE:This study sought to determine whether home environments with higher levels of emotional support and cognitive stimulation predict later academic achievement and whether this relationship is moderated by placement type (i.e. biological/adoptive parent care, kinship care, or non-kinship foster care).PARTICIPANTS AND SETTING:This study included 1,206 children from the second National Survey of Child and Adolescent Well-Being (NSCAW-II) who were involved with CPS between 2-7 years of age.METHODS:Multivariate analyses were completed to examine the effect of the Home Observation for Measurement of the Environment (HOME) score on later Woodcock-Johnson III Tests of Achievement (WJ-ACH) scores. Moderation analyses were conducted to determine the effect of placement type on this relationship.RESULTS:Although these relationships between HOME scores and WJ-ACH scores were significant in bivariate analyses, they were not statistically significant in multivariate analyses, primarily due to the variable of household income. Although children placed primarily in non-kinship foster care demonstrated higher WJ-ACH scores for Passage Comprehension and Letter-Word Identification subscales, placement type did not appear to moderate the relationship between HOME scores and academic achievement.CONCLUSION:Child- and caregiver-level factors, as well as financial resources available in the environment, may account for the relationship between home environment and academic achievement.

Children are potential victims of chemical or biological terrorism. In recent years, children have been victims of terrorist acts such as the chemical attacks (2017-2018) in Syria. Consequently, it is necessary to prepare for and respond to the needs of children after a chemical or biological attack. A broad range of public health initiatives have occurred since the terrorist attacks of September 11, 2001. However, in many cases, these initiatives have not ensured the protection of children. Since 2001, public health preparedness has broadened to an all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks (eg, natural events such as earthquakes or pandemic influenza or man-made catastrophes such as a hazardous-materials spill). In response to new principles and programs that have evolved over the last decade, this technical report supports the accompanying update of the American Academy of Pediatrics 2006 policy statement "Chemical-Biological Terrorism and its Impact on Children." The roles of the pediatrician and public health agencies continue to evolve, and only their coordinated readiness and response efforts will ensure that the medical and mental health needs of children will be met successfully. In this document, we will address chemical and biological incidents. Radiation disasters are addressed separately.

The vast majority of children experience the death of someone close to them. Although common, such losses can have a significant and profound impact on children’s social and emotional development, as well as their academic functioning. Educators can play a critical role in helping children understand and cope with their loss, implement accommodations to ensure they make continued academic progress, and follow practical strategies to promote coping and minimize their distress. Advice is provided for school-employed mental health professionals on how to identify and support children who would benefit from additional services, how to respond to unique situations such as death due to suicide or in the context of a school crisis, and how to establish appropriate school policies such as approaches to commemoration and memorialization.

Children and adolescents should be included in exercises and drills to the extent that their involvement advances readiness to meet their unique needs in the event of a crisis and/or furthers their own preparedness or resiliency. However, there is also a need to be cautious about the potential psychological risks and other unintended consequences of directly involving children in live exercises and drills. These risks and consequences are especially a concern when children are deceived and led to believe there is an actual attack and not a drill and/or for high-intensity active shooter drills. High-intensity active shooter drills may involve the use of real weapons, gunfire or blanks, theatrical makeup to give a realistic image of blood or gunshot wounds, predatory and aggressive acting by the individual posing to be the shooter, or other means to simulate an actual attack, even when participants are aware that it is a drill. This policy statement outlines some of the considerations regarding the prevalent practice of live active shooter drills in schools, including the recommendations to eliminate children’s involvement in high-intensity drills and exercises (with the possible exception of adolescent volunteers), prohibit deception in drills and exercises, and ensure appropriate accommodations during drills and exercises based on children’s unique vulnerabilities.

Objectives: Virtual tabletop exercises (VTTXs) simulate disaster scenarios to help participants improve their emergency-planning capacity. The objectives of our study were to (1) evaluate the effectiveness of a VTTX in improving preparedness capabilities specific to children’s needs among pediatricians and public health practitioners, (2) document follow-up actions, and (3) identify exercise strengths and weaknesses. Methods: In February 2017, we conducted and evaluated a VTTX facilitated via videoconferencing among 26 pediatricians and public health practitioners from 4 states. Using a mixed-methods design, we assessed participants’ knowledge and confidence to fulfill targeted federal preparedness capabilities immediately before and after the exercise. We also evaluated the degree to which participants made progress on actions through surveys 1 month (n = 14) and 6 months (n = 14) after the exercise. Results: Participants reported a greater ability to identify their state’s pediatric emergency preparedness strengths and weaknesses after the exercise (16 of 18) compared with before the exercise (10 of 18). We also observed increases in (1) knowledge of and confidence in performing most pediatric emergency preparedness capabilities and (2) most dimensions of interprofessional collaboration. From 1 month to 6 months after the exercise, participants (n = 14) self-reported making progress in increasing awareness for potential preparedness partners and in conducting similar pediatric exercises (from 4-7 for both). Conclusions: Participants viewed the VTTX positively and indicated increased pediatric emergency preparedness knowledge and confidence. Addressing barriers to improving local pediatric emergency preparedness—particularly long term—is an important target for future tabletop exercises.

Dworkin, Paul H. MD*; Kelly, Desmond P. MD†; Schonfeld, David J. MD‡ Author Information

Rosaura Orengo-Aguayo, PhD; Regan W. Stewart, PhD; Michael A. de Arellano, PhD; Joy Lynn Suárez-Kindy, PsyD; John Young, PhD