Emergency events can vary significantly. Frequent types of emergency events include motor vehicle accidents, violence, home fires, natural or manmade disasters, and medical emergencies. In a given year, approximately 9.2 million children in the United States receive emergency medical care for unintentional injuries (e.g., motor vehicle crashes, falls, fires, dog bites, and near drownings; Centers for Disease Control and Prevention, 2024). In addition, other emergencies can indirectly involve and impact children’s lives, including events experienced by parents, peers, siblings, extended family members, and neighborhood friends.
Several factors influence how children respond to traumatic events that can prove useful when assessing a child’s risk and vulnerability to negative psychological and neurobiological outcomes from traumatic events. These factors include the amount and type of exposure and personal, family, and social factors (Pfefferbaum, Jacobs, Griffin, et al., 2015; Pfefferbaum, Jacobs, Houston, et al., 2015). There is also a dose-response relationship between trauma exposure and negative effects on individuals (Furr et al., 2010). The more one experiences during a traumatic event (death, injury, loss, etc.), the more likely they are to experience negative effects. In addition, the cause (e.g., natural or manmade), size (i.e., scope and intensity), expectedness (i.e., warning or sudden), and timing (e.g., holidays and time of day) of the event greatly impacts the way individuals and communities respond and cope (Halpern & Vermeulen, 2017). Regardless, nearly everyone that experiences a traumatic event will demonstrate normative stress response symptoms that must be supported to minimize the long-lasting and detrimental psychological effects. Typical symptoms might include an increase in clinginess to caregivers and loved ones, sadness, sleep disturbance, somatic symptoms (stomachaches and headaches), irritability, and problems with schoolwork and concentration (Substance Abuse and Mental Health Services Administration, 2024). However, if these symptoms of distress are prolonged and normal functioning does not resume after a short period (several weeks to months), further concern for more severe psychological impact occurs, including potential for anxiety, depression, and post-traumatic stress symptoms and disorders (Substance Abuse and Mental Health Services Administration, 2024). Studies have indicated prevalence rates as high as 30 to 40% for anxiety, depression, and/or post-traumatic stress disorder for children affected by disasters (Bonanno et al., 2010; Pfefferbaum, Jacobs, Houston, et al., 2015).
A trauma-informed approach involves understanding, recognizing, and responding to the effects of trauma (Substance Abuse and Mental Health Services Administration, 2024). Trauma-informed care acknowledges the physical, psychological, and emotional safety needed for both care providers and trauma survivors and helps to rebuild a sense of control and empowerment (Jones & Smith, 2023). Providers supporting children during emergency events should use a trauma-informed approach to mitigate the potential for negative impacts. While there are many models for implementing trauma-informed care, the Center for Pediatric Traumatic Stress offers the D-E-F framework (Distress, Emotional Support, Family) as a model for best practice following support for the A-B-Cs (airway, breathing, and circulation; Center for Pediatric Traumatic Stress, n.d.). Given the emergency response context this model may be most appropriate for emergency response system implementation. According to the D-E-F model, providing support for distress might include providing the child with choices and control, assessing pain, providing developmentally appropriate and accurate information and reassurance, and promoting a sense of hope. To support children emotionally, available caregivers should be encouraged to listen and be present, empowered to help their children, and encouraged to promote normalization. Supporting the family might include encouraging basic self-care, acknowledging individual family member’s needs, and being sensitive to the cultural and resource needs of the family (Center for Pediatric Traumatic Stress, n.d.).
First responders are in a unique position to mitigate the traumatic effects of events, as they are often one of the first to encounter individuals involved. Though they may have the opportunity to decrease continued trauma exposure, first responders are trained and ethically obligated to focus on immediate medical care and safety and may have little time or capability to emotionally support children in emergency situations. Researchers have found that law enforcement experience powerlessness and despair when responding to events involving children (Karlsson & Christianson, 2003); however, is it unclear how first responders perceive children’s reactions to the event and emotional needs in emergencies. It is also unclear if they view psychosocial support for children as part of their role, and, if so, what resources they need to provide such support.
The purpose of this study was to gain insight into the lived experiences of first responders during emergency events involving children (0 to 18 years old), focusing on first responders’ perceptions of 1) children’s reactions to the event, 2) their roles in supporting children’s psychosocial needs, and 3) the gaps in services to support children in emergency events. Certified Child Life Specialists (CCLS) are trained professionals who provide psychosocial support to children and families experiencing stressful circumstances in a variety of settings (ACLP, 2024). This study will inform the field of child life in developing collaborative processes with first responders by learning what first responders experience with children in emergency events and what role, if any, first responders perceive they have in providing psychosocial support. When integrating child life services into any community, it is essential to seek a better understanding and assess needs by learning directly from those already serving and living in the community targeted. Insight from first responders regarding children’s reactions to the event and first responders’ capacity to provide psychosocial support is vital to assess if there is the potential need to integrate child life services into the community and develop informed models of support to decrease the potential traumatic and long-lasting effects these events cause children.
This study was guided by the following research questions: 1) What do first responders experience as children’s reactions to emergency events? 2) How do first responders identify their role in the psychosocial and emotional care of children during emergency events? 3) What are the perceived gaps in services to support children’s psychosocial needs in emergency events?
Method
A phenomenological approach was carefully chosen with first responder organizational culture in mind. First responders are an extremely tight-knit community. Living in tight quarters, relying on each other in dangerous situations, and sharing experiences in service creates a community that is often referred to as “family” (Woody, 2005). First responders also have a reputation for being closed off to mental health services and sharing of their experiences to outsiders (Kupersanin, 2002). This largely relates to fears of occupational efficacy being questioned and being observed as “weak,” and a desire to protect lay persons from traumatic exposure (Kupersanin, 2002). For these reasons, first responders often process their work-related traumatic exposures and receive support from close colleagues who have had similar experiences (Stinchcomb & Ordaz, 2007). It is important that research is conducted in a manner that builds trust and allows first responders to share their experiences at their own pace. This descriptive phenomenological approach allows multiple interviews to take place in the first responders’ workplace environment, increasing the ability for first responders to gain trust with the researcher and to utilize their environment to help share their lived experiences. The focus of the interviews was on sufficiently gaining insight into their experiences of being a first responder and working with children during emergency events to enable informed comparison of other participants’ experiences in the same phenomenon (Porter & Cohen, 2012).
By understanding the collective experiences of these first responders involved with children and using those experiences to inform a model of trauma-informed care, supportive systems of service delivery can be developed to meet the needs of children with the goal of minimizing trauma and promoting resilience. In addition, this phenomenological approach enables the researcher to gain a deeper understanding of emergency response systems already in place that can best inform trauma-informed systems of care in the future.
Participants
Convenience sampling was used to describe participants’ common experiences (Creswell & Poth, 2017). The researcher first contacted first responders in the region with whom the researcher already had a personal connection and explained the researcher’s interest. This region was a large metropolitan city in the Midwest, with a population of approximately 300,000 (U.S. Census Bureau, 2024). Following the chain of command processes, the researcher gained research approval from the site and obtained a signed permission letter from the appropriate personnel. Once permission was obtained, the researcher met with the first responders in their place of work to initiate building rapport amongst that contact’s colleagues, which included informing first responders about the research study to gauge interest. Using the snowball sampling method (e.g., first responders speaking with other first responders who have had significant experiences with children during emergency responses), additional first responders were identified for interviews. This method allowed the researcher to access participants who were information-rich (Goodman, 2011).
To maintain a description of similar experiences, inclusion criteria were set to include first responders who were English speaking and served in a specific Midwest fire department who had worked with children during emergency events. Recruitment took place in late August through October 2018. Having a sample concisely serving within the same community increased the likelihood of common experiences due to similar support systems, training, and organizational structures.
Procedures and Data Collection
After Institutional Review Board approval was granted from the University of Missouri (#2010794), an initial on-site visit was conducted which included a tour of the participants’ workplace and hours of building rapport with the first responders present on shift. Initial interviews took place in November and December 2018 with those first responders willing during the latter half of the first visit; second interviews were then carried out in February 2019. Interviews were audio recorded.
Data were collected using semi-structured interviews, each lasting approximately 20 to 50 minutes (see Appendix A for interview questions). During the first interviews, the first question was broad, asking first responders to describe a time they responded to an event and children were involved. This allowed first responders to drive the interview and the researcher to use follow-up probes to elicit more details about their lived experiences during these events. Follow-up probes asked participants about the reactions children had to the event, their perceptions of their role in the emotional support for children, and the resources they desire for working with children in emergency events. Participants were encouraged to share about multiple events involving children. Second interviews allowed participants time between interviews to reflect on their lived experiences with children after gaining trust with the researcher in their first interviews. The second interview began by asking participants if they had any specific thoughts on the topics discussed since the last interview and then continued asking them to describe any encounters with children they had since the previous interview took place.
The first author’s lens is that from experience in both the child life field and disaster relief. Thus, several steps were taken to ensure that this research was trustworthy, credible, and rigorous. First, methods and research procedures were explicitly outlined prior to engaging in data collection. Second, interview protocols were reviewed by experts both within and outside the field to minimize bias. Third, the second interviews focused on gathering more information and probing the data collected during the first interviews. Unique and common experiences identified by participants in the first interviews were clarified and asked among all participants during the second interviews, utilizing member checking throughout the research process. Last, the researcher also kept a reflexive journal documenting her own experience with the phenomenon prior to engaging in the research and throughout the entire research process. This journal served as a collection of self-reflexivity documenting breakthroughs, thoughts, and observations made, acknowledging the interplay between the researcher’s positionality and the participants’ experiences of the phenomenon.
Data Analysis
All analyses were conducted by the first author. Interviews were transcribed verbatim by the first author, undergraduate research assistants, and a university-based transcription service and checked for accuracy by a second transcriber. After transcription was complete, data were converted to a table format for further analysis. Next, in accordance with Porter’s descriptive phenomenological methods, the first author reviewed the data for ideas that were irrelevant, part of the life-experience, and those part of the life-world context to create units of analysis (Porter, 1998). Irrelevant data were excluded in the analysis.
Life-world contextual units were marked using the reference marking citation and table of codes tools in Microsoft Word, capturing ideas related to the reality of the phenomenon that is typically taken for granted, often influenced by social norms (Porter & Cohen, 2012). Using Porter’s (1995) guidelines, life-world units were then extracted into a separate table and subcategorized into elements (i.e., most specific), descriptors (i.e., groups of elements), and features (i.e., broadest level of life-world units of analysis). For example, when participants described children’s reactions during emergency events, groups of elements (e.g., “a lot of them were just emotionless…like they’ve seen this before” and “some kids don’t seem to react to much…it seems like they’re normally used to it”) were grouped together and given a descriptor (e.g., “unphased” or “going about their business”). Descriptors were then compared and similar descriptors were then grouped into features, the broadest level of the life-world context (e.g., “lack of reactions”).
Similarly, life-experience data were distinguished using the reference marking citation and table of codes tools in Microsoft Word, color-coded in relation to specific research questions they addressed, and then extracted using a separate table to further classify into three levels: intentions, component phenomena, and phenomena (Porter, 1998). Intentions are the ways in which respondents understand and shape their experiences. Intentions were discerned by describing, comparing, distinguishing, and inferring from the data continuously evaluating, “What is the first responder wanting to do in this experience?” (Husserl, 1962). Intentions were captured using quotes that represent commonalities among first responders. Component phenomena represent patterns of intentions that emerge from multiple participants by comparing interviews with first responders and assessing them for similarities and differences. Lastly, at the broadest level, phenomena were extracted from the data. Phenomena represent general patterns of component phenomena (Porter & Cohen, 2012). For example, when participants referred to their role in supporting children on the scenes of emergency events, groups of intentions with commonalities (e.g., “they were scooted out of the room pretty quickly” and “let’s get the kids out of here…we kind of scooted them out”) were grouped together as component phenomenon (e.g., “scooting out” or “diversional conversation”). Component phenomena were then compared; similar ones were then grouped into phenomena, the broadest level of the life-experience (e.g., “distraction”). Throughout the entire data analysis, features and phenomena were continuously discussed with first responders during subsequent interviews to confirm accurate representations of their experiences (Yin, 2011). Results are presented below using participants’ own words to describe the identified broadest level as features and phenomena.
Results
A total of eight male first responders participated in the study. All eight hold the role of first responder and were trained emergency medical technicians (EMT) and paramedics. Their overall first responder years of experience ranged from 3 to 20 years (mean of 9.75 years), and their years in their current role at the time of the interview ranged from 2 to 11 years (mean of 5 years). First responders were initially located in two separate firehouses (4:4); however, at the time of the second interview, a first responder from each site was transferred to a different firehouse, making the total number of sites visited four. First responders revealed several features and phenomena; each are presented below using direct quotations from first responders. They discussed their experiences with children differently between the east and west sides of the city. They described children’s reactions to the emergency events as a lack of reaction, an emotion-based reaction, an information-seeking reaction, or an observant reaction. The roles they identified for themselves in emotionally supporting children on the scene were to distract, provide reassurance and promote a sense of calm, and to educate the children about what was happening. Finally, the gaps they identified in current services for children included specialized and dedicated support for children on the scene and effective first responder training.
Life-World Context
Differences between East and West City
During on-site visits and interviews, it became clear there are two distinct areas of the city – the east side and the west side. First responders were interviewed from both areas and in each area, first responders consistently described the divide in the city. First responders described the west side of the city as more “well off” and “mansions and million-dollar incomes,” and the east side as an impoverished population, high on violence and drugs, short of resources, and living in a state of static trauma. Another first responder described this area of the city as “a completely different world…most…of us have never known…me, at ten years old, could never have imagined living in a house that’s falling apart, there’s no heat, no food, trash piled to the ceilings, bugs and stuff all over the walls. I just can’t imagine…It’s the norm here.” Another first responder described responding to a call for an apartment fire and upon arrival, they found an immobile caregiver in one room; with further investigation they then found six children in the back bedroom. The participant said, “I went in the room, and these kids, it was clear they hadn’t been bathed, they hadn’t had diaper changes, and they had dog food in the bed, and it was what they were eating…” This divide in the city was an important context when understanding first responder differences in their experiences with children during emergency events.
While all reactions were noted in each area of the city, socio-cultural contexts became clear through first responders’ experiences. Those working in the east side more often described the phenomena of children having a lack of reactions and observant reactions; whereas, those on the west side more often described emotion-based reactions and information-seeking reactions. On the east side of the city, trauma was assessed to be more a static part of life, and therefore, emergency events were often not appraised by first responders as being traumatic for children. Whereas, on the west side emergency events were often more appraised as traumatic for children and out of the ordinary.
First Responders’ Experiences of Children’s Reactions to the Event
Each first responder described a variety of reactions from children on the scenes of emergency events, either as survivors of the event themselves or as bystanders. These reactions varied greatly from situation to situation; however, four features were apparent from their collective experiences.
Lack of Reactions. First responders often described an absence of reactions from children on the scene of emergency events. These children were described as not even paying attention to the emergency itself. One first responder described the children on the scene of a parental drug overdose as “going about their own business…sucked into their video game…may not have noticed anyone else was even in the house.” Another first responder described in general that “most kids don’t seem to react much to things going on. It seems like they’re normally used to it. It’s like we aren’t even there…more often than not they won’t even look up at us off the TV. It’s just not even interesting.” During a response to care for a mother who was having difficulty breathing, another first responder described six children, ages 1 to 10 years old, as being in the house, and “they really didn’t seem phased by the fact that there were other people in the house or emergency responders, or that we were taking her mom to the hospital, or anything.”
Emotion-based Reactions. Not surprisingly, first responders also discussed common emotional reactions from children in emergency situations. Crying, worrying, screaming, anger, sadness, and guilt were all mentioned numerous times. One first responder described a child’s reactions during an accidental shooting, “The child that pulled the trigger, I just remember him crying and like, you know saying he was sorry and it was, that wasn’t what he meant to do…just uncontrolled weeping…shaking…just overload with adrenaline…just emotion.” Another first responder described responding to an emergency event in which brothers were wrestling and one put the other on a rusty fence post, which then ripped his leg open. The first responder described the sibling responsible as “telling his little brother ‘I’m sorry’… ‘don’t die’” and as being “in a huge worry frenzy…panic, cry, scream.”
Information-seeking Reactions. Other reactions from children discussed by first responders included children seeking answers and information related to what was happening and the status of their loved one(s). In describing a medical response to a mother in critical condition with two children present in the home, the first responder stated that the “kids were very inquisitive of what was going on with mom…one of our guys was taking care of mom and the other guy was telling the kids what was going on, and that we were going to take care of their mom, and answering their questions and stuff like that.” Another first responder discussed a car accident in which a mother was driving, and three children were in the back seat. Upon arrival the mother was dead, and two of the three children were still conscious and stable. The participant recalled, “The little girl asked me…not even asked me, basically told me, you know, is my mom dead?”
Observant Reactions. Other times first responders described children as observing the situation from either near or far. One first responder said, “Kids were all just kind of standing around watching. Not much to say.” Similarly, another first responder described arriving at a heroin overdose scene, and the “kids are just sitting around watching it like it’s Sesame Street or something.” These observant reactions differed from the “lack of reaction” in that these children were attentive to the emergency response unfolding.
Results also revealed that these reactions were experienced disproportionately in each area of the city. For example, one first responder described children’s reactions to an event on the east side:
Me, as a ten-year-old could have never…fathomed someone on my street getting shot, let alone seeing it happen multiple times throughout the summer…could never have thought about or fathomed having a friend who’s been shot…so stepping into that situation you’ve got to almost be aware…this isn’t the thing I’m used to…I mean you can sit there and tell a child ok…this is going to be alright…when in reality they could really give two shits less…because they’re like ‘so and so got shot! I’ve seen people shot before you know’ so you got to approach it differently.
First responders also described this area of the city as having more children out and about unsupervised and that “lots of times the groups of kids are kind of free roaming…even with something like that going on, the parents won’t come check on the groups of kids, they just kind of let them be.” They described when responding to an event, it was common to have children watching in packs on the outskirts. One first responder, in discussing a response to a drug overdose, stated upon their arrival, there were “probably 10,11,12 kids there…all just kind of gathered around watching.” Another first responder stated, “If you are in a poorer place, you’re gonna interact with it [first responders] more, more likely than not because the first responders are more present in their lives, for just general sickness, illness…it’s just a side effect of where they live…whereas if you go to a higher income neighborhood, you’re interacting with them still, but it’s almost differently…you don’t have as much face one-on-one interaction and they don’t deal with someone’s coming to pick up my mother or my little brother…there’s a big difference and I think that’s a major contributor.”
Life-Experience
First Responders’ Roles in the Psychosocial and Emotional Care of Children
When first responders were asked to identify their role with children on the scenes of emergencies, all emphasized their number one priority as patient medical care and scene safety, “situation mitigation…whatever the situation is, to solve it…the top priority is life safety.” Several first responders individually described the same emergency response to a motor vehicle accident on an exit ramp involving four fatalities and six ejected victims. Each of them described their steps in treating the victims, which included five children, four who were unconscious. When the researcher inquired about the fifth child’s emotional response or involvement on the scene, none of the first responders recalled any details about how this child was responding or who was with this child while they were providing patient medical care: “I don’t remember anything about that one.” They each emphasized in various ways that in large critical scenes, such as that, “when you have…a person in that critical need and…chaos brewing…you gotta stay pretty focused on what’s in front of you.”
Despite their number one priority being patient medical care, all first responders described how they supported children, when able, using a variety of techniques and skill sets. Three phenomena became clear regarding how first responders identified their role in supporting children emotionally on the scene: distracting, providing reassurance and promoting a sense of calm, and education.
Distraction. First responders often used distraction as a method to support children on the scenes of emergencies. They discussed using conversation, a TV show or movie, giving them tours of the fire truck, and assigning roles to the children as common modes of distraction utilized on the scenes. One first responder discussed how he tries to “take their mind off of it…talk to them about school…a favorite show…redirect their thoughts of the bad stuff that’s happened.” Another first responder described how he tried to “take the kids out, and let them see the truck, play with the lights and stuff.” Others described how the mode of distraction depended on the situation and if the children were comfortable separating from the victim/their loved one or not. One participant said, “It just depends on the situation. Or you keep them busy. Give them a task that they believe might be important…you tell them that you might need a blanket. If they get you a blanket, tell them to get you a pillow…keep them busy, move them around.”
Calming and Reassurance. Many times, first responders discussed how they try to calm children down on the scene of emergency events by providing reassurance. They described how when they are confident things are going to be okay, they try to let children know that. However, if they are unsure, they often will give simple information “but not a conclusion…we are going to take them to the hospital immediately…we are doing this…we’re helping…” One first responder described how he tries to calm and reassure children. He said, “I always kneel down next to them, and [say],‘Hey listen. I promise we are going to take very good care of her. Your mom’s sick, but we’re going to take good care of her. We’ll bring her back here to you. She’s going to feel much better.’”
Education. First responders often described helping children understand what was going on and answering their questions as a way of providing support to children during emergency events. One first responder described how he tries to “get them to understand a little bit better what’s going on.” Another first responder remembers “telling the kids what was going on and that we were going to take care of their mom, and answering their questions…” Another first responder recalled avoiding answering more difficult questions posed, specifically during a response to a fatal car accident involving three children and two adults. After extricating the survivors out of the car “the little girl asked me…‘is my mom dead?’…you know, what do you say to that? Especially you can tell she knows…it’s not like the little kids who you can distract them from that…she’s old enough to know what was going on…I knew the answer to the question. I would avoid answering it if it was an adult asking, let alone a kid.”
Although not an aim of this study, it became clear that first responders’ emotional reactions are important to consider in these situations as well. One first responder described how “my heart was breaking for the kids…I wish I could just adopt these kids…it’s hard for me to realize that it wasn’t an isolated event…which was pretty upsetting.” Another first responder recalled arriving to a call for a three-year-old who was unconscious, barely had a pulse, and “the kid had been down for so long, he was pretty much brain dead…the worst part about that call was that there were probably about 11 people in that house and nobody knew what happened to this kid…that still upsets me because we come to find out the kid ended up dying.”
Gaps in Current Services
First responders were asked to describe what would have been helpful or what resources they need to support children affected by these emergency events. They identified two gaps: 1) the need for readily available support for children from professionals trained in working with children, and 2) additional training for first responders to best work with children on the scene of emergency events.
Specialized and Dedicated Support. Numerous times first responders described situations in which support for children was lacking; most often, this occurred during critical situations when medical care took priority. First responders often discussed being unable to identify who or if anyone was supporting the children who were less critical or bystanders to the incident. One participant said, “I really don’t remember just the bystanders of situations. I don’t necessarily have tunnel vision, but those things go out of my head pretty fast. I remember the patients, never, not necessarily ever the scenes.” Other times, first responders described caregivers or neighbors as being oblivious to the children needing support. For example, one participant recalled how “…the family is concerned about the patient, who is in distress or critically injured…not realizing there is a three-year-old over their shoulder watching.” An example of the specialized and dedicated support desired by first responders was described as “a social worker in the car following us to the call…someone…who specializes in taking care of kids to help them right away. Not when they get to the hospital, right away…a little police car looking thing driving behind the fire truck, it would be great!” Another first responder said that “I think if there was already a social worker…someone else there with us, it would just be better.”
Effective First Responder Training. Most of the first responders included in this study described feeling somewhat confident with how to support children on the scene. When the researcher inquired how these skills were gained, all described learning these skills organically on the job by modeling more experienced first responders. One participant said, “You kind of zone in on, gosh, that looks horrible, I don’t know what I would say there…but then you’re also observing and picking up on okay that’s how, that’s how to do it and then you put it in your pocket of tools…” Others described gaining these skills based on previous experiences with children (either their own child(ren) or in other settings). One first responder described gaining these skills through mimicking others in the field and how having children as first responders helps and said, “I’m sure in a chapter in a book in this room somewhere…bedside manner, that’s what it comes down to, which I did not have. I had to look at other successful people and what they were doing, mimic them and what they were doing and then…having kids helps.” Another first responder described his knowledge of working with children during emergencies coming from his previous experience working at a children’s hospital for six years. He said, “Most of it’s just been from…I guess from Children’s, learning it there, and bringing it out to the street…I had it down pat…I knew how to do it.” Of those first responders in this group, no one described formal training as being effective in teaching them these skill sets. One participant recalled how “…they talk about it in EMT school, like those stages of stuff like that…they don’t teach you how to look at them and understand what’s going on. You know, there’s a little bit, but not enough.” One first responder even pulled a book off the shelf in the interview room that had a chapter on working with children but described its ineffectiveness in how that small chapter did not result in skills gained on the scenes with children. Some even described having not received any formal training regarding working with children aside from medical training. For example, one participant said, “As far as emotional support…I don’t know if I’ve ever had a class or had anything offered to me specifically for emotional support on the scene…not for children anyways.”
Most first responders in this study reported being confident working with children though several reflected on how earlier in their careers, they were not particularly skilled or lacked confidence working with children. Other recalled specific scenarios that were more challenging for them when working with children, and some described colleagues lacking the skills needed to work with kids. When these first responders were asked what would have helped them gain this confidence and skill set, they described more experience and formal training. One participant explained:
Formal training would be extremely helpful…As far as focusing on children, in training one thing we need to…emphasize in training, we’ve gotta make sure that someone is there to focus on the children…a lot of times you’ll go to a scene and for example, shootings, you’ve got one, even multiple shooting victims, everybody wants to go towards that. If it’s one person with one bullet hole, you’ve got six people trying to help one person…obviously if there’s ten people shot and there is five of you, you got to do what you gotta do. But, if there’s the resources and personnel…then training needs to say ‘hey, you’ve got to make sure one person has to take the children to the room…’ Everybody wants to get in on the action a lot of time, and some of the people just forget about…they look at what is right there in front of them and they forget about everything that is surrounding…
First responders also described a desire for training for more challenging situations, for example, when children are asking difficult questions such as “is my mom dead?” or involving children with developmental delays. When recalling a time when responding to a scene where a mother tried to overdose to commit suicide and there was a young child with a developmental delay, one first responder said, “You try to talk to her…she just looks at you with a blank stare…you try to do little tricks to kind of keep her happy…she didn’t quite understand…I think we tried to pull out…every trick…between all of us, everybody tried.” Another first responder remembered a child asking if her mother was dead “and like all the blood and gore never has bothered me, but that, like I just…what the hell do you say?” When the interviewer asked what might have helped in these situations, while some said “nothing,” others described wanting better training on what to say and do in these situations. For example, one participant said, “Training is always a good thing in general from people with different backgrounds…from people who know the path to take.” When further prompted about what type of training would be most effective, first responders described training that is hands-on and specific. Other first responders described the plethora of online-format classes they are "bombarded with’’ and how “personal classroom training” might be a more effective format to utilize.
When asked what resources would help children involved in emergency events, first responders in the east side described broad community-based resources such as more social workers and division of family services resources and better access to food. One first responder discussed how “a lot of those kids don’t know that there’s other opportunities out there…they idolize gang bangers…drug dealers…they idolize the people in their neighborhoods.” He went on to say, “You know, join the military…you don’t see recruiting offices in east city…so a lot of those kids probably…don’t know that there’s other opportunities out there.” Another first responder working on the east side responded “There’s a lot of resources in this area specifically, being impoverished, that I think could be used, but you’d have to put a social worker in every residence…explain to the parents…you have the ability to give your kid a bed to sleep in…to feed your kids healthier food…” Whereas, first responders working on the west side identified resources used when working with children during emergency events such as “stuffed animals…some departments have stickers…I can guarantee there’s none in this engine house right now” and “we need to do a program of some sort…something almost to teach some of the guys how to deal with kids, like the redirection…breaking it down for them.” Therefore, resources desired from first responders differed based on location.
Discussion
This study explored first responders’ experiences during emergency events with children, their perceived roles in providing support, and their needs to best mitigate the traumatic effects on children and families. First responders experienced a range of reactions from children during these events. Despite their efforts to distract, calm, reassure, and educate in those moments, they identified a need for additional training and specialized, dedicated team members that could support the developmental and psychosocial needs of these children during responses.
First Responders’ Perceptions of Children’s Reactions to the Event
Focusing on first responders’ descriptions of children’s reactions to the emergency event provides necessary insight to understand the needs of children and first responders during these events. Using a trauma-informed perspective, the observant reactions might be most concerning as these children are often not included as victims or survivors of an event needing support but are experiencing trauma exposure through the sensory experience of observation. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) defines trauma exposure as inclusive of both witnessing an event and vicarious exposure through close friends or family members (American Psychiatric Association, 2022). There is also a dose-response relationship between exposure and the traumatic effects on individuals. Therefore, this observation with little support could be one of the most detrimental for children (Furr et al., 2010; Pfefferbaum, Jacobs, Griffin, et al., 2015).
Several times during interviews, first responders also described their own emotional reactions in relation to emergency events involving children. Their ideas of additional training, which would presumably increase feelings of competence, could potentially have an impact on both the first responder’s and children’s mental health. Stamm (2010) found that first responders are more likely to experience compassion satisfaction when they feel effective in making a difference in individuals and the community they served. In addition, training may have an important influence on how first responders cope with their daily work. Existing studies also suggest that fewer negative psychological outcomes are prevalent among first responders who were trained when compared to those who are volunteer first responders (Perrin et al., 2007).
Roles of First Responders
First responders described how they support children during emergency events by providing distraction, reassurance, and education and promoting a sense of calm. While some first responders seemed to think distraction was the best way to support children, others felt distraction was not always what the children needed. Some children cope best with more information (i.e., active), while others cope best with less information (i.e., passive). Distraction might be most effective for those who seek less information, while distraction for those seeking more information might be more stress-inducing (Lazarus & Folkman, 1984). Therefore, providing more information related to what they are doing to help and statements aimed at supporting and reassuring children might be most effective (Goldberger et al., 2018).
Gaps in Services
It became clear that first responders’ top priorities are medical care and safety. First responders noted the need for dedicated and specialized team members to assist as well as the desire for more training to support children during emergency events.
The Need for Dedicated and Specialized Support
First responders described their organic competency building in providing psychosocial support to children on the scene but also recognized that other professionals are trained for this role and do this on a regular basis (e.g., social workers). Therefore, these types of professionals would likely be more effective in mitigating any potential trauma experienced by children than first responders. First responders described a desire to have a social worker present with them on the scene and someone there to support prior to arriving at the hospital. Emergencies involving children are unpredictable; logistically, there would be challenges to integrating dedicated support and having it readily available when and where it is needed. Some of the challenges include the availability of trained professionals in rural areas and chronic underfunding for psychosocial and mental health services (McDaid & Park, 2011).
Training for First Responders
In some cases, first responder descriptions were well-aligned with evidence-based practices for trauma-informed care and psychological first aid (SAMHSA, 2014; World Health Organization, 2011). Other times, the first responders did not follow these practices. For example, one first responder reported not answering the child’s question regarding if her mom was dead when it was evident the child already knew the answer. First responders have identified a desire for more effective training in responding to children’s needs during emergency events (Papazoglou, 2023). Given the known vulnerability of children and the potential for long-term detrimental effects, it is important that further education and training is provided to first responders to help them respond most effectively in these situations (Sharma & Khatiwada, 2023).
Implications for Child Life
Certified Child Life Specialists (CCLS) are trained professionals who focus on the coping and developmental needs of children and families. They “promote and protect emotional safety in times of duress” which “minimizes both the immediate and long-term effects of stress, anxiety, and psychosocial trauma” (Association of Child Life Professionals, 2024, para 2). First responders identified various reactions by children in different parts of the city. This finding indicates that psychosocial support services need to be adapted to individuals, especially taking into context their life experiences and own personal assessment of an event being traumatic. Therefore, specialized services must be directed and individualized to the specific needs of the various individuals being served; services supporting each of these groups would need to take into account the personal appraisal of trauma for each individual. It would also be imperative that trained professionals collaborate with other supportive services to provide comprehensive services when needs became apparent that require multiple specialties and are outside of the scope of any one profession. For example, a CCLS could provide the necessary psychosocial support on the scene or after the event if admitted to the hospital. However, if a child needed to be placed in the legal care of someone, this need would be best supported by a social worker.
First responders also identified child reactions on the scene and described bystanders and observers often. It is critical that all children, both directly and indirectly affected, receive preventative services to promote coping and mitigate these events as being appraised as traumatic. While sending a CCLS out directly would be ideal, there are potential barriers to providing this type of specialized and dedicated support that would need to be overcome. First and foremost, if this was an integrated emergency service, there likely would be financial barriers due to chronic underfunding of mental health and psychosocial services (Hollander & Vliet, 2022). Logistically, it would also be necessary to have someone who is readily available and promptly able to respond to emergency calls, much like the first responders. If this was a service integrated as more of a partnership or on-call service, more flexibility might be gained by being able to leverage external funding not available to city services. However, in this case the direct referrals would solely rely on the assessment by the fire administrator (e.g., Fire Captain or Chief) on the scene. Thus, the referral would likely be called in once time allowed, and a CCLS would provide services post-event versus on the scene during an event. Providing education to first responder administration on services available for children who are at greater risk for experiencing an emergency events’ traumatic effects would be essential for any new resource in the community. In addition, new resources would need to be connected through the appropriate channels to “Fire Alarm” who would essentially dispatch this specialized and dedicated service for children to the scene.
CCLS have the knowledge and expertise required to assist in more effective training for first responders working with children. Simplifying this training to include basic methods of providing “Psychological First Aid” (PFA) to include establishing contact, addressing basic needs, protecting from further harm/exposure, listening, providing reassurance and education, assisting with coping and problem solving, and connecting to other systems of support would be most crucial (North & Pfefferbaum, 2013). This training would also validate first responders’ current use of PFA strategies (e.g., limiting exposure by “scooting out” children and assisting in trying to calm children and provide reassurance). Emphasizing the importance of supporting emotional reactions (not suppressing), validating and addressing fears expressed, and answering questions in a developmentally appropriate way would need to be an essential part of this education. These are specific competencies of the CCLS that go above and beyond the expertise of other organizations currently providing PFA training opportunities (e.g., American Red Cross). Specifically, being trained to best evaluate the children’s coping needs and motivation behind children’s questions would be critical. Formatting the training in a way that is effective in skill-building not just knowledge-building is important to consider. Using relevant case studies provided by first responders would be useful to dissect real-life scenarios recently experienced. In addition, follow-up support and education would be beneficial to keep knowledge and skills fresh throughout the year.
Finally, understanding first responders’ experiences with children during emergency events is useful to a CCLS’s assessments upon children’s arrival to the hospital. Understanding child reactions as these events are taking place and first responder support already provided on the scene and in route benefits the continuity of care and assessment for ongoing psychosocial interventions needed upon the child’s arrival to the hospital.
Limitations
There were several limitations to this study. First, there was a limited number of participants and limited demographic data were gathered on each (e.g., no participant age or race). In addition, data were only gathered from one setting of first responders, the fire department, which included those trained as emergency medical technicians, paramedics, and firefighters. Future research should evaluate whether there are demographic differences such as age, race, gender, specific first responder role, and setting. Given the differences between first responders’ experiences in east and west city, these data would assist in gathering a better understanding of the mechanisms behind those differences between east and west city to inform best interventions and support. It is also important to recognize that the authors’ worldviews and professional lens, both in disaster relief and child life, inherently shaped this study. Future research should engage multiple researchers in data analysis to increase validity and reliability.
Conclusion
First responders play a critical role in the psychosocial and emotional care of children during emergency events and experience a range of reactions from children. They provide psychosocial support to children, when able, using distraction, reassurance, education, and promoting a sense of calm. First responders identified gaps in services including a need for dedicated support to focus on the children’s emotional needs during events requiring emergency response and more effective training in working with children. Training and education related to supporting the psychosocial and emotional needs of children is imperative to mitigate the potential long-lasting traumatic effects of these events. Training must also include socio-cultural contexts to best support children in various environments. Further, a dedicated and trained psychosocial professional to provide support may be necessary to focus on these needs during events that require more intensive medical treatment by first responders. CCLS hold the competencies needed to effectively support children and families during and immediately following emergency events and provide the additional training described.
Disclosure of Interest
The author reports no conflict of interest.