Terrorism—a planned, often politically motivated event designed to kill many innocent victims and inflict physical pain, psychological suffering, and fear on an entire community—is new to our Western culture, but not to children worldwide. Terrorism, violence, and disaster have involved children in the form of naturally occurring events; transportation accidents; exposure to war; social, ethnic and religious conflict; and as collateral damage in adult mass casualty incidents. Throughout childhood and adolescence, children are physically less capable and emotionally more vulnerable to the effects of terrorism. This fact may make children likely primary targets for terrorism in the future. Children are unique from the perspective of their anatomy, physiology, emotional development, and response to specific physical and psychological insults. These unique needs of children have rarely been considered in disaster planning. Civilian emergency physicians and Emergency Medical Services (EMS) systems have learned about mass casualty incidents through military models, focused on the needs of adult victims; consequently, they have limited personal clinical experience with pediatric disaster medicine. A terrorist attack with predominately pediatric casualties would have a tremendous and far-reaching impact on all child survivors, family members, and the community at large. All facets of the EMS system must be aware of this potential and be prepared to meet the special and divergent needs of children in the setting of a chemical, biological, radiation, or explosive event that involves large numbers of children. A paradigm shift that deals with unaddressed issues of treatment, equipment, triage, and training is a critical step in preparing to address the needs of children in the midst of terrorism.