Access to and Need for Counseling Among Children after the September

11th Attacks on the World Trade Center

Jennifer Stuber, PhD

Sandro Galea, MD, MPH

Betty Pfefferbaum, MD, JD

Alan R. Fleischman, MD This research was supported by grants from the National Institute of Mental Health (MH66385 and RO1 MH66081-01) and the William T. Grant Foundation.

Presentation to the2003 Pediatric Academic Societies

Annual MeetingMay 3-6, 2003Seattle, WA

Gerry Fairbrother, PhD New York Academy of Medicine

Children often need mental health support after a traumatic event

But children’s access to services depends on– Availability of services– Ability of adults to recognize need– Ability of adults to find the service– Often, ability to pay

The experience of September 11th offers lessons for the future about service provision

Background

To describe children’s need for and receipt of counseling after September 11th

To describe sources of counseling

To determine predictors of counseling

Objectives

Methods

Cross-sectional Random Digit Dial survey

Population-based in New York City

2,011 respondents of whom 434 were parents of children 4-17 years old

60% cooperation rate

Conducted January, 2003 (four months after the September 11th attacks)

Instrument Assessed

Children•Disaster Exposure•PTSR

Parents•PTSD•Depression

Demographic Information•Family Structure•Income•Borough of Residence

•Behavior Problems•Counseling Received

•Crying in Front of Child•Disaster Exposure

•Gender•Race/Ethnicity

Children’s Disaster Exposure/Experiences

22%14%

Most Children Were in School or Day Care at Time of Attacks and Learned About Them From a Teacher

Source: Fairbrother G, Stuber JP, Galea S, Fleishman AR, Pfefferbaum B. (2003) Post-Traumatic Stress Reaction in New York City Children after the September 11th Terrorist Attacks. Report to the W.T. Grant Foundation. New York Academy of Medicine. New York City.

91%64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Were at Home at Time of Attack

Were at School/Day Care at Time

of Attack

Learned From

Parent

Learned From

Teacher

Learned From Other

Source

% Yes

9%

Few Children Saw the Disaster in Person, But Almost All Saw Vivid Images on TV

Source: Fairbrother G, Stuber JP, Galea S, Fleishman AR, Pfefferbaum B. (2003) Post-Traumatic Stress Reaction in New York City Children after the September 11th Terrorist Attacks. Report to the W.T. Grant Foundation. New York Academy of Medicine. New York City.

In Person On Television

8%

86% 87% 87%

48%

0%10%20%

30%40%50%60%

70%80%90%

100%

Saw Disaster In Person

Saw Airplane Hitting the Building

Saw Building Collapsing

Saw People Running From

a Cloud of Smoke/Debris

Saw People Falling or

Jumping From Towers

% Yes

Approximately 18% of New York City Children had Severe or Very Severe Post-Traumatic Stress Reactions (PTSR) Following the September 11th Attacks

Source: Fairbrother G, Stuber JP, Galea S, Fleishman AR, Pfefferbaum B. (2003) Post-Traumatic Stress Reaction in New York City Children after the September 11th Terrorist Attacks. Report to the W.T. Grant Foundation. New York Academy of Medicine. New York City.

Doubtful or Mild 16%

Moderate 66%

Severe 15%

Very Severe 3%

Approximately 10% of New York City Children Received Some Type of Counseling following the September 11th Attacks, Over Half in the Schools

Source: Fairbrother G, Stuber JP, Galea S, Fleishman AR, Pfefferbaum B. (2003) Use of Counseling Services by Children in New York City Following the September 11th Attacks on the World Trade Center Report to the W.T. Grant Foundation. New York Academy of Medicine. New York City.

20% 14%

30%36%

90% No Counseling 10% Counseling

School Psychologist or

Counselor

TeacherReligious Leader or

Unspecified

Mental Health Professional Outside of School

Counseling Services after September 11th Divided Fairly Evenly between Children with Severe/Very Severe PTSR and Children with Moderate PTSR

Source: Fairbrother G, Stuber JP, Galea S, Fleishman AR, Pfefferbaum B. (2003) Use of Counseling Services by Children in New York City Following the September 11th Attacks on the World Trade Center Report to the W.T. Grant Foundation. New York Academy of Medicine. New York City.

90% No Counseling 10% Counseling

Moderate PTSR

Severe/Very Severe PTSR

50%

47%

3%

Mild or Doubtful

PTSR

Only 27% of Children with Severe/Very Severe PTSR Received Any Type of Mental Health Services, and Only 14% of Those With Behavior Problems Did

14% 27%

0%

10%

20%

30%

Severe/Very SeverePTSR

Behavior ProblemsPer

cen

t R

ecei

vin

g

Co

un

seli

ng

Source: Fairbrother G, Stuber JP, Galea S, Fleishman AR, Pfefferbaum B. (2003) Use of Counseling Services by Children in New York City Following the September 11th Attacks on the World Trade Center Report to the W.T. Grant Foundation. New York Academy of Medicine. New York City.

% Receiving Counseling

Having Counseling Before 9/11 and Severe/Very Severe PTSR were Major Predictors of Counseling After 9/11

Counseling after 9/11

*** p< .001

Yes

No

Counseling before 9/11 7%

38%

6%

27%

0% 10% 20% 30% 40%

Severe/Very Severe PTSR

Yes

No

***

***

Multivariate Model Showing Relationships between Receipt of Mental Health Services and Covariates of Interest Adjusted Odds Ratios and 95% Confidence Intervals (n = 434)

Model adjusted for borough of residence

Child's Post-Traumatic Stress After Disaster

Odds Ratio(Adjusted) p-value

Parent's Reaction to/ Experience with the DisasterParental PTSD since 9/11 0.79 0.69

Crying in Front of Child 1.60 0.26

3.02Relative or friend killed 0.02

Received counseling before September 11 4.44 0.005

Child's PTSR is severe or very severe 3.59 0.002

Odds Ratio(Adjusted) p-value

Child's Mental Health Experiences Before Disaster

Child and Family Demographic CharacteristicsBlack, Hispanic and Other 3.59 0.020

Single-parent household 1.87 0.13

Limitations

We could not describe the intensity of mental health services

We relied on parental report for both counseling services and PTSR for children

We did not measure functional impairment as a result of PTSR, instead we relied on presence of PTSR to indicate need

Conclusions

There was a substantial disparity between apparent need (PTSR) and receipt of counseling services

There is a need for enhanced effort to identify, refer, and treat children in need

This need is particularly acute for children not already in a therapeutic relationship

An enhanced role for pediatricians is indicated