1. Access to and Need for Counseling Among Children after the September 11 th 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 the 2003 Pediatric Academic Societies Annual Meeting May 3-6, 2003 Seattle, WA Gerry Fairbrother, PhD New York Academy of Medicine

2. 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 11 th offers lessons for the future about service provision Background

3. To describe children’s need for and receipt of counseling after September 11 th To describe sources of counseling To determine predictors of counseling Objectives

4. 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 11 th attacks)

5. 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

8. Children’s Disaster Exposure/Experiences

9. 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%

10. 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 PersonOn Television 8% 86% 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

11. 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%

12. 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. 90% No Counseling 10% Counseling School Psychologist or Counselor Teacher Religious Leader or Unspecified Mental Health Professional Outside of School

13. 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

14. 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 Percent Receiving Counseling 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

15. 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 ***

16. 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 Disaster Parental PTSD since 9/11 0.790.69 Crying in Front of Child 1.600.26 3.02 Relative or friend killed 0.02 Received counseling before September 11 4.440.005 Child's PTSR is severe or very severe 3.590.002 Odds Ratio (Adjusted) p-value Child's Mental Health Experiences Before Disaster Child and Family Demographic Characteristics Black, Hispanic and Other 3.590.020 Single-parent household 1.870.13

17. 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

18. 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