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Jennifer Stuber, PhD Sandro Galea, MD, MPH Betty Pfefferbaum, MD, JD Alan R. Fleischman, MD

Access to and Need for Counseling Among Children after the September 11 th Attacks on the World Trade Center. Gerry Fairbrother, PhD New York Academy of Medicine. Jennifer Stuber, PhD Sandro Galea, MD, MPH Betty Pfefferbaum, MD, JD Alan R. Fleischman, MD. Presentation to the

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Jennifer Stuber, PhD Sandro Galea, MD, MPH Betty Pfefferbaum, MD, JD Alan R. Fleischman, MD

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  1. Access to and Need for Counseling Among Children after the September 11th Attacks on the World Trade Center Gerry Fairbrother, PhD New York Academy of Medicine Jennifer Stuber, PhD Sandro Galea, MD, MPH Betty Pfefferbaum, MD, JD Alan R. Fleischman, MD Presentation to the 2003 Pediatric Academic Societies Annual Meeting May 3-6, 2003 Seattle, WA This research was supported by grants from the National Institute of Mental Health (MH66385 and RO1 MH66081-01) and the William T. Grant Foundation.

  2. Background • 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

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

  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 11th attacks)

  5. Instrument Assessed • Behavior Problems • Counseling Received • Crying in Front of Child • Disaster Exposure • Gender • Race/Ethnicity • Children • Disaster Exposure • PTSR • Parents • PTSD • Depression • Demographic Information • Family Structure • Income • Borough of Residence

  6. Children’s Disaster Exposure/Experiences

  7. Most Children Were in School or Day Care at Time of Attacks and Learned About Them From a Teacher % Yes 100% 90% 80% 70% 60% 50% 91% 40% 64% 30% 20% 22% 10% 14% 9% 0% 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 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.

  8. % Yes Few Children Saw the Disaster in Person, But Almost All Saw Vivid Images on TV In Person On Television 100% 90% 80% 70% 60% 50% 87% 87% 86% 40% 30% 48% 20% 10% 8% 0% Saw Disaster In Person Saw Building Collapsing Saw Airplane Hitting the Building Saw People Running From a Cloud of Smoke/Debris Saw People Falling or Jumping From Towers 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.

  9. Severe 15% Moderate 66% Very Severe 3% Doubtful or Mild 16% 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.

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

  11. Moderate PTSR 50% Mild or Doubtful PTSR 90% No Counseling 3% 10% Counseling 47% Severe/Very Severe PTSR 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.

  12. % Receiving Counseling 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.

  13. Counseling after 9/11 Yes Yes No No 7% 38% 27% 6% 0% 10% 20% 30% 40% Having Counseling Before 9/11 and Severe/Very Severe PTSR were Major Predictors of Counseling After 9/11 Counseling before 9/11 *** Severe/Very Severe PTSR *** *** p< .001

  14. Parental PTSD since 9/11 0.79 0.69 Crying in Front of Child 1.60 0.26 Relative or friend killed 3.02 0.02 Multivariate Model Showing Relationships between Receipt of Mental Health Services and Covariates of Interest Adjusted Odds Ratios and 95% Confidence Intervals (n = 434) Odds Ratio (Adjusted) Odds Ratio (Adjusted) p-value p-value Child and Family Demographic Characteristics Child's Mental Health Experiences Before Disaster Black, Hispanic and Other 3.59 0.020 Received counseling before September 11 Single-parent household 4.44 0.005 1.87 0.13 Parent's Reaction to/ Experience with the Disaster Child's Post-Traumatic Stress After Disaster Child's PTSR is severe or very severe 3.59 0.002 Model adjusted for borough of residence

  15. 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

  16. 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

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