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* Mount Sinai School of Medicine, New York, New York
American Academy of Pediatrics, District II, NY Chapter 3, New York, New York
New York Academy of Medicine, New York, New York
|| American Academy of Pediatrics, District II, NY Chapter 2, New York, New York
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Methods. One year after the September 11th disaster, a hyperlink to a web-based 42-item survey was sent to all New York, Connecticut, and New Jersey American Academy of Pediatrics members with e-mail addresses (N = 4330), and a paper version of the survey was sent via postal mail to a random sample of those without e-mail (N = 1320). The survey requested demographic data, personal and practice experience of 9/11, perceived knowledge and skills regarding mental health, and perceived barriers to accessing mental health services for their patients. Both groups were contacted a total of 3 times at 2-week intervals, resulting in 1396 completed surveys from providers who were actively seeing patients.
Results. Twenty-nine percent of respondents stated that they were seeing affected patients, and 32.6% reported seeing children who were exposed to at least 1 9/11 event. Sixty-four percent of the respondents identified behavioral problems in directly affected children: 41.6% identified acute stress disorder, and 26.3% identified posttraumatic stress disorder (PTSD). However, a majority of these professionals indicated that they either lacked or were uncertain (50.8% PTSD, 51.7% acute stress disorder) of their skills to identify children with mental health problems and that they were "not" or only "somewhat" knowledgeable (76.8% PTSD) in these areas. The majority agreed that child health professionals should be trained to screen for these 2 disorders. Generalists as compared with specialists were more likely to report seeing patients who were affected by 9/11. Gender, race/ethnicity, and geographic location were associated with reported effects of 9/11 on respondents' practice and perceived skills and knowledge related to the psychological effects of community disasters.
Conclusions. Pediatric practitioners in the tristate area reported that children/families sought care for an array of mental health–related concerns. Generalists in the areas affected and those who identified gaps in knowledge or skills in responding to the psychological effects of community disasters should be targeted for additional education.
Key Words: children • mental health • acute stress disorder • posttraumatic stress disorder • depression • bioterrorism • environmental health • toxins
Abbreviations: AAP, American Academy of Pediatrics • ASD, acute stress disorder • PTSD, posttraumatic stress disorder • WTC, World Trade Center • WTCD, World Trade Center Disaster • OR, odds ratio • CI, confidence interval
The terrorists' attacks of September 11, 2001, resulted in mass destruction in Lower Manhattan areas. Health professionals and families across the tristate area of New York, Connecticut, and New Jersey witnessed the events. Many children were left bereaved, directly witnessed the attacks, feared for their lives (or the lives of loved ones), or were displaced from their homes and schools, and millions witnessed these events repeatedly on television.
Since September 11th, a number of studies have reported the effects of these events on adults' and children's mental health, the change in health care services utilization, and parental reactions to the attacks.1–8 However, to date, no study has examined the impact of these events on child health professionals and their readiness to meet the needs of children and families in the future.
Most pediatricians today are aware of the term "new morbidity" coined by Haggerty in the 1970s to reflect the changing child morbidity and mortality represented by an increase in child health–related problems associated with emotional, social, economic, and demographic factors.9–13 In addition, most clinicians are aware that violence-related injuries (eg, homicide, suicide) are now among the leading causes of death and disability for children through young adulthood.14 The past 3 decades saw an increase in the identification of psychosocial problems presenting in the primary care setting.15 Nonetheless, surveys and clinical experience pointed to physician acknowledgment of their lack of skills in the realms of biopsychosocial care.16
Given the magnitude of the events of 9/11, we believed that primary care professionals would see a broad population of affected children. We believed that surveying these professionals would help to identify the challenges that they faced in responding to the acute and long-term needs of children and their families and hypothesized that they would report gaps in their knowledge and skills in recognizing and managing a range of trauma-related child mental health problems.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Survey Instrument Development
On December 3, 2001, in response to the calls of pediatricians in the area, the AAP, NY Chapter 3, in collaboration with the New York Academy of Medicine, hosted a half-day conference covering the topics of mental health, environmental health, and bioterrorism related to September 11th. The summary and recommendations from this conference suggested that area practices were affected and that there was a need for additional professional training, medical education, support services and patient education related to children's mental health services. These results formed the basis for the development of a research collaboration among the AAP, the New York Academy of Medicine, and Mount Sinai School of Medicine that brought together pediatricians, child psychologists, and health services researchers to conduct this regional post-9/11 survey.
The 42-item pilot survey detailed demographic information, personal and practice experience with 9/11, perceived knowledge and skills, perceived barriers to delivery of mental health services, and reports of collaborative models of care. Respondents were also asked whether they had identified any children with behavioral problems related to 9/11, acute stress disorder (ASD), or posttraumatic stress disorder (PTSD) and whether they perceived any barriers to accessing mental health services, as well as to provide key medical demographic information. The rationale for this study was that a pilot survey detailing the characteristics of the physicians whose practices were most affected by these events might help elucidate how best to intervene to support physicians in the detection and treatment of children's psychological distress after a disaster.
Independent Variables
Our analyses included 3 demographic variables and 6 practitioner characteristics. Demographic variables included gender, age, and race/ethnicity (Table 2). Age was collapsed into 5 categories: <35, 35 to 44, 45 to 54, 55 to 64, and 65 to 74 years of age. Race/ethnicity was coded into 6 categories: white, Asian, African-American, Hispanic/Latino, Native American, and other (write-in). For some analyses, groups represented by <5% of the total sample were collapsed into the race/ethnicity category of "other." The practitioner variables included practice location, specialty, years in practice, and practice setting (Table 2). Location was based on 2 distinct variables: 1) the AAP chapter to which the practitioner belonged (NY 1: counties north of Dutchess; NY 2: Queens, Brooklyn, Nassau County, and Suffolk County; NY 3: Staten Island, Manhattan, Bronx, and counties south of Dutchess, including Dutchess County; New Jersey; and Connecticut) and 2) practice location as defined by zones based on proximity to the World Trade Center (WTC) site and assigned by first listed zip code of practice reported in the survey. These were then collapsed into 6 areas: Manhattan, the other 4 NYC boroughs, NY Downstate (10 lower counties exclusive of NYC), NY Upstate, Connecticut, and New Jersey. The practitioner's specialty was coded as being in general pediatrics, pediatric subspecialty, or residency training. Years in practice included 5 years or less, 6 to 10 years, 11 to 20 years, 21 to 30 years, and >30 years. The variable for primary setting of practice included community hospital, university hospital, private practice, and "other" settings. Finally, the degree to which practitioners felt personally affected by the events of 9/11, "within the first week" and "currently" were used as explanatory variables and assessed using a Likert-type scale (not affected to very affected, 1-10). These responses were then dichotomized into "not affected" versus "very affected" on the basis of a distributional analysis (a score of >8 for first week and >7 for currently = very affected). Survey modality (e-mail vs mail) was used as a control variable in our multivariate analyses.
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Effect of 9/11 on Practice
Two indicators of the direct influence of the attacks on patients were whether pediatricians were seeing patients who were affected by 9/11 and whether they were seeing children who had directly witnessed the events of 9/11, lost a parent (or parents), lost a guardian, lost a family member, lost a close friend, knew someone who died, were displaced from home, or were displaced from school. We also examined 2 outcomes related to whether respondents had a mental health provider as part of their practice before the attacks and whether they would allow a mental health provider to be part of their practice after the WTC disaster (WTCD; coded as no/uncertain vs yes).
Knowledge and Skills
Seven items measured knowledge about issues related to the WTCD. The items were factor analyzed into 2 scales, 1 of which reflected psychological problems. Knowledge about psychological problems (Likert-type scale 1-4, not knowledgeable to very knowledgeable) was the average of 3 items regarding posttraumatic stress, death/dying, and bereavement. Cronbach 
for this scale was .77, with the scale divided into low knowledge (score 0-2.0) versus high knowledge (score of 2.1-4.0), based on a distributional analysis of respondents' scores.
Respondents were also asked to assess whether they had skills regarding ASD, PTSD, depression, and bereavement counseling. Lack of skills to detect mental health problems in patients was the sum of the 4 items ( = .76) with a score of 1 to 8 coded as lacking skills and 9 to 12 having skills, again, based on a distributional analysis of respondents' scores. Finally, respondents were asked whether they would be willing to obtain additional training to screen or treat children with ASD, PTSD, or depression (yes/no/uncertain).
This project was approved by the Institutional Review Boards of the Mount Sinai School of Medicine and the New York Academy of Medicine on July 13, 2002, and June 25, 2002, respectively. Waiver of signed consent was granted by both Institutional Review Boards.
Statistical Analysis
All analyses were conducted using SPSS (SPSS, Inc, Chicago, IL) and data weighed by a case weight developed on the basis of the sampling fraction of the e-mail and mail survey results. Our analyses focused on 2 questions: What were the effects of 9/11 on the respondents' practice? What were the factors associated with respondents' perceived skills and knowledge related to community disasters? As discussed, scales were developed for skills and knowledge about mental health. 
2 test was used to determine the bivariate associations between independent variables and the effect of the WTCD on respondents' practices, and the associations between independent variables and the respondents' perceived skills and knowledge about the psychological effects of community disasters. Multiple logistic regressions with odds ratios (OR) and 95% confidence intervals (CIs) were calculated for the effect of independent variables on respondents' practice (as measured by the 4 outcome variables detailed above) and perceived knowledge and skills regarding mental health issues. In addition, multiple logistic regressions examined the effect of the independent variables on willingness to obtain training to screen and/or treat children with ASD, PTSD, and/or depression. We also tested for interactions among the variables in terms of age, gender, race, and practice location.
Nonresponse Analysis
Using cross-tabulations, we compared the differences in survey response by age, gender, region, and membership status (candidate fellow, fellow, other) among our final weighted sample of eligible survey participants and found few differences compared with the overall AAP membership sample and eligible survey nonparticipants. For example, in most cases, we found less than a 2% to 3% difference between these 2 groups (responders vs nonresponders) on the different variable categories examined. The one exception was for the NY 1 Chapter of AAP (proportionally 5% were more likely to complete the survey). We comment in the discussion section on the potential limitations that may relate to our response rate.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Nearly one third (29.2%) reported seeing patients who were affected by 9/11, and of these, 63.6% identified children with behavioral problems, 41.6% identified children with ASD, and 26.3% identified children with PTSD (Table 3). In the group of 108 practitioners who reported children in their practice with PTSD (not shown), 16.9% reported this in children with death of a close family member/friend, 15.7% in children with underlying mental health problems, 14.8% in children with chronic anxiety/preoccupation with death, 8.3% in children with parents/relatives who had worked in/around the WTC site, and the balance in children with an array of characteristics such as parental PTSD and witnessing the attacks.
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Fourteen percent of practitioners indicated that their medical education had prepared them for the events of 9/11. The majority did not feel knowledgeable about mental health, death/dying counseling, or bereavement counseling (Table 3). When asked whether they believed that they had the skills to detect mental health problems in children, 19.9% stated that they did not. The greatest number of practitioners perceived that they had skills to detect depression in children (88.3%) but were less certain of their skills to detect PTSD (49.2%), ASD (48.3%), and those who need bereavement counseling (65.8%). The large majority (76.7%) of respondents believed that primary care providers should obtain additional training to allow them to screen for PTSD, ASD, or depression, and 44.1% believed that primary care providers should obtain additional training to treat PTSD and ASD. Only a minority of practitioners (15.3%) stated that they would be interested in a practice-based research network that addresses the effects of 9/11 on children (Table 2).
Bivariate Associations
Across the board, generalists were more likely than either subspecialists or residents to report that they were seeing patients who were affected by 9/11 and that children in their practice were exposed to 1 or more 9/11-related events (Table 4). These practitioners were less likely to report having had a mental health provider as part of their practice before the events of 9/11 and less likely to consider the addition of such a professional after 9/11. However, after 9/11, the proportion of physicians in each of the practice settings that would allow a mental health provider as part of their practice increased over their baseline rates of actual presence of such providers before 9/11. Similar results were found for those in private practice as compared with those in hospital settings (Table 4). Although generalists less often reported deficiencies in their skills to detect mental health problems, they more often reported gaps in their knowledge of these issues. Eliminating depression from the skills scale did not change this result. University-based practitioners more often reported having had previous training in community disasters (data not shown), with those in nonhospital settings more often reporting lack of knowledge but having sufficient skills in dealing with children's mental health. The knowledge and skills of mental health issues scales were positively associated (P < .0001) but apparently reflected slightly different parameters.
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Gender differences were also noted, with female child health professionals more often reporting that their practice was affected and that many demands were placed on the practice (data not shown). They more often reported being willing to consider having a mental health provider as a part of their practice as compared with male physicians (Table 4). Women practitioners also perceived themselves to be less knowledgeable about mental health (Table 4).
Younger practitioners seemed more often to report having had a mental health provider as part of their practice and a willingness to incorporate such a professional as part of their practice after 9/11 as compared with older ones (Table 4). To test for this age trend, we used the eta statistic and found both of these trends to be marginally significant (P ~ .10). It is interesting that younger practitioners reported less often wanting additional training to treat patients with mental health problems than older practitioners (Table 4).
Racial/ethnic differences were noted, with Asian and other minority practitioners more often reporting perceived lack of skills in detecting mental health problems in children and in their knowledge of mental health issues as compared with white practitioners. Asian and other minority child health professionals more often reported wanting additional training to treat children with mental health problems. When race/ethnicity was subdivided further, Latino and Asian physicians more often reported lacking the skills to detect mental health problems in children as compared with white and African-American physicians (P = .004, data not shown).
Multiple Logistic Regression Results
The ORs and CIs shown in Table 5 all are adjusted for the variables shown (representing key medical demographics and practice characteristics), plus the survey modality (e-mail vs mail). Adjustment for survey modality was made because bivariate analyses indicated significant differences in the demographics of e-mail and mail respondents. The results for Table 5 indicate that generalists were more likely than specialists to report seeing affected patients and to report seeing children who were exposed to 1 or more 9/11 events, were less likely to have had a mental health provider as part of their practice before 9/11, and were not significantly more likely to want to incorporate a mental health provider after 9/11. Likewise, adjusting for medical demographics and practice characteristics, those in non–private practice settings were significantly less likely to report seeing patients who affected and seeing children who were exposed to 1 or more 9/11 events as compared with private practitioners. However, they were much more likely to have had a mental health provider as part of their practice than private practitioners and much more likely to report willingness to consider incorporating a mental health professional within their practice than private practitioners. Generalists, as compared with specialists, were also significantly less likely to report having knowledge of mental health issues but, interesting, less likely to report lacking the skills to detect mental health issues (Table 5).
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It should be noted that the practice location was examined both by chapter and by zip code, and minor differences resulted from the logistic regression analysis when one or the other variables were used in the analysis. When defining practice zone by zip code, practitioners from other than the Manhattan zone were less likely to report seeing affected patients or patients who were exposed to 1 or more 9/11 events. When practice location was defined by chapter, additional findings were that NY 1 was more likely to report lacking skills to detect mental health problems in children (OR: 1.57; CI: 1.02-2.41). No interaction effects were apparent in terms of age, gender, race/ethnicity, or practice location for the logistic regression models.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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As hypothesized, many practitioners believed that they lacked the skills needed to identify children with symptoms of ASD, PTSD, need for bereavement counseling, and, to a lesser extent, depression. The most pronounced perceived deficiencies were in detecting ASD and PTSD. Despite this finding, many practitioners did state that they had identified children in those categories. The survey did not attempt to define ASD or PTSD but relied on the respondent's understanding of those terms.17–19 Practitioners may have felt comfortable enough to know generally when children were experiencing these acute and chronic effects of trauma but still believed that their diagnostic skills merited improvement. They clearly identified gaps in their knowledge, with the majority not believing that they were knowledgeable in a broad array of child behavior symptoms. Their reported rates of identification of behavioral changes, ASD, and PTSD in affected children did suggest that practitioners understood these terms because a larger proportion of children were noted to have nonspecific behavioral changes, fewer had acute stress reactions, and even fewer had PTSD, as might be expected. Although this physician survey could not capture information on prevalence of PTSD, it did provide descriptive information on the experience of the practices surveyed and suggests that additional physician training is needed in the area of children's mental health. The burden on the practices was clearly demonstrated with one third reporting seeing children who were exposed to 1 or more 9/11 event. Even 1 year after 9/11, these data suggest the need to provide concrete services to these practitioners. Some proportion of children will most likely continue to exhibit symptoms of PTSD, and the issues of bereavement after the loss of a parent, family member, or close friend are likely to persist and vary depending on a child's developmental stage.17,20–24
Although studies have shown that children and their parents were affected by 9/11, the responses to identified mental health issues have varied. Redlener and Gant6 identified a disparity between the desire for mental health services by families and the receipt of such services. Russonello and Stewart2 noted in their study that although schools were initially commended by parents for their response to children's emotional needs, 9 months after 9/11, 54% of parents reported that despite continued need for emotional support, schools were no longer meeting these needs. Studies of posttraumatic stress in children have shown that symptoms of PTSD may persist for years, especially if not addressed, and may be unrelated to the degree of exposure to the event.22,25 However, as shown by Chemtob et al,26 treatment can substantially ameliorate such symptoms. The majority of practitioners in our study did in fact want to gain additional information to screen children, and those in the 4 NYC boroughs were more likely also to want additional training to treat their patients. Generalists and private practitioners experienced the most demands on their practice after 9/11, suggesting that they should be targeted for assistance in responding to the demands on their practices. However, the strategies to address these needs must be considered carefully given that this group is also the least likely to have had or currently to want to incorporate a collaborative model of care in their practice. The discordance between generalists' reported skills and knowledge of mental health issues might be explained in part because the skills-based scale included identifying depression, an area that professionals generally felt more comfortable assessing, but the knowledge scale included items most related to trauma and death/dying, areas in which respondents were less sure of their skills. Nonetheless, more research is needed to clarify this point. The chapter-specific findings may aid in targeting chapter activities, perhaps inclusive of a practice-based research network.
This study has several limitations. The survey sample may not be representative of the population of child health professionals in the tristate area. Although the AAP data capture ~77% of board-certified pediatricians, this database does not capture non–board-certified clinicians or family physicians who care for children. Moreover, the survey sample included relatively few nonwhite, non-Asian practitioners. Because the AAP does not collect information on member race/ethnicity, we could not determine whether the minority respondent numbers were representative of the AAP membership in general. However, the Association of American Medical Colleges Student Record System, April 2002 of US Medical School Graduates 2001, indicates that nearly one third of all medical school graduates were minorities and 11% underrepresented minorities.27 These numbers are comparable to those in our database, but they do not necessarily reflect the tristate area, and efforts to understand the specific needs of these minority practitioners and the populations that they serve will most likely require oversampling of this group and directed questions regarding their practices.2,27–31 In addition, the simple finding of differences by race/ethnicity or gender does not elucidate the origins of these differences or help to delineate intragroup heterogeneity. Finally, although the sample size of ~1400 practitioners is sizable, the total cooperation rate at 36% was lower than ideal. Although e-mail may have presented the benefit of rapid response to the survey, our results indicate that limitations of this method at this time are lack of e-mail addresses for a large proportion of physician members and a lower response rate. Future web-based surveys will have to depend on more accurate e-mail databases and consider mix-methodology in surveying physicians.32 Last, although the obtained sample medical demographics did not differ substantially from that of the master AAP membership list, it is possible that the results are not fully representative of the AAP membership. As noted, professionals from the NY 1 Chapter of the AAP were somewhat more likely to respond to the survey. Because these physicians were less likely to be seeing affected patients or seeing children who were exposed to 1 or more 9/11 events, we believe our findings to be conservative.
The broader implication of this survey is that although pediatricians may perceive that they lack the knowledge or skills to respond to community disasters and might benefit from interventions aimed at improving their skills in these areas, they are in fact a major part of the system of care that promotes the psychological recovery of children after such traumatic events. This role is further magnified because, as revealed by this study, traumatized individuals often present to the primary care setting and, as shown by others, may do so instead of seeking help from the more traditional mental health system.26 Moreover, while events such as 9/11 are, fortunately, rare, motor vehicle crashes, domestic violence, child abuse, and exposure to community violence are not, and child health professionals must be prepared not only to identify such problems but also to be well positioned to intervene effectively.18,33–35 As indicated by our respondents, addressing identified barriers such as poor reimbursement, lack of training, readily available back-up systems, or access to linguistically and culturally competent mental health professionals may aid in supporting them to provide needed mental health services to their patients, yet current models of postdisaster response and responses to the general mental health needs of children in the United States have failed to appreciate fully the critical role that pediatricians play de facto. McInerny et al36 showed that although physicians diagnose and treat insured and uninsured children similarly, they do underrecognize behavioral problems in uninsured children, probably because these children had fewer clinician visits than insured children. Improving access to health care, including mechanisms to reimburse for mental health services provided within pediatric primary care, most likely will be an important determinant to the recognition and treatment of children's mental health problems.37 Improving physician comfort and skills in responding to children's mental health needs is essential to appropriate disaster preparedness and is certain to improve the care that is given to children and the support that families receive in times of crisis.
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ACKNOWLEDGMENTS |
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We acknowledge the leadership of the American Academy of Pediatrics NY Chapters 1, 2, and 3; the CT Chapter; and the NJ Chapter for support and collaboration. We thank District II leadership for encouragement and support; Robert Corwin, MD (District Chair); and Thomas McInerny, MD, for insightful comments. We thank the pediatricians in the New York area who responded to the crisis, in particular Bonita Franklin, MD, and Susan Levitsky, MD.
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FOOTNOTES |
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Reprint requests to (D.L.) Mount Sinai School of Medicine, Department of Pediatrics, Box 1198, New York, NY 10029-6574. E-mail: danielle.laraque{at}mssm.edu
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  T.-H. Shih and Xitao Fan Comparing Response Rates from Web and Mail Surveys: A Meta-Analysis Field Methods, August 1, 2008; 20(3): 249 - 271. [Abstract] [PDF]
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 C. DiMaggio, S. Galea, and D. Abramson Analyzing Postdisaster Surveillance Data: The Effect of the Statistical Method Disaster Med Public Health Preparedness, June 1, 2008; 2(2): 119 - 126. [Abstract] [Full Text] [PDF]
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 Committee on Environmental Health and Committee on Chemical-Biological Terrorism and Its Impact on Children Pediatrics, September 1, 2006; 118(3): 1267 - 1278. [Abstract] [Full Text] [PDF]
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J. F. Hagan Jr, and the Committee on Psychosocial Aspects of Child, and and the Task Force on Terrorism Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician Pediatrics, September 1, 2005; 116(3): 787 - 795. [Abstract] [Full Text] [PDF]
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G. Fairbrother, J. Stuber, S. Galea, B. Pfefferbaum, and A. R. Fleischman Unmet Need for Counseling Services by Children in New York City After the September 11th Attacks on the World Trade Center: Implications for Pediatricians Pediatrics, May 1, 2004; 113(5): 1367 - 1374. [Abstract] [Full Text] [PDF]
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D. J. Schonfeld Are We Ready and Willing to Address the Mental Health Needs of Children? Implications From September 11th Pediatrics, May 1, 2004; 113(5): 1400 - 1401. [Full Text] [PDF]
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