Posttraumatic stress in children with first responders in their families. Journal of Traumatic Stress, 19(2), 301-306

Abstract

High levels of exposure and occupational stress of first responders may have caused children in first-responder families to become traumatized following the September 11th, 2001 terrorist attacks. New York City public school children (N = 8,236) participated in a study examining mental health problems 6 months after the World Trade Center attack. Results revealed that children with emergency medical technician (EMT) family members had a high prevalence of probable posttraumatic stress disorder (PTSD; 18.9%). Differences in rates of probable PTSD among EMTs' and firefighters' children were explained by demographic characteristics. Where EMTs are drawn from disadvantaged groups, one implication of this study is to target EMT families in any mental health interventions for children of first responders.

Full text

Journal of Traumatic Stress, Vol. 19, No. 2, April 2006, pp. 301–306 (C
2006)
BRIEF REPORT
Posttraumatic Stress in Children With First
Responders in Their Families*
Cristiane S. Duarte, Christina W. Hoven, and Ping Wu
Columbia University and New York State Psychiatric Institute
Fan Bin
New York State Psychiatric Institute
Sivan Cotel
Wesleyan University
Donald J. Mandell
Columbia University and New York State Psychiatric Institute
Megumi Nagasawa
New York State Psychiatric Institute
Victor Balaban
Macro International Inc.
Linda Wernikoff
New York City Department of Education
David Markenson
New York Medical College School of Public Health
High levels of exposure and occupational stress of first responders may have caused children in first-
responder families to become traumatized following the September 11th, 2001 terrorist attacks. New
York City public school children (N =8,236) participated in a study examining mental health problems
6 months after the World Trade Center attack. Results revealed that children with emergency medical
technician (EMT) family members had a high prevalence of probable posttraumatic stress disorder
(PTSD; 18.9%). Differences in rates of probable PTSD among EMTs’ and firefighters’ children were
explained by demographic characteristics. Where EMTs are drawn from disadvantaged groups, one
implication of this study is to target EMT families in any mental health interventions for children of
first responders.
*This article was edited by the journal’s previous editor, Dean G. Kilpatrick.
Without the NYC-DOE (formerly BOE) leadership of Francine Goldstein, participation of Vincent Giordano, Linda Wernikoff, superintendents, principals, teachers, and, most of all,
students, this study could not have succeeded. This investigation is the result of collaboration between the NYC-DOE; Children’s Mental Health Alliance (Pamela Cantor); MSPH
Columbia University-NYSPI: Christina W. Hoven (Principal Investigator), J. Larry Aber, Patricia Cohen, Christopher P. Lucas, Cristiane S. Duarte, Donald J. Mandell, George J. Musa,
Ping Wu, Fan Bin, Ezra Susser, Judith Wicks, Renee Goodwin, Andrea Versenyi, and Barbara P. Aaron; statistical consultation Henian Chen, Mark Davies, Steven Greenwald and Patricia
Zybert; The Michael Cohen Group, LLC (formerly ARC): Michael Cohen (Contract Principal Investigator), Nellie Gregorian, Chris Bumcrot, Craig Rosen and Victoria Francis; CDC:
Bradley Woodruff; NCCEV, Yale University: Steven Marans; NYU: Elissa Brown; V.A, Honolulu, HI: Claude Chemtob; University of Oklahoma: Betty Pfefferbaum; NCCTS, UCLA:
Robert Pynoos, Alan Steinberg, William Saltzman.
Correspondence concerning this article should be addressed to: Cristiane S. Duarte, 1051 Riverside Drive, Unit #43, New York, NY 10032. E-mail: duartec@childpsych.
columbia.edu.
C
2006 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20120
301

302 Duarte et al.
First responders are frequently involved in high-stress,
life-threatening situations, which puts them at elevated risk
for becoming traumatized. Considering society’s depen-
dence upon first responders, it is important to understand
how their occupation may impact their children.
Approximately 13% of first responders develop post-
traumatic stress disorder (PTSD), according to stud-
ies conducted with convenience samples (North et al.,
2002; Robinson, Sigman, & Wilson, 1997) using struc-
tured interviews measuring lifetime PTSD according to
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV; American Psychiatric Associa-
tion, 1994). The same prevalence of PTSD was also identi-
fied 42 months after a disaster by an earlier study conducted
in a representative sample of firefighters, using DSM-III cri-
teria (APA, 1980; McFarlane & Papay, 1992). The preva-
lence estimated by previous investigations is potentially
elevated when compared with the lifetime prevalence of
PTSD (6.8%) recently reported in a national probability
sample (Kessler, Berglund, Demler, Jin, & Walters, 2005).
Even among persons directly exposed to a traumatic sit-
uation, the frequency of lifetime PTSD, assessed using
DSM-IV criteria, was only 9.2% (Breslau et al., 1998).
Children in close contact with traumatized first respon-
ders may develop posttraumatic symptomatology through
secondary traumatization. Parental psychological function-
ing has been identified as a predictor of children’s mental
health problems following disasters (e.g., Laor, Wolmer,
& Cohen, 2001). More specifically, some studies have de-
tected an association between PTSD among parents and
their offspring (Stoppelbein & Greening, 2000; Yehuda,
Halligan, & Bierer, 2001). Six months after the Septem-
ber 11th, 2001 terrorist attack on the World Trade Center
(WTC), one factor associated with probable emotional dis-
turbance in children throughout New York City was having
a family member exposed to the attack (Hoven et al., 2002,
2005).
If exposure to trauma is common among first respon-
ders, and if such exposure has considerable impact on their
children, then we would expect those children to be more
susceptible to developing PTSD than their peers. How-
ever, is this statement true for all first responders, or are
some subgroups at higher risk than others? In this article,
we examine children’s posttraumatic stress reactions after
September 11th, according to having different categories
of first responders in their families. Our aim in these anal-
yses is not only the identification of populations in need
of special attention after a disaster, but also to contribute
knowledge about how familiar exposure to trauma affects
children.
METHOD
Participants
Participants included 8236 children and adolescents, ages
9 to 21. The sampling frame, developed in collaboration
with the Centers for Disease Control (CDC), included
all New York City public school students in grades 4–12
(716,189) 6 months after September 11, 2001, and was de-
signed to accurately represent this (non-special education)
population, oversampling specific areas, such as Ground
Zero (Hoven et al., 2005). By grade group, compliance
among those in school on the day of the survey, ranged
from 69.0% (fourth to fifth graders) to 95.8% (sixth to
eighth graders).
Measures
A self-report questionnaire was used (Hoven et al., 2002),
with probable PTSD assessed by the PTSD screening
module of the Diagnostic Interview Schedule for Chil-
dren (DISC) DISC Predictive Scales (DPS) (Lucas et al.,
2001). Psychometrics of the DPS PTSD scale were ade-
quate (sensitivity =85% and specificity =98.4%). Post-
traumatic stress disorder symptoms present in the past
month were evaluated, with the WTC attack as the an-
choring traumatic event.
Information about family members’ occupations was
obtained through the question “Does anyone in your
familywork as...”followedbyalistofoptions.Multiple
responses were acceptable and they included police officers
(PO), firefighters (FF) and emergency medical technicians
(EMT).
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Child PTSD and First Responders 303
Children’s exposure to trauma was measured by (a) pre-
vious exposure, defined as exposure to traumatic situations
before September 11 (Saltzman et al., 1999); (b) atten-
dance in a Ground Zero Area school; (c) direct exposure,
defined as two or more of the following types of exposure:
personally witnessing the attack, being hurt in the attack,
being in or near the cloud of dust and smoke, having to be
evacuated to safety, or being extremely worried about the
safety of a loved one; (d) family exposure, defined as having
a family member killed or injured in the attack, or witness-
ing the attack but having escaped unharmed; and (e) high
TV exposure, child spent a lot of time watching attack
coverage on the TV (Hoven et al., 2005). Demographic
variables included gender, age, race/ethnicity, maternal
education and family composition.
Data Analysis
Children were divided into five mutually exclusive groups,
according to information about relatives’ occupations:
those with at least one family member who was a (a) police
officer (PO) (but not EMT or FF); (b) EMT (but not PO
or FF); (c) a FF (but not EMT or PO); (d) those with family
members in at least two of the three possible first-responder
occupations; and (e) no first responder in the family. De-
scriptive information about PTSD, demographics, and ex-
posures among children with family members in different
first-responder groups is presented (Table 1). The associa-
tion between type of first responder in children’s families
and prevalence of probable PTSD was assessed through hi-
erarchical logistic regression, controlling for exposures and
demographics (Table 2). Statistical analysis was performed
using SUDAAN software (version 8.0; Research Trian-
gle Institute, 2001) to account for the complex sampling
design.
RESULTS
Of 8,236 participants, 53.1% were female. The most rep-
resented ethnicity was Latino (40.1%), followed by African
American (27.9%), White (13.4%), Asian (12.8%), and
Mixed/Other (5.7%). In the total sample, 15.5% had at
least one first-responder family member.
The highest rate of probable PTSD (18.9%) occurred
in children with EMT family members (Table 1). The rate
among children who had PO family members (10.6%) was
similar to that among children without any first responder
(10.1%), whereas children with FF family members had
the lowest prevalence of probable PTSD (5.6%).
Groups were roughly comparable regarding attendance
in Ground Zero schools, direct and TV exposure. How-
ever, those with EMT family members or at least two of the
first responder professions in their families had high levels
of prior exposure. In addition, family exposure was less fre-
quent among children with only POs or no first responders
in their family. Most children with EMT family members
were non-White (92.4%); about two thirds of the FFs’
children were White (62.5%). Almost one third of chil-
dren with EMT family members were in the youngest age
group and 46.6% did not live with both parents (Table 1).
Table 2 reports the results of logistic regression analysis
of probable PTSD. When being the child of a first respon-
der was considered (model 1), children from all groups
were less likely to have probable PTSD compared to chil-
dren who had an EMT family member (reference group),
although the results were only statistically significant for
children of FFs and marginally significant for those without
a first responder in their family (p=.0516). When con-
trolling for different types of exposure (model 2), children
with FFs in their family were still less likely than children
with EMTs in their family to have probable PTSD. How-
ever, the introduction of demographic variables (model 3)
resulted in the adjusted odds ratio for this comparison
being only marginally significant (p=.07).
DISCUSSION
This appears to be the first study to assess mental health
problems in children with different categories of first re-
sponder family members. We observed a high rate of prob-
able PTSD among children with EMT family members in
a representative sample of NYC public school students 6
months after the WTC attack. Further analysis suggested
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

304 Duarte et al.
Tab l e 1. Prevalence (%) of Posttraumatic Stress Disorder (PTSD) (Probable), Exposure, and Demographics Among
NYC Public School Students With First-Responder (FR) Family Members (N=8,236)a
Family member occupation
Police Officer only EMT only Firefighter only At least 2 FRs No FRs in the family
PTSD, Exposure and Demographics n=670 n=288 n=83 n=237 n=6,957
PTSD (probable) 10.6 18.9 5.6 17.0 10.1
Prior trauma exposure 32.6 42.2 31.2 44.6 29.4
Attendance in Ground Zero area school 0.7 0.5 1.1 0.5 1.4
Direct World Trade Center exposure 29.5 30.0 30.6 35.6 23.4
Family World Trade Center exposure 12.2 21.1 27.5 26.6 11.5
World Trade Center TV exposure 64.2 68.6 72.6 73.1 62.6
Gender
Girls 55.2 53.6 56.0 62.2 52.6
Race/Ethnicity
White (non-Hispanic) 11.2 7.6 62.5 20.6 13.0
African American 33.5 40.3 13.9 31.4 27.0
Latino 45.7 39.8 19.5 40.8 39.8
Asian 3.4 5.3 0.2 3.5 14.6
Mixed/other 6.2 7.0 3.8 3.7 5.7
Grade
4th–5th 21.4 32.3 17.5 16.2 25.8
6th–8th 36.5 29.4 30.3 41.4 33.4
9th–12th 42.1 38.3 52.2 42.4 40.8
Low maternal education 14.7 13.1 14.2 11.6 17.7
Not living with both parents 44.0 46.6 21.7 41.1 38.1
aWeighted data.
Tab l e 2. Logistic Regression Models Predicting Probable Posttraumatic Stress Disorder (PTSD) Among Children
With First Responder (FR) Family Members
Probable PTSD
Model 1 Model 2 Model 3
FR FR +exposureaFR +exposure +demographicsb
First Responder (FR) Group OR (95% CI) AOR (95% CI) AOR (95% CI)
EMTs (Reference group) 1.00 1.00 1.00
Police Officers 0.51 (0.21, 1.26) 0.56 (0.21, 1.46) 0.62 (0.23, 1.68)
Firefighters 0.26 (0.08, 0.79) 0.23 (0.07, 0.76) 0.30 (0.08, 1.08)
At least 2 FRs 0.88 (0.32, 2.40) 0.76 (0.26, 2.19) 0.88 (0.30, 2.62)
No FR in the family 0.48 (0.23, 1.01) 0.57 (0.26, 1.26) 0.58 (0.26, 1.27)
Note. Weighted data. OR =odds ratio; AOR =adjusted odds ratio; CI =confidence interval. Results for the complete model are available upon request.
aControlling for being in a Ground Zero school, direct, family, prior, and media exposures. bControlling for all exposures, plus gender, age, ethnicity, maternal
education, and single-parent family.
that the high rates of PTSD observed in children with
EMT family members are explained by a combination of
their exposure to the WTC attack and sociodemographic
characteristics.
Exposure to trauma might have a strong impact on
EMTs themselves. For example, 21% of ambulance work-
ers in a UK study had PTSD resulting from their chronic
exposure to trauma (Clohessy & Ehlers, 1999). Moreover,
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Child PTSD and First Responders 305
EMT/paramedics have been found to have higher distress
levels compared with police and fire personnel, in a sample
that combined first responders who had been chronically
exposed to trauma with people exposed to a specific disaster
(Marmar et al., 1996).
More detailed analysis revealed that the possible differ-
ences in risk of probable PTSD among EMT children,
compared to children in families with no first respon-
ders, was mostly explained by differences in WTC at-
tack exposure. Compared to children with FFs in their
families, a great part of the elevated risk among children
with EMTs in their families could be attributed to demo-
graphics. However, given the marginal statistical signifi-
cance of this result, and the small sample size of the group
of children with FF relatives, other factors might also be
relevant.
Career selection, pre-employment psychological status,
recruitment practices, training, and work group support
may help to explain the study’s findings. For example,
EMTs’ erratic work schedules might hinder their ability
to rely on co-worker support as a stress coping mechanism
(Spitzer & Neely, 1992), whereas strong co-worker support
might contribute to FFs’ lower risk to the effects of trauma
exposure (Fullerton, McCarroll, Ursano, & Wright, 1992;
North et al., 2002; Renck, Weisaeth, & Skarbo, 2002). The
lower rate of PTSD in children of FFs might be associated
with the aggregation of FFs in families. The FF culture,
adopted across generations, may also be translated into
clear role expectation and acceptance. The “heroism” asso-
ciated with being a FF might also be important in helping
FFs’ children cope with stress. Such a hypothesis warrants
investigation, as it might help to develop interventions to
foster resilience based on children’s positive appraisal of a
family member’s occupation.
Because of the nature of our survey, certain questions
remain unanswered. For example, it was not possible to
ascertain the total number of first responders in a child’s
family or the precise relationship between the child and
first-responder family member. It also would have been
helpful to have demographic and specific additional ex-
posure information and mental health status of the first-
responder relatives. Differences in first-responder groups’
sample sizes may also have interfered with the precision of
the results.
The clinical and public health relevance of this study
should be considered. First, if this study’s findings are con-
firmed, evidence will be available supporting the need,
after a mass disaster occurring in a similar context, to di-
rect attention to the mental health of children of EMTs. In
addition, these results indicate interesting directions for us
to expand our investigation about mechanisms related to
transmission of trauma within a family and its prevention,
by suggesting that children’s traumatization might be in-
fluenced by factors besides their own or their parent’s level
or type of exposure to a disaster.
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