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


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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.
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Journal of Traumatic Stress, Vol. 19, No. 2, April 2006, pp. 301–306 (C
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.
2006 International Society for Traumatic Stress Studies. Published online in Wiley InterScience ( DOI: 10.1002/jts.20120
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,
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
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).
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
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
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).
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
Girls 55.2 53.6 56.0 62.2 52.6
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
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
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
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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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
... 46). Following the WTC attacks, Duarte et al. [53] found "probable PTSD" among the children of emergency medical technicians, police officers, and firefighters. The importance and need for education and information regarding the prevention and early treatment of secondary trauma for PSP families are prominent in the literature [8,37,66,76]. ...
... Informal debriefing was available for some PSPs but not available for family members, and when social support is garnered from co-workers after a shift, it conflicts with family time [10,69,73]. Recommendations by both study participants and researchers highlight a need for organizations to include family members in debriefing when there is a significant event to support the PSP family member and not become traumatized themselves [6,36,37,48,53,74]. Support from organizations in terms of "induction events" was also recommended to familiarize family members with the PSP's work environment, the risks, the impact on both PSPs and families, and available resources [37,48,51]. ...
... 428) which corresponded with the "hero" status noted in Bochantin [11], Carrico [47], and Sommerfeld et al. [73]. Studies associated with the WTC attacks also suggest that positive appraisals by children regarding the PSP parent's occupation (i.e., 'hero' status of firefighters) may be a protective factor that enhances resilience [53,58]. In contrast, police have been regarded with "public suspicion and disdain" [78] (p. ...
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The families of public safety personnel (PSP) face demands that are unique to these occupations. Nonstandard work, trauma exposure, and dangerous work environments affect both workers and the families who support them. This narrative review aims to identify the stressors that PSP families experience and the support and resources needed to enhance family resilience. Due to a lack of research on PSP families, this review is a necessary first step to summarizing and interpreting a diverse body of research. The studies included addressed structural and emotional work-family conflict with reference to PSP sectors. A framework from the military family resiliency literature interprets the findings. Factors influencing family functioning and the availability and accessibility of resources provide clues about the type of skills and supports that PSP families rely on. Meaning-making, collaboration, a sense of coherence, and communication were identified as themes associated with intrafamilial processes. Extrafamilial themes included public perceptions, a lack of recognition for the roles families fulfill, and the need for information and education. The results suggest that the vulnerability of PSP families is variable and extrafamilial resources in the form of formal and informal supports are necessary to enhance family resiliency.
... 15. Seeks to better understand the lived experiences of first responders (Duarte et al., 2006;Haddock et al., 2015;Rutkow, 2011). 16. ...
... T. Patterson, 2003). 2. Is aware that there is a complex nature of stressors faced by first responder families, including factors related to separation and relocation (Duarte et al., 2006). 3. Understands the high level of adaptation and resiliency skills that are beneficial for families to meet the common demands of the lifestyle, including stress, uncertainty, and frequent separations (Miller, 2007) . ...
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The intention of the BPCFRP is to provide a research-based framework to help counselors who work with first responders. The referenced practices are intended to be used as a guideline and resource to assist and promote the effectiveness of counselors working with first responders. The described practices are referred to as “best practices,” meaning that they are presented as examples of desirable practices in this area. This is one model. It is not necessarily the only effective model. These best practices are not presented as requirements. We recognize that there can be other effective approaches to working with first responders. We hope you find this document to be a useful resource.
... Research following the World Trade Center attacks indicated children of paramedics experienced vicarious traumatic stress symptoms, such as repetitive traumatic play, separation anxiety, difficulties with sleep, and behaviour problems [15]. Children of paramedics who responded to the World Trade Center attacks experienced more problems than children of police officers and firefighters, suggesting differences may exist among PSP groups [16]. Many more children (18.9%) from families with a paramedic met criteria for posttraumatic stress disorder (PTSD) than did children from families with police officers (10.6%), firefighters (5.6%), or no PSP (10.1%) [16]. ...
... Children of paramedics who responded to the World Trade Center attacks experienced more problems than children of police officers and firefighters, suggesting differences may exist among PSP groups [16]. Many more children (18.9%) from families with a paramedic met criteria for posttraumatic stress disorder (PTSD) than did children from families with police officers (10.6%), firefighters (5.6%), or no PSP (10.1%) [16]. Similarly, children with paramedic family members had higher prevalence of probable major depressive disorder than children in families with police officers, firefighters, or no PSP following the World Trade Center attacks [17]. ...
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Public safety personnel (PSP) often experience stress due to their occupational demands that affect the family environment (e.g., work-family conflict, marital breakdown, disruption to home routines, and holidays). A substantial base of research has focused on the impact of PSP work on the marital relationship, but fewer studies have focused specifically on children’s functioning within PSP families. The current study investigated mental health, well-being, and functioning among children of PSP in Canada, as reported by PSP. Data were collected between 2016 and 2017 as part of a large pan-Canadian study of PSP. Participants (n = 2092; 72.5% women) were PSP parents who responded to questions about their 4- to 17-year-old children. Overall, a substantial proportion of PSP parents reported their children have at least some difficulties with sadness (15.4%), worries and fear (22.0%), disobedience or anger (22.0%), attention (21.0%), and friendships (11.4%). Firefighters reported the fewest problems among their children compared to other PSP groups. Almost 40% of participants indicated that their child’s problems were related to their work as a PSP. The results highlight the need to find ways to identify children that are struggling and provide support to those families. Organizations and PSP leadership should develop and prioritize efforts to support families of PSP members, with the likely outcome of enhancing PSP member well-being.
... In a review of disaster research on children, there were no other census-based 9/11 children studies identified [14]. Second, the sample size of the WTCHR children exceeded that of most other 9/11 children disaster studies, with the exception of a series of cross-sectional studies based on self-reported information collected from a New York City wide sample of 8236 public school attendees enrolled in 4th to 12th grade [15][16][17][18]. That study data did not include information necessary for continued follow-up. ...
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The World Trade Center Health Registry (WTCHR) was established in 2002 as a public health resource to monitor the health effects from the World Trade Center (WTC) disaster. We evaluated the representativeness of the WTC youth population (<18 years on 11 September 2001) by comparing the distributions of age, gender, race/ethnic groups, and income to 2000 census data for the matched geographic area, including distance from disaster. There were 2379 WTCHR enrolled children living in Lower Manhattan south of Canal Street on 11 September 2001, along with 752 enrolled students who attended school in Lower Manhattan but were not area residents. The WTCHR sub-group of children who were residents was similar to the geographically corresponding census population on age and sex. Black and Hispanic children are moderately overrepresented at 0.9% and 2.4% in the WTCHR compared to 0.8% and 1.7% in census population, respectively, while lower-income households are slightly under-represented, 28.8% in the WTCHR and 30.8% for the corresponding census information. Asian children appear underrepresented at 3.0% participation compared to 6.3% in the census. While the demographics of WTCHR youth are somewhat skewed, the gaps are within expected patterns of under-representation observed in other longitudinal cohorts and can be effectively addressed analytically or through targeted study design.
... Some respondents were first responders and partners of first responders and that family decision-making was influence by these occupation roles. Research by Fullerton suggests that stress in firefighters can be mediated by social support (Duarte et al., 2006;Fullerton et al., 1992). First responder families with infants and young children may need extra support services such as psychosocial first aid following a disaster. ...
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In theoretical research on disaster vulnerability, access to resources is critical for optimal outcomes. Studying the impact of a hurricane on maternal stress can expand theories of disaster vulnerability. This is a cross-sectional mixed-methods prospective study of maternal stress during Hurricane Florence in the United States. Results from chi-squares compared the proportion of respondents who reported having support for a financial emergency were significant, specifically that higher income respondents indicated the ability to rely on someone in case of an emergency. A regression analysis indicated that social support was significant and negatively related to stress as a dependent variable, while evacuation status and pregnancy status were not significant predictors of stress. Five themes emerged from the overall qualitative data: concerns about infant feeding, evacuation logistics, general stress, family roles, and 'other' issues.
... Some other studies have examined the impact on first responder families of specific crises. Studies conducted after the 11 September, 2001 terrorist attack on the World Trade Centre show that rates of probable PTSD were found to be high among children with emergency medical technician family members (Duarte et al., 2006), and children of first responders were at heightened risk of behavioural problems (Uchida et al., 2018). Spouses of firefighters also reported insomnia and anxiety after 9/11 due to worries about their partners' health and safety (Menendez, Molloy, & Magaldi, 2006). ...
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Background: The COVID-19 pandemic has had a well-documented negative impact on the mental health and wellbeing of frontline healthcare workers (HCWs). Whilst no research has to date been carried out to explore the challenges experienced by the families of HCWs, some previous research has been conducted with military families, demonstrating that family members of deployed military personnel may also be affected seriously and negatively. Objectives: This study aimed to explore the experiences, views, and mental health impact on frontline HCWs' families during the COVID-19 pandemic in the UK and what support the families of frontline HCWs may need. Method: Close family members and friends of HCWs were interviewed. Transcripts were analysed in line with the principles of reflexive thematic analysis. Results: We completed fourteen interviews with three siblings, one mother, one friend, and nine spouses of HCWs. Family members were highly motivated to support healthcare workers and felt an intense sense of pride in their work. However, they also experienced increased domestic responsibilities and emotional burden due to anxiety about their loved ones' work. The fact that sacrifices made by family members were not noticed by society, the anxiety they felt about their family's physical health, the impact of hearing about traumatic experiences, and the failure of healthcare organisations to meet the needs of the HCWs all negatively affected the family members. Conclusions: We have an ethical responsibility to attend to the experiences and needs of the families of healthcare professionals. This study emphasises the experiences and needs of family members of healthcare professionals, which have hitherto been missing from the literature. Further research is needed to hear from more parents, siblings and friends, partners in same sex relationships, as well as children of HCWs, to explore the variety of family members and supporters' experiences more fully. Highlights: • COVID19 has impacted families of HCWs as well as workers themselves. They have experienced more anxiety, increased practical burden, significant physical health risks and been exposed vicariously to workers' traumatic experiences. We must ensure HCW families are better supported.
... 18 Increased rates of PTSD and other behavioral issues have been reported in children of first responders to the World Trade Center attacks; 19 one study found that children with an emergency medical technician family member who was exposed to the 9/11 terrorist attacks reported a probable PTSD prevalence of 18%. 20 Similarly, children aged four to 19 of US law enforcement officers who were involved in the large-scale interagency manhunt following the 2013 Boston Marathon bombing attack were 5.7 times more likely to have PTSD symptoms than those without parents involved in the manhunt. 21 The 2018 South Australian Metropolitan Fire Service Health and Wellbeing Study showed a significant impairment in family functioning associated with the serving member's mental health symptoms. ...
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Objective: The objective of this review is to understand the perceptions and experiences of family members of emergency first responders with post-traumatic stress disorder. Introduction: Research indicates that rates of post-traumatic stress disorder in emergency first responders (EFR) are approximately double civilian rates; however, little is known about the effects of post-traumatic stress disorder on family members. This review seeks to identify qualitative research on families' experiences and perceptions. Inclusion criteria: This review will consider all studies of family members of current or former emergency first responders with diagnosed or undiagnosed post-traumatic stress disorder of any level of severity. All possible familial configurations and family members will be considered, including nuclear, separated, and blended families, of a current or former emergency first responder. There will be no age restrictions on emergency first responders or their family members, or limitations on recency of service. Emergency first responders may include police, ambulance workers, paramedics, firefighters, or rescue personnel, with no restriction on geographic location. Methods: The databases to be searched will include PubMed, PsycINFO, Embase, CINAHL, PTSDpubs, and Scopus, as well as handsearching of relevant journals. Unpublished studies and gray literature will be searched via PTSDpubs and OpenGrey.The search will be completed for English language publications with no time limits. Titles and abstracts will be reviewed and then full texts, all screened by two independent reviewers against the inclusion criteria. Any conflicting views will be resolved by discussion or a third reviewer.Results will be critically appraised for methodological quality. Data extraction results will be synthesized and evaluated for credibility and dependability. Systematic review registration number: PROSPERO CRD42020196605.
... Early studies described the views and reactions of adolescents to the traumatic events of the WTC disaster [107][108][109][110][111]. PTSD, anxiety, and depression are the top three certified mental health conditions among WTCHP youth members. Several studies have evaluated these outcomes [112][113][114][115][116][117][118][119][120]. For example, six months after the WTC attack, New York City students in grades 4-12 with direct WTC exposure reported an increase in media consumption about the WTC attack (e.g., TV, Web, radio, and print media) [121]. ...
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The terrorist attacks on 11 September 2001 placed nearly a half million people at increased risk of adverse health. Health effects research began shortly after and continues today, now mostly as a coordinated effort under the federally mandated World Trade Center (WTC) Health Program (WTCHP). Established in 2011, the WTCHP provides medical monitoring and treatment of covered health conditions for responders and survivors and maintains a research program aimed to improve the care and well-being of the affected population. By 2020, funds in excess of USD 127 M had been awarded for health effects research. This review describes research findings and provides an overview of the WTCHP and its future directions. The literature was systematically searched for relevant articles published from 11 September 2001 through 30 June 2020. Synthesis was limited to broad categories of mental health, cancer, respiratory disease, vulnerable populations, and emerging conditions. In total, 944 WTC articles were published, including peer-reviewed articles funded by the WTCHP (n = 291) and other sources. Research has focused on characterizing the burden and etiology of WTC-related health conditions. As the program moves forward, translational research that directly enhances the care of individuals with chronic mental and physical health conditions is needed.
Objective: The objective of this review was to examine the perceptions and experiences of family members of emergency first responders (EFRs) with post-traumatic stress disorder (PTSD). Introduction: Research indicates that EFR rates of PTSD are approximately double civilian rates, however, very little is known about the resultant effects on their family members. This review identifies the qualitative literature and data examining the perceptions and experiences of families with a current or former EFR member with diagnosed or undiagnosed PTSD. Inclusion criteria: This review includes all relevant articles, books, reports, and doctoral theses in English, globally, with no time limits, examining the experiences of family members of current or former EFRs with diagnosed or undiagnosed PTSD. All possible familial configurations and family members were considered, including nuclear, separated, and blended families, of an EFR. There were no age restrictions on EFRs or their family members or limitations on recency of service. EFRs included police, ambulance/paramedics, firefighters, and rescue personnel. Methods: The databases searched included MEDLINE (PubMed), PsycINFO (Ovid), Embase, CINAHL (EBSCOhost), and Scopus. Hand-searching of relevant journals was conducted across Australian Paramedic, Australasian Journal of Paramedicine, British Paramedic Journal, International Paramedic Practice, Irish Journal of Paramedicine, Journal of Paramedic Practice, Prehospital and Disaster Medicine, and Prehospital Emergency Care. Sources of unpublished studies and gray literature, such as dissertations, were searched via PTSDpubs (ProQuest) and OpenGrey (DANS ESASY Data Archive). The search was updated in October 2021. Titles, abstracts, and full texts were screened by 2 independent reviewers against the inclusion criteria, and any conflicting views were to be resolved by discussion or a third reviewer, which was not required. Results were critically appraised for methodological quality. Post-data extraction results were synthesized and evaluated for credibility and dependability in accordance with the a priori protocol. Results: The search yielded 1264 records and 48 were deemed eligible for full-text review. Seven studies were critically appraised, and 5 studies were agreed upon for inclusion in the synthesis. From these 5 results, 53 findings were extracted with associated illustrations and synthesized into 9 categories. Following meta-aggregation, 4 broad synthesized findings were developed: i) Changed family member roles, spousal relationships difficulties and family functioning when living with an EFR PTSD; ii) Spouses of an EFR with PTSD, may experience vicarious trauma, secondary trauma, and/or overburden as a consequence of protecting the family unit; iii) Children of an EFR parent with PTSD may experience secondary trauma, vicarious trauma and/or separation anxiety; and iv) Spouse's help seeking and support needs for their EFR Partners with PTSD, their children and for themselves. The first 3 findings received a low ConQual score due to low dependability and moderate credibility. The final finding received a moderate ConQual score due to low dependability and high credibility. Conclusions: The findings of the 5 qualitative studies included in the review showed significant mental health and functional impacts for family members of EFR with PTSD. Most studies focused on spouses, with some limited data on children. Two of the 5 studies included focused on the 9/11 World Trade Center terrorist attacks in the United States of America. The findings also indicate the need for targeted psychological and social services for EFR family members. Recommendations derived from the synthesized findings of this review include the need for further qualitative research, not only to deepen the understanding of the impacts and needs of EFR with PTSD on family members, but also to inform the design and provision of support services. Systematic review registration number: PROSPERO CRD42020196605.
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Emergency responders (ERs), often termed First Responders, such as police, fire and paramedic roles are exposed to occupational stressors including high workload, and exposure to trauma from critical incidents, both of which can affect their mental health and wellbeing. Little is known about the impact of the ER occupation on the mental health and wellbeing of their families. The aim of the current study was to investigate what mental health and wellbeing outcomes and experiences have been researched internationally in ER families, and to examine the prevalence and associated risk and protective factors of these outcomes. We conducted a systematic review in accordance with an a priori PROSPERO approved protocol (PROSPERO 2019 CRD42019134974). Forty-three studies were identified for inclusion. The majority of studies used a quantitative, cross-sectional design and were conducted in the United States; just over half assessed police/law enforcement families. Themes of topics investigated included: 1) Spousal/partner mental health and wellbeing; 2) Couple relationships; 3) Child mental health and wellbeing; 4) Family support and coping strategies; and 5) Positive outcomes. The review identified limited evidence regarding the prevalence of mental health and wellbeing outcomes. Family experiences and risk factors described were ER work-stress spillover negatively impacting spousal/partner wellbeing, couple relationships, and domestic violence. Traumatic exposure risk factors included concerns family had for the safety of their ER partner, the negative impact of an ER partners' mental health problem on the couples' communication and on family mental health outcomes. Protective factors included social support; however, a lack of organisational support for families was reported in some studies. Study limitations and future research needs are discussed. Progressing this area of research is important to improve knowledge of baseline needs of ER families to be able to target interventions, improve public health, and support ER's operational effectiveness.
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Emotional, cognitive and behavioral stress can negatively affect the performance of fire, rescue and law enforcement personnel responding to emergency situations. Impaired professional performance in these crises not only endangers the incident victims, all involved responders and their families, but potentially the lives and property of entire communities. This article describes the major administrative and clinical leadership of a hospital-based Social Work department in implementing one of the few statewide critical incident stress debriefing teams for emergency service personnel in the United States. It represents a model for program development by other organizations.
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The study estimates the relative importance of specific types of traumas experienced in the community in terms of their prevalence and risk of leading to posttraumatic stress disorder (PTSD). A representative sample of 2181 persons in the Detroit area aged 18 to 45 years were interviewed by telephone to assess the lifetime history of traumatic events and PTSD, according to DSM-IV. Posttraumatic stress disorder was assessed with respect to a randomly selected trauma from the list of traumas reported by each respondent, using a modified version of the Diagnostic Interview Schedule, Version IV, and the World Health Organization Composite International Diagnostic Interview. The conditional risk of PTSD following exposure to trauma was 9.2%. The highest risk of PTSD was associated with assaultive violence (20.9%). The trauma most often reported as the precipitating event among persons with PTSD (31% of all PTSD cases) was sudden unexpected death of a loved one, an event experienced by 60% of the sample, and with a moderate risk of PTSD (14.3%). Women were at higher risk of PTSD than men, controlling for type of trauma. The risk of PTSD associated with a representative sample of traumas is less than previously estimated. Previous studies have overestimated the conditional risk of PTSD by focusing on the worst events the respondents had ever experienced. Although recent research has focused on combat, rape, and other assaultive violence as causes of PTSD, sudden unexpected death of a loved one is a far more important cause of PTSD in the community, accounting for nearly one third of PTSD cases.
Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:593-602), an author’s name was inadvertently omitted from the byline and author affiliations footnote on page 592, and another author’s affiliation was listed incorrectly. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” The author affiliations footnote should have appeared as follows: “Author Affiliations: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Dr Kessler; Mss Demler and Walters; and Mr Jin); Institute for Social Research, University of Michigan, Ann Arbor (Ms Berglund); and Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Rockville, Md (Dr Merikangas).” On page 601, the first sentence of the acknowledgment should have appeared as follows: “The authors appreciate the helpful comments of William Eaton, PhD, and Michael Von Korff, ScD.” Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
Emotional, cognitive and behavioral stress can negatively affect the performance of fire, rescue and law enforcement personnel responding to emergency situations. Impaired professional performance in these crises not only endangers the incident victims, all involved responders and their families, but potentially the lives and property of entire communities. This article describes the major administrative and clinical leadership of a hospital-based Social Work department in implementing one of the few statewide critical incident stress debriefing teams for emergency service personnel in the United States. It represents a model for program development by other organizations.
A three-group quasi-experimental design contrasted the responses of rescue workers to the 1989 Loma Prieta earthquake Interstate 880 freeway collapse (n=198) with responses to critical incident exposure of Bay Area Controls (n=140) and San Diego Controls (n=101). The three groups were strikingly similar with respect to demographics and years of emergency service. The I-880 group reported higher exposure, greater immediate threat appraisal, and more sick days. The three groups did not differ on current symptoms. For the sample as a whole EMT/Paramedics reported higher peritraumatic dissociation compared with Police. EMT/Paramedics and California road workers reported higher symptoms compared with Police and Fire personnel. Nine percent of the sample were characterized as having symptom levels typical of psychiatric outpatients. Compared with lower distress responders, those with greater distress reported greater exposure, greater peritraumatic emotional distress, greater peritraumatic dissociation, greater perceived threat, and less preparation for the critical incident.
The psychological responses of two groups of fire fighters were examined following the performance of rescue work. Four types of responses were reported: identification with the victims, feelings of helplessness and guilt, fear of the unknown, and physiological reactions. Stress was found to be mediated by availability of social support, type of leadership, level of training, and use of rituals. Implications of these findings for preventive intervention measures are discussed.
A population of the fire fighters who had been exposed to a natural disaster were screened using the General Health Questionnaire 4, 11, and 29 months after a natural disaster. On the basis of these data, a high-risk group of subjects who had scored as cases and probable cases and a symptom-free comparison group were interviewed using the Diagnostic Interview Schedule 42 months after the disaster. The prevalence of posttraumatic stress disorder (PTSD), affective disorders, and anxiety disorders was examined. Only 23% of the 70 subjects who had developed a PTSD did not attract a further diagnosis, with major depression being the most common concurrent disorder. Comorbidity appeared to be an important predictor of chronic PTSD, especially with panic disorder and phobic disorders. The subjects who had only a PTSD appeared to have had the highest exposure to the disaster. Adversity experienced both before and after the disaster influenced the onset of both anxiety and affective disorders.
This study examined the effects of duty-related stress on police officers. Using a sample of 100 suburban police officers, an anonymous questionnaire requested demographic information and included a measure of duty-related stressors, SCL-90-R, the Posttraumatic Stress Disorder scale of the Impact of Events Scale-Revised, and a locus of control scale. Also assessed was whether Critical Incident Stress Debriefing was experienced. The results showed significant correlations between scores on duty-related stress, somatization, and symptoms of PTSD. 13% of the sample met the DSM-IV (1994) diagnostic criteria for PTSD. Results of the regression analysis showed the best predictors for the diagnosis of PTSD were associated with the factor of Exposure to Death and Life Threat, which corresponds to the DSM-IV AI criteria. Finally, 63% of the respondents stated that a critical incident debriefing would be beneficial following an extremely stressful event related to duty.
To examine the relationship of coping strategies and responses to intrusive memories with post-traumatic stress disorder (PTSD) and other psychiatric symptoms in ambulance service workers. Fifty-six ambulance service workers describe the most distressing aspects of their work and completed questionnaires designed to measure their coping strategies in dealing with distressing incidents. They also described their intrusive memories of particularly distressing incidents and completed a questionnaire designed to measure their interpretation of these intrusions and their responses to them. In addition, they completed the Post-traumatic Stress Symptom Scale (PSS; Foa, Riggs, Dancu & Rothbaum, 1993) and the General Health Questionnaire (GHQ; Goldberg & Hiller, 1979). Of the participants, 21% met DSM-III-R criteria for PTSD, and 22% met GHQ screening criteria for psychiatric symptoms. Wishful thinking and mental disengagement when confronted with critical incidents at work, negative interpretations of intrusive memories, and maladaptive responses to these memories (rumination, suppression and dissociation) correlated with PTSD severity. The results are consistent with the hypothesis that coping strategies and responses to intrusive memories that prevent emotional processing of the distressing event maintain PTSD. They also support Ehlers & Steil's (1995) hypotheses about the role of negative interpretations of post-traumatic intrusions in PTSD. A substantial subgroup of emergency service personnel may need support in processing distressing incidents at work and may benefit from information that normalizes post-traumatic symptoms such as intrusions.