[Senate Hearing 107-540]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-540
 
     CHILDREN OF SEPTEMBER 11: THE NEED FOR MENTAL HEALTH SERVICES
=======================================================================

                                HEARING

                               BEFORE THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

EXAMINING WHAT WE NEED TO DO TO HELP OUR CHILDREN HEAL FROM THE WOUNDS 
                          LEFT BY SEPTEMBER 11

                               __________

                             JUNE 10, 2002

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions








                          U.S. GOVERNMENT PRINTING OFFICE
80-498                             WASHINGTON : 2002
_____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpor.gov  Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001









          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio
           J. Michael Myers, Staff Director and Chief Counsel
             Townsend Lange McNitt, Minority Staff Director


















                            C O N T E N T S


                              ----------                              

                               STATEMENTS

                         Monday, June 10, 2002

                                                                   Page
Clinton, Hon. Hillary Rodham, U.S. Senator from the State of New 
  York...........................................................     1
Corzine, Hon. Jon, U.S. Senator from the State of New Jersey.....     3
Switzer, Anna, principal, P.S. 234; Scarlet Taveras, student, 
  High School for Leadership and Public Service; Mary Ellen 
  Salamone, Director, Families of September 11; Kerry Kelly, 
  M.D., Chief Medical Officer, FDNY; Dominick Nigro, Director of 
  Pupil Personnel Services, District 31, Staten Island; and Risa 
  Cullinane, Red Bank Regional School Based Youth Service 
  Program, Red Bank Regional High School, Little Silver, NJ......     5
Levy, Harold, Chancellor, New York City Board of Education; Brad 
  Gair, Federal Recovery Officer, FEMA; Charles G. Curie, 
  Administrator, Substance Abuse and Mental Health Services 
  Administration; Chip Felton, New York State Associate 
  Commissioner and Director of the Center for Performance 
  Evaluation and Outcomes Management, New York Office of Mental 
  Health; and Thomas R. Frieden, M.D., New York City, 
  Commissioner of Health.........................................    22
Pfefferbaum, Betty, M.D., Professor and Chairman, Department of 
  Psychiatry and Behavioral Sciences, University of Oklahoma 
  Health Sciences Center; Christina Hoven, M.D., Mailman School 
  of Public Health, Columbia University, New York State 
  Psychiatric Institute; Harold Koplewicz, M.D., Director, NYU 
  Child Study Center; and Pam Cantor, M.D., Founder and 
  President, Children's Mental Health Alliance...................    40

                          Additional Material

Statements, articles, publications, letters, etc.:
    Pam Cantor, M.D..............................................    55
    A New York City School District's Response to the WTC 
      Disaster...................................................    60
    Schuster, M.A., B.D. Stein, L.H. Jaycox, R.L. Collins, G.N. 
      Marshall, M.N. Elliott, A.J. Zhou, D.E. Kanouse, J.L. 
      Morrison, S.H. Berry.......................................    63
    The New York Academy of Medicine.............................    68









     CHILDREN OF SEPTEMBER 11: THE NEED FOR MENTAL HEALTH SERVICES

                              ----------                              


                         MONDAY, JUNE 10, 2002

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 9:10 a.m., in the 
Auditorium, U.S. Customs House, One Bowling Green, New York, 
NY, Hon. Hillary Clinton presiding.
    Present: Senators Clinton and Corzine.

                  Opening Statement of Senator Clinton

    Senator Clinton. The hearing is now called to order, and I 
thank you all for attending this field hearing of the United 
States Senate Committee on Health, Education, Labor and 
Pensions. I am very honored that Chairman Kennedy was so 
interested in this subject that he authorized this important 
field hearing on the critical subject of Children and September 
11th: The Need for Mental Health Services.
    Immediately after September 11th, Senator Kennedy convened 
a hearing to look at some of the long term mental health 
problems, and he is very well aware of the needs that we have, 
particularly here in New York. He was sorry that his schedule 
did not permit him to actually be here in person, but I wanted 
personally to thank him. I am, however, delighted that my 
friend and colleague, Senator Jon Corzine from New Jersey could 
join me today to look at what we need to do to help our 
children heal from the wounds left by September 11th. We 
obviously have to look at this problem comprehensively and to 
make sure that we have a seamless delivery of services for 
children in New York and New Jersey, anywhere that children 
were impacted.
    This hearing is the result of many months of hard work and 
dedication by a group of individuals who have been advising me 
on the needs of children post-9/11, and before we officially 
get started I want to thank them. Larry Aber of the National 
Center on Children and Poverty at Columbia University; Gail 
Nayowith of the Citizens Committee for Children of New York; 
Eric Brettschneider of The Agenda for Children Tomorrow; Ruth 
Massinga and Whitney Williams of the Casey Family Program; Dr. 
Irwin Redlener of the Children's Health Fund and two of the 
individuals who will be testifying today, Pam Cantor of the 
Children's Mental Health Alliance and Dr. Harold Koplewicz of 
the NYU Child Study Center.
    Now, tomorrow we will mark nine months since the day our 
world was turned upside down and the worlds of many of our 
children were changed forever. We cannot possibly understand 
the impact that this has had on families and particularly 
children, but today we are going to hear from people who have 
been directly involved.
    We know that, for example, the Fire Department has left 600 
children behind who lost a parent. Cantor Fitzgerald estimates 
that 1300 children lost a parent. I know that many of the 
witnesses here today will speak to those particularly tragic 
effects on our children.
    There were also a large number of children who were in the 
immediate area of the World Trade Center. They fled to safety 
led by courageous and heroic teachers, principals, child care 
providers and others, but they have not been able to flee from 
the images of that terrible day.
    We have other children in our community who were just 
beginning to regain their own perspective on the world when we 
had a plane crash in Belle Harbor, Queens. We lost many parents 
of children left behind in New York City and elsewhere, and of 
course there have been so many images of that terrible day that 
have repeatedly played affecting children who were vulnerable 
to begin with.
    In New York, the community has banded together to assist 
our children. We have had great leadership from Chancellor 
Levy, who understood the importance of assessing the mental 
health needs of children and we have had many nonprofit and 
philanthropic organizations working specifically on this issue. 
The Afterschool Corporation with funding from The New York 
Times Neediest Fund started Downtown After 3 to insure that all 
children in the downtown area had access to afterschool 
programs. The M&B Donaldson Institute started the Permanency 
Project to provide support services to children who lost a 
parent. The Jewish Board of Family and Children's Services has 
formed a partnership with Herzog Hospital in Jerusalem to learn 
from one another in order to provide school-based services to 
help create greater resilience in populations exposed to 
chronic threats. Each of these organizations have submitted 
written testimony that will become a record of this hearing.
    Today's hearing will focus on three major themes: 
Experiences of children, parents, schools and professionals who 
suffered great losses and trauma on September 11th; response of 
the public sector to mental health needs of both our children 
and our families; and research and best practices-what are the 
mental health needs that can be defined and what should we do 
to meet them.
    I hope that the hearing will help to illuminate an 
understanding about our mental health infrastructure and 
services available, how we can have a better public 
understanding, how we can educate parents, teachers and others, 
how we can improve our intergovernmental coordination to 
provide comprehensive services, and what we need to do to be 
prepared in the event of another terrible disaster.
    Now I would like to ask my colleague, Senator Corzine, for 
any opening comments he would like to make.

                  Opening Statement of Senator Corzine

    Senator Corzine. Thank you, Senator Clinton. First of all, 
I would like to thank you for convening this hearing today on 
this very special and important topic. There is no one in 
America who has shown more care and love for America's children 
as a leader in their behalf for our nation than Hillary 
Clinton, and I think this is just another statement of your 
effort to care for America's children.
    And I also appreciate Senator Kennedy offering us this 
opportunity to hold this committee session here in New Jersey 
and in the New York metropolitan area as we go through this 
problem. There is no question our lives have changed 
dramatically since September 11th. This is particularly true 
for our most vulnerable, our kids. No matter how hard we may 
try as parents, caretakers, teachers to shelter our children's 
pain, the world has tragically altered. In fact, terrorism is 
inherently a psychological phenomenon. That is the intent of 
terrorism, and to not recognize it in the context of our 
children I think is very, very mistaken, so I think that is 
what we are here today to review and study.
    While we have been increasingly vigilant to our nation's 
security needs, we must not lose track of the needs of our 
kids. The greatness of America is measured not just by the 
might of the military, but also by the strengths of her 
communities and the health of her children.
    I was very concerned to read the recent report by the New 
York City Board of Education which showed a significant number 
of New York City students are suffering symptoms of post 
traumatic stress disorder, generalized anxiety or depression. 
This is a critical indicator of the trauma faced by children as 
a result of the terrorist attacks and it is a clear warning 
sign of both the ongoing mental health needs of our children 
and the potential lifelong difficulties that they can face as a 
result of the trauma. These are warning signs that our nation 
cannot ignore.
    As many of you know, New Jersey lost almost 700 people--
fathers, mothers, and loved ones, in the terrorist attack of 
September 11th. That means that thousands of children in New 
Jersey as well as in New York are dealing with the loss of a 
loved one, many suffering silently. I know we will hear later 
from a teacher at Red Bank Regional High School in Monmouth 
County, which alone lost 160 people on September 11th.
    I am pleased today that we will focus on the special needs 
of those children that have been directly affected by the 
attacks. We need to determine if we are doing all we can in 
Government to help cope with this trauma and we cannot forget 
the hundreds of thousands of children in New Jersey alone, and 
many, many more in New York who, while not directly affected by 
the attacks, have nevertheless been traumatized. They, too, are 
vulnerable and their needs must also be addressed.
    So let me thank the witnesses, the many witnesses that are 
here, particularly the two from New Jersey; Mary Ellen Salamone 
from North Caldwell who lost her husband on September 11th and 
has three beautiful young children. She has worked tirelessly 
with the group Families of September 11th and founded Children 
of September 11th.
    I also want to thank Risa Cullinane, who runs the school 
based health clinic at Red Bank Regional High School in Little 
Silver, New Jersey, and I, too, want to thank Harold Koplewicz 
of the NYU Child Study Center. As Senator Clinton knows, I 
served on the Board of the Child Study Center for a number of 
years. He is a tremendous leader, a national leader on 
children's health issues and I look forward to his comments and 
those of all of the other panelists. You really have insights 
on a subject that we all care dearly about, and I hope that out 
of this hearing we may come to some practical suggestions with 
regard to actions that our nation might take in the context the 
Homeland Security Department has talked about and with regard 
to making sure that we have the resources that we need to 
address this issue in a serious and thoughtful manner so that 
our children go forward in a better way.
    So I congratulate, again, Senator Clinton, thank you very 
much for having this. There is not a more important issue for 
our metropolitan region than making sure that our children and 
their health is attended to, their mental health is attended to 
after September 11th and I look forward to this hearing.
    Thank you.
    Senator Clinton. Thank you very much, Senator Corzine.
    In order to provide enough time for each of our witnesses 
to offer his or her testimony, I will introduce the first panel 
together and ask each to offer the testimony one right after 
the other. Each has been given five minutes to present. That is 
not enough time. One of the problems in these hearings is to 
make sure we hear from a number of people that have something 
to say, we must ask them to be brief. It is a great privilege 
to have all of our witnesses here today and we will certainly 
include their entire statements in the record. After the 
witnesses, we will have a chance for questions.
    Our first panel will help all of us to understand the 
children's faces behind the statistics and the studies. Our 
first witness will be principal Anna Switzer of P.S. 234. She 
is one of the heroes who led all of her children to safety on 
September 11th.
    She will be followed by Scarlet Taveras, a high school 
student at the High School for Leadership and Public Service, 
who along with her classmates found herself running for safety 
on September 11th.
    Mary Ellen Salamone is the mother of three children who was 
widowed when she lost her husband Don, a Cantor Fitzgerald 
employee. She has become a very strong compelling voice on 
behalf of families. She now directs Families of September 11th.
    Dr. Kerry Kelly, who is the chief medical officer of the 
New York Fire Department has been a constant advisor to the 
Congress, particularly to my office, about what needs to be 
done to make sure that the needs of firefighters and their 
families, their children, are taken into account in everything 
we do, and I thank her for once again being here to help.
    Dominick Nigro is a community and school leader from Staten 
Island. Staten Island was one of the places in the city that 
was most tragically impacted by September 11th. Hundreds of 
children lost their parents. Finally, Risa Cullinane is the 
program director of the Red Bank Regional High School's Youth 
Services Program in Little Silver, New Jersey.
    So if we could, we will start please with principal Ann 
Switzer.

   STATEMENTS OF ANNA SWITZER, PRINCIPAL, P.S. 234; SCARLET 
    TAVERAS, STUDENT, HIGH SCHOOL FOR LEADERSHIP AND PUBLIC 
 SERVICE; MARY ELLEN SALAMONE, DIRECTOR, FAMILIES OF SEPTEMBER 
 11; KERRY KELLY, M.D., CHIEF MEDICAL OFFICER, FDNY; DOMINICK 
   NIGRO, DIRECTOR OF PUPIL PERSONNEL SERVICES, DISTRICT 31, 
 STATEN ISLAND; RISA CULLINANE, RED BANK REGIONAL SCHOOL BASED 
 YOUTH SERVICE PROGRAM, RED BANK REGIONAL HIGH SCHOOL, LITTLE 
                           SILVER, NJ

    Ms. Switzer. On behalf of the children of P.S. 234 I want 
to welcome you to New York City and thank you for focusing on 
the mental health needs of the children in our community.
    My name is Anna Switzer and I am the principal of P.S. 234, 
the closest elementary school to Ground Zero. I believe if you 
listen to our story, you will understand that we are in dire 
need of expanding and continuing mental health services for our 
students.
    At 10:30 a.m. on September 11th, my staff, children and I, 
ran out of our school as smoke and debris rained down upon us. 
Immediately before that, for a period of two hours, we waited 
as frantic parents picked up their children one by one. While 
waiting, we herded both children and adults together, finally 
ending up in the basement in an effort to find a safe space 
within our building. As this happened, teachers sang songs, 
read stories, shut the blinds on the windows facing the Towers 
and above all, remained calm as alarms went off, lights 
flickered and the building trembled.
    Without benefit of radio or news, we were open to the 
terrible rumors that were circulating. We knew only that 
something awful was happening in the place where our children 
lived, went to school, played in the parks and thought of as 
home. Finally, at 10:30 on or own without benefit of police or 
any security, we decided we had to leave and walked our 
remaining children two and a half miles north to P.S. 41. Most 
of us managed to get out just as the second tower collapsed and 
smoke turned our day into night. In total darkness our youngest 
children and their teachers were told to run for their lives. 
The remaining few of us watched them disappear into the black 
opaque cloud. Those fleeing turned around to see the rest of us 
pushed back into blackness, having no idea what befell us or 
whether there was even a school still standing. Worse were the 
other horrific scenes that too many children witnessed that day 
as they fled from the towers.
    It was one of our children that uttered that now famous 
line, ``Look, the birds are on fire.'' The truth of what he was 
seeing was too awful to understand.
    Eventually, miraculously, we managed to find refuge. Over 
the longest hours imaginable, we waited for our families to 
safely claim their children. Thanks to the teachers, 8,000 
school children were safely evacuated that day from downtown 
New York schools.
    We did not realize that this was the beginning of an 
odyssey that would take over six months. For our school 
community, this crisis has lasted well beyond the 11th. Our 
families, many of them unable to return to their homes, began 
to rely on the idea of our school as a safe haven and the 
community's glue. We only slowly understood just how long and 
how complicated it was going to be simply to go back to our 
building.
    What saved us during this year was our relationship we had 
with our extraordinary school psychologist, Dr. Bruce Arnold, 
and the services he was able to provide for us. Bruce, the 
teachers, parents and I had worked together for ten years 
helping our children and families in need. We had a very strong 
relationship of mutual trust and respect. Bruce arrived on the 
11th and has stayed close ever since, working with our 
teachers, a counselor and parents, he gave us the tools which 
enabled us to help our children. Through weekly parent 
meetings, almost daily teacher meetings, support groups, 
surveys, letters, he and the counselor supported our 600 
children and families through the difficult times that were yet 
to come.
    For many months we were out the anchor of our community, 
our school building. Exhausted and anxious, we set school up 
for 600 children again and again. Our first new school, P.S. 41 
was welcoming, but already at capacity. As many as 90 of our 
kids were in one room without benefit of cafeteria, gym or 
yard. After four weeks we moved to our next home, an abandoned 
parochial school. The Board of Education was Herculean in its 
efforts to get it ready for us, but, once again, the task of 
making it ready for a school was primarily the job of an 
unflagging, increasingly-tired staff and dedicated parent body.
    We stayed at St. Bernard's for four months. We found we had 
additional challenges to meet and I found I spent the next four 
months as principal wearing the ever-changing hats of 
negotiator, counselor, general contractor, goods purveyor, 
mover, designer and even upon occasion educator.
    It was our constant worry that our community would fragment 
or fall apart on the issue of our return. Who could assure us 
our beloved 234 was a safe place for children to be? Did each 
of us have to become an expert in asbestos, lead and dioxide 
poisoning? Again, thanks to Dr. Arnold, we found a way to build 
consensus, allay fears and return home.
    Our return on February 4th was the highlight of our year. 
The joy was palpable. Unfortunately, it is become increasingly 
clear that merely wanting the normalcy of our lives is not 
enough to make it happen. We collectively experience the shock 
of a loud noise, a plane too low, a sudden announcement over 
the loudspeaker. We hear about kids' nightmares, their 
unwillingness to go to large public places, their avoidance of 
the subway, their fears of flying. Two weeks ago we found 
ourselves unwilling to go on our annual field day. We canceled 
all our subway trips for the rest of the year. In announcing 
this, we found ourselves thrust right back into the fears and 
terror of September 11th.
    In school, many of our children appear to be coping. 
However, in our own surveys 30 percent of our kids are asking 
for additional support. They are very worried about their fears 
for the upcoming year. The communities are suffering, families 
are not doing well. At meetings in this charged atmosphere, 
parents and teachers are looking for guidance about how to 
relieve the stress and tension and how to help their kids. I 
hear parents who are unwilling to allow their kids to go two 
blocks to the movies, accompanied by their grandparents because 
of fear of being separated. I know families that have mock fire 
drills and escape routes at home to settle their children's 
fears.
    My kids write about the 11th when they do their summer 
essays for camp. Before the 11th, Tribeca was a small village; 
everyone knew each other. The children were always safe. This 
was a result of pioneer New Yorkers willing to settle downtown 
and actively pursuing urban life. I had the privilege of 
watching the neighborhood grow its first library, soccer league 
and even the first coffee shop.
    In the shadow of so many tall buildings, a residential 
Mecca was created. Our community and children and adults alike 
need to learn how to regain our Mecca and the productivity of 
their lives. Our children and families have the right to grow 
up whole and go through their daily tasks without fear.
    Please know at this time I have no commitment of funds for 
mental health services for the fall. Thank you for listening. 
Thank you for your efforts in supporting us and thank you for 
your efforts in securing financial assistance for us and I am 
happy to answer any questions that you have.
    Senator Clinton. Thank you very much.
    Ms. Taveras?
    Ms. Taveras. Good morning, Senator Clinton, Senator 
Corzine. Thank you for the opportunity to testify on behalf of 
all New York City students.
    My name is Scarlet Taveras. I am a student at the High 
School for Leadership and Public services. The World Trade 
Center concourse was our place to hang out. We had a beautiful 
view from our classroom and just being down here made us feel 
great.
    On September 11th everything changed. The downtown area, 
known for its beauty and economic status as well as its level 
of safety became a very dark and scary place. Seeing the Towers 
in flames, buildings collapsing, people running, crying, 
bleeding, vomiting, dying and giving birth is more than I or 
anyone should be asked to handle.
    The events of the last nine months have not been easy for 
New York City children and young adults. The effect of being 
attacked by air and anthrax and seeing planes fall accidentally 
have caused us to now experience what we now refer to as post 
traumatic stress disorder. The lives of many of us have been 
changed dramatically. One of my friends has moved from a high-
rise apartment where she lived on the 17th floor to an 
apartment on the first floor because the sound of airplanes on 
the high floors terrorized her every moment. I have seen 
students go from an A average to a C average.
    Many students are going through major depression and cannot 
perform at school or home yet we are required to maintain the 
same academic standards in school. Many are able to overcome, 
but there are more who cannot. Are we considered failures?
    Students at my school, including myself, have seen an 
increase in anger and aggressive outbursts. Sleepless nights 
are the norm. Sleeping instead means we have nightmares, so we 
find solace on the Internet where we are able to continue 
communicating with each other, sometimes many hours into the 
night, which then makes it difficult to wake up in the morning 
and get to school on time. Some call it irresponsible, but that 
is how we cope.
    Does anybody care? Are we considered important? What else 
can we do when we cannot sleep? The worst is when some of our 
peers avoid the situation and say they are all right when they 
are not. What about our concerns about the air quality? I know 
we hear everything is okay, but what about ten years from now? 
Will anyone listen then?
    Leadership and Public Service is a great school helping 
students cope with the events. Some of our students have 
participated in the Environmental Civics Club where they 
planted trees and flowers in our local city parks as a sign of 
rebirth. Many companies have supported us by donating things 
such as books and computers. Local flower shops donated plants 
in order to make our school feel more pleasant and to insure 
clean air. We felt the need to give back, so we started a 
knitting club and donated the garments we made to those less 
fortunate than us in homeless shelters. These activities helped 
us greatly, but we still need more.
    We would like chiropractors to help relieve our stress, 
more knitting supplies, more counselors to talk to, more 
artistic activities for students to express themselves and 
relieve their anxieties. Adults around Ground Zero are not the 
only ones affected. All students and teachers need help and 
services.
    There were many heroes that day, but the news has not shown 
the teachers who took us home, the students handing out towels 
to the ashen refugees, our principal who evacuated us quickly 
and safely. There are many campaigns to help the families of 
firemen. Please do not forget the survivors who struggle every 
time a plane flies buy.
    I am happy to answer any questions.
    Senator Clinton. Thank you very much.
    Mary Ellen Salamone?
    Ms. Salamone. Good morning, Senators. My name is Mary Ellen 
Salamone and I am from North Caldwell, NJ. On September 11th my 
husband was killed when Tower One of the World Trade Center 
collapsed. He worked on the 104th floor for Cantor Fitzgerald. 
John was daddy to our three beautiful children; our two sons, 
aged 6 and 5, and our daughter who is 3. That is the hardest 
part for me to get through.
    Thank you, Senator Clinton, and Senator Corzine for the 
honor of participating in this panel. I hope to call attention 
to some of the issues and challenges facing our children that 
are of great concern to us as parents.
    I am a director of the organization called Families of 
September 11th. We have launched an initiative entitled 
Children of September 11th and have been meeting with parents, 
schools, outreach programs and charitable organizations in an 
effort to aid children affected by the attacks. As a group who 
has family members in over 40 states we must aggressively 
stress that while although this metropolitan area indeed 
sustained the greatest loss of life, there are children all 
over this nation suffering from the loss of a parent on 
September 11th.
    Abundant attention and money is being dedicated to areas 
hardest hit, so to speak. Despite living in West Essex, a 
community of six neighboring towns where a great number of 
residents work in New York, my children are the only ones who 
lost a parent. Certainly they along with a two-year-old boy in 
Massachusetts and the teenager in California deserve the 
benefits of all services and programs offered to aid children 
effected by the attacks.
    It is becoming clear to all that post traumatic symptoms 
seem worse for the children now left behind. Grief over the 
loss of their parent is exacerbated and prolonged due to the 
violent nature of the cause of death and the persistent media 
attention. While it is important for our nation to remember 
these tragic events, incessant focus on the death and 
destruction forces our children to relive September 11th every 
day. They need to be able to take a step forward. Our children 
need it to finally be September 12th.
    So how do we help them heal? Besides working with purveyors 
of the media to curtail the repeated broadcasts of the attacks, 
which I stress, we must find what is effective to reach as many 
children as possible. Traditional models of grief and 
counseling are simply not working. Input we have received 
consistently reports that families with children are not taking 
advantage of available counseling services. Many factors 
contribute to this reality, including time constraints, the 
stigma of mental health counseling and grief overload. Many 
newly widowed parents are still engulfed in their own grief, 
rendering them unable to handle the commitment of counseling 
intervention for their children and many kids just do not want 
to go.
    So if traditional modalities are not effective, then we 
need to be inventive. Programs must be developed which are 
interesting to children, yet convenient for parents, and 
outreach in this instance is essential. A lot of the outreach 
programs we have spoken to have said that there are federal 
monies available to them, but have restrictions on the outreach 
that they are allowed to do to families. Many parents have not 
necessarily sought the services of a social worker, but have 
spoken to and accepted services from case workers coming to 
their home.
    I can tell you what is not effective in an outreach program 
and that is the introduction of an individual without adequate 
experience or with less knowledge of available services than 
the parent already possesses. This has been a huge error 
committed by many well-intended post-9/11 programs and has 
served only to alienate families further.
    Outreach should also be an essential component of services 
offered by our children's schools. School systems need to 
realize the fragile state of many parents and they should take 
the initiative to establish frequent contact with families, to 
share information on the well-being of children, both at home 
and at school. Otherwise, it is likely both parents and 
teachers will assume that all is okay, when in fact we have 
children that are suffering.
    If families remain hesitant to pursue direct services, then 
we must pursue indirect intervention. It is counterproductive 
on any level to have a guidance counselor or crisis 
intervention specialist in schools or programs that families 
are choosing to avoid. It is necessary that children 
traumatized by September 11th be handled with sensitivity by 
all those who come in contact with them on a daily basis. 
Symptoms of grief and traumatic stress do not necessarily 
surface in a child when a counselor is present, nor do they 
fade when a counselor is unavailable.
    Traumatic loss education and crisis intervention training 
should be offered and even required for all those responsible 
for the care of children in schools or day care facilities. How 
daily situations are handled will either cause or correct the 
problems our children face every day. In-service education to 
teachers, day care aides, coaches and even parents is a 
necessary component of any plan to help heal our children.
    Another area of special concern for parents is how 
September 11th, 2002 will be addressed in schools. In 
consideration of all the studies that demonstrate that symptoms 
of traumatic stress increase with repeated exposure to the 
triggering event, the mental health community, our Government 
and schools must work collaboratively to issue guidelines for 
all schools planning remembrance events and parents must 
certainly be given an opportunity to know of these plans 
beforehand so they may make an informed decision as to whether 
or not to send their children to school that day.
    There are many other children falling through the cracks, 
such as children with special needs who lost a parents in the 
attacks. Raising a physically or emotionally challenged child 
is a difficult task for a two-parent home and simply 
overwhelming for a newly widowed single parent. Many 9/11 
families with children with special needs fall above income 
requirements for State sponsored services, yet they do not fall 
within the guidelines for additional assistance from charitable 
organizations. Scholarships have been developed for college 
educations, but there is no assistance currently available for 
additional uncovered services a challenged child might require. 
Children with attention deficit disorder and other disabilities 
who have lost a parent are faring poorly in school, yet there 
is no increase in supplemental services. We as an organization 
cannot stress enough that the needs of all children suffering 
from September 11th be fairly and adequately addressed 
regardless of location, language or ability.
    This hearing and this panel is a step in the right 
direction and I am so honored to have an opportunity to 
participate. I believe the needs of our children must be 
addressed without delay. The terrorists have already stolen the 
life of their parent or loved one, their security and their 
innocence. If we leave them unattended, the terrorists will 
have destroyed their chance at a productive future as well.
    We are not going to get a second chance to do this right. 
Thank you.
    Senator Clinton. Thank you very much.
    Dr. Kelly?
    Dr. Kelly. Good morning and thank you for the opportunity 
to appear before this committee today. I want to thank Senator 
Clinton for all her efforts in the past and her continuing 
interest in our Department.
    As Chief Medical Officer of the New York City Fire 
Department, I witnessed the devastation and human tragedy on 
September 11th. When faced with the loss of 343 members, we 
well understood that this tragedy would take a severe emotional 
toll on our entire Department. The men we lost that day were 
fathers, sons, brothers and friends and they left behind over 
600 children, some just born.
    In the days and months that followed, our surviving members 
continued to remain committed to the rescue and recovery 
efforts, working tirelessly to bring home their fellow members 
and the thousands of innocent victims of the attacks. In 
testimony before the Senate less than a week after the 
disaster, I explained our need for funding to provide crucial 
counseling services to our members and their families.
    Today I would like to describe how we address these issues 
over the past nine months and what challenges lay ahead for our 
department. Through funding and assistance from various 
agencies and organizations, we have been able to establish a 
network of counseling and family assistance services. The 
designation of the FDNY Counseling Services Unit as a 
participant in Project Liberty was key in getting us the funds 
we needed.
    With this funding, our counseling services unit under the 
direction of Malachy Corrigan has expanded its staff and 
developed new sites. In addition, funding from the Silver 
Shield Foundation has insured that every child of a deceased 
New York City firefighter, police officer, EMT and Port 
Authority police officer can be evaluated and treated through 
the NYU Child Study Program with Dr. Robin Goodman.
    We have also received assistance from renowned experts in 
the field of childhood bereavement and family counseling 
services, including Dr. Cynthia Pfeiffer from the New York 
Cornell Weill Medical Center and Dr. Grace Christ from Columbia 
University's Family Bereavement Program. They have been 
providing assessments and counseling services and will continue 
to serve our bereaved families in the months and years to come.
    Clearly, the needs of families change as time goes on and 
the impact of this event on a child of two months or a year 
will not be felt at this moment, but will be felt differently 
as time goes on. Funding from the Fallen Firefighters 
Foundation has enabled us to send our families a bimonthly 
counseling publication called ``The Link'' which provides 
ongoing counseling information. The foundation has also funded 
special programs for our families and continued education for 
our counselors and family liaisons. These family liaisons are 
firefighters who voluntarily help the families of the bereaved 
with practical concerns.
    In November, our Fire Department established a family 
assistance unit with its own Assistant Commissioner to help 
coordinate resources for our affected families. This unit 
provides assistance wherever possible to families of missing, 
deceased and active members and has developed a monthly 
newsletter for families that contains information about events, 
services and resources available to them. With the support of 
FEMA, the New York State Office of Mental Health and the New 
York City Department of Mental Health, we have also established 
programs in the communities where our members and their 
families live. Every member of our Department has received a 
letter sent to their home, outlining available counseling 
resources. We are expanding our efforts with a program called 
``The Other Side of the Firehouse.'' This will address the 
needs of spouses and with the funding from the United Way we 
have developed a booklet called ``Helping America Cope,'' which 
will serve as a tool to guide our families as they help their 
children cope with the tragedy. This booklet has information 
for parents side by side with activities for children that are 
designed to help them explore their feelings about the attack.
    Obviously, our surviving members, over 16,000 in number, 
have been deeply affected by this event. For every firefighter 
and EMT there is a family waiting at home wondering if their 
loved one will return home safely. In the post 9/11 world, the 
families of uniformed workers face new fears and have even 
deeper concerns for their safety. They have seen the haunted 
look of their loved ones after days of working tirelessly at 
the site. Children have witnessed their mothers and fathers 
standing on lines, saluting their fallen friends and they will 
forever have the terrifying images from that infamous day in 
mind.
    Our health services and counseling units have been meeting 
with experts from prior tragedies to better understand the 
needs of our members and their families after this tragedy. 
These experts include Dr. John Schorr, Dr. Betty Pfefferbaum 
and Dr. Carol North from the Oklahoma City Research Project, as 
well as Dr. Francis Murphy and Dr. Terry Keane from the 
Veterans Administration. They have helped us shape a behavioral 
health survey that will be given to all our members in the next 
month. This survey will help us to continue to assess the needs 
of individuals and the department as a whole.
    Clearly, the Fire Department's recovery will be an ongoing 
and lengthy process. The strengths and resilience of our 
members has been extraordinary so far, providing inspiring role 
models for the youngsters. Our members' mental and physical 
health is critical to the successful rebuilding of this 
Department and it is equally critical that we not forget the 
children and families that nurture these members at home. We 
must continue to support these families in every way possible.
    I would like to thank you for this opportunity to present 
this information and I would be happy to answer any questions.
    Senator Clinton. Thank you very much, Dr. Kelly.
    Mr. Nigro?
    Mr. Nigro. Thank you for the opportunity to be here today. 
We all have a story about September 11th, 2001; where we were, 
with whom, how we felt, what we wished we could do. We all 
remember the weeks after the tragedy, how we would greet 
friends and associates, tentatively; ``Is your family okay?'' 
These were our experiences as adults, but what were the 
experiences of children? This is a question we constantly ask 
teachers, parents and children themselves. Consistently the 
answer includes uncertainty, fear, sadness, anxiety, pessimism 
and isolation.
    I was asked to come here today to speak about the 
initiatives that Community School District 31 has developed to 
address the mental health needs that precipitated from the 
World Trade Center disaster. Community School District 31 
encompasses the whole borough of Staten Island. It is the 
largest School District in New York City and it is the second 
largest School District in New York State.
    Presently we have 43,719 students, as of Friday. The 
borough of Staten Island has 5 percent of New York City's 
population, yet on September 11th, 28 percent of the 
firefighters and police officers that lost their lives were 
residents of this borough. 285 of our students sustained the 
loss of a family member or loved one. 54 staff members also 
sustained a similar loss. At one middle school, six boys lost 
their fathers. At one elementary school, 28 children suffered a 
direct loss.
    As you can see, our School District is hurting. These 
statistics, however, do not take into account the other 43,434 
students, many of whom are struggling in a post-9/11 world, 
with the security consciousness that has underlying fear and 
anxiety. This was made very clear to me when I granted 
permission for a five-year-old kindergarten girl to change her 
school. She was fearful that an airplane was going to crash 
into her school, it was four stories tall. We transferred her 
to a single story building.
    Her fears were compounded by her concern for her father, 
who is a firefighter. We have seen from the art work, and I 
brought some of the art work that is around here today, we see 
it in the art work of a second grade boy who writes on his art 
work in March, late March, six months after the attack and I 
quote: ``I dreamed I fell off a building. Other people were on 
the building. Someone was coming to save me and the people. She 
saved the people. She was going to save me last, but I fell off 
the building.''
    We have many such students. It is our mission to help our 
children, parents and staff deal with the many emotional and 
social concerns that we now face.
    Our approach to assist all students was supported by the 
recent study completed by Applied Research and Consulting and 
as I heard some of the witnesses say before me, and I think it 
is very important, it is our challenge to walk that fine line 
between overwhelming families with services, versus not 
providing adequate services to meet their needs.
    So what have we done?
    Our first concern on September 11th was that some students 
would come home to empty homes, so we developed a strategy to 
insure that all students were released to a family member. We 
set up two holding areas for students who were not picked up at 
school or at bus stops. Their safety was our primary concern. 
Fortunately, by 7:00 all students were appropriately released. 
But this was only the beginning. We knew that any strategy that 
we had planned would to have included interventions for 
students, parents and staff, and we knew this from our work 
confronting individual crisis. However, twelve members of the 
District's crisis team would not go far in addressing the needs 
of fifty schools.
    Our approach was divided into three phases. This enabled us 
to assist children and families in a variety of ways. Phase one 
began on September 12th when an assortment of crisis management 
resources were developed and distributed to our schools. These 
materials also provided direction to each school, as to how to 
assist students in understanding the confusion surrounding the 
disaster. Schools were instructed to use these materials to 
develop strategies that would address the needs of the 
children. School teams first developed a plan of action to 
assist all students and enable a plan to assist individual 
students who expressed a greater need. These schools developed 
age appropriate lesson plans, met with staff members and 
designated a crisis room for those students who needed 
counseling that day.
    But on September 13th, Staten Island's problems were 
compounded by a lockdown of the borough due to a report that 
police were pursuing a terrorist that had entered Staten Island 
via one of the three New Jersey bridges. This proved to be 
false, but further inculcated fear and anxiety into our 
families. 28 percent of our students attended school that day. 
Normally 93 percent of our students are in attendance.
    During October, phase 2 of the District's plan was 
implemented in which we partnered with local mental health 
community-based agencies. Mental health professionals from 
these agencies were available to discuss any concerns that 
parents and staff members may have had with respect to their 
children or any other family member. A plan was formed and a 
schedule developed so parents and teachers could meet with the 
phase 2 professionals in a designated space within the school 
building. Referrals were made to appropriate resources for 
those students that needed further assistance. Materials and 
resources were made available with our partnership with the 
Educators for Social Responsibility and through our own 
District's media library.
    Phase 3 of the District's response is called Project Cope. 
This was made possible through a federal serve grant. Project 
Cope is composed of ten intermediate school guidance counselors 
who are responsible for counseling all those children who 
suffer indirect loss in the corresponding elementary schools. 
Project Cope counselors receive crisis management training and 
were given the resources necessary to respond to the tragedy. 
These counselors began reaching out to their assigned schools 
in early January. The Project Cope counselors contacted those 
students who suffered a loss, but first they reached out to 
their families. By February, the counselors updated the 
District database to reflect the number of students in our 
district that sustained direct losses and that was the number I 
gave you before. Project Cope, of course, is ongoing.
    The Office of Student Services within District 31 has been 
in contact with a number of organizations throughout the 
country that were eager to assist the District's students. 
Organization and school districts donated the following items 
which were distributed to our children: 16,000 teddy bears, art 
supplies, musical instruments, gift packages, survival kits, 
professional sports and theater event tickets.
    Finally, we recently received a grant from The New York 
Times Foundation to assist our students in the aftermath of the 
World Trade Center disaster, because there were limitations on 
some of the ways we could use the existing funding. The funding 
from The New York Times will enable us to provide academic 
support and tutoring for those students who suffered a direct 
loss and have shown an academic decline compared to past years, 
and in addition to that, to prepare our teachers for the 
opening of school, we have contracted with a production company 
to develop a bereavement video that specifically is designed 
around the World Trade Center disaster. It will be shown to all 
of our staff members prior to the arrival of students in 
September, and it will help them to impart some of the skills 
that are needed for dealing with the anniversary.
    As you can see, we have attempted to address as many issues 
as we can with limited resources. The public has demonstrated a 
generosity that is beyond anything I could have ever imagined. 
Unfortunately, at a time when identification budgets are being 
cut nationwide, our School District is lacking the additional 
resources to effectively confront the unmet mental health needs 
that our students have developed as a result of the World Trade 
Center disaster.
    The anniversary of September 11th occurs five days into the 
new school year. Our challenge is to provide all of our 
students with the emotional, social and academic support that 
will insure that they are not revictimized by our failure to do 
so. This support will enable them to simply be children, not 
citizens anxious or fearful about every passing airplane or 
stranger.
    The message that we are trying to impart to our students is 
one of hope. Giving a sense that as the anniversary of 
September 11th approaches, the situation is different. But we 
are a stronger and more caring community as a result.
    One of our second graders expresses this message of hope in 
a poem called Spring and I would like to quote it now.
    ``Spring--''
    ``The sun comes out, so let's all shout. The flowers bloom, 
so you have to make room. You can sing a tune and get ready for 
June. Spring has arrived, and you do not have to hide.''
    Thank you.
    Senator Clinton. Thank you very much, Mr. Nigro.
    And our final witness on this panel, Miss Cullinane, 
welcome.
    Ms. Cullinane. Good morning. My name is Risa Cullinane and 
I am program director of our school-based clinic, The Source, 
at Red Bank Regional High School in Little Silver, NJ.
    I am pleased to be here today to talk about our school's 
response to 9/11. I would first like to recognize my colleague 
Mr. John Avella, who is here with me today. He's been our co-
leader in our program crisis intervention implementation and 
development.
    Immediately following the World Trade Center crisis, 
children began streaming into our office. There were those who 
were directly impacted and those who suffered the secondary 
trauma of the event. Approximately thirty students suffered 
direct losses; a parent, sibling or other family member. The 
numbers were not immediately apparent.
    We moved rapidly in our attempts to triage the students 
according to their needs. We debriefed over 170 students in 
total in the days following the tragedy. More than 100 of those 
were students suffering from secondary fallout, traumatized by 
the event on some level, although not suffering direct impact.
    The focus of my presentation is to elaborate on the 
application of critical incident stress debriefing in the 
school setting and to give concrete examples of how this model 
has continually been utilized as a needs assessment tool in our 
school. We adapted our existing skills to the unique demands of 
trauma and disaster response in the school-aged population.
    Red Bank Regional High School is comprised of three diverse 
sending districts. Local school districts can send their 
children to Red Bank Regional and we have several academies, 
including the Academy of Performing Arts and Information 
Technology. Prior to September 11th our school had a small 
crisis team in place, a diversity program and school-based 
counseling center. We had a crisis team consisting of twenty 
school employees trained in the critical incident response 
model and a District-wide policy had been implemented.
    We also had a pre-existing diversity program. In response 
to the World Trade Center events, our team implemented the 
following: We designed debriefing groups based on the impact of 
the crisis. We provided triage to students in need. We 
organized groups for students who were potential targets for 
bias crime. We had faculty meetings based on the NOVA and FEMA 
models. We sent letters home to parents to inform them of the 
services that we had both at our school and in the community. 
We gave our supplemental readings to our staff, families and 
students. We requested assistance from our local community 
agencies, including our churches, our mental health agencies 
and local funeral homes. Donations were solicited for families 
in need.
    We provided memorialization activities to provide closure 
for students and staff. One of the main reasons our crisis 
response was so effective was we had a school-based program in 
place. This program, known as The Source, is a haven for our 
students. We offer all forms of counseling, preventive health 
care, job coaching and recreational opportunities, all free of 
charge to all students and their families. There is no stigma 
and the program is well recognized by our students and our 
staff.
    On the day of the World Trade Center crisis, and during the 
weeks following the event, The Source was a place where kids 
knew they could receive care, counseling and help coping with 
the tragedy. Being a fixture at our high school, we were there 
every day for all kids affected directly or indirectly by this 
and by other types of trauma. Additionally, in the aftermath of 
9/11 I applied for a grant from the New Jersey Department of Ed 
and this grant award which we received allowed us to implement 
the following services for our affected students and staff:
    We were able to train an additional 60 staff members and 
community members in crisis response. We were able to implement 
a crisis and antibias reduction plan. We were able to expand 
our diversity training to include students and we were able to 
provide continued counseling services for more than 170 
students. Our staff worked diligently to meet our students' 
needs in the aftermath of the World Trade Center crisis and in 
doing so, we developed several hands-on programs and we did so 
involving our students. We had a student drama troupe, we did 
an art therapy program, we did the diversity training for our 
kids. We had reading/writing workshops conducted by local 
authors and we implemented a Tai Chi anger management program.
    I would like to take a moment to recognize a very special 
program developed by the students in our high school 
facilitated by my colleague John Avella. This program, called 
Teens for Teens, is a peer support group for students 
throughout Monmouth County who have suffered a direct loss. It 
is a support activities program seeking to provide some degree 
of normalcy in our abnormal times. Some activities included 
assisting parents who lost a spouse in the World Trade Center 
and implementing a Big Brother/Big Sister program for younger 
children who lost a parent.
    I believe it is critical to acknowledge those teens who 
have suffered indirect losses as well. The nature of 
adolescence is such that throughout the teen years children may 
experience several types of trauma. Any event which threatens 
their security may awaken repressed trauma. These teens are at 
high risk for post traumatic type reactions, including 
depression, anxiety and substance abuse.
    The counseling staff at Red Bank Regional is dedicated to 
providing all possible services for our students and our 
families. We are proud of our students our staff and the 
response of our community leaders in the face of tragedy.
    We live in a time of diminishing community resources and 
continuing uncertainty. Our commitment to provide followup 
services for all our affected youth must remain strong.
    Thank you.
    Senator Clinton. Thank you very, very much. I want to thank 
the entire panel. Senator Corzine, do you have any questions 
you would like to address to the panel?
    Senator Corzine. First of all, I thank all the panelists 
again for the specific comments. There is a lot of courage and 
incredible effort on people's part.
    I do have some questions. I would like to ask Ms. Salamone, 
you mentioned the media coverage and concern about its effects. 
This is not only to you, but other panelists you have worked 
with, how serious a problem is this? We have seen a number of 
quite highly publicized television programs and other events 
that have brought forth issues. Is this a recurring issue, is 
it something that is a concern among the community of the 
grieving?
    Ms. Salamone. It is a huge concern in the community, and I 
think I can illustrate it best by giving you an example of how 
the persistent media coverage affects the children directly 
affected. I as a parent obviously do not choose to have my 
children, I cannot watch coverage of the events and I do not 
choose to have my children relive it by watching it. My son 
came home from school one day in tears, saying that one--he 
says one of the students in his class--please do not write this 
in any of the papers--one of the students in his class had come 
up to him and said, ``They are only finding body parts at the 
World Trade Center and they are putting them in garbage bags. 
Do you think that that is where your daddy is?''
    When we found my husband in April and we buried him, my son 
went to school and did not say a word about it to anybody. When 
I asked him why he would not tell anybody, he said, ``Because 
the kids all they want to know is what bones they found and I 
do not think that is what I want to talk about, about my dad.''
    Whether or not parents are letting children watch coverage 
of the events and what is on TV all the time, by having adults 
watching it all the time, it is always a topic of conversation, 
and no matter where we go and what we do, you cannot escape 
dramatic portrayals, either in the paper, in pictures, 
verbally. We were at the diner on Saturday and the people 
behind us were taking about the latest recovery of body parts 
they found even though the Trade Center had shut and I was 
there with my three children.
    I understand that this is news and that it has to be 
covered, but there has to be at some point some sort of line 
that is drawn between covering the events and blasting it on 
the front page of the paper all the time. There could be on the 
news a recording of the events and in the background is the 
picture over and over again of the plane going into the 
buildings and the fire and the towers and as this poor student 
here was talking about, I mean, it is not just my kids who have 
to relive this every time they see it because they lost their 
father, there are other students that have to relive it that 
actually saw it themselves.
    It is a big problem. Our organization has been trying to 
work with the media and making sure that if they are going to 
be showing shows that are portraying very realistic depictions 
of the event, that there is some kind of warning prior to 
showing that, so that families can make a judgment whether or 
not they want their students to watch that.
    You see it all the time. ``Please be aware that you might 
want to change your channel.'' They do it for election results. 
If you do not want to know, do not watch this until it is all 
over. And the media has basically said, no. It is freedom of 
speech and this is our right to do it, and I was speaking to 
Senator Clinton before, the media has never really had to self-
edit themselves before and that is what they say, we have never 
had to do this before, but something like September 11th has 
never happened in our country before and certainly the 
magnitude of this disaster is like no other and they compare it 
to no other loss on our soil since the Civil War and certainly 
we can handle it differently, I think.
    I think persistent, and I am sure a psychologist can say 
that persistent media coverage forces our children to stay in 
the day that it happened and it does not let them move beyond 
that.
    Senator Corzine. Does anyone else want to comment from 
their own experiences?
    In addition to the children who sustained a direct loss, as 
she pointed out, the issue is there for all of the children, 
because they are extremely security conscious. We have the 
Brooklyn Bridge that closed a few weeks ago, some of our school 
trips were canceled. So the general student population in 
addition to those who sustained a direct loss is also bombarded 
in the media constantly.
    We come to school with lots of questions, lots of fears and 
lots of concerns. I agree wholeheartedly.
    Ms. Switzer. Could I just add to that? What is so 
interesting on the 11th is that as families were taking their 
kids and fleeing, large numbers of families sat on the street 
and watched the event, and we would go out and tell families to 
take their kids home. My point is that in some ways it was so 
compelling, these images are so compelling, that it was hard 
for the families to filter out what kids should or should not 
be seeing and I think that you cannot always depend on what the 
media could do, but what we can possibly do is provide 
guidelines for parents and really be proactive about what 
parents should be encouraging their kids to look at and what 
they should not be encouraging them to look at, because for 
many parents it took them weeks to turn CNN off and there were 
their kids watching it, and it was hard. So I think if we could 
really explain to parents and give them guidelines for what is 
going to happen, that would help with the anniversary.
    Senator Corzine. There were a number of specific 
suggestions that I think get translated potentially into public 
policy initiatives. Dr. Kelly talked about a family assistance 
unit. How do we go about knowing, from your view, how effective 
these particular programs are, because we also heard sometimes 
about responses that have interefered with families, I am not 
talking about the family assistance unit, but there were people 
who were well meaning but not necessarily delivering efforts 
that were actually solving or at least helping aid in the 
problem? How do we develop the checks and balances, the 
accountability to make sure that our initiatives are operating 
effectively?
    Dr. Kelly. Well, some of our programs were in place to 
begin with, because the nature of our job has always been one 
of danger. In a given year we often have between, we average 
between three and five deaths, so that unfortunately we have 
had experience with violent and sudden deaths of our members, 
so that some of the resources that were in place were pre-
existing because of that. What we found after this event is 
there was such a tremendous need on so many different levels to 
take care of this, that the family assistance unit was a 
response to problems of communication, of bringing information 
to so many different people.
    Clearly one of the problems is really what you outlined, 
that families at different times are ready for assistance and 
we see this with our members or surviving members, that some 
people were ready to talk and needed assistance on September 
12th and others are just now reaching out for help. The closure 
of the site has brought forth more people who need assistance 
and are looking for help, so I think our focus needs to be on 
long term, putting things into place that remain and stay 
available for people, and offering people a variety of 
resources, bringing those resources to the communities and 
helping the individual schools develop programs, because we ran 
into similar problems where some of the children who went to 
school had questions or comments made about body parts to them 
also and that is been an ongoing problem.
    Senator Clinton. Well, thank you. I just want to ask each 
of you to give us your top priority for us to follow up with, 
because I have heard several different things, both from Ms. 
Switzer and from Mr. Nigro. I have heard that you do not yet 
know if you have got any resources in place for next school 
year and that has to be a priority. If we could just quickly go 
down the panel and have each of you summarize what your top 
priorities are, especially in terms of what you think could be 
provided to assist you in dealing with the issues that you 
confront. Ms. Switzer?
    Ms. Switzer. I think you said it, we want to have assurance 
that we can continue our program. I also want to put a piece in 
about the teachers. I do not know if anyone has thought about 
what kind of services teachers might want to enable them to 
help themselves as well as the children.
    Senator Clinton. Scarlet, I have heard Ms. Cullinane refer 
to a Teens for Teens program. Is that something that might be 
helpful with you and your friends?
    Ms. Taveras. Actually, yeah. What we would like is more 
people to talk to. Because despite the fact there are some 
people, counselors, it is hard for teenagers and young children 
in my experience to open up to people, this might sound wrong, 
but elderly, more younger people to talk to kind of like to 
open up.
    Senator Clinton. Well, maybe one of the things we can work 
on is getting a better idea of how the Teens for Teens program 
works in the Red Bank High School and see if there are some 
models that we could use right here. Ms. Salamone.
    Ms. Salamone. I think because the magnitude of this 
disaster encompassed so many people, that it is easier to set 
up programs where there are so many people that are directly 
affected and more difficult where there is very few. I think 
outreach and education would be my most important issues I 
would think. Outreach to families who are at any stage of 
bereavement right know and coping and education, I think it is 
very important that not just counselors are trained, because 
there are a magnitude of people who deal with these children, 
all children every day and they all have to have some kind of 
training and crisis intervention knowledge to be able to handle 
these children. From the simple thing of a student who lost a 
parent who cannot cope with the national anthem being sung in 
his classroom. I think training is extremely important.
    Senator Clinton. I think that is absolutely right, and I 
especially like what you said in your testimony about training 
for all those daily situations that come up that people need to 
know how to respond to.
    Dr. Kelly?
    Dr. Kelly. Our challenge is I think to get continued 
resources for our members who are survivors and who continue to 
go about the work that they do as first responders facing 
continued possible terrorist attack, and helping their 
families, so The Other Side of the Firehouse, which is the 
program we developed needs to be expanded, as well as continued 
education for both the spouses and the children.
    Senator Clinton. I really want to underscore that, because 
clearly with the increased emphasis on preparedness and 
homeland security our front line soldiers, who are our fire, 
police, emergency first responders, are going to be expected to 
do a lot, and if we do not have these programs in place, it is 
not only going to be difficult on them, but as you so aptly 
said, the other side of the firehouse is also going to be under 
a lot of stress, so we need to focus on that.
    Mr. Nigro. Senator Clinton, of course we would like to know 
what the resources are for next year so we can plan to address 
the unmet needs, mental health needs of our children. One of 
the things I would like to get across is that we need some 
flexibility. When I met with different people to try to come up 
with a mechanism to try to address the academic needs of those 
children who showed a decline in academic performance, I had to 
go to the Foundation, The New York Times Foundation who were 
able to fund that, but most of the other State and Federal 
agencies did not have that in their description, so we felt 
that was an important ingredient, which ties in, Senator 
Corzine, to your statement, how do we monitor, and how do we 
evaluate a program.
    For us we monitor attendance, improvement or decline, we 
also monitor improvement or decline in academic performance and 
that is one way that we can gauge what those kids need in those 
two areas.
    The other thing I think is important is some kind of 
coordination. There are a lot of people out there, well-
intentioned with lots and lots of resources. We need 
coordination, otherwise we will be stepping over each other, 
and I do not think that helps anyone, and we need do not have 
the kind of dollars that we can afford that.
    Finally, I would like to say, as I mentioned, we gave out 
16,000 teddy Bears and loads and loads of gifts from across the 
country. That is stopping now. And what we have to be cognizant 
is what the needs of these kids are emotionally, we have to 
come up with some kind of master plan that follows these kids 
emotionally, because a teddy bear only lasts so long. So I 
would like to leave you with that.
    Senator Clinton. Thank you very much. Ms. Cullinane?
    Ms. Cullinane. I think the most important lesson we learned 
at Red Bank is we need to have something in place into adults' 
conversations, the anxiety level increases and we need to make 
this just a part of the daily lives of our children, so that 
they can go someplace and talk to somebody, a parent can find 
the resources that is needed of teachers feeling well trained. 
So these posters that are up here were part of an effort to 
begin that process, and we want to build on that and your 
suggestions will be very helpful as we do that.
    So let me thank you very much for being here and I look 
forward to continuing, as I have been privileged to do already 
for some of you, our work is being moved forward.
    Senator Corzine. Thank you all. You were so helpful.
    [Applause.]
    Senator Clinton. I would like to go ahead and invite our 
second panel to quickly come up and we can begin as soon as 
they are in place. The first panel had so many compelling 
stories and recommendations, that we obviously have gone over 
the time, but I think it was certainly well worth it and very 
important.
    As the second panel gets set up, I want to acknowledge New 
York City Council Member Alan Gerson. Alan, thank you very much 
for being here. Alan represents downtown and has been a great 
partner in our efforts to improve air quality. I thank Alan for 
being here with us.
    Mr. Gerson. Thank you, Senator.
    Senator Clinton. Now, our second panel as they are moving 
forward and taking their places are people who have many of the 
responsibilities for dealing with the issues that we have heard 
discussed on this first panel, and I would like to welcome 
them. I have been very pleased to work either with them 
directly or with many of their agencies as we have attempted to 
deal with 9/11. And, again, I am going to introduce all the 
panelists, at the same time so that we can hear from them.
    Our first witness is Chancellor Harold Levy, the New York 
City Board of Education, and I want to acknowledge and 
recognize Chancellor Levy's superb leadership of the school 
system in the wake of 9/11. He will specifically be addressing 
the needs assessment that he had commenced, knowing full well 
that we were going to face some of the problems that we have 
already heard about, and it was a far-sighted and very 
important decision.
    Next witness will be Brad Gair, the FEMA Federal Recovery 
Officer for the World Trade Center and I have to publicly thank 
Mr. Gair, because he's been a friend and a true leader for all 
of us in New York. He has worked tirelessly to insure that New 
York gets the support that it needs from the federal 
Government, and I also wish to thank Joe Allbaugh, the director 
of FEMA who has been a partner as well, and I thank you for 
everything you have done, Brad.
    Charles Curie is the director of the Federal Substance 
Abuse and Mental Health Services Administration, so-called 
SAMHSA, that has been very helpful in giving us some of the 
resources that we have needed to be able to deal with the 
problems that we have heard discussed.
    Chip Felton, who is the Associate Commissioner for Mental 
Health is here representing the Governor and it has been a 
tremendous effort and partnership with Federal, State and local 
governments working together to try to deal with this 
unprecedented disaster.
    Finally, Dr. Thomas Frieden the City's new Commissioner of 
Health. We welcome you, Dr. Frieden, and you are here on behalf 
of the Mayor and I want to thank the Mayor and all those in 
City Government for your willingness to work on some of these 
issues and challenges we face.
    Let me now ask Commissioner Levy to begin the second panel.

 STATEMENTS OF HAROLD LEVY, CHANCELLOR, NEW YORK CITY BOARD OF 
 EDUCATION; BRAD GAIR, FEDERAL RECOVERY OFFICER, FEMA; CHARLES 
  G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH 
SERVICES ADMINISTRATION; CHIP FELTON, NEW YORK STATE ASSOCIATE 
    COMMISSIONER AND DIRECTOR OF THE CENTER FOR PERFORMANCE 
EVALUATION AND OUTCOMES MANAGEMENT, NY OFFICE OF MENTAL HEALTH; 
  AND THOMAS R. FRIEDEN, M.D., NEW YORK CITY COMMISSIONER OF 
                             HEALTH

    Mr. Levy. Thank you, Senator. This is an important 
footnote, an important punctuation mark in our understanding of 
what happened. I want to thank both Senator Clinton and Senator 
Corzine for convening this hearing. I think it is an important 
punctuation mark in how we think about what happened on 9/11 
and what to do to make sure in the future that we handle these 
kinds of situations in the most professional way, the most 
careful and sensitive way we can. I also want to compliment you 
on the panel that I just heard, quite extraordinary group. Very 
poignant, very thoughtful and people have clearly given this a 
lot of thought.
    I want to thank you for the opportunity to discuss our 
system's efforts to meet the mental health needs of our school 
children in the wake of 9/11. I believe that the school system 
has pursued an aggressive and thoughtful plan designed to 
confront and overcome the many challenges posed by this single 
horrific act of terrorism.
    The testimony by Scarlet, Anna, Dominick, provide 
compelling accounts of the many issues facing the New York City 
public schools following this tragedy and their words speak to 
the lingering impact on our school system on our children, as 
well as on the staff, and I thought Anna Switzer's point was 
absolutely well taken.
    We focus on the children and we forget the children lean on 
the teachers, on the guidance counselors and they themselves 
are traumatized by what has happened and they themselves have 
issues to deal with in their home lives of which this 
exacerbates the moment.
    I would be remiss if I were not to recognize the 
outstanding performance of the entire school community in its 
initial reactions to the events of 9/11. The school leadership 
and staff took students through the streets to safety and 
remained with many students into the early hours of the morning 
to insure that all children were safe and accounted for. You 
heard the testimony of the Deputy Superintendent for at Staten 
Island. The same could be said all around the City. It was an 
extraordinary day and people really rose to the occasion, and 
it is something that brought the professionalism in the school 
system really to bear.
    I would make the observation as I think back on that day. 
There were about 75 principals who, for whom this was their 
third day on the job. A hell of a way to start your career as a 
principal. What they did, interestingly, is they rose to the 
occasion because they had a choice. I worried about how all of 
these many, many new principals would be able to lead their 
buildings on that day they learned how to lead their buildings. 
They made decisions all day long.
    Sure, I sent an e-mail saying today we will allow parents 
to pick up their kids. Today, unlike other days, the parent 
comes in in the middle of the day, give the kid. Today, unlike 
other days, when the buses go around and deliver the kids, they 
have to give them into the hands of an adult, not just to leave 
them on a corner. Because we do not know when the parents will 
be there.
    The thing I learned was the strength of our family 
structure. Much stronger than I think anyone might have 
considered in advance.
    I was worried about being left with orphans by the end of 
the day, not children who had merely lost one parent where 
there is a two-parent family, but children who had lost either 
their only parent or both parents and all the children were 
cared for by the families. Although we made provision 
immediately talking with Family Services, we did not need to 
avail ourselves of those services.
    There are many unspoken heroes in this.
    Within hours of the disaster, I spoke to the Oklahoma State 
Commissioner because I thought about Oklahoma City and was 
informed that based on their experience in Oklahoma City, the 
students outside the immediate Ground Zero area would also be 
psychologically impacted and furthermore, we could expect 
mental health problems to manifest themselves months later. And 
that conversation was really pivotal to my thinking and my plan 
to carefully monitor the mental health needs of students.
    We provided principals and teachers with guidelines for 
identifying and addressing the immediate needs of students, 
including recommendations for explaining the disaster to their 
children. Guidance counselors and staffs sought to assure 
students that they thought about their safety and well-being. 
Within a day we had a listing of mental health providers 
available for students and their families. With the help of 
Fran Goldstein and her staff, I also convened an advisory 
group, now called The Partnership for the Recovery of New York 
City Public Schools, comprised of mental health experts that 
continue to assist us; Harold Koplewicz, the NYU Child Study 
Center, Dr. Edward St. Vincent, people from all around the 
country who had volunteered their help and came forward 
quickly, and really gave us the best advice that we could 
possibly get from across the country.
    And because of our system's diversity we worked to 
implement strategies to reduce anger and violence in the 
schools very early on, to stem any potential increase in bias 
incidents. Materials on diversity, antibias and conflict 
resolution were distributed to the schools immediately. 
Interestingly, we also worked with Penny Harvest, this is the 
Common Cents program, we collected $720,000 in pennies from 
children in elementary schools primarily, but also the junior 
highs, 940 schools participated.
    It is not so much the quantity of money but the fact that 
we were able to give other children an outlet to participate to 
help to feel that they were not helpless in the face of an 
anonymous terrorist.
    We had very few incidents of bias or anger that occurred 
that could be attributed to the events of 9/11, but an 
interesting phenomenon there, too. In the days immediately 
after the 9/11 attack, we had about 20 or 25 incidents a day 
for two or three days, and I went around to all the schools 
where this was occurring and specifically to the schools that 
had significant Moslem population or children dressed in 
traditional garb, or who came from the Middle East.
    To make the point, these children have no sympathy for the 
terrorist, any more so than any of the rest of us, and as 
citizens, as Americans, our job is to ensure their safety and 
to make sure that they feel supported in the face of these 
threats, and a funny thing happened, because as soon as you 
said it, whether I said it to the teachers or the students, 
they said, ``Well, of course, we know that.'' But until you 
said it, we had incidents. But the moment it was said, it was 
as though they were innoculated and they took it in the form 
of, ``This is our job as citizens, and as Americans.''
    I took great pride in the way they responded. And I think 
it also speaks to our diversity and our strengths in our 
diversity that with this kind of horrendous act, we did not 
have significant ethnic unrest. Quite the contrary. There was a 
recognition that the terrorists have made a very bad error in 
uniting us.
    Prior to conducting any formal studies, we assessed the 
immediate mental health issues facing our Moslem school 
community by asking the Superintendent to survey the schools 
and determine the number of staff or students who lost a family 
member or relative or very close friend. This informational 
survey revealed in 700 of our 1100 schools, a member of the 
school community had lost a loved one. If you think about in 
your office, if someone dies, a family member dies, everyone is 
aggrieved by that, everyone feels the grief, feels the sense of 
loss. Here we had a situation where in 700 of our 1100 
buildings such a thing happened.
    I was able to write letters of condolence, provide 
information on accessing mental health services. But the data 
also enabled us to direct $5 million emergency Federal funds to 
schools near Ground Zero as well as to the districts with 
significant numbers of students who experienced personal loss. 
All superintendents in District level crisis response teams 
were provided training by the National Center for Children 
Exposed to Violence, Yale University and that was enormously 
helpful.
    After implementing these short-term strategies I wanted to 
insure that the long-term decisions were made after carefully 
examining research on the topic and not based on anecdotal 
information and intuition alone, and I was particularly struck, 
Senators, by the paucity of literature and the lack of research 
on the impact of disasters on large communities.
    There is actually a fair amount of literature about the 
immediate victims and their families and people who immediately 
escaped it. But not on the larger community, and that I think 
is, it was quite surprising to me, and it helped push me in the 
direction of the decision to insure that our experience in 
dealing with the disaster was well documented to guide others 
in the event of future tragedies.
    We commissioned Dr. Michael Cohen and the Applied Research 
and Consulting Group that he heads in collaboration with 
Columbia University School of Public Health, which was just 
wonderful in their quick and thoughtful and really very 
professional response to conduct a comprehensive needs 
assessment to determine the psychological impact of the attack 
on City school children. Great care was taken to collect the 
information in a scientifically validated manner six months 
after the attack.
    It was intentionally six months after, because what we 
wanted to do was see what was the continuing grief, what was 
the continuing psychological injury. A study was approved, 
recognized by the Centers for Disease Control and looked at 
psychological disorders beyond post traumatic stress disorder, 
such as agoraphobia, which is significant in a city like New 
York where hundreds of thousands of children travel to school 
on mass transit each day.
    The release of a study in May reported disturbing evidence 
detailing the extent to which last fall's tragedy still 
impacted school children across the city. The study found that 
students in grades four through twelve are experiencing serious 
mental health problems at a higher rate than expected after the 
attacks. In fact, we now estimate 190,000 children in grades 
four through twelve exhibit at least one mental health problem 
which may inhibit their productivity in school, which 
subsequently requires some form of intervention. These ailments 
and the percentage of students estimated to be affected are 
post traumatic stress disorder is about 10 percent; major 
depression, about 8 percent; generalized anxiety disorder, 10 
percent; separation anxiety, 12 percent; agoraphobia, 15 
percent; panic attacks, 9 percent, and generalized panic 
disorder, 10 percent.
    I put this out there for the proposition, you have to press 
how much of that data is background and how much of that 
preexisted. At least, that was my initial reaction and the 
answer to that seems to be these numbers are elevated, 
significantly elevated beyond anything that has been seen to 
the extent one has comparable studies, and there are not many, 
but what it also says is that we have a larger problem 
potentially in the country with these kinds of ailments among 
children in large public school systems. I think it is clearly 
more pronounced here and I think it is clearly the result of 9/
11.
    I am looking forward to reading the full report when it is 
published, but the question that comes to mind is the child who 
has continuing nightmares about towers or about things which a 
Freudian would not have trouble identifying too quickly. Or the 
child who is thinking about these things all the time, or is 
worried now about going into subways or does not really like 
taking elevators anymore or who reports they think about the 
towers and where are their parents repeatedly during the day. 
These kinds of things invariably are distracting from their 
school work, but much worse are the kind of ailment that we as 
a society need to give recognition to, to support the children 
and help them.
    While not surprising, it is particularly important to note 
that despite the students requiring mental health systems was 
not limited to Ground Zero schools. As presaged by the 
experience in Oklahoma City, students in schools outside of 
Ground Zero were psychologically impacted as they were more 
likely to have family members who were present at the World 
Trade Center.
    Unfortunately, too many students have not received a level 
of mental health services needed due to inadequate resources. 
Left untreated, these psychological ailments could compromise 
long-term educational and personal development in these school 
children. To bridge this gap we requested $40 million from FEMA 
to expand our current efforts.
    I want to join with Senator Clinton. FEMA director Joe 
Allbaugh has expressed support for our proposal, working with 
FEMA, New York State and New York City Department of Health to 
secure these funds and I want to publicly thank the director 
and his representative, Mr. Gair, for his commitment and the 
progress made by the Agency in addressing the system's other 
post 9/11 needs.
    In implementing our mental health plan we have to look 
beyond the traditional service models, and here I am a great 
believer in the value of community-based organizations and in 
the local school district being the one to contour how that 
should work. Local school districts need to have the 
flexibility to tailor individualized approaches that best fit 
the needs of their communities, utilize a combination of 
school-based health providers and mental health agencies. This 
are areas where if a child is labeled as needing mental health 
services, they will be reluctant. If you say to a parent in a 
community, ``Your child has a mental health problem,'' that is 
taboo they do not want to hear about it. However, if they say, 
``We think your child should participate in an after school 
program,'' and it happens there is counseling in the after 
school program, that is a whole different approach and I think 
in some instances of greater value.
    The way services are delivered depends heavily on each 
community's culture. Because some communities will not 
participate in activities labeled counseling, districts have 
sought some other approaches to develop programs. These include 
recreation, art and music programs, all which allow children to 
express themselves in more comfortable settings. You need only 
look at the arts program to look at the sort of release we saw 
in the poetry, the pictures and the music that came out of the 
school system. I got mounds of them. Children needed to express 
themselves, teachers needed to have them do it.
    Still, today, if you have children of a young enough age, 
you say, ``draw me a picture,'' the picture too often is of the 
Towers and the planes. Our mental health community can assist 
us by linking schools with community providers where 
established partnerships currently do not exist.
    While our capacity to implement these strategies requires 
assistance from FEMA, these monies do not cover long-term 
treatment. To provide the full range of services each child may 
require, consideration should be given to broadening our 
ability to use FEMA funding, child health insurance programs or 
other sources of funding for these purposes.
    As we move forward, we must insure that our students are 
provided with services needed to help them heal and begin the 
process of renewal. Each child must be given an opportunity so 
they may achieve to their highest potential and ultimately lead 
healthy and productive lives.
    Senator Clinton in particular has consistently fought for 
and delivered new resources to help fund many of our programs, 
helping deliver a world class education to our poor students 
and increasing the quality of our teachers. Your recent 
efforts, along with Senators Schumer, Corzine, Representatives 
Maloney, Nadler, Serrano and Sweeney to secure federal 
assistance from FEMA to help us meet the mental health needs of 
our students is another example of your strong commitment to 
our School District, and we thank you.
    This is what I have learned in the course of this 
experience, is the extraordinary strength of the professionals 
in the school system, the strength of the family structure in 
the face of these kind of extraordinary challenges, and also 
the depth of professionalism that we see in the school system 
and in the community based and mental health provider community 
generally.
    I do not know that I share with the parents who spoke 
before, I thought very eloquently, the issue, the need or the 
belief she has that the press has to discipline itself, because 
I think in that respect the press is responding to the societal 
need for information and to balance that. I know what that need 
to balance is about. I think what we need to do is to be 
sensitive to the children in particular but also the adults who 
are going to see these images, but not having assimilated it, 
not having responded to it and understood the moment, are still 
struggling with it. Those are people we need to be very 
sensitive to, whether they are young ones or older ones.
    I have seen children who responded by writing poetry and 
talking about it, wanting to watch every single image on TV, 
because that was the way they got into the news. This was their 
eye-opening event. Then I have seen other children and other 
adults who just do not want to talk about it still today. And 
our society is both blessed and cursed with memory. Blessed to 
have moments like this where we try to attempt healing and in a 
sense cursed for those who relive this on a daily basis. That 
in my judgment is the hard part.
    I say again, I am very grateful to both of you for having 
convened this. I think these are important moments for us to 
try to assess how we do this. Thank you.
    Senator Clinton. Thank you very much, Chancellor. I 
apologize for our apparently irritated microphone. It has a 
hard time being consistent today, but your testimony was 
extremely eloquent and I know that it will help guide us and I 
appreciate your being here with us.
    Mr. Gair?
    Mr. Gair. Thank you, Senator Clinton, Senator Corzine. On 
behalf of our director, Joe Allbaugh, I do want to thank you 
for inviting us to participate in this important hearing. You 
have my official testimony for the record. I think I will just 
summarize it, because we have a fairly simple role in this 
particular issue. I think it is more important to hear from the 
mental health experts and the subject matter experts.
    At FEMA we are not mental health experts, we are emergency 
managers, emergency responders. In this specific case, 
essentially our role is we are your banker. So far you have 
entrusted us with more than $6 billion of precious federal 
resources. You are considering supplemental appropriations that 
may give us another 2.75 billion and we want to assure you we 
will be not only good and caring bankers, but try to be smart 
bankers to help direct the funds to the programs that help all 
people recover from the disaster, but of course especially the 
children.
    FEMA programs are not really children specific. The 
children and families are direct beneficiaries of many things 
we do. I will highlight a couple of those that we have done so 
far. Through our normal programs we try to do everything we can 
to restore the school system in New York City back to pre-9/11 
conditions. We are working with the Board of Education, our 
partners, to provide the millions of dollars of funding 
necessary to clean the schools and continue to test the air in 
the schools and continue to meet the other disaster-related 
expenses that they incurred as a result of the disaster.
    Beyond that, we are now working with our partners at the 
EPA to begin to clean residences in lower Manhattan in order to 
add another level of assurance to children and families that it 
is safe to live here.
    Beyond that, we are working with our partners in the City 
and the State to restore infrastructure, hopefully improve 
infrastructure so that life in Manhattan can return to normal 
and perhaps even be better than it was before 9/11. Most 
relevant to your hearing today is our crisis counseling program 
and this is a program that we find is needed in almost every 
disaster, but here even more so than ever. Shortly after the 
disaster we awarded what we call immediate crisis counseling, 
grants, in New York, New Jersey, Connecticut, Pennsylvania and 
Massachusetts. This was to provide the very, very short-term 
crisis counseling needs and in New York that allowed for the 
establishment of Project Liberty and all the great work they 
have done.
    More recently in late May, we awarded and additional grant 
to the State of New York for $132 million for what we call our 
regular crisis counseling program. That will insure that the 
process continues, that the needs continue to be met and the 
services continue to be provided well into next year, and we 
recognize that that is a start. We are looking to our partners 
at the local, State and Federal level to tell us what else is 
needed, what more we can do to look beyond not only the 
deadlines for our normal programs, but to provide more 
flexibility in our programs to meet the more therapeutic needs 
that may be evident among our children of New York.
    In closing, I would just like to tell you, remind you and 
assure you, that children's issues are absolutely the primary 
concern for Commissioner Allbaugh and to our Federal family and 
we continue to working with you and cooperate amongst ourselves 
to deliver these invaluable services. Thank you.
    Senator Clinton. Thank you very much.
    Mr. Curie? And thank you for your brevity as well, Mr. 
Gair. You have done this before, I can tell. Thank you.
    Mr. Curie. Good morning. Thank you, Senator Clinton, Senate 
Corzine for inviting me to appear before the committee today 
and thank you both for your abiding interest in children's 
meant health.
    It is my privilege and honor to serve this Administration 
and Health and Human Services Secretary Tommy Thompson as the 
administrator of Federal Substance Abuse and Mental Health and 
Human Services, or SAMHSA. Over its ten year history, SAMHSA's 
programs have shown that prevention, early intervention and 
treatment for mental health and substance abuse disorders pay 
off in terms of reduced health care costs, educational and job 
losses, suicide, homelessness, crime and sometimes violence. 
When it comes to the lives of children, SAMHSA-supported 
programs are helping to fulfill the promise of productive 
independent fulfilling adulthood for millions of children 
experiencing or who are at risk for mental illness.
    Today the need to achieve that mission can never be more 
important. The opportunity has never been greater, particularly 
when you focus on the mental health implications. In the wake 
of September 11th, America's consciousness about the emotional 
trauma of man made fear has been heightened as never before. 
The number of children affected by trauma of this kind has 
never been greater. Today we have the obligation to remind 
parents and caregivers that seeking help to recover from the 
mental health effects of trauma is not shameful. We have the 
opportunity to help in the stigma surrounding mental illnesses, 
such as depression, anxiety and post trauma stress disorder 
that can result from trauma and we have a responsibility to the 
children of New York that will strengthen their resilience and 
promote their mental health today and tomorrow.
    This hearing can be a very important part of that effort. 
Already today hearing from the first panel, and it was very 
moving I was humbled hearing from those individuals, the 
parents, children and educators that are on the front line 
teaches us a lot about lessons to learn that we need to apply.
    The word ``trauma'' has meaning to both body and mind. Most 
of the time we think of trauma as a critical or serious bodily 
injury or wound. From my perspective as a social worker, 
though, trauma means a something a bit different. When I speak 
of trauma, it can have a lasting psychological effect.
    Emotional trauma, just like physical trauma, can be caused 
by nature or by human hands. It can be the result of natural 
disasters like floods or earthquakes, or it can be the 
emotional trauma from physical or sexual abuse or by physical 
injury or chronic illness. But more than any other cause of 
trauma today, I am talking about the potential severe and 
lasting trauma of witnessing or experiencing violence, the 
trauma of losing families, friends or even a sense of community 
safety. In a word the trauma of terrorists.
    When it comes to physical trauma, we treat it readily. We 
set broken bones, stitch and bandage wounds, provide 
rehabilitation to heal. We can and should do no less for 
emotional trauma.
    We have the scientific knowledge, the evidence base from 
which to act. We know an increasing number of risks and 
protective factors that help or hinder the ability to bounce 
back from traumatic experience and we know how to help promote 
resilience even for those at greatest risk, through mental 
health service.
    From both a physical and emotional perspective, children 
have the greatest capacity for healing and the greatest 
capacity for scarring as a result of this trauma.
    The vast majority of children who experience trauma, 
particularly catastrophic events, are able to cope with the 
event and its consequences by themselves or with support from 
family, peers or other adults. Other suffer worries and bad 
memories that may fade with time, yet for some the trauma can 
precipitate chronic, serious mental health issues, such as 
depression, chronic anxiety, PTSD. Some youth may seek drugs or 
alcohol to cope with these emotional difficulties.
    When it comes to trauma related to September 11th, the 
effects on children in New York City are starkly evident in a 
the startling report in the New England Journal of Medicine, 
Chancellor Levy quoted statistics from those studies. Based on 
reports from parents, the study found 35 percent of children 
had one or more stress symptoms--nightmares, sleep problems, 
distractibility, withdrawal, anger that could point towards a 
more serious problem such as PTSD. 47 percent were worried 
about their own safety or the safety of a loved one.
    We know PTSD has been present in more children than 
previously believed. Three factors have been shown to increase 
the likelihood children will develop PTSD. One, the severity of 
the traumatic event; two, the parental reaction to the 
traumatic event and three, the physical proximity to the event.
    In general, all studies find that children and adolescents 
who report experiencing the most severest traumas also report 
the highest level of PTSD symptoms.
    But post traumatic stress disorder isn't the only problem a 
child may experience in the wake of traumatic experience. The 
effects of trauma on the still developing body and mind can be 
significant and result in depression, anxiety, drug abuse and 
suicide attempts. That is why in the immediate aftermath of a 
traumatic event in the weeks following, it is important to 
identify the youngsters who are in need of more intensive 
support and therapy because of profound grief or some other 
extreme emotion.
    We owe our children with emotional wounds no less the same 
kind of support and caring, intervention and treatment that we 
routinely provide to those with wounded bodies. And the faces 
and the voices of children and adults from the first panel show 
exactly why.
    SAMHSA and the Department of Health and Human Services have 
been working with New York City and New York State in the days, 
weeks and months since the World Trade Center attacks. Within 
24 hours of September 11th, thanks to hard work by Secretary 
Thompson and departmental staff, both SAMHSA staff and $1 
million from the Department of Health and Human Services mental 
health specific resources were on the way. Within two weeks 
additional personnel and $6.2 million was made available to all 
nine affected jurisdictions. Within a month, another $20 
million was awarded. These dollar specific to meet urgent 
mental health needs were but a part of the much larger infusion 
of federal dollars Mr. Gair talked about.
    A few weeks later, SAMHSA convened a meetings for nine 
directly affected jurisdictions to share their experiences and 
to set an agenda for a national summit three weeks later. In 
the national summit, Senator Clinton, you and your staff were 
helpful in helping us find a place in New York City for a 
meeting here in November. Representatives from 42 states, five 
territories, the District of Columbia and two tribal 
governments made progress towards developing their own disaster 
emergency plans that include both mental health and substance 
abuse.
    At the same time, SAMHSA is identifying and disseminating 
information about programs that can serve as models for 
adoption or adaption in communities across the country. 
SAMHSA's traumatic stress initiative, which was an initiative 
begun in October 2001 provides federal support to include 
treatment and services for children who experienced trauma. 
Initially, that included trauma due to sexual abuse, physical 
abuse, other types of abuse. We were able to build on that 
network and on that program to incorporate the trauma now of 
terrorism.
    Here in New York the network includes the North Shore 
University Hospital Adolescent Trauma Treatment Developmental 
Center, Mt. Sinai Hospital's East Harlem Adolescent Traumatic 
Services Community Practice Center and Safe Horizons, St. 
Vincent's Child Trauma Center Continuing Care. And today I am 
pleased to announce that SAMHSA is making $11.4 million in new 
awards under this same initiative.
    Here in New York three additional organizations can be 
counted among the total of 18 grantees. New York University, 
Westchester County Health Care Corporation and the Jewish acts 
of terror and other disasters.
    In conclusion, I appreciate the opportunity and we 
appreciate the yeoman's work that has been done here in New 
York to help meet the crisis and determine the needs of 
children, parents, grand parents and caregivers who are 
affected by the World Trade Center attacks. Without question, 
we are learning over and over as we work to heal New York's 
children and families, that lesson that mental health is as 
precious as physical health. It is as much a part of our 
imperative as any physical communicable disease.
    We look forward to working with you and your colleagues in 
the Senate, not only to respond to the effects of trauma on 
children today, but also recognizing that we are not, we are 
far from finished yet that in the months and years ahead we 
need to keep pressing ahead and addressing these needs because 
we have only just begun seeing the evidence resolve. Thank you.
    Senator Clinton. Thank you very much, Mr. Curie.
    Mr. Felton?
    Mr. Felton. Good morning, everyone. I would like to thank 
Senator Clinton and Senator Corzine for the opportunity for me 
to discuss what New York State is doing to meet the mental 
health needs of children in the wake of the World Trade Center 
disaster. My name is Chip Felton, I am Associate Commissioner 
for the New York State Office of Mental Health and I currently 
oversee what has become the largest mental health relief effort 
in the history of nation. That is what is called Project 
Liberty.
    What I would like to do is begin my testimony by briefly 
reviewing how the activities of the Office of Mental Health 
have changed since September 11th and then I will speak in 
detail about how we are addressing the mental health needs of 
children through Project Liberty and also other related 
initiatives.
    The first part is really our traditional line of business 
at the Office of Mental Health. We oversee a public mental 
health system that serves approximately 400,000 adults and 
100,000 children and adolescents each year. The majority of 
these individuals require services because they are diagnosed 
with a mental disorder that has led to serious impairment in 
day-to-day functioning. For example, it is estimated that about 
70 percent of the children we serve in our public mental health 
system immediate criteria for serious emotional disturbance. 
New York's public mental health system follows a full continuum 
of care of children from the most intensive inpatient 
hospitalization through self-help oriented family services with 
a vast majority of children receiving mental health services in 
community settings.
    Also, the Office of Mental Health maintains an ongoing 
planning function and the purpose of that is to insure a system 
of care for children with severe mental health needs and we 
also fund substantial ongoing research to advance the evidence 
base for children's mental health services. The events of 
September 11th, though, required us to expand this focus 
dramatically beyond our traditional focus on individuals with 
severe mental illness to include the entire general population 
of New York City and the surrounding areas. Responding to the 
broad-based mental health impact of the terrorist attacks 
required the Office of Mental Health to mount a major new 
public health intervention which we accomplished in a few short 
weeks after the attacks. We are proud to have been able to 
launch Project Liberty quickly while at the same time 
maintaining our traditional roles and functions in overseeing 
and providing services to individuals with severe mental 
illness.
    So now to talk a little bit about Project Liberty. Project 
Liberty is a collaborative effort of the Office of Mental 
Health, local governments and over 100 provider mental health 
services. It is funded by the Federal Emergency Management 
Agency with program assistance from Center for Mental Health 
Services which is part of SAMHSA. In New York City, Project 
Liberty is jointly administered by the Office of Mental Health 
and the New York City Department of Mental Health, Mental 
Retardation and Alcoholism Services. The New York City Board of 
Education and also the Administration for Children's Services 
are formal participants in Project Liberty of New York City. 
And we really could not operate this program without the 
tremendous cooperation and collaboration between our federal 
partners and your City and County partners. This as well as all 
the other collaborations that happened since 9/11 I think are 
one of the outstanding reminders of the community resilience 
and capacity that we have here in New York City.
    Project Liberty provides free supportive counting to anyone 
affected by the events of September 11th. It also funds a range 
of public education activities, to help people identify, 
understand and cope with their reactions to this traumatic 
event. Project Liberty staff also help identify people who 
would benefit from more specialized mental health services and 
links them to those services. For instance, in terms of public 
education, the posters that we have here that the mental health 
administration has developed, this is an example of sort of a 
public private partnership. I believe some of the funding has 
come from the Hasbro Foundation and Project Liberty is helping 
to underwrite the distribution of this child educational 
campaign.
    The scope of Project Liberty is truly enormous. To date 
over 104,000 individuals have received direct face to face 
counseling and educational services through the program. This 
number is increasing rapidly. Three weeks ago, when we had our 
wonderful announcement from FEMA of $132 million followup 
grant, that number was about 80,000, so we are continuing to 
serve many, many individuals with the outreach and service 
delivery continues to grow.
    People can get Project Liberty services wherever they want 
them and the vast majority take place out in the community 
wherever it is convenient to meet. There are many populations 
that have special focus in Project Liberty, including school 
age children, families of victims, survivors and their family, 
emergency and recovery workers and the elderly, to name a few.
    Another statistic that so far Project Liberty has provided 
direct face-to-face services to over 4500 individuals who have 
lost a family member in the attacks.
    We are very focused on mental health needs of children and 
adolescents for very good reason. Assessments we conducted for 
our initial FEMA application in September found that the 
largest group of individuals in New York City likely to 
experience significant traumatic stress reactions following the 
attacks were school-aged children. We know from studies of 
prior disasters that communities and individuals are very 
resilient and that most people will recover quickly. I think 
this is a finding that is really worth emphasizing. This is not 
in any way to downplay the mental health needs, but the factors 
of resiliency and wellness are very abundant in the disaster 
and are really our greatest allies in trying to mount an 
effective response. The resiliency is true for both adults and 
children, but nevertheless there is an impact and range of 
response to trauma and some individuals do not recover quickly. 
This can be due to the intensity of their exposure to the 
event, it can also be compounded by prior trauma or other 
personal or family risk factors, including for children the 
reaction of their parents and other family members to the 
traumatic event.
    So, of course, it is important when treating children that 
we have to think about the family and social context in which 
they live. Highly traumatized children are at risk for a number 
of mental disorders so here we are talking about the subset of 
kids who have been so heavily traumatized that they may in fact 
have developed or are at high risk for developing a diagnosible 
condition like post traumatic stress disorder anxiety and 
depressive disorders.
    These conditions may surface weeks or months after a 
traumatic event. Other anxiety disorders, such as panic 
disorder or agoraphobia also develop and these can lead to 
substantial impairment in a child's ability to function at 
school and in home.
    I know our speaker in the previous panel talked from her 
own and classmates' experience about this kind of impact. 
Regardless, though, of the level of impact, we know the ability 
of a community to offer support is a critical part of the 
child's recovery from trauma and this is where Project Liberty 
comes most into play.
    Project Liberty has provided a comprehensive disaster 
response in New York City schools, including crisis counseling, 
classroom education, support groups for parents and Board of 
Education staff, and referral to other services when needed. 
Children and their families are able to access Project Liberty 
services through the schools or through Project Liberty 
providers in their areas, and to date, we have about 40 mental 
health agencies that are providing Project Liberty services to 
New York City schools.
    Project Liberty counselors have been very active in the 
highly effective schools near the World Trade Center site and 
continue to expand services into schools throughout New York 
City. Clearly the needs assessment showed that the impact was 
throughout the city and it is very important to continue the 
extent the relief effort accordingly.
    Agencies participating in Project Liberty have provided 
hundreds of group crisis counseling and public education 
sessions to school children, their parents, teachers and 
administrative staff. These sessions review coping strategies 
and skills, crisis management, stress reduction and management 
and strategies for support of school children and sessions have 
also been held to help students identify symptoms of distress 
and to build a positive outlook for their future.
    Let me just add a few more statistics. In New York City, 10 
percent of the nearly 40,000 supportive counseling sessions 
that have been provided in New York City have been delivered to 
children and adolescents. 11 percent of all Project Liberty 
services have been delivered right within schools and over 
23,000 children, teachers and parents have participated in 
these school-based Project Liberty activities.
    Although time constraints preclude any fuller discuss of 
this last point, it is important to note that Project Liberty 
data indicate the program is reaching nonwhite, non-English 
speaking children at rates that are proportional to New York 
City's general population.
    The cultural component of our outreach effort is pivotal to 
its success. We are trying to reach every community in New 
York. Although Project Liberty is helping many thousands of 
children, we do recognize that the range of services funded to 
date under Project Liberty may not be sufficient to meet the 
full amount of health needs of all children. Office of Mental 
Health is committed to helping New York meet these remaining 
mental health needs and we are working on several fronts to 
accomplish this.
    Let me close by briefly highlighting some of these 
activities. Next month the Office of Mental Health will be 
awarded 300 million that we have received from SAMHSA to 
providers with an expertise in specialist mental health trauma 
treatment services. This initiative will bring Project Liberty 
agencies together with other treatment providers and academic 
experts. They will join forces to deliver effective treatments 
to those children that have been so heavily traumatized by 
September 11th that they have developed a diagnosable mental 
illnesses or are at high risk of developing a serious mental 
health condition. OMHS is committed to funding these services 
for one year and we are very actively soliciting additional 
funding from private foundations and other 9/11 charities and 
it is our hope to expand the number of proposals that we can 
fund and also to extend services for an additional year.
    Just parenthetically, we have received 32 proposals from an 
RFP. We are reviewing them now, we will be issuing awards on 
July 1. These programs are expected to be operational by the 
beginning of September in time for the school year. It is our 
hope to expand the number of proposals that we can fund and 
also extend services for an additional year. We also plan to 
conduct a rigorous evaluation of this project to insure that we 
learn as much as we can about delivery of trauma treatment to 
children and adolescents with mental health needs.
    In addition, we are working with the New York City Board of 
Education and the New York City Department of Mental Health to 
develop a comprehensive plan for expanding our Project Liberty 
services to additional schools. During the coming several 
months, Project Liberty will partner with city schools to 
provide services in conjunction with summer school sessions and 
after school programs. The summer programs will help prepare 
children for the return to school just prior to the one-year 
anniversary of the disaster and we hope to broaden the scope of 
services we are able to provide under Project Liberty in 
preparation for schools reopening and the obvious impact of a 
one-year anniversary that will have on our city.
    Elements of the plan being discussed include a curriculum 
that will anticipate and deal with the impact of the 
anniversary and also a screening protocol to insure that 
children with ongoing traumatic symptoms related to September 
11th are linked to all necessary supports.
    So to close, I would like to thank the two Senators for 
convening this hearing and bringing us together to discuss the 
mental health needs of the children. The events of September 
11th are unlike any our nation ever experienced and we have 
created a mental health response unlike anything we ever 
mounted before in response. We recognize that the mental health 
impact of this terrible event is unprecedented; that those 
impacts will continue to unfold over time and that we will need 
to continually refine our interventions to meet those needs as 
they unfold. The Office of Mental Health remains committed to 
meeting the mental health needs of all New Yorkers who have 
been affected by the events of September 11th.
    Finally, I would just like to salute the compassion, 
collaborative spirit and creativity of everyone in New York and 
in particular the mental health community as well as the 
educational service communities. It has really been a 
tremendous pleasure and privilege to serve as part of this 
unique effort and to see the wonderful creativity and 
collaboration and resources that this City has.
    Thank you.
    Senator Clinton. Thank you very much, Mr. Felton.
    Dr. Frieden?
    Dr. Frieden. Good morning. I am Dr. Thomas Frieden. I am 
Commissioner of Health and Mental Health for New York City. 
Terrorism is intended to sow terror. Terror is a psychological 
phenomenon which requires a societal response and in that 
regard I am particularly grateful to you for convening these 
hearings today and for the opportunity to address what has been 
New York City's response to date and what are our plans for the 
future.
    As the recently released Board of Education report 
indicates, many children continue to feel the effects of the 
attacks in the form of increased anxiety and symptoms related 
to the trauma. We know from research on previous disasters that 
as we move farther away from the event, depression will be a 
more prominent symptom confronting children.
    We are concerned that children who are most effect by the 
disaster, such as those that lost a close relative or witnessed 
the event, are at greater risk of developing long-term mental 
health symptoms if they do not receive adequate support in 
coping with and mastering this intense experience. Children in 
general are considered at risk for emotional and behavioral 
symptoms following a disaster. This is because of their 
developmental limitations in understanding the complexity of 
the situation and their dependence on their family and their 
contacts for help with the healing process.
    Unfortunately, the intense media coverage following 
September 11th, the country's ongoing state of alert and 
incidents of bioterrorism helped produce a heightened state of 
anxiety making it difficult for some children and families to 
regain a sense of safety. A sense of safety is crucial for the 
healing process. For all of these reasons, the Department has 
made children and youth a priority in our plans and service.
    Let me take a few minutes to describe the scope of the 
activities. For directly bereaved children, immediately 
following the event, the Department's crisis intervention 
services unit provided mental health services at the Armory and 
then as soon as it was set up, at the Family Assistance Center 
at Pier 94. At these sites more than 85,000 mental health 
contacts were made. In addition, following the President's 
declaration of disaster, the State Office of Mental Health in 
collaboration with the City's Department of Mental Health, 
Mental Retardation and Alcoholism Services applied to FEMA for 
funding to establish the crisis counseling assistance and 
training program now known as Project Liberty.
    The FEMA funding was intended to provide short-term 
individual and group crisis counseling, outreach, education 
services and referrals for longer term psychiatric or substance 
abuse treatment. These interventions are aimed at assisting 
individuals in coping with the extraordinary stress caused by 
the disaster and its aftermath.
    Project Liberty under the immediate services program grant 
is providing free crisis counseling at more than 110 community 
mental health sites, including all public hospitals throughout 
the five boroughs of New York City. Providers were selected to 
reflect the culturally diverse makeup of the city to offer 
community-based services, to insure that every geographic area 
is served and to provide quality crisis counseling and public 
education in a variety of languages.
    A recent New York Academy of Medicine survey found that one 
in four New Yorkers know of Project Liberty. To access Project 
Liberty services, families can all 1-800-LIFENET as featured by 
the Citywide advertising campaign on radio, television, subways 
and buses and in brochures. The hotline is also available in 
Spanish, Chinese and other languages. Children and families can 
receive services at a neighborhood based mental health center, 
a selected community location or in their own home, depending 
on what is comfortable for them. Many children who lost a 
parent in the tragedy did have access to Project Liberty and 
traditional mental health services in their school.
    Part of the Department's ongoing services are contracts 
with agencies to run more than 100 satellite mental health 
clinics based in schools in every borough. In addition to their 
usual function, these clinics have been treating children 
affected by the disaster. They report a significant increase in 
symptoms related to trauma as well as generalized anxiety.
    Project Liberty has also earmarked $1 million for the 
City's Administration for Children's Services or ACS, the 
agency concerned with the welfare of children, including those 
in foster care and out of home settings, to address the needs 
of these vulnerable children. These children often have 
extensive history of trauma and loss and are therefore at 
higher risk than the general population. ACS is designing 
specialized training for parents, foster parents and staff on 
recognizing signs of increased trauma response and on how to 
support children better. This Department, working closely with 
other state and City agencies, created several initiatives to 
respond to the needs of children. I will mention three in 
particular.
    First, we convened a children's advisory committee of 
national and local experts on children's mental health after 
disaster. The group has been helping the Department form its 
plans for the future. These plans include a focus on school-
based services, bereaved children, children directly exposed to 
the disaster, children in foster care directly affected by the 
disaster and the general population.
    Second, the Department continues to work closely with the 
Board of Education and third, with the Agency for Children's 
Services to finalize a plan to address children and families in 
that system. The Department also has been working closely with 
the Mental Health Association of New York and the 9/11 Fund to 
develop a school-based poster and brochure campaign geared to 
alert parents of young children and youth about the lingering 
effect of the disaster on mood and behavior.
    In fact, even before September 11th this Department in 
partnership with the Mental Health Association was developing a 
media campaign for parents and adolescents because of a 
recognized need to focus on mental health issues that affect 
adolescents. The campaign will be released soon and will help 
with our further attempts to address emotional issues 
adolescents are experiencing because of or independent of 
September 11th.
    As I and others have noted, the crisis counseling and 
education program funded under Project Liberty have 
accomplished a great deal and will continue to serve even more 
people as the program continues. However, we know that some 
adults and children need more intensive treatment beyond what 
crisis counseling can provide. When Project Liberty providers 
see individuals whose needs cannot be met by short-term crisis 
counseling and education services, they must refer them to 
licensed mental health professionals or appropriate agencies.
    As you know, FEMA funding for crisis counseling cannot at 
present be used for longer term mental health treatment. This 
limitation should, we believe, be evaluated and a change in 
policy should be considered. We believe that the need for 
mental health clinic services may well exceed what can be 
provided with the funds that have been provided so far. 
Additional federal funding to increase the capacity of the 
mental health system to assist those most in need of treatment 
over the next 18 months would help. Intensive, well-structured 
interventions have been shown to be effective in helping those 
with disaster related symptoms to recover and return to their 
normal lives. Funding to provide mental health treatment for 
this population now will be most beneficial in the long run. In 
addition, as you know, Senator Clinton, the New York City 
Department of Health has been working with the U.S. Centers for 
Disease Control and Prevention to develop the World Trade 
Center registry. The registry would enable us to evaluate long-
term health and mental health effects as objectively and 
comprehensively as possible. We urge our colleagues to avoid 
any further delay in implementing this important project.
    We know certain things from other experiences and from the 
data that has accumulated to date in New York City. We know 
that repeated contact of children with intense media images is 
not helpful. We know that efforts to further strengthen the 
associations and bonds of children with their families and 
communities and to restrengthen the bonds of the communities is 
helpful. And we know that many of the aspects that had to do 
with the cultural construction of meaning go far beyond the 
health and mental health sectors and are areas where the whole 
society needs to be involved. We know that planning for the 
anniversary on 9/11/2002 is critically important and for all of 
these reasons we thank you for your interest and attention and 
for this opportunity to be here this morning.
    Senator Clinton. Thank you very much, Dr. Frieden.
    Well, I am so grateful to each of you and the agencies and 
institutions that you represent, because the collaboration and 
the partnership is obvious. Do you have any questions, Senator?
    Senator Corzine. In light of the time--
    Senator Clinton. I am just going reiterate a point that was 
made. Because this was such an unprecedented disaster in our 
history and because we are now looking forward to determine how 
we are better prepared in the future, it is important that we 
recognize the long-term effects and the questions that have to 
be asked about FEMA's ability to continue more long-term 
planning about special funding that SAMHSA and others might 
have for this kind of specific need will certainly be on the 
table. We look forward to working with all of you and I cannot 
thank each of you enough for the really terrific job you have 
done of making it up as you went because we did not have any 
blueprint or guideline to tell us how to deal with this.
    So let me thank you for being here today.
    Senator Corzine. Senator Clinton, I would like to make one 
point which I believe I heard from at least two of the 
witnesses, which I believe we can work on. It flows out of the 
Board of Education study, which demonstrated that real data 
actually is one of the bases on which we should be working. I 
compliment you on working on this registry, but if there is any 
message here that I can see, it is that we ought to be working 
off of information that is scientific as opposed to anecdotal. 
So if I have gained anything from this, it is underscoring the 
importance of that and we should get on with that project.
    Senator Clinton. Thank you very much. Well, we are going to 
call up the third panel so that we can hear finally this panel, 
some experts in this area both here in the New York area as 
well as in other parts of the country.
    [Pause.]
    Senator Clinton. I will get on and introduce the panelists 
and then ask each of them to provide their testimony and then 
we will have time, I hope for questions. We are very pleased to 
have with us Dr. Betty Pfefferbaum. Dr. Pfefferbaum is the 
professor and Chairman of the Department of Psychiatry and 
Behavioral Sciences, the University of Oklahoma Health Sciences 
Center, and she has been a tremendous resource to many, many 
people in the New York area following 9/11 and I personally 
want to thank you, Doctor, because you have been so generous in 
sharing your time and your expertise and experience coming out 
of Oklahoma City. She will be outlining the research that has 
been conducted on children in Oklahoma, and providing some 
specific information about what has worked, which is very 
critical to our future planning.
    Next we will hear from Dr. Christina Hoven, the Mailman 
School of Public Health at Columbia University, the New York 
State Psychiatric Institute, who was the lead investigator for 
the New York City Board of Education study. Earlier this 
morning, I was with Dr. Larry Aber, who is also one of the 
investigators. The team that was put together was really the 
basis for the kind of factual analytic information, Senator 
Corzine, that we are both looking for and we are very grateful, 
Dr. Hoven, for your being here to outline the program and the 
recommendations.
    Dr. Harold Koplewicz from the NYU Child Study Center, has 
been a partner in the efforts to reach out and assist children 
from the very beginning. He has provided a lot of support to 
many, many people and institutions and has been a source of 
great good advice to my staff. And finally, Dr. Pam Cantor from 
the Children's Mental Health Alliance, who will be discussing 
models of best practices for making systemic improvement to our 
mental health system to try to address our challenges. Of 
course I have to put in a plea for the mental health parity law 
that we passed in the Senate, it died in the House, we are 
going to bring it back up in the Senate. The President has now 
said he supports it, and I hope that our friends in the House 
of Representatives will pass it, because if there wasn't any 
doubt about the need for mental health parity before September 
11th, it is even clearer now. So, I thank all of our witnesses 
for being here and Dr. Pfefferbaum, if we can start with you.

STATEMENTS OF BETTY PFEFFERBAUM, M.D., PROFESSOR AND CHAIRMAN, 
DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES, UNIVERSITY OF 
OKLAHOMA HEALTH SCIENCES CENTER; CHRISTINA HOVEN, M.D., MAILMAN 
 SCHOOL OF PUBLIC HEALTH, COLUMBIA UNIVERSITY, NEW YORK STATE 
 PSYCHIATRIC INSTITUTE; HAROLD KOPLEWICZ, M.D., DIRECTOR, NYU 
 CHILD STUDY CENTER; PAM CANTOR, M.D., FOUNDER AND PRESIDENT, 
               CHILDREN'S MENTAL HEALTH ALLIANCE

    Dr. Pfefferbaum. Thank you. I appreciate the opportunity to 
share with you some of my experiences that might have 
application to your efforts here. Exposure to trauma occurs 
directly through the physical presence or indirectly through 
relationship with victims or through the media. There are no 
studies of the long-term impact of the Oklahoma City bombing on 
direct child victims, but research from other disasters 
indicate that many children who are directly exposed to severe 
trauma will develop diagnosable psychiatric disorders. Many 
more will develop symptoms which, while not qualifying for 
diagnosis, may be disabling. Symptoms typically decrease over 
time, but in some individuals they persist. That would be 
particularly true in those children who are most directly 
impacted or who have the strongest initial reactions. The 
children of direct victims and of rescue populations in 
Oklahoma City have been followed clinically, but they, too, 
have not been systematically studied.
    We are currently conducting a study of the long-term impact 
of the bombing on the adolescent children of Oklahoma City 
victims, so hopefully by the end of the year we will have some 
information that will shed light on the developmental services 
here.
    It is remarkable to those of us in Oklahoma City that some 
victims and their family members are only now beginning to 
access mental health treatment, seven years after the bombing. 
Late occurring problems in children may be triggered by 
developmental factors or by exposure to secondary adversities, 
such as economic hardship or disruptions in the social support 
network. In some situations, we simply do not recognize that a 
late occurring problem which may present as a learning problem 
or a behavior problem had its origin in the disaster, or that 
the disaster aggravated some underlying vulnerabilities or 
predisposed the child to later problems.
    Children in the general community are also likely to 
experience emotional reactions that have been discussed 
previously, that is a population in Oklahoma City that has 
received a great deal of research attention. We were able to 
document the emotional reactions of children in the greater 
community and also the reactions of children who live some 
distance from Oklahoma City.
    Perhaps most interestingly, we also documented a small but 
significant relationship between media exposure and post 
traumatic stress reactions. Now, it is very important to note 
that it may be impossible to distinguish the impact of media 
exposure and the impact of the event itself. It is also true 
that the positive relationship between media exposure and post 
trauma stress reaction does not establish a causal connection. 
It is quite likely that children who are most distressed will 
be drawn to media coverage and it is also possible that other 
factors underlie this association.
    Parents and other adults tend to underestimate the impact 
on children. Many impacts are not readily observable. In 
addition, parents tend to be consumed with many other problems 
in the face of chaos and disaster such as occurred here and 
children who may be attuned to the distress in their parents 
may conceal their reactions to avoid further burdening them. 
Therefore, it is essential that children be evaluated directly.
    In Oklahoma City, most of the services for children were 
provided in the schools. Schools provided access to children 
and school-based services minimized stigma and tend to 
normalize the experiences of children. In addition, teachers 
and other school personnel are aware of development issues and 
are natural sources of support for children. It is imperative, 
however, and I underscore, that school-based interventions not 
supplant efforts to identify, refer and treat children who have 
greater needs. Those in need of more comprehensive and 
intensive services.
    The mental health needs of children in the current 
environment of terror are compelling. We have heard much 
evidence of that. The goal of terrorism, evident in the word 
itself, is measured not only in the death and injury of direct 
victims, in the grief and sorrow of family members, in the 
wreckage of property or in the disruption of Government, 
commerce and travel, it includes as well the fear and 
intimidation that accompany a new way of life for all of us.
    Therefore, the mental health implications, and I applaud 
you for conducting this hearing, must be included in the 
general response that addresses security, preparedness, 
intelligence and public health. Thank you.
    Senator Clinton. Thank you very much, Doctor.
    Dr. Hoven?
    Dr. Hoven. Thank you, Senators, for inviting me here today. 
As the principal investigator of the New York City Board of 
Education study and the primary author of the report entitled 
``Effects of the World Trade Center Attack on New York City 
Public School Students, Initial Report to the New York City 
Board of Education, May 6, 2002,'' which has been submitted as 
Appendix one to this written testimony, I am honored to appear 
before you to discuss significant implications of our findings 
and to suggest possible responses by policy makers such as 
yourselves, who control the resources and have the 
responsibility to adequately address the current mental health 
needs of New York City's public school children.
    First, however, I want to acknowledge the contribution of 
the many people who made this groundbreaking study possible. 
Their individual names appear in the written testimony. Let it 
suffice here to say this study was truly a collaborative effort 
by the New York City Board of Education, Applied Research and 
Consulting, the Centers for Disease Control and Prevention, the 
Columbia University Mailman School of Public Health, the New 
York State Psychiatric Institute, numerous expert consultants 
and of course the brave Superintendents, principals, teachers 
and students who made this study possible through their 
participation.
    Before presenting our results, I want to put the findings 
important as our country enters an era of ongoing conflict with 
potential for future acts of terrorism in our cities and homes, 
on our waterways and to our power plants.
    As in the years following the explosion of the first atom 
bomb, the youth of America are under new stress, potentially 
lowering the threshold for the onset of mental illnesses. To 
better appreciate the complexity and challenges faced by the 
New York City Board of Education as they struggle to assess 
this situation, I want to identify a few issues contributed to 
our conceptualizing the study the way we did, that is, to view 
the aftermath as a probable citywide phenomena, not just a 
Ground Zero event.
    One, there are approximately 1.2 million children enrolled 
in the New York City public schools. Two, approximately 750,000 
of them take public transportation every day, including 
subways, buses and boats, passing through tunnels and going 
over bridges on their way to school.
    Three, whereas only 35,000 people reside in the area 
surrounding Ground Zero, more than twenty times that number 
commute there to work each day. Similarly, the schools near 
Ground Zero, especially the specialized middle and high schools 
are attended primarily by students living outside the area, 
coming every day from each of the boroughs of New York City. To 
put this study into context, it is important to also understand 
the following:
    One, 8,266 children participated in the study from public 
schools located throughout all five boroughs of New York City; 
the Bronx, Brooklyn, Manhattan, Queens and Staten Island.
    Two, classrooms were selected using probability samples, so 
that every public school child in New York City, in grades four 
through twelve, had an equal chance of being selected to 
participate in our study. This is important, as the 
participants were not self selected and therefore were not 
biased in the direction of having more problems than the 
average student.
    Most importantly, this methodology allows us to project our 
findings back to the entire New York City school population, 
including all students in grades four to twelve, excluding the 
public education district.
    Three, an assessment of mental health problems was 
conducted six months post 9/11, meaning the disorders do not 
reflect simply an immediate post-disaster condition, but a 
persistent disturbance, a fact which has very significant 
service delivery implications.
    Because I have submitted a complete copy of our initial 
report, I will only briefly summarize our findings. We observed 
throughout the City a higher than expected prevalence of a 
broad range of mental health problems or psychiatric disorders 
among New York City public school children. It is estimated 
that as many as 75,000, 10\1/2\ percent of New York City public 
school children, have multiple symptoms consistent with post 
traumatic stress disorder, PTSD, and that 190,000, 26\1/2\ 
percent, have at least one of the seven assessed mental health 
problems, excluding alcohol abuse, which we also assessed. Each 
of the probable psychiatric disorders assessed, not just PTSD, 
exceeded expected rates, based on pre-9/11, non-New York City 
community estimates. It is also important to emphasize that the 
prevalence of mental disorders are elevated throughout the 
City, the effects not being limited only to PTSD or only to 
children at the Ground Zero schools.
    New York City public school students were exposed to the 
effects of the attack in different ways. Almost all of students 
of Ground Zero and two-thirds of children in the remainder of 
the City experienced some type of personal physical exposure to 
the attack, such as being near a cloud of smoke and dust, 
having fled to safety, having had difficulty getting home that 
day, and/or continuing to smell smoke after 9/11. Having a 
family member exposed to the attack, that is, having a family 
member killed, injured or in the World Trade Center at the time 
of the attack but who escaped unhurt was more frequent in 
schools outside of Ground Zero than among students in schools 
near Ground Zero.
    We know the previous exposure to trauma elevates an 
individual's response to any new trauma. We found that nearly 
two-thirds of the New York City school children had been 
exposed to one or more traumatic events prior to 9/11, 
including seeing someone killed or seriously injured, seeing 
the violent accidental death of a close friend or family 
member. Again, a disproportionate number of the children with 
previous exposure go to schools outside the Ground Zero area.
    Exposure to the media was also very high. Almost two-thirds 
of the surveyed population spent a lot of their time learning 
about the attack from television. For the preliminary report of 
May 6, 2002 we concentrated on factors that were associated 
with increased risk for PTSD. Each of the different types of 
exposures just described, including personal, family, previous 
trauma and media, were found to be associated with this 
disorder. However, exposure of a family member and previous 
exposure to a traumatic experience were more important than 
personal physical exposure in who developed PTSD. Being 
younger, female and Hispanic also increased one's risk for the 
disorder.
    According to our findings, one of every seven children, 15 
percent, has agoraphobia. Rates for the other psychiatric 
disorders are as follows: 8 percent with major depressive 
disorder, 10 percent with generalized anxiety disorder, 12 
percent with separation anxiety disorder, 9 percent with panic 
disorder 11 percent with conduct disorder and 5 percent with 
alcohol abuse in grades nine through twelve. All of these 
reported mental health problems were determined to be 
associated with impairment, that is, they were so severe as to 
indicate need for an immediate intervention. Yet at least two-
thirds of children with probable PTSD following the 9/11 
attacks have not sought any mental health services from school 
counselors or from mental health professionals outside of 
school.
    We expect to find similar rates of not seeking help for the 
remaining seven disorders we measured.
    Currently we are analyzing the data to understand issues 
such as depression and bereavement and reasons for possible 
heightened vulnerability among specific populations, such as 
Hispanics. It is important to emphasize again that the 
prevalence of psychiatric disorders are elevated all across the 
city. Ameliorating these conditions and preventing them from 
developing into disorders in the future requires actively 
reaching out to the nearly 1.2 million students enrolled in the 
New York City public schools.
    As a child psychiatric epidemiologist who has spent my 
career concerned with the delivery of mental health services, I 
take the liberty to present here an overview of issues that I 
believe are critical to address the child and adolescent mental 
health needs identified by the New York City Board of Education 
study. To effectively address the mental health needs of 
children and adolescents will require more than isolated and 
piecemeal actions. However, it is crucial to consider the child 
mental health services as a comprehensive system of care. That 
implies recognizing the central role that should be played by 
the school system, the place where most children can be found 
and where services can most easily be delivered.
    First, about treatment: We may confidently infer that many 
children have developed a psychiatric disorder as a consequence 
of what happened on September 11th. The most critical issue 
facing us today is developing a strategy regarding how do we 
engage these children in treatment. Children do not ordinarily 
seek treatment themselves and in the case of internalizing 
disorders, which are the majority of disorders assessed in this 
study, parents and teachers may not even recognize them. 
Therefore, intensive outreach strategies must be employed.
    Research tells us that many children as well as parents may 
also not be receptive to the idea of seeking care for mental 
health problems. Once children enter services, the next 
important step is keeping them in treatment, as most children 
drop out after just a few sessions. Therefore, when treatment 
issues are considered, we conclude that the school setting may 
well be the best place to provide mental health treatment since 
outreach, stigma and service dropout can be handled there more 
directly. Moreover, the school setting is one of the most 
important places where education about the possible mental 
health sequela from terrorism and terrorist attacks can be 
taught to all children.
    I believe the leadership for improving child mental health 
services must come from the great medical institutions within 
New York City, which must accept the responsibility for 
increasing their collaboration with the Board of Education 
through school-based clinics.
    Second, referral and screening, or screening and referral: 
Children respond best to treatment when a problem is identified 
and treated in its early stages. About 25 percent of the 
children and adolescents presenting with a mental disorder will 
go on to develop more severe conditions and therefore will be 
in need of more intensive care. An important percentage of 
those who passed through their school years without being 
identified as needing mental health services will go on to a 
life of pain, anguish and dysfunction, including violent and 
aggressive behavior towards themselves, others and society in 
general.
    While we are not able to avoid every personal tragedy such 
as the ones that have become so common in our society today, we 
can certainly do better through routine screening and treatment 
intervention. Previous studies have shown that fewer than 50 
percent of adolescents with significant treatable mental 
disorders are correctly identified as having any problem by 
school counselors and teachers. Similarly, pediatricians 
correctly identified only 25 percent of those with diagnosable 
mental disorders. Parents, the most important gatekeepers, like 
the professionals, tend to identify external sign such as 
disruptive behaviors, rather than depression and anxiety. There 
is a need, therefore, to systematically screen and identify the 
considerable number of students with previously unrecognized 
treatable mental disorders.
    Screening alone, however, is not enough. It must be coupled 
with the provision of treatment. In the multilingual, multi-
ethnic communities of New York City, where 85 percent of the 
total public school student population is non-white, every 
effort must be made to insure that culturally competent 
screening and treatment interventions are available to every 
student.
    Third, education and training: Parents, caregivers and 
teachers must be taught how to be alert to signs of significant 
impairment in their children so that the education of parents 
is integrated into the existing system of care for all 
children. The media can be a useful partner in this outreach. 
The interest already exists. Our studies showed that after 9/
11, school children dramatically increased their reading of 
newspapers and magazines and consulted the Internet to learn 
more about world terrorism. Surely they would want to know more 
about themselves and their emotions if interesting, engaging 
material were developed and made available to them.
    I must add that the mental health professionals, too, must 
be retrained to provide state of the art, evidence-based 
treatments, particularly for those disorders likely to arise in 
the aftermath of a disaster.
    I must say something about the role of schools in mental 
health services. Every school in New York City already has some 
kind of mental health service capacity. Although the quality 
and extent of these services differs considerably. Individual 
school structure their mental health services differently. For 
example, some schools have mental health clinics, others have 
health clinics with a mental health component. Still others 
schools may provide space where non-school-based mental health 
professionals can provide interventions, whereas other schools 
refer their students to the professionals in the community. 
Strengthening the Board of Education's mental health delivery 
capacity is extremely important that the schools receive 
adequate financial support to advance the development of 
school-based clinics. In the existing school system, what is 
needed first is a better recognition that the educational 
mission and the mental health agenda are intimately related. A 
service system that separates them artificially is at best 
inefficient or can actually do harm by failing to meet the 
needs of children and adolescents, particularly in difficult 
times such as these.
    Even when the need to provide mental health services in 
schools is recognized and accepted, the implementation of 
school-based mental health services faces many difficulties. 
First, need greatly exceeds capacity. In fact, while all 
schools have counseling support, fewer than 10 percent of New 
York City schools currently have a formal on-site mental health 
clinic. They urgently need help, financial help, to change 
this.
    Implementation of an effective service model is very likely 
to have broad impact, including the strengthening of the 
ability of children and adolescents to perform well 
academically, thus reducing the number of children placed in 
special education due to emotional disturbance.
    In summary, on that new day of infamy, September 11th, 
2001, the New York City schools were in full session at the 
very moment of the attack on the World Trade Center. For most 
public school students, their first knowledge of this 
calamitous incident came from their teachers and principals. 
These messages were carefully scripted and followed guidelines 
set down by the American Psychological Association and other 
experts.
    In the handling of the immediate aftermath of 9/11, the New 
York City schools administration, staff and teachers, as well 
as its 1.2 million student body can justly be proud. A study of 
the Chancellor's memos, the principals and Superintendents 
messages and most significantly of all the web pages and 
activities of students themselves, show clearly the message 
that the response of the entire New York City community to this 
crisis of enormous proportions was strong and adaptive. 
However, we have only just begun to try to understand what this 
new post-9/11 world means to children and how it will influence 
their beliefs, behaviors and outlook into the long run.
    I have attempted to provide you here with limited, 
documented evidence of what to date has been a most pernicious 
and challenging assault on the lives, hearts and minds of New 
York City's public school children. The study we conducted for 
the New York City Board of Education is unique in its scope and 
value, and has alerted us all to the vast unmet mental health 
need among our city's public school students six months post 9/
11. After studying its findings, I strongly believe that an 
effective and coherent response should be grounded within 
school-based mental health services which can utilize state of 
the art screening, assessment and evidence-based treatment 
approaches.
    Specifically, I recommend, one, the development of a 
flexible mental health system of care for children based on a 
localized coordination system of clinical responsibility, 
insuring that each school receive crisis intervention services 
and support immediately after any future terrorist threats or 
events.
    Two, the development of a comprehensive school-based mental 
health service system developed in collaboration with all of 
the major medical centers, as well as private and public mental 
health providers in New York City, such that every single 
school and every individual child has ready access to quality 
clinical care.
    Three, develop a permanent enhancement of school-based 
mental health resources, including screening and treatment for 
children and adolescents with persistent needs. It should be 
noted that this type of therapeutic service is specifically 
excluded from Project Liberty funding.
    Four, establishment of an ongoing research and monitoring 
agenda to further understand the nature and effects of 9/11 on 
New York City public school children, to assess if optimal 
treatment is being provided to those most in need, both today 
and in the years to come, as the long-term sequela of 9/11 
unfolds.
    Finally, I must add, that none of the people involved in 
this study, including myself, from Columbia University, Mailman 
School of Public Health or from the New York State Psychiatric 
Institute has received any remuneration for their efforts. 
However, as I tell my students, being an epidemiologist will 
not earn you very much money, but if you are lucky, you will 
have the good fortune to conduct a study that truly makes a 
difference.
    All of us have been proud to do this investigation, humbled 
by the dedication of the senior administration of the New York 
City Board of Education, impressed by the strong commitment and 
efforts of all our collaborators, and very proud that you, 
Senator Clinton, are taking the leadership to use this 
information to help meet the mental health needs of New York 
City's public school children. Thank you for allowing me this 
time. I am happy to answer any questions.
    Senator Clinton. Dr. Hoven, I have to thank you for that 
absolutely extraordinary testimony.
    [Applause.]
    Senator Clinton. And I am well aware that your written 
testimony includes many other significant points that place 
this particular set of issues into the broader context of our 
failure to provide adequate financing for mental health as well 
as all kinds of health, and the other related issues that 
surround this. But I wasn't aware until you just said that you 
received no remuneration for this ground-breaking work, and it 
is something that we need to address, because, as Senator 
Corzine said, if we do not have good work like this on which to 
base the decisions we make, then we are once again acting on 
the basis of what we believe or feel or think rather than the 
evidence, and all too often I am sometimes fond of saying 
Washington is an evidence-free zone, and the more we can try to 
fill that evidence-free zone with some real evidence like you 
have presented us today, the better off we will be.
    I am going to ask our next two witnesses to try to 
summarize their testimony, because Senator Corzine has to leave 
and he very much wants to hear both of you, and he will want to 
have some closing comments about New Jersey and answer any New 
Jersey questions and larger questions as well.
    So Dr. Koplewicz?
    Dr. Koplewicz. First I would like to thank both of you, 
Senator Clinton and Senator Corzine, you are great friends of 
America's kids, and today's Senate hearing is an example of 
that. I would also like to thank you for the opportunity to 
present to you the current public health problem facing 
children and adolescents throughout the entire New York 
metropolitan area.
    On September 11th, 2001 or world changed and the world of 
our children changed as well. Nine months later we are trying, 
and fortunately most of us are succeeding in living with a new 
sense of normal. A vital part of this adjustment is the 
realization that our children are now growing up in a very 
different world from the one we knew. In a single day the 
illusion of our nation's invincibility was shattered for them. 
And the overwhelming majority of children are handling that 
sense of vulnerability. Their parents, other children and 
teachers can help them handle that eventual outcome. However, a 
small but significant group of children are at risk.
    In New York City groups of children were exposed to trauma 
in various ways. Hours after the attack the NYU Child Study 
Center began working with the Chancellor's office of the New 
York City Board of Education. Within 24 hours of the attack, 
our faculty prepared and distributed two manuals on helping 
children and teens cope with this event. First, to public, 
private and parochial schools in New York City and then 
educational, medical and religious organizations throughout the 
nation and on September 12 we met with principals from schools 
that had been evacuated and then with teachers and eventually 
with parents and students. In the following weeks we 
established a child and family recovery program which sent 
teams of specially trained mental health professionals into 
schools where children had been evacuated and we continue to 
work with the schools their families and the school staff.
    Working with the Silver Shield Foundation, we have been 
evaluating and treating any child of a fireman, policemen, Port 
Authority worker or medical emergency worker who lost their 
lives on 9/11. And we have committed to being available to 
these families for the next three years and are conducting the 
only treatment study that is evaluating the effectiveness of 
our interventions with these groups.
    But I sadly have to tell you nine months later many of 
these high risk children and teens are getting worse, not 
better. The needs assessment conducted that Dr. Hoven just 
discussed suggests we are only dealing with the tip of the 
iceberg. According to the Surgeon General's Report on Mental 
Health in 1999, 12 percent of the population 18 and under had a 
diagnosable psychiatric disorder. With approximately 1.1 
million students in New York City public school systems we 
would expect that 130,000 students would have a mental health 
disorder. The Board of Education survey estimates that we have 
nearly 190,000 students with a mental disorder. That means not 
only are the students with existing problems suffering and at 
risk for increased difficulties, but it suggests that an 
additional 60,000 students who are well are now showing 
significant symptoms due to this horrific event.
    Unfortunately, the epidemic does not stop at the City line. 
Many people who died that day have lived outside of New York 
City and their families are suffering. Many children in New 
Jersey schools had a bird's eye view of the attack that day. In 
addition, the images of the event were repeatedly present on 
television and available for children everywhere. The bad news 
is that children who are suffering rarely identify themselves 
and usually are silent sufferers, going unnoticed by teachers 
and parents. We actually have a good idea which children are at 
greater risk: Those whose parents are symptomatic and those 
with previous history of trauma. However, that information is 
generally not known by the educational or medical communities 
or the general public.
    We have a public health problem that is not being 
addressed. In a public health crisis with physical illness like 
polio or tuberculosis, we know what to do and we do it. But we 
have forgotten that we are now 60 years after the first 
outbreak of polio. Now we are at the first outbreak of the 
potential psychological epidemic of the aftermath of this 
terror and that requires us to identify, treat and develop 
interventions for prevention all at the same time.
    First, we must immediately educate the general public, 
teachers and pediatricians about the signs and symptoms of 
anxiety disorders, depression and post trauma stress disorder 
in children and adolescents. This campaign has to include 
television, radio and print, but it has to have the same type 
of importance as the AIDS National Education Campaign or the 
Breast Cancer Awareness campaign and has to be done now. We 
need to screen every child in the New York metropolitan area. 
Those who have symptoms will receive a full evaluation and 
specialized treatment will be made available. That is the same 
way we would address tuberculosis and we need to train a corps 
of mental health professionals to provide evidence-based and 
specific treatments for traumatized children.
    Currently, we do not have enough specially trained 
individuals for this work. LifeNet, which the number you can 
see all over here, is doing a great job referring patients. 
However, we need quality control and we must monitor outcomes. 
We need to know what treatments work so we have more knowledge 
if this ever occurs again anywhere in our nation. The CDC 
trains local health care workers when a special outbreak occurs 
of physical illness. We need their help now to help us with 
this training and we need a system with fewer barriers. 
Currently, the FEMA funding is for crisis counseling. We need 
more flexible funding for evaluation and treatment and for 
systematic studies to evaluate the best treatments for these 
children.
    The child mental health system was overburdened on 
September 10th. It is now incapable of adequately addressing 
the current public health problem that we face and we know that 
the anniversary of this event will be a difficult day for all 
of us, but it will reinfect these children who are most 
vulnerable. A plan of action has to be put into effect now for 
the weeks surrounding September 11, 2002. Our wish that 
everything goes back to normal is understandable, however, we 
are warned almost daily of the potential for future attacks. 
Those warnings alone are enough to trigger symptoms. This level 
of uncertainty scares all of us, but it has the greatest effect 
on the most vulnerable, our children. Therefore, while we all 
know that we are going to die some day and we take precautions 
- we try to eat healthy, exercise and avoid too much risk, we 
go forward and work, love and have fun and most of us do that 
quite effectively. We want the same for all kids.
    While most of them are doing just that, a significant 
minority is still suffering and if ignored, their symptoms will 
get worse. They are at high risk for substance and alcohol 
abuse, poor school attendance, suicidal thoughts, attention 
depletion. Their world has changed and therefore the strategy 
for dealing with these real psychiatric problems has to change 
as well. Thank you for your attention.
    Senator Clinton. Thank you very much, Dr. Koplewicz.
    Dr. Cantor?
    Dr. Cantor. I have to apologize in advance for the state of 
my voice. Actually, Larry--
    Senator Clinton. I hope that did not happen this morning? 
Larry Andrews to the rescue. Do you want to add a few points, 
because I want to ask Senator Corzine to ask questions.
    Mr. Andrews. Do you want me to read her statement?
    Senator Clinton. Read it or just summarize it.
    Mr. Andrews. Well, the highlighting of the vulnerability of 
children in the City and in the region and the nation really 
needs to have a focus, as several panelists have said on the 
nature of this as a public health crisis involving the mental 
health of our youngest citizens.
    You heard about the numbers, that 200,000 children have 
diagnosable trauma-related mental health problems and this 
situation, because of its scope, demands a public health 
response. The vast majority of these children have not received 
any help to date by their own report, so if three quarters of 
the children do not report getting help inside or outside of 
the school system despite the heroic efforts of everyone 
described, so it is a bigger problem than understood.
    Dr. Cantor has long written testimony that will be 
available for the Committee, and I know you will take a look at 
it. She wanted to focus today on how to move from things we did 
in the face of an emergency to what we really need to do now in 
terms of the long-term challenge and reiterates the call for 
adopting a public health model. In that model, complete 
information on an infrastructure by which needs assessments, 
not just for fourth through twelfth graders, but for kids zero 
based to third grade; screening of the type that Dr. Koplowicz 
and Dr. Hoven and others encouraged, and ongoing tracking and 
surveillance system would all be part of what we were doing.
    To insure that professionals are properly trained in the 
psychoeducational supportive and evidence-based treatments, a 
lot more training is required and a public education campaign 
to do that as well. The crisis response teams that have been 
begun in selected school districts can be expanded 
dramatically.
    In her written testimony she describes a lot of work in two 
districts, District 2 at Ground Zero and District 31 in Staten 
Island, in which extensive work has been done and could be a 
model for the future. And it was funded by multiple sources: 
Federal, state, local, public, private and that sort of 
consortium of funding is going to be important.
    In the immediate aftermath of September 11th the governance 
and planning structure for the mental health response came from 
the Board of Education and many people emphasize how important 
the Board of Education is, in a group called the Partnership 
for Recovery in New York City Schools. Dr. Cantor believes, and 
I do too, that we now have the knowledge in the face of this 
magnitude and scope to really create new planning and 
governance structures to address the needs of children both in 
a public health context and a public education context, a new 
level of coordination between health and education is required. 
This structure must include the Board of Education, who has 
provided great leadership. They must also continue to receive 
advisory reports, but leadership for the advisory of the mental 
health approach should resolve with the Mental Health 
Department of the City. This work should build upon the 
accomplishments of the first five structures, to incorporate 
City, State and Federal agencies that already share the 
responsibility for meeting the needs of mental health of the 
City's children.
    If leadership from the City can bring education, health and 
mental health together, the challenge in front of all of us to 
really develop a partnership for recovery of New York's 
children can happen.
    She asks you to end by imagining a health contagion that 
was affecting 200,000 children in a serious way with many more 
subclinically affected. If we faced a clinical contagion like 
that mit would be clear we have no choice but to pool our 
knowledge, our experience and resources to create a partnership 
for recovery of New York City's children. There is no other 
choice for mental health for our children today.
    [The prepared statement of Dr. Cantor may be found in 
additional material.]
    Senator Clinton. Thank you very much for pinch hitting. 
Thank you, Dr. Cantor.
    Dr. Hoven. I feel compelled to respond to something that 
was said that is incorrect and I do not want to have you misled 
about the numbers. The number, approximately 200,000 children 
having a disorder and needing intervention is only based on the 
eight disorders, actually, that number is based on the seven 
disorders. There are approximately 30 disorders that affect 
children's mental health, so the example that was given about 
the small discrepancy I think it was 60,000 between what would 
be expected based on the Surgeon General's report and these 
data is a true undercount. It only reflects seven disorders out 
of the 30 possible.
    Senator Clinton. Thank you, Dr. Hoven.
    Senator Corzine?
    Senator Corzine. I would take Dr. Hoven's lead, first of 
all, I want to compliment both you and the Board of Education 
for the study, but the 200,000 includes kids in the New York 
City school system. If you took those same studies and applied 
them to the kids in Jersey City and Hoboken and Bayonne, and 
other places, or Monmouth County, or those scattered children 
around the nation that Ms. Salamone talked about in her opening 
testimony, I think we have far more than 200,000 children 
impacted by these, but I would certainly love to hear your 
comments with respect to what you would think if we had that 
evidence-based analysis for other children in other venues and 
how far does that reach.
    Dr. Hoven. It is a complicated question, but in fact, 
people from New Jersey have been meeting with Dr. Michael Cohen 
at Applied Research and Consulting and with me about actually 
doing the study in New Jersey similar to the New York City 
Board of Education. The day after the New York City Board of 
Education report was released, I was inundated with phone calls 
from people, particularly from Westchester County where I do a 
lot of work, and they were castigating me, ``What are you doing 
there in New York City? This is just an artificial border. How 
can you be looking at New York City, what about us? And what 
about us? This is not only a phenomenon in the metropolitan 
area.''
    I think because of the nature of this disaster which many 
people have talked about, we are having responses from all 
over, not only the United States, but all over the world. I 
have received phone calls from people all over the world, and 
in fact, tomorrow, for example, the Chilean national television 
is coming to do a story, and I asked them why, and they said 
because at about the same time that our data was released, they 
had done a national survey in the Chilean national schools and 
they found that the issue that most concerned students was fear 
that an event like 9/11 was going to happen to them.
    We are talking about a worldwide problem, a worldwide 
perception that terrorism is at all of our doors. It is not 
just a problem of the metropolitan New York City area that we 
are here to talk about today, but you as senators, leaders of 
our country, have to think about the mental health policy that 
is almost nonexistent for children. We have to do something 
about mental health policy. We have to do something about 
parity. We have to do something about supporting research that 
would give us the kind of data that we need to answer the 
questions that you have asked. What does it look like here, 
what does it look like in Indiana? What does it look like pre-
9/11, what does it look like post 9/11? We do not know. 
Research in this area is very, very underfunded. Thank you.
    Senator Clinton. Dr. Pfefferbaum, could I ask you, you 
mentioned in your testimony that for the first time in seven 
years some people were coming in asking for services. Did the 
events of 9/11 trigger that, do you believe or is there some 
other explanation?
    Dr. Pfefferbaum. Well, I think there are a number of 
explanations, but our impression in Oklahoma City certainly our 
delivery of care much between Oklahoma and New York City, we 
are very reactive and we haven't thought about this in a new 
thinking out of the box of how do schools and how do we prepare 
for instance, for September 11, 2002. We know that is going to 
be a difficult week for the 1.2 million kids in the New York 
City public schools, but it is going to be difficult for kids 
throughout the United States.
    Senator Corzine. I think, first of all, the testimony from 
all of you dramatically underscores how little we are investing 
in mental health. Carrying that back to Senator Clinton's first 
comment before this panel, parity does not hack it, we are just 
not there with treating these kinds of problems on an 
equivalent basis with physical illnesses. So I hope that we can 
get specific suggestions for training the folks that would be 
delivering these programs. And we need to make sure that we are 
providing the kinds of dollars and resources to conduct 
research so that we can move forward in an evidence based 
effort. Without that, I think we are truly underserving our 
people, because terrorism is really trying to strike at the 
psychological well-being of our nation. So, I would like to 
tear apart some of the studies, but I think we have got a job 
to do to get the resources and the focus and the parity that we 
need on these efforts as well as other efforts of homeland 
security.
    Dr. Koplewicz. Do you think the topic that Dr. Hoven raised 
about Project Liberty's mission and what it can be used for 
funding and FEMA using it only for crisis counseling really has 
to be addressed at some level so that we have more flexibility. 
These kids need more than just crisis counseling.
    Senator Clinton. Well, in fact, Senator Corzine and I, 
based on your previously submitted testimony and the work that 
we and our staffs have done, have put together six points that 
we would like to try to work on in the upcoming months.
    First, to establish an office for the protection of 
children in whatever the newly created Department of Homeland 
Security will be, because I think without a specific focus of 
responsibility for children, their physical well-being, their 
mental well-being, the technology, the equipment, the vaccines, 
the antidotes, everything that children need, it will not be a 
top priority. So that is our first recommendation.
    Secondly, we do want to encourage the launching of a 
children's mental health public education campaign, to get that 
up and going by the end of June, to do more to link resources 
up with training of parents, teachers, child care providers and 
others. We want to include mental health tracking of children 
and adults in the CDC World Trade Center Registry that was 
mentioned by the previous panel. We also are going to be 
advocating for the release of FEMA funds to insure quality 
comprehensive mental health screening and referral for all New 
York City school children based on this study, but of course we 
want to go beyond that. Obviously, Senator Corzine wants to 
make sure those resources are available in New Jersey. We want 
to make them available, as we heard earlier, to everyone who 
would need them and we are going to be working with Mary Ellen 
Salamone and others who are trying to represent all the 
families, because really they represent the country, if you 
will, and the needs that are out there.
    We also believe strongly that we should guarantee access to 
long-term mental health services for victims of terrorism. That 
would speak to the point Dr. Hoven and Dr. Koplewicz made about 
the problem in our emergency crisis response-that it is 
supposed to be short-term. That is what it is designed to do, 
but clearly, many of these problems have much longer term 
effects. We want to try to begin to put an emphasis on the 
terror trauma that can come not only for an event, but from the 
constant warnings, the media images, some of the other issues 
that you have raised for us, and a mental health disaster 
response program between New York and New Jersey which would be 
regional, could serve as a model for how to go about doing 
this.
    Many of the issues we are looking at now in trying to 
prepare for future potential attacks on our vulnerabilities 
have no borders, they cross all borders, and we need to do a 
better job. We are going to ask the HHS to assist all the 
states and all of you in working with us to facilitate this 
better coordination in response to disaster.
    So we have six points coming out of this. I know the press 
and maybe the public has some questions. I am going to invite 
all the witnesses from the previous panels who are still here 
to join these witnesses and Senator Corzine and I on stage. 
Again, I think we owe a great round of applause to these 
witnesses.
    [Whereupon, at 12:28 p.m., the committee adjourned.]

                          ADDITIONAL MATERIAL

               Prepared Statement of Pamela Cantor, M.D.
    The terrorist attacks on September 11, 2001 have highlighted the 
vulnerability of children and their families, as well as the vital 
systems on which they depend. We have just heard about how trauma has 
affected children throughout the city. What we are faced with in New 
York City is a public health crisis involving the mental health of our 
city's youngest citizens. Two hundred thousand children in the city 
meet criteria for at least one major psychiatric disorder. Children who 
are affected by a few to several symptoms those with sub clinical 
syndromes will number in the thousands and they too are experiencing 
impairment in their ability to learn and to function positively in 
their lives.
    The majority of these children have not received help of any kind.
    In addition, the Needs Assessment demonstrates what literature from 
other communities facing catastrophes have observed: that is, that the 
effects are felt in a wide perimeter beyond the geographical area of 
the event. Children were exposed to this tragedy throughout the region 
and the nation. They were faced with questions about their personal 
safety and that of their parents. If they or their parents had exposure 
to any other traumas or losses in their lives they would be 
particularly at risk for the onset of new or recurring psychiatric 
symptoms. The experience that we are having in New York to fully 
understand the emotional impact of this event on children and families, 
as well as our schools, will have much to offer other communities in 
the tri-state region and the nation.
                           aftermath of 9/11
    From the very first minutes of the terrorist attacks, the Board of 
Education in New York City recognized the urgent health and mental 
health concerns that were going to be facing the population of children 
and families that it serves. It reached out to many local and national 
figures experts on child mental health issues, trauma, as well as those 
organizations and communities that had faced catastrophic events 
before. In a short time it became clear that coordination and 
collaboration were going to be essential tasks to bring about an 
effective response to an event of this scale. In many instances this 
meant a series of often uncomfortable ``arranged marriages'' among 
scientists, clinical providers, community organizations, and funders. 
Competitive issues had to be overcome for the benefit of children and 
to accomplish this the Partnership for Recovery in the New York City 
Schools was established. With the Children's Mental Health Alliance, a 
non profit organization in New York playing the facilitating and 
coordinating role, institutions such as the National Center for 
Children Exposed to Violence at the Yale Child Study Center, Columbia 
University School of Public Health, NYU Child Study Center, the 
Department of Public Health, the Office of Mental Health, Mt Sinai 
Medical Center, Jewish Board of Family and Children's Services, Saint 
Vincent's Hospital, the Center for Social and Emotional Learning, 
Applied Research and Consulting and many many others joined with the 
Board of Education to develop and implement the Partnership Mission.
    The goals and progress of the Partnership to date have included:
    Goal:
    Identifying the needs of different populations of children 
throughout the city using the scientifically valid screening instrument 
which has been developed by the Partnership.
    Progress: Separate testimony is being provided about the Needs 
Assessment study conducted by Applied Research and Consulting (ARC), 
Columbia University School of Public Health, and the New York State 
Psychiatric Institute.
    The report written from the Needs Assessment data allows all of us 
to better understand how children have been affected, and guide us in 
making thoughtful and appropriate decisions about how to meet those 
needs and how to allocate resources. The report makes a powerful case 
for a coordinated, broad-based response to a public health crisis 
involving the mental health needs of our children. In the NYC Public 
Schools alone, there are an estimated 200,000 children whose daily 
functioning is impaired by mental health issues.
    Goal:
    Develop the capacity of the New York City schools to meet the short 
and long-term emotional needs of its children.
    Progress: a pre-K through 12th grade Social Emotional/Health 
Education curriculum, in addition to a related series of training 
manuals is in development stages. Some of this curriculum developed by 
the Partnership will be available as a resource to schools as early as 
September in the form of September 11th Anniversary related guidelines, 
training manuals, and related education/trainings (awareness sessions 
to ongoing technical assistance). These materials are intended for use 
by educational administrators, school security officers, parent 
leaders, and heads of after-school settings who want to create safer, 
and more responsive settings that foster learning with an attunement to 
children in distress in particular. Social and Emotional Education can 
increase the resiliency of children and reduce risky behaviors.
    Goal:
    Improve the process by which schools respond in times of crisis 
enhancing the mechanisms for a coordinated and effective response. 
Crisis response model should incorporate critical partnerships between 
schools and mental health providers, law enforcement, and other 
community based services and organizations.
    Progress: As of this past Friday, Dr. David Schonfeld and his team 
from the National Center for Children Exposed to Violence at Yale 
(NCCEV) have completed their training calendar for this school year. 
All NYC BOE Superintendents, district offices and 12 school district 
crisis teams have now received training in the NCCEV model for school 
system crisis response.
    These trainings have begun to lay the groundwork for a system-wide 
architecture of crisis response which will allow schools, districts and 
the central office to manage crisis situations in a more effective, 
consistent, and integrated manner. Crisis response teams are instructed 
in an organizational model which delineates team structure and roles. 
The training team also provides information on staff support and 
bereavement issues.
    These trainings have offered an opportunity for district and school 
level personnel to create partnerships and develop networks in 
surrounding communities to efficiently implement crisis response. 
School level teams have been asked to identify local mental health 
providers with whom they wish to partner and invite them to the 
trainings. Representatives from the NYPD, who play a crucial role in 
crisis response and school safety, also attended the training sessions 
in an effort to strengthen their partnerships with districts and 
schools.
    In addition to the team trainings, a Citywide Crisis Response 
Steering Committee met throughout the school year on a monthly basis. 
The steering committee met to address system-wide crisis response 
policy (e.g., revising the School Safety Plans to incorporate mental 
health representation), facilitate implementation of the training 
schedule, and discuss city-wide crisis issues such as the plans for the 
one year anniversary.
    Goal:
    Coordinate an effort to guarantee that the children who are 
affected by a catastrophe have access to appropriate clinical 
interventions. This will include a review of best practices and models 
for working with children and staff following a disaster.
    Progress: The Partnership is creating a comprehensive database of 
mental health resources currently working with or willing to work with 
schools, after-school programs, and other child-serving organizations. 
This information is being collected from various data sources and 
detailed interviews with District Superintendents, Principals, and 
Pupil-Personnel Directors about the relationships they have or want to 
have with mental health providers and community-based organizations. 
This database will be district specific but in and of itself will not 
guarantee access to care. A major effort will need to take place to 
facilitate new relationships between these resources and schools, as 
well as to strengthen existing ones. There are many hurdles to the 
actual utilization of mental health services that will need to be 
overcome. The mapping process has begun in three pilot school 
districts.
    The Partnership is committed to creating a multi-layered approach 
to meeting the mental health needs of children. In the immediate 
aftermath of September 11th, members of the Partnership met with The 
New York Times 9/11 Neediest Fund. This collaboration resulted in the 
initiation of The Times' Strength in Schools program, which issued 
immediate grants to three providers that had pre-existing relationships 
with the schools in and around Ground Zero and additional grants to 
other districts. Through funding by The New York Times, augmented 
direct services have been provided in Districts 1, 2 and 31. Plans are 
underway to expand the list to include District 6 and 27.
                       a new public health model
    Using a public health model to look at mental health need we can 
view the children of our city and region have been exposed to a serious 
toxin. The Needs Assessment has told us how children were affected, the 
disorders that resulted, the levels of severity, the numbers of 
children affected, and the pre-existing conditions which increase the 
vulnerability of children. We know this by means of the study's 
methodology. The presence of a representative sample of New York City 
Public School Children grades 4-12--allows us to make inferences about 
children throughout the city. This study has confirmed what many 
professionals feared in terms of the very large numbers of children 
affected and the very large numbers of children who have not received 
help. The mental health infrastructure before September 11th was not 
sufficient to meet the pre-existing needs which existed. This 
infrastructure has suffered serious erosion in recent years. Both 
school-based and community based resources are now faced with a demand 
and an urgency which has never been greater.
    From the point of view of the Needs Assessment there is still 
information missing. We do not know about children K-3rd grade. We do 
not know about children who are not in the public schools and we do not 
know about children under the age of 5. In addition, school staff that 
have also experienced multiple traumas (plane crash, bioterrorism, 
etc.) have not been assessed. This work must be done.
    The information the Needs Assessment does not give us it does not 
tell us which children are suffering. This is a very complicated 
problem from many dimensions. Children exposed to trauma are not easy 
or obvious to identify. They often do not stand out in a classroom and 
at home, the initial subtle changes in their behavior may not be 
noticed especially by parents who are suffering themselves. Even 
programs designed for aggressive parent and staff outreach will not 
identify all of these children. In a public health model screening is 
essential to identify these children and to insure their access to 
treatment. Screening has not been done on any appropriate scale in New 
York following this event. There are many examples that we can draw 
upon in which public health issues, such as HIV, were dealt with (e.g. 
confidentiality of carriers, the confidentiality of partners and a 
parent's inalienab le right to decide upon treatment for their 
children). Screening of children to identify cases and provide proper 
treatment must be done. The cost of not doing it will be huge and risky 
in terms of the serious impairment and suffering children will endure. 
Children with untreated depressive and anxiety disorders as well as 
PTSD are at much greater risk for self destructive and other risk 
taking behaviors.
    In addition to screening children, there must be a methodology for 
tracking the outcome of interventions. Only through an ability to track 
can we see the effectiveness of what we are doing and make 
modifications along the way. Contagious diseases like TB or sexually 
transmitted diseases have had the benefit of ongoing government 
surveillance through the Department of Health. Using care and great 
sensitivity to confidentiality, it has been possible track what happens 
to people who have been exposed or who have these conditions. The 
mental health emergency which exists among our young people carries 
enormous risks for them and those around them. The same kind of public 
health surveillance should be carried out for mental health issues.
                  public education--primary prevention
    Mental Health issues still labor under a tremendous burden of 
stigma which hinders access to treatment. This is even more the case 
when children are affected. Parents do not want to have their children 
labeled as having a psychiatric illness. In a city where 175 different 
languages are spoken reflecting huge cultural diversity, the obstacles 
to access to treatment grow larger. In situations like September 11th, 
many people regard whatever reaction they are having as not indicative 
of a mental illness, but rather a normal response to a highly abnormal 
stress. For all of these and many other reasons, a public education 
campaign which reaches out to parents and children helping them to 
understand what they are feeling, when they may need additional help 
and what can be done about it is crucial to insuring access to 
services.
    Even if we are successful in the daunting task of increasing our 
capacities to offer mental health services we will need to make an 
equally huge effort in insuring that these services are offered in a 
way which is ``user-friendly'' and culturally acceptable or they may 
not be utilized.
    The Mental Health Association of New York City is working with its 
partners in the community, local government and private philanthropic 
organizations with the vision of a collaborative city-wide, multi-
dimensional public education campaign promoting mental health for 
children and families. There are currently two campaigns under 
development. The first is a broad scale children's mental health 
``anti-stigma'' print campaign. The other campaign is a disaster-
related public education campaign focusing directly on how the events 
of 9/11 impacted children ages 14 and under, and speaks directly to 
parents and adult caregivers.
        preventive services/healthy social emotional development
    School and home can and need to be places where students can learn 
to face the tests of life. The Partnership for Recovery in NYC Schools, 
The New York Academy of Medicine and the Center for Social and 
Emotional Education (CSEE) are now developing a five-year educational/ 
training plan to:
    Develop a pre-K through 12th grade Social Emotional/Health 
Education curriculum and related series of training manuals, 
educational forums that will range from introductory awareness sessions 
to ongoing technical assistance.
    Synthesize and create guidelines, the creation of training manuals 
and related education/trainings (awareness sessions to ongoing 
technical assistance) for educational administrators, school security 
officers, parent leaders, and heads of after-school settings who want 
to create safer, more caring and responsive settings that foster 
learning in general and an attunement to children in distress in 
particular.
    Organize SEL/Child Development Resource Center. This Resource 
Center will be web-based and/or available on CD-ROM
    Supporting, educating and nurturing the healthy social and 
emotional development of children promotes academic success, reduces 
violence and increases the ability to recognize others in distress. It 
is one of the most powerful tools that we have to promote the recovery 
from traumatic events and enhance resilience.
                     Education in Trauma Treatment
    There is a body of knowledge of evidence-based practice available 
to us for preventing and treating the disorders which people experience 
following a trauma. Much more needs to be done to create a knowledge 
base about effective practices, especially with younger children. 
Across the country organizations like the National Center for Child 
Traumatic Stress, The National Center for Children Exposed to Violence 
at the Yale Child Study Center and here in New York the Consortium for 
Trauma Treatment and Safe Horizon have begun the work of training many 
different kinds of professionals in trauma and grief treatment. There 
needs to be a huge expansion of training in effective models of 
treatment for school based as well as community based professionals. If 
professionals working in all different kinds of settings received 
training in their abilities to identify affected children, provide 
psychoeducational supports to children, staff and parents (which in 
many instances will be a sufficient treatment) and where appropriate, 
provide more extensive treatment, our true capacity for addressing 
trauma-related mental health problems would be greatly increased.
                   capacity of mental health services
    The first objective in augmenting the capacity to prevent and treat 
the mental health problems associated with trauma, is the creation of a 
multi-layered continuum of settings in which children in distress will 
be reco gnized and identified, receive supportive and counseling 
services and where it is appropriate, receive longer term treatment. 
The first layer might be schools, after-school programs, Project 
Liberty Sites. At this layer the conditions for success would be the 
ability to correctly identify a trauma related mental health problem, 
to provide immediate counseling support to child and family, to provide 
a correct referral to a setting appropriate and acceptable to a child 
and family for more in- depth evaluation and treatment.
    To establish the second layer a comprehensible system of resources 
to schools or Project Liberty providers as well as to families directly 
a massive organization and coordination task is ahead to insure access.
                        key elements of success
    Over the last several months through the work of the Partnership, 
we have begun to understand some of the many problems and potential 
solutions to the mapping and linking of resources. The conditions for 
success rely upon three key components:
    District leadership at the Superintendent and Principal level
    Provider Leadership
    Strong Leader for Coordination and Collaboration
    In the districts where we have worked, which include Districts 
1,2,6,27 and 31 there are models in which the success achieved so far 
in meeting the demand for mental health services is being significantly 
affected by the presence or relative absence of one or more of these 
factors.
    Among the more successful examples are District 2 and 31. In these 
districts there has been very strong leadership at the district level 
and very active involvement of this leadership in mental health issues. 
In District 2, which is in Ground Zero, there is also strong Provider 
Leadership. The NYU Child Study Center, Saint Vincent's and the Jewish 
Board for Family and Children's Services as well as a visionary funder 
in the New York Times 9/11 Neediest Fund, which augmented the funding 
for services already received through FEMA and Project Serve, are an 
example of a public private financial and service partnership which 
supported the many needs of teachers, parents and children in that 
area. In District 31, the accomplishments were led by the work of Dom 
Nigro, Director of Pupil Personnel Services, who created the District's 
own network of four providers to address the needs of the largest 
number of children who had lost at least one parent and the needs of 
many staff members who had losses as well.
    In many other districts the leadership and organization from the 
superintendents and principals less effective. They may not regard 
mental health as a priority or do not feel they have ability to 
establish relationships with providers and community based 
organizations. The central leadership at the Board of Education has 
made crisis response, safety and preparedness an absolute priority and 
now with the Crisis Trainings being conducted by the team from the 
National Center for Children Exposed to Violence, under the leadership 
of Dr. Steven Marans, they have firmly put health and mental health on 
the school safety map.
    But from there, the linkages to mental health service providers and 
other types of mental health supports are not reliable at best and non-
existent at worse. There is an opportunity and a challenge to take a 
system which has itself been traumatized and build
    a coordinated network of mental health resources and community 
resources with strong active relationships to our schools. Because 
future trauma cannot be anticipated and we are told every day that we 
may expect more, the rapidity with which this type of stable structure 
is established is of critical importance to the restoration of safety.
    Capacity cannot be increased overnight. One of the simplest and 
fastest ways to increase capacity is to strengthen, coordinate and 
better use what we already have.
    This can be done with the creation of a properly designed and 
conceived resource map, a coordination team whose exclusive job is to 
develop the relationships between potential community resources, the 
district leadership and the schools and the kind of outreach, advocacy 
and public education campaign that insures access to these services.
    The work in progress on district resource mapping and relationship-
building:
    Based on information gathered from our pilot work the following 
strengths and limitations of the Districts are apparent:
    The key limiting factors in some Districts include:
    Overwhelming need for children's mental health services
    Limited capacity and overburdened staffing (in both school and 
community)
    Only the most severe behavioral cases get addressed
    Inability to assess and identify children at risk
    Limited understanding of school community mental health needs
    Inadequate funding
    Insurance caps on service provision limit effectiveness and 
outreach
    Shortage of culturally sensitive services
    Absence of focus on primary prevention strategies
    Stigmatization of mental health
    The positive factors found in some Districts include:
    Focus on social and emotional health of children as a component of 
academic success
    Administrative buy-in on district and school levels
    Staff development, training, and support for identifying at- risk 
behaviors
    Established, effective relationships with community mental health 
providers
    Active school-based health and social service centers
                 governance, planning and collaboration
    In the immediate aftermath of September 11th, the governance and 
planning structure for mental health response came from the Board of 
Education in the form of the Partnership for Recovery in the New York 
City Schools. With the knowledge we now have of the magnitude and scope 
of the mental health crisis facing our city's children, a new planning 
and governance structure is needed.
    To address mental health within a public health context there must 
be governance and a pla nning structure in which the critical agencies 
involved in health and mental health are well represented. This 
structure must include the Board of Education and the Board must 
continue to receive the advisory support it has had. Responsibility for 
this new mental health approach should reside within the mental health 
authority of the City.
    This work should build upon the accomplishments of the first 
collaborative structure but must expand its scope to incorporate the 
many City, State and Federal agencies that already share the 
responsibility for meeting the health and mental health needs of the 
city's children. Leadership from the City can bring education, health 
and mental health together working to find an integrated approach to 
meeting children's health and mental health needs. The challenge to all 
of us at this moment is to face up to this urgent situation through the 
creation of the Partnership for Recovery of all of New York City's 
Children.
    If it were know that a health contagion was affecting 200,000 
youngsters in a serious way and many thousands more sub-clinically, in 
a single city, there would be no choice, no alternative than to pool 
our knowledge, our experience and our resources together to create the 
Partnership for Recovery of New York City's Children.
                              Attachment I
    BENEFITS CAN BE EXPORTED TO OTHER COMMUNITIES IN THE REGION AND 
BEYOND
    The Key Elements of a Public Health Model
    1. Information Infrastructure
    a. Needs Assessment Instruments all ages
    b. Screening instruments all ages
    c. Tracking and surveillance techniques
    2. Crisis Response Training
    a. Models available for all communities
    3. Prevention/Social and Emotional Learning Curriculum
    a. In development stages, will be available to schools and 
communities across the country
    4. Resource Mapping/Advocacy, Outreach and Public Education
    a. Once we develop the technique for doing this in NY City, other 
communities can use it as well
    5. Training in Trauma Treatment
    a. Many models available now but more work needs to be done to 
develop age appropriate models for children
    6. Continuum of Services
    a. Multi-layered model can be replicated in other settings
    7. Governance, Planning and Collaboration
    a. ``The ultimate arranged marriage''
     A New York City School District's Response to the WTC Disaster
    Good morning, and thank you for the opportunity to discuss this 
important issue. We all have a story about September 11, 2001. Where we 
were, with whom, how we felt and what we wished we could do. We all 
remember the weeks after the tragedy, how we would greet friends and 
associates tentatively asking, ``Is your family okay?'' These were our 
experiences as adults. What were the experiences of children?
    This is a question we ask teachers, parents and children. 
Consistently the answer often includes uncertainty, fear, sadness, 
anxiety, pessimism, and isolation.
    I was asked to come here today to speak about the initiatives that 
Community School District 31 has developed to address the mental health 
needs that precipitated from the WTC disaster. Community School 
District 31 is the largest school district in New York City and the 
second largest in NY State. Presently, we have 43,719 students. The 
borough of Staten Island has 5% of New York City's population, yet on 
September 11th, 28% of the firefighters and police officers that lost 
their lives were residents of this borough. Two hundred and eighty-five 
(285) of our students sustained the loss of a family member or loved 
one. Fifty-four staff members also sustained a similar loss. At one 
middle school six boys lost their fathers. At one elementary school, 28 
children suffered a direct loss. As you can see, our school district is 
hurting. These statistics do not take into account the other 43,434 
students, many of whom are struggling in a post 9/11 world of security 
consciousness, underlying fear and anxiety. This was made very clear to 
me when I granted permission for a five-year-old kindergarten girl to 
change her school. She was fearful that an airplane was going to crash 
into her school, since it was so large, and it had four stories. We 
transferred her to a single story school. Her fears were compounded by 
her concern for her father, who was a firefighter. We see it in the 
artwork of a second grade boy who writes on his artwork in late March, 
``I dreamed I fell off a building. Other people were on the building. 
Someone was coming to save me and the people. She saved the people. She 
was going to save me last, but I fell off the building.'' We have many 
such students. It is our mission to help our children, parents and 
staff deal with the many emotional and social concerns they now face. 
Our approach was supported by the recent study completed by Applied 
Research and Consulting.
    It is our challenge to walk the fine line between overwhelming 
families with services, versus not providing adequate services to meet 
their needs.
                           what have we done?
    Our first concern on September 11th was that some students would 
come home to empty homes . . . so we developed a strategy that ensured 
that all students were released to a family member. We set up two 
holding areas for students who were not picked up at school or bus 
stops .their safety was our primary concern . . . by 7:00 pm all 
students were appropriately released. This was only the beginning. We 
knew that our strategy had to include interventions for students, 
parents and staff. We knew this from our work confronting other 
individual crises, however, the twelve members of the District's Crisis 
Team would not go far in addressing the needs of all of our fifty (50) 
schools.
    Our approach was divided into three phases. This enabled us to 
assist children and families in a variety of ways.
                                phase i
    Phase I began on September 12th when an assortment of crisis 
management resources were developed and distributed to all our schools. 
These materials provided insight into the disaster and the grief 
process. The materials also provided direction to each school as to how 
to assist students in understanding the confusion surrounding this 
disaster. Schools were instructed to use these materials to develop 
strategies that would address the needs of the children. School teams 
first developed a plan of action to assist all students, and later a 
plan to assist individual students who expressed a need. These teams 
developed age-appropriate lesson plans, met with staff members, and 
designated a ``crisis room'' for those students who needed counseling.
    On September 13, 2001 Staten Island's problems were compounded by 
the ``lockdown'' of the borough due to a report that police were in 
pursuit of a terrorist that had entered the island via one of the three 
NJ bridges. This proved to be false, but further inculcated fear and 
anxiety into our families. Twenty-eight percent (28%) of our students 
attended school that day. Normally, 93% of all students are in 
attendance.
                                phase ii
    During October, Phase II of the District 31 Crisis Plan was 
implemented in which we partnered with local mental health community-
based agencies. Mental health professionals from these agencies were 
available to discuss any concerns that parents and staff members may 
have had with respect to their children or any other family members. 
Mental health professionals met with each principal to get an 
understanding of the school's needs. They collected information from 
various sources in order to get an overall picture of the impact of the 
WTC tragedy at the school. A plan was formed and a schedule developed 
so parents and teachers could meet with Phase II professionals in a 
designated space in the school. Referrals were made to the appropriate 
resources for those students who needed further assistance. The Phase 
II professionals may return to each school for a follow-up visit at a 
later date if the school needs further assistance. Materials and 
resources were made available from The Educators for Social 
Responsibility (ESR) and the District Office Media Library. Parents 
contacted principals to find out the dates and times the Phase II 
professionals were available and appointments were scheduled for those 
requesting services.
                               phase iii
    Phase III of the district's response to the WTC tragedy is called 
Project Cope. This was made possible through our federal SERV funding. 
Project Cope is comprised of 10 intermediate school guidance counselors 
who are responsible for counseling all those children in their own 
schools, as well as elementary schools that have been assigned to them, 
who suffered a loss of a family member. Project Cope counselors 
received Crisis Management training and were given the resources 
necessary to respond to this tragedy.
    These counselors began reaching out to their assigned elementary 
schools in early January. They introduced themselves to staff and the 
PTA.
    The Project Cope counselors contacted those students who suffered a 
loss, but first they reached out to each of their families.
    By February, the Project Cope counselors updated the district 
database to reflect the number of students in our district sustaining a 
loss of a loved one.
    Further training is taking place during the Spring Term and is 
being provided by The Educators For Social Responsibility. This 
training will be for Project Cope counselors and district staff members 
who are providing grief counseling to our students.
                        additional interventions
    The Office Of Student Services has been in contact with a number of 
organizations throughout the country that were eager to assist the 
district's students.
    Organizations and school districts donated the following items, 
which were distributed to students: Sixteen thousand teddy bears, Art 
supplies, Musical instruments, Gift packages, Survival kits, 
Professional Sports and Theater Event tickets.
    Finally, District 31 received a $100,000 grant from the NY Times to 
assist our students in the aftermath of the WTC. The NY Times funding 
will drive an initiative that will:
    Provide students in need of academic support with tutoring services 
during the summer months.
    Provide for the development of bereavement training videotape for 
school staff. The video will give an inside look at how four children 
have experienced loss in the September 11th attack.
    As you can see we have attempted to address as many issues as we 
can with our limited resources. The public has demonstrated a 
generosity that is beyond anything I could ever have imagined. 
Unfortunately, at a time when education budgets are being cut 
nationwide our school district is lacking the additional resources to 
effectively confront the unmet mental health needs that our students 
have developed as a result of the WTC tragedy.
    The anniversary of September 11th occurs five days into the new 
school year. Our challenge is to provide all of our students with the 
emotional, social and academic support that will insure that they are 
not re-victimized by our failure to do so. This support will enable 
them to simply be children, not citizens anxious or fearful about every 
passing airplane or stranger.
    The message we have been trying to impart to our students is one of 
hope, giving a sense that as the anniversary of September 11th 
approaches, the situation is different, but we are a stronger and more 
caring community as a result. One of our second grade students 
expresses this message in a poem called ``Spring":
    ``The sun comes out
    So let's all shout.
    The flowers bloom
    So, you have to make room.
    You can sing a tune
    And get ready for June.
    Spring has arrived
    And you don't have to hide.''
    Thank you.


    [GRAPHICS OMITTED] 
