Ten years after 9/11: what have we (not yet) learned?

Research conducted after September 11, 2001, has largely focused on documenting the widespread, profound, and often persistent impact traumatic events can have on children and adults. Although it is neither surprising nor novel to demonstrate that traumatic events can result in posttraumatic reactions, the breadth, depth, and persistence of these reactions are noteworthy. In 1 study1 involving a highly representative sample of 8000 children attending grades 4 to 12 in New York City Public Schools conducted 6 months after September 11, 2001, 1 of every 4 children (27%) met criteria for at least one of the probable psychiatric disorders assessed in the study (and also reported problems in their day-today functioning). Approximately 1 of 10 children reported symptoms consistent with posttraumatic stress disorder (PTSD) (11%), major depressive disorder (8%), separation anxiety disorder (12%), and panic attacks (9%). Yet, two-thirds of children who reported symptoms consistent with probable PTSD and self-reported impairments in daily functioning also reported that they had not sought any mental health services. Studies using estimates by pediatric practitioners of the incidence of mental health complaints related to the events of September 11th2 and studies using parent self-reports that showed that only 27% of children with severe or very severe posttraumatic stress reactions received any counseling3 confirmed the results obtained by self-reports of children. Together, this serves as a stark reminder of the major gap between mental health need and service delivery in the aftermath of a disaster within the United States.4 The types of reactions that can be seen after a traumatic event include sadness, depression, anxiety (including separation anxiety and school avoidance), and fears; sleep problems and somatic complaints; and difficulties with concentration and academic functioning. Children may demonstrate developmental and social regression and may initiate or increase substance use and high-risk behaviors. As already noted, persistent and marked posttraumatic reactions, including PTSD, are common after a major disaster. The extent and nature of children’s traumatic reactions to a disaster depend in part on the nature of the disaster; man-made, intentional events such as the terrorist attacks of September 11, 2001, generally result in more difficulties with adjustment when compared with natural disasters. How individual children are personally impacted plays a key role in determining the course of their recovery from the event; personal injury or death or injury of loved ones and the perception of life threat at the time of disaster are risk factors for difficulty adjusting. If the disaster results in loss of home and belongings, separation from caregivers, or other disruption of daily routine, children are more likely to have persistent difficulties. Witnessing of the event, whether directly or indirectly such as through the media, is associated with more difficulty with adjustment. We can anticipate that images of the September 11, 2001, attacks will again appear in the media at the time of the 10th year anniversary and may cause particular distress for children who have persistent traumatic reactions and those children who no longer are having ongoing difficulties but did have significant reactions at an earlier time. Parents should be provided advice on limiting children’s exposure to media (e.g., television, internet, social media, radio, and print media) after a disaster or at times of the anniversary when reexposure is likely to occur. How children react and ultimately adjust depends in large part on their preexisting mental health and coping mechanisms; prior unresolved losses or traumatic events place them at increased risk of difficulty coping with the current event. Parents who are having difficulty coping themselves generally have children who are experiencing difficulty as well; support provided by families and communities can, in turn, mitigate the impact.5 While the traumatic impact of a disaster is well documented and generally appreciated by professionals and the lay public, 1 issue that has received relatively little attention in both the research literature and in clinical services delivered after the events of September 11th relates to the impact on children of the death of a family member or friend. Outside the context of a disaster, it is Brief video clips of interviews of children and parents that were conducted by the author and sponsored by the New York Life Foundation can be viewed at www.jdbp.org.