Response of New York City public school children to 9/11

Six months after the September 11, 2001 attack on the World Trade Center, a high proportion of New York City school children had one or more probable anxiety/depressive disorders, according to an article in the May issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

The psychological consequences of a terror attack may be particularly great for children who are exposed to the traumatic event, according to background information in the article. Previous studies have shown that children exposed to mass trauma have elevated post-traumatic stress disorder (PTSD) symptoms as well as symptoms of anxiety and depression.

Christina W. Hoven, Dr.P.H., of the Columbia University Medical Center-New York State Psychiatric Institute, New York, and colleagues interviewed a large representative sample of New York City public school children enrolled in fourth through 12th grade, six months following the World Trade Center (WTC) attack, determining their level of exposure to the event as well as assessing them for eight probable mental disorders. Level of exposure was divided into the following categories: attendance at a ground zero school; severe exposure, defined as having two or more direct or one or more family exposures; moderate exposure, one direct and no family exposure; mild exposure, no direct or family exposure; and media exposure, having spent "a lot of time" watching television coverage. Direct exposure consisted of witnessing the attack, being hurt in the attack, in or near the cloud of dust and smoke, evacuated to safety or being extremely worried about a loved one. Family exposure was having one or more family member killed or injured in the attack or witnessing the attack but escaping unharmed.

One or more of six probable anxiety or depressive disorders were identified in 28.6 percent of the 8,236 children assessed, the researchers found. The most prevalent were probable agoraphobia (14.8 percent, fear of public places where escape may be difficult), probable separation anxiety (12.3 percent, fear of being away from parents or family) and probable post-traumatic stress disorder (10.6 percent). Higher levels of exposure corresponded to higher prevalence for all probable anxiety/depressive disorders.

"This study had six main findings," the authors report. First, six months after the WTC attack, a high proportion of New York City public school children had a probable mental disorder. Second, the severity of exposure to September 11 was related to the likelihood of having one or more of the eight probable disorders assessed. Third, that a wide range of probable mental disorders was elevated, in addition to PTSD. Fourth, that family exposure to the WTC attack was associated with probable mental disorder, even more strongly than direct exposure. The authors suggest some children may experience greater emotional impact from having a family member exposed than from being directly exposed themselves.

"The fifth main finding was that going to a school near the place of the near the place of the attack was associated with lower rates of probable mental disorder," the authors write. "This somewhat surprising finding may possibly be explained by a combination of factors, such as worldwide attention to their situation, increased social support, and the fact that students in the ground zero area schools were the recipients of significant mental health intervention immediately after September 11, 2001."

"The sixth main finding was that exposure to trauma prior to the WTC attack was a major risk factor for a post-September 11 probable mental disorder," the researchers found. "Thinking prospectively, this finding is of considerable public health significance since a significant proportion of New York City children have now experienced a major trauma (September 11), rendering them more vulnerable to mental disorders in the future, especially following any new disaster. Interventions to mitigate the effects of prior trauma, including September 11, have now, therefore, become substantially more important."