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Chapter 31: Child Psychiatry
associated with severity of current PTSD symptoms, empha-
sizing the need to attend to prior trauma in conducting needs
assessments, surveillance, and intervention strategies. Other
risk factors, in addition to younger age, included female gender
and Hispanic ethnicity. The finding of age-related increases in
rates of conduct disorder also needs to be interpreted in light
of adolescent response to an ecology of danger in which overly
aggressive, reckless, and risk-taking behaviors are well docu-
mented and associated with posttraumatic stress reactions. A
major strength of this study was the inclusion of self-reported
impairment as well as symptoms, setting an important standard
for future studies.
J. Stuber and colleagues conducted a telephone survey of a ran-
dom sample of adult residents of Manhattan 1 to 2 months after the
September 11
th
attacks. The sample included more than 100 parents
who were asked to describe the experiences and reactions of their chil-
dren. Not surprisingly, given the time of the incident, most children
were at school or day care when the disaster occurred. Many of the
parents recalled concern about their children’s safety at the time, and
most were not reunited with their children for more than 4 hours. More
than 20 percent of the parents studied reported that their children had
received counseling related to the disaster. Receiving counseling was
associated with male gender, parental posttraumatic stress, and having
at least one sibling living in the household.
Also using parent report in a New York City telephone survey,
researchers assessed predictors of posttraumatic stress reactions in
children between the ages of 4 and 17 years, 4 to 5 months after the
attacks. Almost 20 percent of children were reported by their parents to
have experienced severe or very severe posttraumatic stress reactions,
and approximately two thirds had moderate posttraumatic stress reac-
tions. Parental reactions and viewing three or more graphic images of
the disaster on television were associated with severe or very severe
posttraumatic stress reactions in children. Another study reported that
27 percent of children with severe or very severe posttraumatic stress
reactions received some mental health care 4 to 5 months after Sep-
tember 11
th
.
Two surveys of representative samples of adults were con-
ducted after the September 11
th
attacks; the first between 4
and 5 months and the second between 6 and 9 months after the
attacks. Behavior problems were related to the child’s race or
ethnicity, family income, living in a single-parent household,
disaster event experiences, and parental reactions to the attacks.
The results of these surveys were examined in light of findings
from a representative survey conducted before September 11
th
.
The rate of behavior problems was lower in the first post-Sep-
tember 11
th
survey (4 to 6 months after the attacks) than rates
in the pre-September 11
th
survey, but problems returned to pre-
September 11
th
levels by the second post-September 11
th
study
(6 to 9 months after the attacks). Consistent with findings in
studies of Hurricane Andrew, these results suggest that behavior
problems may decrease in the months after a disaster or that
parents may be insensitive to them, but that they return to pre-
disaster levels over time.
Media coverage of the September 11
th
attacks brought
renewed debate about its impact, especially on children, even
children with no direct exposure. One study reported exten-
sive exposure to television coverage in children throughout the
nation, using a representative survey of adults conducted in the
first days after the attacks. Approximately one third of the par-
ents surveyed attempted to limit or to prevent their children’s
viewing, but, among those whose parents made no attempt
to restrict viewing, the number of hours of disaster coverage
watched was related to the number of reported stress symptoms.
Using a Web-based, nationally representative sample of
adults, another study examined distress in children 1 to 2 months
after the attacks by asking parents if their children were upset
by the events. Among the children perceived as most upset, 20
percent had trouble sleeping, 30 percent were irritable or easily
upset, and 27 percent feared separation from their parents. The
mean age of children perceived as most upset was 11 years, with
no statistically significant gender differences. The proportion of
parents reporting at least one child upset did not differ by com-
munity in analysis of data from the NewYork City metropolitan
area, Washington, DC, other major metropolitan areas, and the
rest of the country.
A strength of these surveys was their examination of rep-
resentative samples, but earlier work points to concern about
assessing children by interviewing their parents. Furthermore,
as with the Oklahoma City studies, the samples were composed
mainly of indirectly exposed children, and the clinical signifi-
cance of the findings is unclear.
Nine-year-old Jason endured the traumatic loss of his father on
the first plane into the World Trade Center. Jason’s father was on
board American Airlines Flight No. 11 on a business trip. Jason and
his siblings were preparing to leave for school when he, his mother
and his siblings learned of the event. Jason watched his mother
nearly collapse when she confirmed the presence of his father
aboard the aircraft. Jason observed the recurring video segments
of the second plane crashing into the second tower several times
that morning before his mother limited television access. Jason, the
oldest child in his family, had enjoyed an exceptionally close rela-
tionship with his father.
Almost immediately after the terrorist attacks, Jason’s mother
became worried that he was despondent, suicidal and unable to
function, just preoccupied with the grisly nature of his father’s
death. He was becoming increasingly agitated as he talked con-
stantly about the gruesome way that his father had died. Jason’s
mother sought immediate psychological treatment for him, during
which he began to ask a continual series of questions about his
father’s death, including aspects of burning, fragmentation, pain,
blood, and the exact moment of his father’s deaths in comparison
with what he had initially observed on television. This became the
main theme of Jason’s early treatment, in which he ruminated (i.e.,
whether this father had been “blown up in a thousand pieces” and
the sequence of fire, burning, pain, and death). Jason developed
nightmares within days in which he awakened and called for his
mother at least three times a night. Jason was unwilling to discuss
the content of his dreams with his mother, given his observations
of her own serious distress. Jason began to express fears that the
“hijackers” would hurt his mother and siblings. He became focused
on the concept that “half our freedom is gone,” and he was con-
cerned that one half of New York City was destroyed. He was
preoccupied with enacting in play, repetitive crashing down of
creating the World Trade Center. Although after 3 months, he was
able to resume sleeping through the night, he reported new trou-
bling dreams with themes of ghosts “popping out” and “everyone
is killed, and then I’m killed.” This worsened after the onset of the
war in Afghanistan, and his mother had to constantly reassure him
that the war was not near their home.
Jason told his therapist of his wish that could find a time
machine and be transported back in time on board his father’s flight
