Long-term Data Reveal Psychiatric, Physical Fallout for Children of 9/11

Pauline Anderson

May 20, 2019

SAN FRANCISCO — Children who were directly exposed to the 9/11 terrorist attack that occurred in New York City in 2001 have significantly more long-term psychiatric and physical disorders than those who were not directly exposed to this trauma, new research reveals.

Results of the largest and longest longitudinal face-to-face study of individuals subjected to the 9/11 attack as children showed that 14 years later, these individuals continued to suffer the consequences of the trauma, including separation anxiety, panic attacks, and drug abuse.

Dr Lawrence Amsel

"This study was not on ongoing abuse but on a single incident of severe mass disaster, but nevertheless, it has had effects for decades. All kids exposed to 9/11 should be followed for their lifetime so we can learn what is the long-term effect of such a trauma. And we can help them by making sure they get all the help they need," said study investigator Lawrence Amsel, MD, assistant professor of clinical psychiatry, College of Physicians and Surgeons at Columbia University, who practices at New York–Presbyterian Hospital, New York City.

The results should remind clinicians that young patients who are exposed to a one-time trauma can have long-lasting physical and/or psychiatric complaints, he added.

The findings were presented here at the American Psychiatric Association (APA) 2019 annual meeting.

Unique Study

Although extensive research has examined the long-term psychiatric consequences of childhood trauma, there has been less exploration of how one-time traumatic experiences during developmentally sensitive periods affect physical-psychiatric comorbidities over the life span.

The Stress and Well Being (S&W) study is an ongoing longitudinal epidemiologic study involving 942 individuals directly exposed to 9/11 as children or adolescents. These individuals were in schools near where the planes crashed and witnessed the crashes and/or the collapse of the World Trade Center towers. Long-term outcomes in these children were compared with those of a control group of 563 children matched for age and sex who lived across the river from the Twin Towers and were not directly exposed to the attack.

The children and adolescents in the study were aged 0 to 17 years on the day of the attack and are now 18 to 36 years of age.

The study sample represented a mix of ethnic groups, including whites, blacks, Asians, and Hispanics. The sample comprised an equal number of male and female persons.

With regard to socioeconomic status, about two thirds lived comfortably; about 17% were doing better than average economically; and 17% lived paycheck to paycheck.

During face-to face interviews, researchers assessed a wide range of physical health conditions through self-reports or reports by parents. These conditions included stomachaches, headaches, asthma, infections, seizures, heart disease, diabetes, cancer, and sexually transmitted diseases.

The investigators assessed psychiatric conditions using the Diagnostic Interview Schedule for Children (DISC). The DISC was designed to obtain information about Diagnostic and Statistical Manual diagnoses by ascertaining the presence or absence of symptoms.

Separation Anxiety

The investigators found that highly exposed children were more than twice as likely as their unexposed counterparts to have separation anxiety (adjusted odds ratio [aOR], 2.19; P = .0279).

The likelihood of other psychiatric conditions was also increased in exposed children. These included panic disorder (aOR, 2.4; P = .0101), marijuana abuse (aOR, 2.09; P = 0.0158), and anxiety disorder (aOR, 1.43; P = .0461).

"Exposed children are now half as likely as the unexposed group to be living with a spouse or partner and half as likely to be living independently. This goes along with separation anxiety; these kids were much more likely to be afraid to move away, to get away from their family of origin, and to break out into their own lives. So there's functional impairment there as well," said Amsel.

The study also found that past-year psychiatric disorders of any kind were more prevalent among persons who were directly exposed to the trauma (35.5%) in comparison with nonexposed individuals (27.9%), and that this was "highly significant," said Amsel. Any lifetime physical health condition was also more common among the exposed group (26.5% vs 10.6%).

Comorbidity was also more common among the exposed group. "About 13% of the people who were highly exposed were comorbid," said Amsel.

The relative risk ratio for psychiatric comorbidity in the exposed group was 1.2 times that of unexposed individuals, and the relative risk for physical comorbidity was 2.4 times greater.

"And for physical and psychiatric comorbidity together, you were four times more likely to have combined psychiatric and physical problems if you were exposed," said Amsel

Contrary to what might be expected, the study did not reveal elevated rates of posttraumatic stress disorder (PTSD) among exposed persons. "We think PTSD symptoms may have morphed into panic disorder, social anxiety disorder, and kids being scared to be alone," Amsel told Medscape Medical News.

These new results highlight the need for clinicians to screen for trauma, said Amsel.

From a public health perspective, the results suggest that "we shouldn’t be waiting; we should be right in there helping those kids," he said.

It might also be helpful to have "universal resiliency programs," he said. "We teach kids algebra; why don't we teach kids resilience as part of their growing up?...kind of a user's manual for the human mind."

The researchers plan to examine whether those whose exposure level was extremely high (eg, those who lost a loved one in the terrorist attack or whose family lost their business) did even worse than the rest of the exposed group.

The investigators also plan to examine the role of age at the time of the disaster and of the availability of social supports. They will examine "double exposure" — exposure both to trauma and to a toxic environment (eg, harmful air quality as a result of the attack).

Amsel noted that firemen who were on duty during 9/11 are dying of cancer at higher rates, including higher rates of death from prostate cancer, which may be linked to an accumulation of certain heavy metals.

Need for Routine Screening

Commenting on the study for Medscape Medical News, emergency psychiatry expert Anthony T. Ng, MD, chief medical officer, Northern Light Acadia Hospital, Bangor, Maine, said "it highlights the close link between physical and psychiatric health."

Although psychiatry is moving toward integrating behavioral health and primary care, sometimes mental health experts "focus on the psychiatric side only," said Ng, who is an advocate for community mental health.

The study results reinforce the need for primary care and mental health experts to "work together," said Ng. He added that in evaluating a patient, taking "a good history" with respect to exposure to trauma "would be helpful."

Even years later after being exposed to trauma, patients may present with headaches, gastrointestinal (GI) problems, or sleep problems. "Upon exploration, these could be due to some long-term, unresolved issues" from a trauma, said Ng.

"One of the things we try to advocate for is looking beyond just the physical and not just medicate the headaches but to look to see if something else is going on," Ng said.

Ng is curious about the ethnic makeup of the study sample. "Different cultural groups may be more somatic; they may present with more physical symptoms," he said. For example, Asians or Latinos may have more GI symptoms or headaches.

Amsel confirmed that future analyses will examine whether the physical and psychiatric fallout from exposure to 9/11 differs between ethnic groups.

An important element of the study was that it had a "longitudinal perspective" on an event that happened 18 years ago, in which the children who were involved are now adults, said Ng.

The results seem to suggest that the connection between physical and mental health occurs not only acutely but also chronically, he said. He agreed that terrorism is a unique type of trauma that's different from traumatic events such as floods or hurricanes.

For one thing, terrorism attacks are unexpected, said Ng. "For example, if you live in Florida, you know that every year you're going to have a hurricane. You can do stuff to proactively deal with it because you know it's coming."

Even in areas prone to earthquakes, such as San Francisco, residents have a certain level of preparedness, with appropriately designed houses and buildings, said Ng.

Dr Lloyd Sederer

Also commenting on the study for Medscape Medical News, Lloyd Sederer, MD, Distinguished Psychiatrist Advisor, New York State Office of Mental Health, who led the mental health response after 9/11, agreed that people respond differently to a terrorist act than to a natural disaster such as a hurricane.

"Terrorism is totally out of your control," he said.

Research shows that the impact on young children exposed to most traumas — be it neglect, physical or sexual abuse, domestic violence, or drug use in the home — is cumulative and long-lasting, said Sederer.

"By the time those children are teenagers, they're not just experiencing psychiatric problems; they're obese, they're showing early signs of cortisol insensitivity; their blood pressure is higher, although it's not hypertensive; and they're smoking more," he said.

The study was funded by the National Institute for Occupational Safety and Health and was conducted by the Global Psychiatric Epidemiology Group of Columbia University.

American Psychiatric Association (APA) 2019: Abstract 124 (session 8). Presented May 19, 2019.

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