The Children of 9/11

The attacks on the World Trade Center in New York City and The Pentagon outside Washington, D.C. were the largest attacks on the U.S. soil by a foreign entity since Pearl Harbor. Historians, war buffs, and armchair foreign policy experts can quibble about the details of this claim, but one thing is clear. The events of that Tuesday morning shifted world events on a scale like nothing in recent memory, except perhaps the end of the Cold War.

Those who watched it unfold on live television will never forget it. We turned on the news to see an iconic skyscraper gaping fire from a jagged hole in its side. We saw passenger plane slam into the adjacent building within minutes. And then the unthinkable. The twin towers of the World Trade Center collapsed into a pile of smoking rubble.

The nation sat paralyzed in shock and disbelief as news cameras showed first responders spring into action. They doused the flames, tended to the injured, and searched for survivors in the debris. The cultural, emotional, and psychological repercussions on the average U.S. citizen reverberate through our collective consciousness to this day. And to this day, members of the U.S. Armed Services are in harm’s way in Iraq, Afghanistan, and several other locations as a direct result of the 9/11 attacks.

What About the Kids?

Analysts and media pundits contribute volumes to the discussion about the long-term effects of 9/11 on the global balance of power and how it changed the priorities and contours of domestic policy across the political spectrum. Congress debates dollar amounts in legislation written to support the first responders who leapt into action. Families mourn those lost. People born after 2001 know no different world. They’ve heard the names Al Queda, Osama bin Laden, and ISIS most of their lives. But there’s a subset of our population that was particularly vulnerable that day, for whom the long-term psychological effects of 9/11 remain unknown. The young children, under the age of five, who may have been exposed either directly or indirectly to the World Trade Center attacks.

The Effect of Terrorism on Children

Early trauma can have significant, long-term negative effects on the physical, emotional, and psychological development of children. The ACE Study, published in 1998, coined the term adverse childhood experiences and presented data linking these experiences with chronic disease and mental health disorders in adulthood. ACEs include, among other things, exposure to violence, witnessing violent acts, and the loss of a loved one due to violence or natural causes. Follow-up studies confirm and expand the findings and predictions in the original ACE study. The body of research indicates adverse childhood experiences are directly related to increased likelihood of:

• Impaired cognitive development
• Decreased neuroendocrine function
• Impaired immune function
• Posttraumatic Stress Disorder (PTSD)
• Depression
• Anxiety
• Suicide attempts
• Alcohol and substance abuse disorders

The Effect of War on Children

In her article “War and Children” published in The American Journal of Psychiatry Residents’ Journal in July 2017, Dr. Michelle Liu synthesizes decades of data on war and terrorism that show children exposed to these experiences display elevated risk of developing:

• Acute PTSD
• Anxiety
• Depression
• Excessive fear of abandonment
• Excessive fear of sleeping in the dark
• Extreme dependency/clinging to parents
• Suicidal thoughts

Three Degrees of Exposure

Further research on the effects of war, terrorism, and armed conflict on young children verifies the conclusions presented by Dr. Liu: children exposed to this type of violence at an early age show an increased likelihood of developing chronic stress, mood, emotional, or physical disorders during later childhood, adolescence, and adulthood. A review of thirty-five studies involving over 4,000 children under the age of six exposed to political violence in the Middle East, sub-Saharan Africa, and North America describes a clear dose-response relationship between the amount and intensity of exposure and the severity of the subsequent mental health outcomes. This comprehensive review identifies three degrees of exposure, i.e. doses:

1. Media Exposure: Children exposed to political violence or war through the media or other forms of reporting
2. Personal Exposure: First-hand witnessing of any type of war, armed conflict, or terror-related events
3. Severe Personal Exposure: Experiencing the death or injury of a loved one due to political violence, or being directly injured by war or terrorist attack

The reported response to these degrees of exposure follows logically. Children with either severe personal exposure or personal exposure showed greater likelihood of developing negative psychological outcomes. Whereas children exposed to solely to media coverage showed less likelihood of developing negative psychological outcomes. However, the salient point here is that media exposure alone to war, terrorism, and armed conflict can have a negative impact on young children. Earlier paradigms held that children were somehow immune to media coverage of violent events because they didn’t understand what they were seeing. Experts thought children ignored what was happening or instinctively compartmentalized the experiences and rendered them insignificant. These paradigms are demonstrably false. Exposure to war and terrorism through news reports or other media coverage can have negative effects on children.

The 9/11 World Trade Center Attacks, Children, and Media Coverage

A national survey conducted via telephone in the week following 9/11 shows children watched an average of three hours of television coverage related to the World Trade Center attacks, and that children who watched the most coverage showed more stress symptoms than those who watched less coverage. Parents questioned in the survey, published in The New England Journal of Medicine in November, 2001, reported 35% of children showed symptoms of stress, and 47% displayed worry about their personal safety or the safety of loved ones. Another telephone survey, focused on residents of New York City, shows that 60.7% of participants with children “identified at least one child who was upset in the aftermath of the September 11^th attacks,” while 57.3% of participants with children in other areas of the country reported similar numbers.

Stats: PTSD in Kids Post-911

Researchers conducted various follow-up studies at one month, four months, and six months after the event, which show that both adults and children in New York City and other geographical areas displayed symptoms of stress and/or PTSD directly related to the World Trade Center attacks. Clearly, children in New York City were particularly vulnerable. Whether they saw the attacks personally, heard about them from others, or watched television news coverage, they were exposed.

The data show that for children:

• In grades 4-12, studies estimated prevalence of PTSD at 10.6%, six months after the event.
• Under the age of 5, studies estimated prevalence of PTSD at 14%, ten months after the event.
• Who lost a parent in the attack, studies estimated prevalence of PTSD at 20.4% ten months after the event.

For a small population of children near ground zero, researchers identified a 35% prevalence of PTSD.

The Long-Term Effects Of 9/11 on Children

It’s a surprise that there are no stiudies available on the long-term effects of the 9/11 attacks on children. A handful of research teams followed adults up to four years post-event. One study assessed the impact of media exposure to the attacks on a group of mothers and children five years post-event. In September 2017, we contacted a lead researcher on the team that conducted telephone surveys in New York City immediately following the event. He indicated he was not aware of any research being conducted on the subject. However, he anticipates such studies will emerge before long.

One New Meta-Analysis

He was correct. In March 2018, a group of researchers published a meta-analytic study on the long-term effects of direct exposure to 9/11 either in person in New York City or Washington, D.C., or through live television coverage the day of the attacks. However, this study did not focus on children. It focused on adults who participated in one of several telephone and online surveys conducted between 2001 and 2007. Meaning there are still no studies available that examine the long-term effects of the 9/11 attacks on young children. Nevertheless, the generalized observations of the researchers are worth noting:

“Our findings suggest that 9/11, a graphic and violent community trauma, left a mark on many individuals across America. Bearing witness to the destruction of fellow countrymen and revered symbols of national pride was associated with ongoing concerns about terrorism. Our study demonstrated that, indeed, 9/11 is a tragedy that U.S. residents did not, and likely will not soon, forget.”

Connecting the Dots

In the meantime, with regards to the children, the dots are there to connect. First: the abundance of research published on the long-term negative effects of ACEs on adults who experienced them. Second: the research on the long-term negative effects of exposure to war, terrorism, and armed conflict on children. Particularly the revelation that indirect exposure to conflict can cause significant psychological distress. Third: the mid-range studies on the persistence of PTSD in individuals directly and indirectly exposed to the World Trade Center attacks.

These three dots form a straight line pointing directly at a group of individuals who are now young adults. The children of 9/11. They’re out there, potentially vulnerable to a host of issues stemming from events they may not even remember. Parents of young adults, mental health professionals helping young adults struggling with addiction or emotional disorders, and anyone with a friend or loved one who fits the description should understand this possibility. Early trauma takes many forms, and can linger long into adulthood. Identifying and processing this trauma is often the first step in unraveling and healing persistent problems. For some, the root cause of their current challenges may be the attacks on New York City and Washington, D.C. almost twenty years ago.