Perhaps like many people, I find it hard to believe that 16 years have passed since the terrible events that took place in New York City, Arlington County, and Stonycreek Township (Pennsylvania) on September 11, 2001. Most of us can remember where we were when we heard or watched it all unfold – I was up late studying for a Developmental Psychology exam in Adelaide, South Australia – and the shock, disbelief, and heightened alert we all felt months after that tragic day; even, in my case, in as far away a place as Australia.
Psychological studies have shown that memories about 9/11 and other publically-experienced events can be distorted and altered over time. However, few of us would argue against the idea that 9/11 is an indelible part of our collective history, and those ramifications for individuals, families, communities, and the wider world are felt to this day. In this way, I think it must be more than a decade-and-a-half on because the world seems to be a very different place, and so much has happened in that time.
Shortly after 9/11, researchers began to examine the psychological effects of the terrorist attacks. A study published in 2002 investigated symptoms of post-traumatic stress disorder (PTSD) with a U.S. nationally-representative cross-sectional sample of 2273 adults. Participants were asked specifically about disturbing thoughts, feelings, and changes in behaviours related to 9/11. The study found that the prevalence of probable PTSD 1-2 months after 9/11 in participants in the New York City metropolitan area was 11.2%, compared with an overall rate for the entire sample (which included participants from all over the United States) of 4.3%. Factors that were related to symptomology included sex (females higher on PTSD symptoms), age (younger people higher), time spent watching television reports of the attacks, and not surprisingly, direct exposure to the attacks (i.e., having been in the World Trade Center or surrounding buildings at the time of the attack). Parents’ reports of their children’s upset indicated between 19.8% and 29.9% of children experienced symptoms such as irritability, upset, and fear of being separating from their parents.
A highway sign after the attacks.
Source: Paul Morse/Wikimedia Commons
A literature review published in September 2011 by American Psychologist found that there were few studies of the longer-term effects of 9/11 on post-traumatic stress disorder. Of the existing literature, while community studies reported decreases in PTSD prevalence over time, increased prevalence and delayed PTSD in some study participants was reported. Studies utilizing large samples of fire fighters found that probable PTSD had increased in this group over a four-year period. In other studies, PTSD in groups such as rescue and recovery workers was also found to have increased, and participants such as building occupants and those on the street/in transit in lower Manhattan on 9/11 reported high levels of PTSD 4-5 years after that day.
The World Trade Center Health Registry tracks the health effects of people who were exposed to the WTC attacks. In a recent study published in 2014 utilizing data from the third wave of data collection (2011-2012), rates of probable PTSD, depression, and comorbid (occurring together) PTSD and depression were 15.2%, and 14.9%, and 10.1%, respectively.
One group undoubtedly affected by the events of 9/11, but who have been less studied or profiled in the media, perhaps due to their age and concerns of vulnerability and re-traumatisation, are the children of those who died in the attacks. However, as time goes on, their stories are emerging in personal remembrances (and those of their families), as well as studies that seek to determine their mental health and wellbeing, and how health professionals might best respond to their needs.
The Children’s Stories
Last year, on the 15th anniversary of 9/11, there were several news stories on children who lost a parent in the attacks. In one article published in the Los Angeles Times, Laura King wrote that the nearly 3,000 people who perished on that day left behind 3,051 children under the age of 18. These children span those who were not even born at the time of a parent’s death, to those who were then on the cusp of adulthood; and, while not included in that statistic, it can be argued that that number should encompass anyone who lost a parent. For example, King profiled Lauren Kestenbaum, who was 24 when her father was killed, describing her as “not a child [when the attacks occurred], but not quite a full-fledged adult either – something she [Lauren] says she only recognized long afterward”.
We learn in the article that the events of 9/11 have influenced the children’s social relationships, mental health and wellbeing, disclosure about their pasts, feelings of being talked about, and sometimes resulted in issues of feeling abandoned by deceased parents. We are told that some families made the decision to move away from small towns that had been particularly touched by the tragedy; grandparents took over the care of their children, or siblings took in their nieces and nephews; and the children themselves have grown in different and varied ways, sharing complex relationships with the events. Francesca “Ces” Picerno, now 24 years old (at the time the article was published), reflected, “You don’t want to be defined by it. But it’s such a huge part of who you are.” For Kahleb Fallon, a 15-year old, his father says that he prefers “to keep at arm’s length a national and family tragedy that is part of him, yet somehow separate”. Reflecting at once the ordinariness of a teenager’s development and the experiences of one who has faced extraordinary circumstance, his father says, “He wants to be Joe Normal … You know what it’s like to be a teenager – they don’t like to be seen as different or weird.”
While the children were mourning the death of a parent, parents also had to address their own grief reactions at losing a partner. In the article, we learn of how, over time, families have addressed issues of changing dynamics, including a surviving parent making the decision to begin dating again.
Similarities and differences in the experiences of these children were apparent, but as Laura King observed, “That day marked these youngsters’ entry into a cohort of bereavement, an exclusive club that, as more than one of them observed, no one would ever, ever wish to join.”
What Do Research Studies Tell Us?
In the early-mid 2000s, some theorists and researchers examined the notion of childhood traumatic grief in relation to 9/11.
In his work on grief, Alan Wolfelt identified a series of what he calls the “reconciliation needs of mourning,” which involve acknowledging the reality of the death; embracing the pain of the loss; remembering the person who died; developing a new self-identity; searching for meaning; and receiving ongoing support from others.
Anthony Mannarino and Judith Cohen suggest that children who experience the loss of a parent in traumatic, violent, sudden and unexpected circumstances, are faced with both the bereavement itself and the nature of their parents’ death. For some children, more persistent symptoms of grief related to the traumatic nature of the death may develop – childhood traumatic grief – that interfere with this reconciliation process. They describe the situation where the child is “unable to complete the tasks of reconciliation because remembering the loved one typically serves as a trauma reminder”; that is, thinking about how their parents died. The child may then try to avoid thinking about their parent and engaging in remembrances, and develop symptoms of PTSD and other mental health concerns such as depression and anxiety. Reconciling a traumatic death can be complicated at any age. Elvis Perkins, who was 25 when his mother, photographer Berry Berenson, was killed in the attacks, reflected in 2007, “I still feel conflicted by the horror and violence of my mom’s passing. Death is hard enough to understand anyway, but when you get totally insane people doing a totally insane thing…”.
Few studies have directly investigated the impact on children who lost a parent in the 9/11 attacks. In a 2007 study that compared 45 children who lost a parent on 9/11 with 34 children who had not experienced parental bereavement over a two-year period, there were statistically significant differences in how many bereaved and non-bereaved children met criteria for an anxiety disorder diagnosis (56.82%, n = 25 vs. 23.50%, n = 8), with 13 bereaved children and one non-bereaved child meeting criteria for PTSD. There were not significant differences between the groups on prevalence of other disorders (e.g., a mood disorder, such as major depressive disorder). In this study, there were also differences between bereaved and non-bereaved children at a physiological level in hypothalamic-pituitary-adrenal axis dysregulation, reflected in increased levels of the stress hormone cortisol.
More reassuring are the findings that the probability of developing an anxiety disorder or PTSD decreased over the two-year study period, although for PTSD, the researchers reported the probability “remained high” for bereaved children.
A study by the same researchers investigated the mental health of some of the parents of these children (23 bereaved parents; 22 non-bereaved parents). Like the children’s’ study, there were significant differences in how many bereaved parents and non-bereaved parents met criteria for PTSD (68.18% vs. 0%) and major depressive disorder (45.45% vs. 9.52%); again, there were differences found in cortisol level measurements between parents in each group. It is concerning that the statistically significant declines in symptoms present in the children’s study were not evident in the parents’ reports.
Therapists and mental health professionals have responded to the needs of the young people impacted by 9/11 since the attacks. Findings in evaluation studies are encouraging. The CATS Consortium was formed by the New York State Office of Mental Health in 2003 to provide and evaluate services for children and adolescents affected by 9/11. The service provided treatments for hundreds of children and adolescents. In one reported study by the group, a sample of 306 young people ranging in range from 5 to 21 years received a cognitive-behavioural therapy (CBT) intervention. Children with moderate to severe reports of PTSD symptomology were assigned to complete trauma-specific CBT, while those with mild PTSD reactions were assigned to a brief CBT skills intervention. In this study, 51% of participants had first-hand experience of 9/11 (e.g., losing someone in the attacks).
The findings revealed that regardless of program, both groups of participants reported lower scores on the measure of PTSD symptoms six months later, with those with initial high scores that involved a “probable PTSD diagnosis” now in the mild range on the measure.
It is likely as adolescents and young adults who lost a parent in 9/11 get older, we will see more examinations in the literature and research of their experiences and perspectives.
Resilience and Hope
The Survivor Tree, a callery pear tree recovered in October 2001 and replanted at the World Trade Center site in 2010, is a symbol of hope and rebirth.
Source: Shannon Wagner/Wikimedia Commons
One topic that comes up when 9/11 is discussed is resilience. In towns such as Montclair, profiled in the Los Angeles Times article and the hometown of nine who perished, one community member reflected, “There’s a sense of resilience here … You see it 15 years out, and you could see it even at the time”.
Delaney Colaio, who was three when her father and two uncles were killed in the attacks, is working on a documentary entitled We Go Higher, which will profile people who lost parents on 9/11. Around 70 interviews have been conducted as of September, 2017, with interviewees ranging in age from 15 to 52 years. Delaney says that “I’ve always been defined by 9/11.” However, she also believes that “People hear 9/11 and think tragedy … They look at the 9/11 kids and see tragedy. It is a tragedy. But we want people to look at us now and see hope. People don’t know that we are OK. People don’t know that we are thriving. But we are”.
A 2016 Associated Press report by Jennifer Peltz profiled eight children who lost parents on 9/11. These adolescents and young adults discussed, in particular, how these deaths led them to pursue interests and careers that they felt would make a difference or bonded them with their parent.
Some, such as Lindsay Weinberg and Sonia Shah believe that their experiences provide them with empathy for others who experience trauma and loss. Lindsay, who works at the New York City medical examiner’s office reflected, “I’m giving them [families of a deceased person] among the worst news they can receive, and I’ve received it.” She continued, “It adds to the amount of empathy that I can have.” Sonia, who has worked with refugees, reflected, “Because I had faced loss at such a young age and in such a different way than many other people, I recognized hardship in other people’s life a lot more easily.”
Alexandra Wald was driven to advance knowledge so that such an attack will not occur in the future. Now working in cybersecurity for the federal government, Alexandra recalled frustration and anger during her studies when “contemplating missed opportunities” to prevent 9/11. In such times, she remembered her father saying to her a few weeks before his death, “You can’t look back with regret … never say, ‘What if?’”
Others intimately affected by 9/11 echo these sentiments. As Lee Ielpi, who lost his fire fighter son on 9/11, said on Australian TV program The Project on 12 September 2016, “It doesn’t go away because time passes. What you have to do, is … focus on tomorrow, making tomorrow that better day”.
In this way, I think that it is very much the job of not only health professionals but, indeed, our common humanity to try to help them to do so.
~ Thomas Jefferson