Feature

Since 9/11, psychologists have been working to answer two critical questions: How can we help children understand such tragedies and how can we foster their resilience and hope in spite of such events?

Researchers and clinicians alike have been exploring a variety of realms to find answers. While research shows that the emotional effects of 9/11 on most children were short-lived, for those children who need the help, psychologists are looking at which interventions work best to help child victims of tragedy heal, how to support adults so they can help children move beyond such crises, and how children's exposure to media affects their healing and future outlook. Here are some of the lessons their work is pointing to:

Use evidence-based treatments. As in other areas of mental health, using practices backed by science can mean the difference between helpful and ineffective care, says New York-based clinician Robin Goodman, PhD, who runs the bereavement program at and is executive director of A Caring Hand, The Billy Esposito Foundation. In treating and studying children and their families in the immediate aftermath of 9/11, an intervention she found particularly useful in helping children who lost parents in the disaster addresses a reaction called "childhood traumatic grief." The method—originally developed to treat sex-abuse victims by psychiatrist Judith A. Cohen, MD, and psychologists Esther Deblinger, PhD, and Anthony P. Mannarino, PhD—recognizes that when a loved one dies as a result of a sudden traumatic event, children may show signs of both trauma and grief, and reminders of the trauma and even positive memories can trigger traumatic reactions and memories. A child with traumatic grief can get "stuck" on the traumatic aspects of the death, which then interferes with the typical grieving process, Goodman explains. The treatment, called trauma-focused cognitive behavior therapy, helps the child confront and manage reminders of the trauma, separating them from comforting memories, Goodman explains. The first part uses cognitive behavioral techniques to address trauma symptoms by teaching the child stress-management strategies; creating a trauma narrative, or story, that helps the child process and make sense of the incident; and addressing cognitive distortions such as undue guilt over the parent's death. The second part of treatment addresses grief-specific issues, such as life changes that result from the loved one's absence, memories of the person and making meaning of the experience. Caregivers are treated separately from the child using an adult version of the protocol, and at specific points in the therapy, the two are brought together for joint sessions.

Several studies have shown the protocol's validity and effectiveness, with the initial pilot study reported in the Journal of the American Academy of Children and Adolescent Psychiatry (Vol. 43, No. 10). In a not-yet-published randomized clinical trial conducted with children and spouses of firefighters, police, Port Authority and emergency medical service personnel killed in the line of duty on 9/11, Goodman, Cohen, Mannarino and Elissa Brown, PhD, compared trauma-focused CBT with client-centered therapy in 40 bereaved children and their mothers. At baseline, the children were in the normal range on standardized measures of psychopathology, while their mothers showed high levels of depression and anxiety. Children improved in both conditions, while the mothers in the trauma-based CBT treatment improved more than those who received client-centered therapy, the team found. 

The findings suggest that trauma-focused CBT can be especially helpful for bereaved people having particularly strong trauma reactions, Goodman says. "They also underscore the importance of including caregivers in treatment planning every step of the way," she says.

Besides these specific techniques, clinicians treating children post-crisis should employ active listening, which can highlight misunderstandings children have about crisis events; keep children's developmental stages in mind; and individualize interventions to a child's gender, social supports, culture, religion, temperament and other specific factors, Goodman says. (See box for links to other evidence-based protocols.)

Foster "post-traumatic growth." Traumas don't have to be all bad: They can strengthen children as well, suggests work by University of North Carolina at Charlotte psychologists Richard G. Tedeschi, PhD, and Lawrence G. Calhoun, PhD. The two have coined the term "post-traumatic growth" to capture the phenomenon, and created an inventory that assesses people's ability to discover new possibilities, better ways of relating to others, new personal strengths, positive spiritual changes and a stronger appreciation of life in the wake of crises. Many adults and teens affected by 9/11 show these kinds of gains, research shows. A 2009 study in the Journal of Traumatic Stress (Vol. 22, No. 2), for instance, found that 57.8 percent of a national sample of 1,382 adults reported greater prosocial behaviors, religiousness and political engagement in the wake of the event. Meanwhile, a 2003 study reported in Traumatology (Vol. 11, No. 4), found that about a third of California adolescents reported positive changes after 9/11, including in their appreciation of life, life priorities, spirituality, relationships and self-reliance.

Adults can encourage these same tendencies in children by using positive coping strategies, especially those that have been effective in past difficult situations, says Robin Gurwitch, PhD, professor and program coordinator of the National Center for School Crisis and Bereavement at Cincinnati Children's Hospital Medical Center. So, instead of allowing children to ruminate on the past trauma, for example, adults can encourage children to remember and reflect on the event, but also to perform positive actions in the present, such as sending cards or cookies to active-duty personnel or helping relatives, friends or others in need.

"When children in distress can reach out and help others who may also be hurting," Gurwitch says, "it not only helps their ability to cope, but also builds their resilience."

Educate parents. Working with parents on communicating with children is a key avenue for psychologists' involvement, says Goodman. "The biggest bang for your buck is to look at social and caregiver support for kids in any of these situations and to understand risk and protective factors," she says.

That said, research is still sparse on how parents can best help. Some studies show that parents' efforts to help their children cope with disasters may have little appreciable effect on their children's mental health. A study in the July/August 2010 issue of Child Development (Vol. 81, No. 4), for instance, explored the effectiveness of three strategies often cited as "good ways" for parents to help their children after a crisis: helping children process their emotions, getting them back into regular roles and routines, and distracting them from the event. However, none of these approaches lessened the children's rates of PTSD or depression, according to study authors Elizabeth T. Gershoff, PhD, of the University of Texas at Austin, J. Lawrence Aber, PhD, of New York University and colleagues.

Other psychologists are starting to identify evidence-based approaches that may improve these outcomes. Jonathan Comer, PhD, of Boston University's Center for Anxiety and Related Disorders, and Philip Kendall, PhD, of Temple University, for instance, have designed a protocol to help parents communicate with youngsters when watching terrorism-related news reports. Their strategies include modeling a sense of psychological security by not conveying anxiety to their children and by assuring their love and protection; offering praise when their children make positive coping statements; and educating their children on how to watch the news, for example by highlighting the unnecessarily alarming and dramatic nature of the coverage. "Without making light of the actual risk of terrorism in today's world, parents are taught to help their children understand the precise probability—as opposed to the possibility—of their actually being the victim of an attack," Comer explains.

In a 2008 study in the Journal of Clinical and Consulting Psychology (Vol. 76, No. 4), Comer and colleagues tested the model with 90 Philadelphia-area children and their mothers. Half were assigned to the protocol, the other half to "communication as usual." The parent-child pairs watched a 12-minute CNN news clip on the risk of future terrorism and the mothers were instructed to talk to their children about it using either the protocol or their normal mode of discussion. Children whose mothers used the model reported lower levels of perceived threat from terrorism than the other children and mothers, the team found. "We're trying to put these threats into a more realistic context," says Comer, "so that parents and children can go about their lives more normally."

Care for caregivers. It's important to remember that parents, teachers, counselors and other adults in a child's life need help for their trauma before they can properly care for children. A 2010 study in Psychology in the Schools (Vol. 47, No. 6) that surveyed 399 Washington-D.C.-area teachers and other school personnel following the 9/11 attacks on the Pentagon, for instance, found that 27 percent had experienced at least one symptom of hyperarousal—the PTSD symptom cluster that includes insomnia, irritability and jumpiness—while 12 percent experienced at least one symptom of intrusively re-experiencing the event, 10 percent at least one symptom of avoidance or numbing, and 11 percent one or more symptoms of depression.

On the positive side, many teachers reported experiencing post-traumatic growth after the traumatic event. Half said they felt better able to handle difficulties, while 56 percent reported feeling more compassion for others. In addition, teachers who sought to provide appropriate psychosocial interventions for children reported feeling prepared to handle student problems and competent to manage their work responsibilities, says the study's lead author, psychologist Erika Felix, PhD, of the Gevirtz Graduate School of Education at the University of California, Santa Barbara. The findings suggest that providing teachers with the psychological or professional support they need to effectively manage crises can make an important difference in how children—and they—adjust to and move on from the event, she says.

Such findings also underscore the general benefits of parents' ability to cope in the face of disasters, Gurwitch adds. "One of the best predictors of children's positive adjustment following a disaster or crisis situation is how well their parents are doing," she says.

Look at the context. Finally, it can be tempting for researchers or clinicians to focus exclusively on how a trauma like 9/11 could damage children's future well-being. Yet research suggests that many children did not suffer long-term mental health consequences unless they had vulnerabilities, such as a prior mental health history.

It's also important to keep the context of the child's life in mind, says Aber. In a 2004 longitudinal study of 768 New York City teens reported in Applied Developmental Science (Vol. 8, No. 3), he and colleagues compared rates of mental health problems among those exposed to the 9/11 attacks with rates of mental health problems among those who had experienced community violence but weren't directly exposed to the bombings. The team found that young people who had witnessed or experienced everyday acts of community violence—physical aggression, drug deals, muggings, break-ins and murders, for example—were far more likely to have mental health problems than those directly exposed to the Trade Center attacks. And the greater young people's exposure to community violence, the higher the levels of PTSD, depression, anxiety and conduct disorder they were likely to have, the researchers found.

The results underscore the importance of addressing problems within our reach, Aber says.

"It is important that we're prepared to help children in the event of another terrorist attack," he says. "But it's at least as important to use our knowledge to protect children against more common traumatic events—the everyday community and family violence that our and others' research has shown is particularly damaging to young people's mental health."


Tori DeAngelis is a writer in Syracuse, N.Y.