Compilation of Written and Verbal Testimony of Robin Goodman, Ph.D., Director, Public Education Programs & AboutOurKids.org, New York University Child Study Center, New York, New York, on behalf of the New York University Child Study Center
Testimony before the Senate Subcommittee for Children and Families Senator Chris Dodd, Chair, United States Senate Hearing November 2, 2001
Mr. Chairman and Members of the Committee: Thank you for giving me the opportunity to discuss the mental health issues of children and families at this time of crisis. I am honored to bring you the stories and voices of New York's children since September 11, 2001.
Eight -year-old Sean's father died. He was one of the first firefighters from Staten Island to arrive in lower Manhattan on September 11, 2001. He was also Sean's Little League coach. Sean now refuses to sleep in his own room, fights with his sister whenever they play catch, has trouble concentrating in school and has a tantrum whenever his mother must leave him with a babysitter.
Carmen had just started her senior year at Stuyvesant High School. When the first plane hit the World Trade Center her teacher had escorted the class to the skyway in order to leave the building. Unfortunately they then had a direct view of the following events of the attack. Carmen witnessed people jumping from one of the towers and as debris starting falling she fled through the streets and made her way across the Brooklyn Bridge. Previously eager to go away to college to study for a career as a doctor, Carmen is now thinking about taking a year off to live at home with her mother and younger sister.
Todd is a 14-year-old boy who was spared any direct exposure to the attack. He was at school on the Upper East Side of Manhattan. A long time fan of the New York Nicks, he was given a ticket for the their first game against the Wizards with the returning Michael Jordan. Hearing about the possibility of new threats and the need to be on high alert he refused to go to Madison Square Garden for the game.
What do we know?
Prior to the events of September 11, 2001, our knowledge of the effects of trauma on children living in the United States was largely based on clinical experience and research with children who suffered abuse or experienced a natural disaster. Given that 75% of all parental deaths are anticipated, our knowledge about the effects of parental death on children is largely based on a model where children have time to prepare for the loss. While our current interventions are informed by past research in these areas, clearly, the details surrounding current events will forever change the conclusions we draw from here forward.
The defining characteristics of the trauma of September 11, 2001 include:
- it was acute with sub sequential traumas
- there was a definite intent to do harm by a small number of terrorists
- there intent to harm the entire United States
- it was extremely rare
- there was severe and widespread devastation
- it was highly visible via the media
Unlike other devastating events, everyone experienced it in some form. The responses and consequences were both private and public, the effects were personalized, and the re-traumatization and re-grieving experiences have not abated. Some children were evacuated into smoke-filled streets; some witnessed people jumping from buildings; some were displaced from their homes; and all confront the changing status of fresh threats and the concomitant daily family and media response. Although posttraumatic stress disorder, one of many reactions that children have, is not diagnosed until at least a month past the traumatic event, given the nature of the ongoing threats in the United States, children have the potential to be continually re-traumatized. Thus the clock is set again and again, the reactions can become chronic, and some responses are even delayed - the sleeper effect.
Who is at risk?
Every child, parent and adult was exposed to the trauma of September 11, 2001. Adults look backward and imagine, with horror and regret, how difficult and sad their lives would have been had they grown up in such difficult times. Children, however, look forward, moving ahead with their development and their dreams even in such horrific times. They do not make the stark comparisons of experienced adults. But that hardly means children travel the road from childhood to adulthood without being affected by the terrorists' actions.
We can predict which children are most at risk for short- and long-term problems as a result of exposure to, and experiencing, such rare and frightening events. Children who had a parent die, who were directly exposed or evacuated, and those who were particularly vulnerable due to other personal and/or family circumstances may have more difficulty. It is helpful to imagine the ripple effect of a pebble dropped into the ocean. Those closest to the trauma often suffer the greatest impact.
Those most vulnerable for developing significant distress and mental health problems following a trauma include those who:
- lost a close relative
- directly witnessed the events
- were in close proximity to the situation
- had other mental health or learning problems prior to the event
- have poor coping skills
- felt no sense of control, predictability and safety
- have parents with poor coping skills
- lack a strong social and support network
Children whose primary caregiver died are most at risk if:
- the death was sudden
- the surviving caregiver is overwhelmed by grief and sadness
- they were facing other life stresses
- they had pre-existing problems
- they had a problematic relationship with the caregiver who died
- they live in a family with strained and ineffective communication
- they have no established or identified source of support
For children experiencing a trauma or loss, age, temperament, personality, and living and family circumstances also impact their coping style and ability. We know that children under the age of five are strongly affected by the reactions of their parents and other adults, that traumatic events experienced prior to age eleven are three times more likely to result in severe reactions, and that parents tend to underestimate both the intensity and duration of their children's stress reactions. Bereaved children are most at risk for problems in the first year after the loss. Although 10-15% of all children may experience depression during this time, some symptoms or problems can emerge one or more years after a death as the child faces new challenges, reminders, and tasks related to the grieving process.
Children's short-term responses to trauma and loss are reflected in their:
- thoughts: worries, hypervigilance, intruding thoughts, images, and memories, problems concentrating, and nightmares
- emotions: numbness, anxiety, depression, fear, changing moods, nervousness, sadness, anger, helplessness
- behavior: irritability, agitation, disorganization, avoidance, clinginess, aggression, regression, sleep disturbance, change in appetite
- physical reactions: headaches, stomach aches, nausea
The long-term effects of trauma and/or loss, as well as untreated or inadequately treated trauma can lead to depression, posttraumatic stress disorder, substance abuse, school refusal, academic decline, aggressive acting out, lowered self-esteem, and impaired interpersonal relationships. Ongoing worldwide conflict and the local effects of a nation at war create the potential for children to misconstrue events, acquire misinformation, and misdirect their fear and anger at innocent individuals.
What do children need?
Now more than ever, children at highest risk for mental health problems -- those already identified to providers -- need additional, targeted treatment. There are 10 million children and adolescents in the United States who already have a mental disorder. That number most likely will grow due to the first time occurrence of a mental disorder or troubling reaction from the 1.1 million New York City school children. The recent tragedy brings into sharp focus the educational and mental health service needs of children and families newly entered into the mental health system who are unaccustomed to and unsure of the best resources.
Our experience since September 11, 2001 in work with hundreds of administrators, teachers, parents, and children tells us the estimates have been correct: that 100% of those exposed to the trauma - adults and children alike, which is 100% of the community we serve -- were in need of psycho-education about trauma-related responses. We also know that in the coming months, 25% of the student population will experience moderate distress and 5% will experience significant to severe distress.
We know how to minimize and prevent the long-term consequences of trauma and loss. Above all, we must be resolute in our message regarding the power of parent and adult participation in children's recovery. Parents and adults must be educated about their influence in how children cope in the aftermath of a traumatic event. On the day of the attack New York City school chancellor Harold Levy called upon the NYU Child Student Center to provide information. Parents and professionals alike were hungry for information in those first days and their hunger has not yet been satisfied as they confront new and ongoing issues.
Parents can help their children by:
- providing a strong physical presence
- modeling and managing their own expression of feelings and coping
- establishing routine with flexibility
- accepting children's regressed behaviors while encouraging and supporting a return to more age-appropriate activity
- helping them use familiar coping strategies
- helping them share in maintaining their safety
- letting them tell their story in words, play or pictures to acknowledge and normalize their experience
- if need be, remember someone who has died
Discussing what to do or what has been done to prevent the event from recurring and maintaining a stable and familiar environment will help make the child feel safe and more confident. Adults also have an obligation to correct misinformation and set an example for tolerance. Research tells us that professionally prescribed and implemented cognitive behavioral approaches are the most effective for those needing direct treatment. Through guided cognitive training children are helped to restructure their thoughts and feelings so they can live without feeling threatened. Through behavioral techniques, such as imaginal exposure, children are exposed to a situation that created stress and are taught how to handle it effectively, thereby regaining their sense of control and self-reliance.
As the elected and recognized symbolic mothers and fathers of the nation's citizens, the government must acknowledge its responsibility for the future adjustment of the nation's children. In counseling parents we have emphasized the need for them to monitor their own strong response and to provide adequate and comforting information to their children while keeping alarming information and intense emotions at bay. Knowing a guarantee is impossible, they must still protect their children from both physical and psychological harm with honest discussion and emotion but tempered delivery of both. The government can echo and emulate the standard applied to good parenting in times of crisis. Well-timed amounts and doses of information are necessary, but conflicting, evolving, or changing information devoid of effective active coping strategies can provoke feelings of helplessness. Adaptation to new levels and contexts of normal is possible, but is more difficult when people are faced with new harsh, stark details. We are advised to get back to normal, but telling someone to "stop thinking about red" is near impossible when told of new instances of "red" looming on the horizon. We know that anxiety and fear are contagious and have potentially damaging consequences for the emotional and physical health of children and adults. A consistent and strong message of leadership and proactive safety measures will stimulate confidence in parents who in turn transmit a positive outlook to their children.
We know the model for treating other public health concerns. When faced with AIDS or cancer - illnesses that have the potential to scare people - revealing startling facts is in and itself inadequate to change behavior or feelings. Advertising information that includes reasoned discussion and a plan of action furthers the appropriate response. The most effective strategy requires systematically informing, training, assessing, treating, and evaluating any and all efforts at prevention and intervention. The goal is not only to make people feel better, it is to make them function better. This is not a sprint. It is a marathon and New Yorkers know how to prepare and endure for a run that will not be over in a matter of days or weeks. Caring for the mental health needs of New York's children and families will require vigilance and attention for months and years.
As a nation we have simultaneously been engaged in both reactive and proactive strategies to combat terrorism and the terror it leaves behind. The same model has been effective in treating children and families. Prevention and early intervention is imperative and necessitate reliance on existing empirical principles as well as accrual of information from the evolving data from children and families affected in the here and now. We have access to the best practices as they already exist. We are confident that the next chapters of those practices have to be researched, written, and disseminated in preparation for the unthinkable, a recurrence of events like September 11, 2001.
There have been many hard questions with more to come. There is no right answer, only the right attitude - one of adjustment to new circumstances and a belief that resilience is part of our nation's character and each child and family's birthright.
About the Author
Robin F. Goodman, Ph.D. , is a clinical psychologist specializing in bereavement issues.