Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

to restrict viewing, the number of hours of disaster coverage watched was related to the number of reported stress symptoms. Using a Web-based, nationally representative sample of adults, another study examined distress in children 1 to 2 months after the attacks by asking parents if their children were upset by the events. Among the children perceived as most upset, 20 percent had trouble sleeping, 30 percent were irritable or easily upset, and 27 percent feared separation from their parents. The mean age of children perceived as most upset was 11 years, with no statistically significant gender differences. The proportion of parents reporting at least one child upset did not differ by com- munity in analysis of data from the NewYork City metropolitan area, Washington, DC, other major metropolitan areas, and the rest of the country. A strength of these surveys was their examination of rep- resentative samples, but earlier work points to concern about assessing children by interviewing their parents. Furthermore, as with the Oklahoma City studies, the samples were composed mainly of indirectly exposed children, and the clinical signifi- cance of the findings is unclear. Nine-year-old Jason endured the traumatic loss of his father on the first plane into the World Trade Center. Jason’s father was on board American Airlines Flight No. 11 on a business trip. Jason and his siblings were preparing to leave for school when he, his mother and his siblings learned of the event. Jason watched his mother nearly collapse when she confirmed the presence of his father aboard the aircraft. Jason observed the recurring video segments of the second plane crashing into the second tower several times that morning before his mother limited television access. Jason, the oldest child in his family, had enjoyed an exceptionally close rela- tionship with his father. Almost immediately after the terrorist attacks, Jason’s mother became worried that he was despondent, suicidal and unable to function, just preoccupied with the grisly nature of his father’s death. He was becoming increasingly agitated as he talked con- stantly about the gruesome way that his father had died. Jason’s mother sought immediate psychological treatment for him, during which he began to ask a continual series of questions about his father’s death, including aspects of burning, fragmentation, pain, blood, and the exact moment of his father’s deaths in comparison with what he had initially observed on television. This became the main theme of Jason’s early treatment, in which he ruminated (i.e., whether this father had been “blown up in a thousand pieces” and the sequence of fire, burning, pain, and death). Jason developed nightmares within days in which he awakened and called for his mother at least three times a night. Jason was unwilling to discuss the content of his dreams with his mother, given his observations of her own serious distress. Jason began to express fears that the “hijackers” would hurt his mother and siblings. He became focused on the concept that “half our freedom is gone,” and he was con- cerned that one half of New York City was destroyed. He was preoccupied with enacting in play, repetitive crashing down of creating the World Trade Center. Although after 3 months, he was able to resume sleeping through the night, he reported new trou- bling dreams with themes of ghosts “popping out” and “everyone is killed, and then I’m killed.” This worsened after the onset of the war in Afghanistan, and his mother had to constantly reassure him that the war was not near their home. Jason told his therapist of his wish that could find a time machine and be transported back in time on board his father’s flight

associated with severity of current PTSD symptoms, empha- sizing the need to attend to prior trauma in conducting needs assessments, surveillance, and intervention strategies. Other risk factors, in addition to younger age, included female gender and Hispanic ethnicity. The finding of age-related increases in rates of conduct disorder also needs to be interpreted in light of adolescent response to an ecology of danger in which overly aggressive, reckless, and risk-taking behaviors are well docu- mented and associated with posttraumatic stress reactions. A major strength of this study was the inclusion of self-reported impairment as well as symptoms, setting an important standard for future studies. J. Stuber and colleagues conducted a telephone survey of a ran- dom sample of adult residents of Manhattan 1 to 2 months after the September 11 th attacks. The sample included more than 100 parents who were asked to describe the experiences and reactions of their chil- dren. Not surprisingly, given the time of the incident, most children were at school or day care when the disaster occurred. Many of the parents recalled concern about their children’s safety at the time, and most were not reunited with their children for more than 4 hours. More than 20 percent of the parents studied reported that their children had received counseling related to the disaster. Receiving counseling was associated with male gender, parental posttraumatic stress, and having at least one sibling living in the household. Also using parent report in a New York City telephone survey, researchers assessed predictors of posttraumatic stress reactions in children between the ages of 4 and 17 years, 4 to 5 months after the attacks. Almost 20 percent of children were reported by their parents to have experienced severe or very severe posttraumatic stress reactions, and approximately two thirds had moderate posttraumatic stress reac- tions. Parental reactions and viewing three or more graphic images of the disaster on television were associated with severe or very severe posttraumatic stress reactions in children. Another study reported that 27 percent of children with severe or very severe posttraumatic stress reactions received some mental health care 4 to 5 months after Sep- tember 11 th . Two surveys of representative samples of adults were con- ducted after the September 11 th attacks; the first between 4 and 5 months and the second between 6 and 9 months after the attacks. Behavior problems were related to the child’s race or ethnicity, family income, living in a single-parent household, disaster event experiences, and parental reactions to the attacks. The results of these surveys were examined in light of findings from a representative survey conducted before September 11 th . The rate of behavior problems was lower in the first post-Sep- tember 11 th survey (4 to 6 months after the attacks) than rates in the pre-September 11 th survey, but problems returned to pre- September 11 th levels by the second post-September 11 th study (6 to 9 months after the attacks). Consistent with findings in studies of Hurricane Andrew, these results suggest that behavior problems may decrease in the months after a disaster or that parents may be insensitive to them, but that they return to pre- disaster levels over time. Media coverage of the September 11 th attacks brought renewed debate about its impact, especially on children, even children with no direct exposure. One study reported exten- sive exposure to television coverage in children throughout the nation, using a representative survey of adults conducted in the first days after the attacks. Approximately one third of the par- ents surveyed attempted to limit or to prevent their children’s viewing, but, among those whose parents made no attempt