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Terrorism and Mental Health in School: The Effects of September 11, 2001, on New York City Schoolchildren
From: Columbia University
| By:
Helene JacksonEzra SusserChristina Hoven |
EDITOR'S INTRODUCTION |
On the morning of September 11, 2001, approximately 1.2 million New York City public school children were beginning their fourth day of the new school year when the World Trade Center was attacked. The events of that day had a profound effect on these children. Some lost parents in the attacks. Others watched events unfold from their schoolroom windows. Elementary school children at Public School 89, located one and a half blocks away from Ground Zero, witnessed the airplanes crashing into the towers. Their teachers, in charge of evacuating them and ushering them to safety, remained responsible for educating these children in temporary classrooms and monitoring their mental health in the coming months.
Ezra Susser and Christina Hoven, both mental health epidemiologists at Columbia University's Mailman School of Public Health and the New York State Psychiatric Institute, have been closely involved with the New York City Department of Health and Mental Hygiene and the New York State Office of Mental Health in assessing the mental health repercussions of the events of September 11 on the people of New York City. Their findings and those of their colleagues showed serious symptoms of post-traumatic stress disorder (PTSD) and other mental health disorders in the months following September 11. One study commissioned by the New York City Board of Education surveyed 8,266 children in grades 4-12 from the five boroughs of New York City. The findings demonstrated that an estimated 75,000 children suffered from multiple symptoms of PTSD and that 190,000 suffered from at least one of seven other mental health disorders. Almost all of the children at Ground Zero and two-thirds of the children throughout the city experienced some personal physical exposure to the attack.
In an effort to assess the trauma incurred by school personnel on September 11 and to develop tools for future crises, Helene Jackson from Columbia's School of Social Work met with a focus group of eight teachers from Public School 89. In this interview, Jackson recounts the trauma sustained by teachers and students on that day and the rest of the school year. She explains how the teachers' impressions and recommendations will contribute to the creation of online-based education and training in trauma and loss for school personnel worldwide. In the accompanying video clips, teachers share their experiences along with comments from Ezra Susser and Christina Hoven.
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Christina Hoven (Principal Investigator, NYC Board of Education Study;Hoven 2002; Hoven et al 2002) explains the significant role school personnel played on September 11, 2001. In a focus group conducted by Helene Jackson, five teachers from Public School 89 share their memories of the attacks and of evacuating and protecting the children.
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Reference 1: Hoven CW. Senate Testimony
Reference 2: Hoven CW, Duarte CS, Lucas CP, Mandell DJ, Cohen M, Rosen C, Wu P, Musa GJ, Gregorian N:
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Fathom: What prompted you to develop education in trauma and loss for school personnel?
Helene Jackson: I think the idea first came to me after September 11--going to meetings and hearing people talk about the needs in the community. I know from my experience that teachers are not trained in trauma and loss, and yet, on September 11, they were on the frontlines, and many of them were traumatized during the ordeal. |
Fathom: How specifically does the approach of social work lend itself to this type of training? |
Jackson: Most people don't know that social workers provide the majority of mental health services in this country. Unlike other mental health and helping disciplines, social workers are trained to consider the person in the context of their environment. That means we don't just think of the person's inner life, or the person being "pathological"--rather, we think of the person being impacted by the environment. Because social workers work primarily with populations at risk, we're very aware of how the environment impacts on people's lives. |
As far as 9/11 was concerned, clearly the reactions that people had, for the most part, are a result of the environment. |
Fathom: Ideas for training of this kind existed prior to September 11, but why did the attacks on the World Trade Center solidify the need for school-based training? |
Jackson: I think it has been in the back of the minds of government and various professionals for a long time, but like everything else September 11 underscored that the need was compelling and acute. |
We've always had social workers in schools as school counselors, but they work with students and families. They don't usually educate the teachers. We really haven't addressed the teachers' needs up until now. Now that we see how this has impacted the children, and that the teachers are with those children more than anyone else they know and that they are a critical part of their environment, the need to develop an intervention to help teachers help the children is so clear. |
Fathom: What research has been done to determine the mental health effects on children in New York City since September 11, and what were the findings? |
Jackson: The research done for the board of health by Columbia's Mailman School of Public Health shows that hundreds of thousands of children have been affected. The studies show that more children who weren't in the Ground Zero area were affected than were those who were at Ground Zero. That's because a lot had friends and family who worked down there. The study also showed a high incidence of pre-existing trauma amongst New York City children, and that these children were more likely to experience trauma and post-traumatic stress disorder (PTSD) as a result of September 11. I think it was something like 64 percent of kids in New York City had had some kind of prior traumatic event--some of them were the loss of a friend, a family member, someone who was injured.... However, there are thousands, hundreds of thousands of kids who did not necessarily have prior trauma, but who also were traumatized and have shown symptoms of PTSD. Some actually meet the criteria for a diagnosis of PTSD, depression, agoraphobia and other disorders. I think agoraphobia increased five times and depression or separation anxiety, three times. The numbers are really astounding. |
Fathom: What was the purpose of forming a focus group of teachers from P.S. 89, the elementary school that was located a block and a half from the World Trade Center? |
Jackson: We wanted to do a focus group as a needs assessment that would be based upon teachers' experiences. They talked a lot about making sense of the experience. Not just for them, but how the children needed to make sense of the experience. And they feel that they haven't. Not only that they haven't, but they haven't worked on it, and they are no more near making sense of it now than they were that day, and that's very sad. |
They remember vividly the first crash sounds, a "kaboom" they called it. The parents started arriving in a panic trying to get their kids out of school. In the classrooms on the south side, they had a spectacular view of the World Trade Center. The ones on the north didn't. The teachers and kids there didn't really know what happened, some until they were evacuated and looked up at the sky. |
There was chaos, confusion, panic--some kids were crying, parents screaming--a lack of leadership. And you can't fault anyone because no one really knew what was happening. Some remember being told they had to leave the building; others made that decision on their own. They all have memories of the evacuation--walking up the West Side Highway--seeing police covered with soot yelling, "Move! Move!, Move!" and most didn't even know where they were going. Some said, "I went north but I could have just as easily gone south--I didn't know the difference." A number talked about coming out of the building, holding kids, feeling terrified. The kids didn't know what was going on, nor did the teachers. They remember dozens of people with cameras flashing and no one offering to help. |
Fathom: What was the experience of the teachers who saw it happen from their schoolroom window? |
Jackson:
They talk about looking out the window and then maybe seconds after thinking, we shouldn't be looking at this, the children shouldn't be looking at this. What's fascinating is how strong they were, and what resources they had that they had no idea was within them. Drawing the blinds and taking them to the rug where they have their activities and saying reassuring things and the right things like, "You're safe, your parents are safe." Safety is the first concern of everyone, children and adults. I think actually the ones on the north side did the same thing once they knew something terrible had happened. The people on the north side saw the faces of the kids at nearby Stuyvesant high school, where they were pressed against the window watching something. The kids noticed and said, "Why are all these people watching?" |
Some kids were crying. Most of them seemed okay, but a few were terrified and worried about their parents. Most of them had families there--that's where they lived. And most of them weren't able to go back to their apartments, and that was another trauma for them. |
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Ezra Susser conveys the psychological impact of the attacks on the World Trade Center, and Christina Hoven explains that many New York City children were already victims of trauma prior to September 11, 2001. In a focus group conducted by Helene Jackson, four teachers from Public School 89 describe the trauma they and their students suffered in the weeks and months after the attacks.
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Fathom: How different was it for these adult teachers versus other adults who worked near the World Trade Center? |
Jackson: Most of the people who were down there were responsible for themselves. These teachers had numbers of children ranging from 3 to 15 because many of the parents had come and taken some of the kids. It was an awesome burden and responsibility. And to add that to your own reactions of terror makes it significantly more of a trauma for them. They couldn't think about taking care of themselves. |
Some of them talk about how, when they realized what was happening, saying to themselves, "I'm a teacher, I'm responsible, I have to take care of these children." Of course that has repercussions for these teachers down the road because they have been so busy taking care of the children that they haven't been able to take care of themselves. |
Fathom: What other crisis in the world mirrored this experience? |
Jackson: As far as I know, there are no studies of teachers in past crises, but certainly there are studies of kids. Those studies have found that the kids are most damaged by this kind of thing. Oklahoma City was somewhat similar, but certainly not the same scale. But the whole idea of a massive catastrophe with malicious intent makes them very similar. The needs of those people and the children are similar to the needs of our children here. |
Israelis have been under terrorist attacks for so many years. PTSD is very prominent, and about 50 percent of the people have symptoms in Israel. There again, so much of what we know about trauma and risk factors are substantiated. During the Gulf War, Israelis who had been in concentration camps during the Holocaust and whose homes were damaged by the SCUD missiles were far more likely to experience PTSD than were their peers who were not Holocaust survivors. A pre-existing trauma has been found to make a huge difference. |
Fathom: What about the aftermath? To what degree has the trauma continued after September 11? |
Jackson: Let's talk about the teachers first. The aftermath for the teachers was a kind of re-traumatization. The evacuation was certainly a trauma for them. Going to PS 3, which was the school that hosted them initially, was also traumatic. They talk about having 70 kids on dirty blankets. There were no resources to teach with, and yet they were expected to perform as they did before. They were then transferred to another school where the same was true. People were nice and tried to accommodate them, but they didn't have the tools and they were displaced. And, at the same time, the children were displaced from their homes. So, you can't expect children to perform up to regular expectations. |
Most of the teachers talk about PTSD symptoms: exhaustion, no energy, loss of creativity, avoidance. One of the teachers says, "I can't go by P.S. 3 because I become so enraged," so she just doesn't go by. |
It took them days before they found out if friends or family were safe. It took them days to find out if all the children were safe. It took them days to find out if any of the parents of the children had been lost. Some of them talk about having nightmares. When you ask them what they do to take care of themselves, they say, "Sleep and eat." I think many of them are still depressed. I think it remains an organizing principle of their lives, and many really haven't had a chance to process it. |
Fathom: At what point do you pick up the pieces and move forward because you have to teach? For how long should counseling continue as schools try to get back to normal? |
Jackson: I don't think we know really. I don't know how we'll find out, but I do know that the teachers in this school felt very angry and betrayed that 48 hours after the attacks they were called to a meeting and were expected to think only about what to do to take care of the children without any acknowledgment that they themselves had gone through a trauma. I think, sure, life has to go on, but sometimes life can't go on until you've dealt with what has happened in the past. |
First they needed to know how to take care of themselves before they could care for the children. They needed to talk about it with their peers and colleagues. But they didn't. They all assumed that they had had the same experience. They didn't talk about it, and no one gave them the space to talk. They didn't know that they needed that space until they had the focus group many months later. It was just mind-boggling to them and to us that they hadn't talked about it. They had no idea what each other's experiences had been. They assumed it was all the same. I think looking back now that had they had the opportunity to meet, they wouldn't feel the way they do now. |
Fathom: Did they feel called upon to act as mental health workers? |
Jackson: They were asked to diagnose
children and refer them, which again reinforces how important this program is. They were asked to identify kids in trouble. They had no idea really unless the kid was screaming and yelling, but that's not the way it happens. Many of the children react so similarly. They describe post-traumatic play where they build blocks and tear them down, build those blocks and tear them down--as though constructing the World Trade Center and knocking it down. |
And the drawings of towers: interestingly some with the sun and a rainbow--it's a kind of denial--and others blowing up with fire. Also, kids with anxiety can act out with obsessive-compulsive behavior, like this boy who all he could talk about or think about was Osama Bin Laden. Reading had to be about Osama Bin Laden. Play had to be about Osama Bin Laden. Everything had to be about Osama Bin Laden. The teachers did the best they could with this child. The parents couldn't hear that this kid was really in trouble, and eventually they withdrew the child from the school. This is the kind of thing we can be helpful with in this project. They will learn how long traumatic play should go on, and when you should interfere to disrupt and redirect it in a way that will be growth-producing for the child. |
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Christina Hoven conveys the alarming findings of mental health disorders as a result of September 11, 2001. Six teachers from Public School 89 speak with Helene Jackson about the stress, fear and fatigue they experienced, as well as the troubling behavior their students have exhibited in the months since September 11, 2001. Ezra Susser stresses the need for enhanced mental health training and support.
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Fathom: Dr. Ezra Susser explained that in many ways we cannot prevent a future crisis, but we can be better prepared. What are the challenges and future recommendations for school personnel and children? |
Jackson: The teachers were quite articulate about what their challenges are, and the main challenge for all of them seems to be how to balance the academic needs of the children with their emotional needs. How do you adjust your expectations of children once they've been through this thing without the sanction of the administration, whose expectations, for both teachers and children, are still the same? How do we respond to parents when parents ask us, "What should I do when my child is having nightmares?" How do we identify the normal process of trauma and grief? How do we differentiate that from something that is pathological? And if we do, what do we do about it? They have no idea where to go or who to speak to and they expressly ask for that. And that's one of things we plan to do, to provide them with a database of resources. |
Fathom: When you do a degree in teaching and education, should this be integral to the curriculum? |
Jackson: I think education certainly needs to change its curriculum so that it does include this kind of information. We've learned that it's more than just the events at the World Trade Center that have created a crisis, particularly when you see those statistics of how many kids suffered trauma prior to 9/11. We see this program being generalizable to all schools all over the country, and all over the world. |
Fathom: Should there be legislation and increased funding for more mental health/social work professionals in the schools? |
Jackson: I think every helping profession should train and educate its people in trauma and loss, and that's not something they ordinarily do. At the School of Social Work, we developed a course in trauma and loss right after 9/11 and were able to offer it in the spring. |
I think mental health is the stepchild of all health. Hopefully all these surveys that show how much damage can be done will make people and legislators realize that funding mental health is important. |
Fathom: Is there collective concern about PTSD in the long-term as well as the short-term, especially if it goes untreated? |
Jackson: Most of my research has been with the trauma experienced by sexually abused children and adults. Certainly there you see what happens when children never talk about it or tell anyone about it. They become depressed, and many become alcoholics or other substance abusers. They develop other anxiety disorders. They use defenses that were adaptive when it first happened to them. But as they get older those defenses don't work anymore, or they work too well. So it disrupts and compromises development. |
If a child is traumatized and isn't given the opportunity to resolve that trauma, and if he or she cannot resolve it, then if left untreated we can speculate that a large number of them will have learning problems, substance abuse problems, problems with depression and anxiety, with interpersonal relationships, with living. I want to emphasize that most kids are resilient and most kids will be okay, but even when we're talking about such a small minority, we're talking about hundreds of thousands in New York City, and not all of them are resilient, unfortunately. |
What you have to think about is that when someone is traumatized, especially by this type of thing, their whole world view is challenged and shaken. Children in particular take it for granted that the world is safe and secure, that their parents are going to protect them, and that people are basically good. Then this happens, and they watch TV and hear over and over about the Axis of Evil and good versus evil. It's very hard. |
I think the other thing to say is that many parents, even educated and well meaning, think that if your child doesn't talk about it, it means that he or she is fine. We also want to help teachers to help children and their parents feel comfortable to talk about it and to know how to respond so kids feel they are being listened to. |
Fathom: How can the teacher play an important role in the lives of children whose trauma is the result of the loss of a parent, and where the surviving parent may not be able to give the support the child needs because of their own grieving? |
Jackson: One of my colleagues, who is working with the families of firemen who were lost on September 11, has certainly found this. Many of the women, although they're amazing, are depressed. It's hard for them to talk. The children don't want to burden the parent because they see the parent is having a difficult time. My colleague was saying how different it is for the kids in schools where the teachers seem to know what to do versus those where there's nothing for the kids. The support of the school is critical. Teachers are in a unique position, and they are trained in terms of what to expect in terms of learning--when the child is having problems with learning, problems with concentration and interpersonal relations. |
Fathom: Can symptoms of PTSD and trauma occur long after the traumatic event? |
Jackson: Very often we think children are fine, and then a reminder happens. It stirs something not just in children but also adults. We've all had experiences where we've had tragic events happen. It fades and then something happens that just reminds us of it. It could be something that to another may not seem to be a reminder but to that person it's a trigger, and all of a sudden you're right back there again. And that's of course when people become more anxious--symptoms return, and people become very upset. |
It's important to help teachers and parents understand this is a normal reaction and how to react so the child knows it's a normal reaction. To normalize these feelings can be so helpful in the recovery process. |
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