Elementary School Children's Responses 3 Months After the September 11 Terrorist Attacks: A Study in...

American Journal of Orthopsychiatry 2004, Vol 74, No. 4. 509-528

Copyright 2004 by the Educational Publishing Foundation 0002-9432/04/$12.00 DO1 10 1037/0002-9432.74.4.509

Elementary School Children’s Responses 3 Months After the September 11 Terrorist Attacks:

A Study in Washington, DC Deborah Phillips, PhD, Shantay Prince, MPP, and Laura Schiebelhut, MPP

Georgetown University

This study examined the responses of elementary school children in Washington, DC, to the September 1 1 terrorist attacks. Parents (primarily mothers) of children in kindergarten through Grade 6 and children in Grades 4 to 6, including 47 matched parent-child pairs, completed questionnaires regarding exposure, stress reactions, and constructive actions taken 3 months after the attacks. Parent reports and, to an even greater extent, children’s self-reports revealed high levels of negative reactions to the attacks on behalf of the children. These reactions were best understood in the context of their exposure to the attacks, primarily through television news, and the reactions of and coping assistance provided by their parents. Implications for school personnel, health care professionals, and intervention efforts are discussed.

Young children have received far less attention than adults in the emerging research literature on the human repercussions of the terrorist attacks of Sep- tember 11,2001. Focused studies of college students, Bight attendants, pilots, and firefighters (Pezdek, 2002) and population surveys that have identified parents (Phillips, Featherman, & Lui, in press; Schus- ter, Stein, Jaycox, Collins, Marshall, Elliott, et al., 2001; Traugott, Hill, Groves, & Featherman, 2001)

Deborah Phillips, PhD, Department of Psychology, Georgetown University; Shantay Prince, MPP, and Laura Schiebelhut, MPP, Georgetown Public Policy Institute, Georgetown University.

We thank the principals, guidance counselors, and teachers at the participating elementary schools in Wash- ington, DC, without whose support this study would not have been possible, as well as the Foundation for Child Development for its support. We also thank the participating families for their willingness to share their experiences immediately after the terrorist attacks on September 1 I , as well as the anonymous reviewers who offered very helpful suggestions. Rusan Chen, Academic Technology Coordina- tor at Georgetown University, provided invaluable statistical assistance. David L. Featherman, director of the Institute for Social Research at the University of Michigan, and Liz Gershoff, research associate at Columbia University, gen- erously shared their instruments and insights about mea- surement. Samuel Lawrence, who conducted a prior study on this topic, inspired many of our own analyses and observations.

For reprints and correspondence: Deborah Phillips, PhD, Department of Psychology, 306B White-Gravenor, Georgetown University, 37th and 0 Streets, NW, Washing- ton, DC 20057. E-mail: [email protected]

are beginning to reveal the powerful emotional and behavioral responses generated by the attacks. The research with parents, in particular, is calling attention to the serious negative reactions that some children are experiencing, including symptoms commonly associated with posttraumatic stress (Kaufman & Henrich, 2001; Foy, Madvig, Pynoos, & Camil- lieri, 1996). Clinical observations, such as those reported by Schecter, Coates, and First (2001-2002), are further suggesting that young children are displaying signs of stress associated with severe parental reactions to the attacks.

Empirical studies of children remain rare, however, leaving school personnel, health professionals, and government officials with minimal guidance regarding how children experienced the terrorist attacks. Two studies of children in New York City- one of school-age children in Grades 4 through 12 (Aber, Hoven, & Kotler, 2003) and one of elementary-age children in Grades I through 6 (Gershoff & Kotler, 2003)- have revealed higher than expected rates of mental health problems after September 11 and a particularly high prevalence of posttraumatic stress symptomatology associated with various forms of exposure to the terrorist attacks. The current study of elementary school-age children in Washington, DC, extends these results to children in another heavily impacted urban area. It supplements the New York City study by embedding children’s self-reported reactions to the terrorist attacks within the context of their parents’ own reactions to the attacks, behaviors toward their children, and reports of their children’s reactions.

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Disasters, Children, and Stress Responses

Previous natural and man-made disasters, such as the 1986 Challenger space shuttle explosion (Terr et al., 1997; Wright, Kunkel, Pinon, & Huston, 1989), Hurricane Andrew (LaGreca, Silverman, Vernberg, & Prinstein, 1996), and the Oklahoma City bombing (Gunvitch, Sitterle, Young, & Pfefferbaum, 2002; Pfefferbaum et al., 2001), have afforded the oppor- tunity to study children’s reactions and coping strategies in the face of sudden, traumatic events of national proportions (see LaGreca, Silverman, Vern- berg, & Roberts, 2002, for a compilation of this research). This research has revealed the pervasive effects of these disasters on children that, for some, can endure months and even years after the event (LaGreca et al., 1996; Prinstein, LaGreca, Vernberg, & Silverman, 1996; Vincent, 1998).

LaGreca et al. (1996; Prinstein et al., 1996), for example, found that more than half of third through fifth graders had moderate to severe posttraumatic stress symptoms 3 months after Hurricane Andrew; 12% displayed serious symptoms in a 10-month follow-up study and 4 in 10 of this subgroup still reported high levels of stress symptomatology more than 3 years after the storm (Vincent, 1998). Re- search on the Oklahoma City bombing is particularly relevant to the current study given that it also focused on children in the aftermath of terrorism in a country where such acts of mass violence are still rare (Gur- witch, Sitterle, et al., 2002; Pfefferbaum et al., 1999). Qualitative assessments of preschoolers and questionnaire data from third to fifth graders revealed a sizable minority of young children with clinical levels of stress symptomatology (Gurwitch & Pfeffer- baum, 1999; Gunvitch, Pfefferbaum, & Leftwich, 2002).

The most common symptoms observed in young children are posttraumatic play, reexperiencing (including disaster-related dreams), and hyperarousal (including difficulty sleeping, irritability, and exag- gerated startle responses; Silverman & LaGreca, 2002). The majority of parents (78% of those with a 5- to 18-year-old child) in a nationally representative sample studied immediately after September 11 reported at least one symptom of this nature in their child after the September 11 attacks (Schuster et al., 2001; Stein et al., 2003). The New York City study of school-age children after September 11 found that 87% of the children experienced at least one symptom of posttraumatic stress disorder (PTSD); intrusive thoughts, poor concentration, and sleep problems characterized at least 24% of the children (Aber

et al., 2003; Applied Research & Consulting LLC, Columbia University Mailman School of Public Health, & New York State Psychiatric Institute, 2002). This study also revealed elevated rates of comorbid problems such as major depressive disorder, generalized anxiety disorder, and separation anxiety disorder. Even at subclinical levels, it is common for children to report symptoms of anxiety, fears and security concerns, and depression after traumatic events (Silverman & LaCreca, 2002).

Factors That Contribute to Children’s Postdisaster Reactions

A pressing issue concerns distinguishing which children will succumb to severe stress and other reactions and which will display resilience in the face of disasters (Briere, Berliner, Bulkley, Jenny, & Reid, 1996; Kaufman & Mannarino, 1995; Okun, Parker, & Levendosky, 1994; Foy et al., 1996). Much of this research, including the current study, is guided by a conceptual model that emphasizes four components (Korol, 1990; Green et al., 1991; LaGreca et al., 1996): (a) aspects of the traumatic exposure, (b) preexisting characteristics of the child, (c) characteristics of the postdisaster environment, and (d) the child’s psychological resources.

Aspects of Traumatic Exposure

Degree of exposure and characteristics of the traumatic event, rather than direct experience per se, appear to affect the nature of the child’s response. Importantly, posttraumatic stress symptoms are present in children who have witnessed or otherwise been indirectly exposed to abusive behavior, war, and specific disasters (Barbarin, Richter, & deWet, 2001; Pynoos & Eth, 1986; Pynoos, Steinberg, & Wraith, 1995; Terr et al., 1997). Influential factors are physical proximity to the disaster, perceived threat to life and life disruption, loss or separation from family members, personal injury, human intent as the cause of the disaster, and witnessing the injuries or death of others (Norris, 2001; Prinstein et al., 1996; Saylor, Belter, & Stokes, 1997). Virtually all of these fea- tures, as well as widely publicized child deaths, characterized the September 11 attacks for children living in Washington, DC.

Evidence has directed attention to the medium of television as a powerful indirect source of exposure for both adults and children (Cantor, Mares, & 01- iver, 1993; Cantor & Nathanson, 1996; Pfefferbaum et al., 2001; Wright et al., 1989). Cantor et al., for

CHILDREN’S RESPONSES TO ATTACKS 51 1

example, identified routine television news as a significant source of fear reactions and sleep distur- bances in preschoolers and elementary school-age children. Third and tenth graders’ reactions to television coverage of the Challenger explosion included numerous stress-related symptoms (Terr et al., 1997). Research on middle school children’s reactions to the Oklahoma City bombing also indicated that watching extensive news coverage of the bombing was associated with more severe stress (Pfefferbaum et al., 2001).

This association between exposure to news coverage of catastrophes and stress reactions in children has recently been replicated in Schuster’s national survey of responses to the September 11 terrorist attacks (Schuster et al., 2001). A significant association was found between the extent of TV viewing (which parents reported to average 3 hr on September 11) and the number of child stress symptoms reported by parents. The study of New York City school children also found that extensive media exposure to the events of September 11 was a risk factor for higher rates of posttraumatic stress symptoms (Aber et al., 2003).

In the current study, we examine both direct exposure to the attacks in the form of personal loss and indirect exposure through TV viewing of the attacks as these variables affect elementary school children’s reactions in their aftermath.

Preexisting Characteristics of the Child

Both demographic characteristics and predisaster functioning have been associated with children’s negative reactions after a disaster (Silverman & La- Greca, 2002). Associations between trauma and stress responses in children are sometimes found to vary for different age groups (Belter & Shannon, 1993; Eth & Pynoos, 198.5; Vogel & Vernberg, 1993), although it is difficult to draw conclusions about developmental patterns from this literature given inconsistent results and the narrow age ranges that are often studied. Perhaps as a result of the large age range encompassed in the New York City school- age study (Grades 4-12), child age was the strongest predictor of risk for PTSD; fourth and fifth graders were significantly more prone to stress symptoms than children in Grades 9 through 12 (Aber et al., 2003).

Gender is also frequently examined; some re- searchers reported no association between gender and symptoms (Block, Silber, & Perry, 1965; Terr, 1981), and others reported that girls are more distressed

(Green et al., 1991; Gurwitch, Leftwich, Pfeffer- baum, & Pynoos, 2000; Stein et al., 2003). When gender differences are found, girls tend to report more internalizing symptoms (e.g., depression, specific fears), whereas boys are more likely to exter- nalize their reactions (e.g., acting out; Aber et al., 2003; Saylor et al., 1997; Vogel & Vernberg, 1993). The literature is more consistent regarding the negative influence of preexisting anxiety, depression, and attention problems on postdisaster adjustment (Nolen-Hoeksema & Morrow, 1991; LaGreca et al., 1996; Vogel & Vernberg, 1993).

In the current study, given our inability to collect data on predisaster adjustment, we focused on the responses of children in kindergarten through Grade 6 and of boys and girls.

Characteristics of the Postdisaster Recovery Environment

This domain of influence focuses on the availability of social support and the occurrence of major life events or stressors in the aftermath of disasters. The availability of a supportive parent or alternate guard- ian has been demonstrated to be one of the most important factors distinguishing traumatized children with good developmental outcomes from those who succumb to more deleterious impacts (Barbarin et al., 2001; Buka, Stichick, Birdthistle, & Earls, 2001; Cicchetti & Toth, 1995; Prinstein et al., 1996). Chil- dren are most adversely affected by circumstances that separate them from their primary caregiver, either physically or emotionally, which is likely due to the fact that their successful coping is heavily dependent on the ability to demand compensatory care from parents and other attachment figures (Baum & Davidson, 1990; Garmezy, 1983; Leiderman, 1983). Foy et al.’s review of 25 studies examining etiolog- ical factors of PTSD in children has confirmed the positive association with parents’ trauma-related distress (Foy et al., 1996).

It is, however, difficult to interpret this evidence when parents report on their own as well as their children’s reactions. The few studies that have compared data provided by parents who are serving as informants about their children and either self-report data or professional assessments of the children suggest that parents are prone to underreporting children’s trauma-related reactions (Almqvist & Bran- dell-Forsberg, 199.5; Gurwitch, Sitterle, et al., 2002; Handford et al., 1986; Silverman & LaGreca, 2002). This problem is compounded by evidence that parent reports of children’s reactions are affected by their


own well-being after disasters. Parents who are more upset also report higher levels of negative reactions on behalf of their children (Belter & Shannon, 1993; Vogel & Vernberg, 1993). This is the case with reports on reactions to the terrorist attacks in which parents and adults who reported higher levels of distress about the terrorist attacks also reported more distress in children (Featherman & Liu, 2003; Klein, DeVoe, & Miranda, 2003; Phillips et al., in press; Schuster et al., 2001; Traugott et al., 2001).

The current study explored associations among children’s self-reported reactions to the terrorist attacks, parent’s own reactions, and parents’ reports of their children’s reactions. This enabled us to examine the extent of agreement between parent and child reports and to explore associations between parent and child reactions independent of the biases that are introduced when parents are the informants about their own, as well as their children’s, postdisaster functioning.

The Child’s Psychological Resources

Children’s coping skills, ranging from their tem- peraments and mental health to their competence in enlisting social support, are also likely to affect their posttrauma responses. These influences, and protective factors more generally, have received very little attention in the empirical literature on children and disasters, with the exception of work linking adaptive parental responses to adaptive child responses. Vem- berg (1999; Vogel & Vemberg, 1993) linked children’s intelligence, perceived self-efficacy, and good communication skills to their postdisaster reactions and recovery. Others have also emphasized the im- portance of verbal communication as a means of enabling children to process the event (see, e.g., Bromet, Hough, & Connell, 1984; Cohler, 1991).

In one of the few studies to examine the specific types of coping assistance that parents offer to children, Prinstein et al. (1996) found that parents of third through fifth graders emphasized the continua- tion of normal roles and routines in the aftermath of Hurricane Andrew. The emerging literature on Sep- tember 11 suggests a greater emphasis on direct emotional processing, primarily through parent-child conversations (see Gurwitch, Sitterle, et al., 2002). In Schuster et al.’s (2001) study, for example, the vast majority of parents talked to their children about the attacks. This study has also revealed the important role that parents play as monitors of children’s exposure to news coverage of disasters. Specifically, a significant association between the extent of TV

viewing and the number of reported stress symptoms was found but only for those children whose parents did not limit their TV viewing.

In the current study, we focus on the coping resources and strategies of parent-child communication, constructive actions taken by children (e.g., donating to relevant charities), and parents’ encouragement of such actions. We also explore the role of parental monitoring of TV viewing and parent-child discussions about TV coverage of news about the attacks.

The Current Study

We examine the responses of students in kindergarten through sixth grade in Washington, DC, to the terrorist attacks of September 11. Our study inte- grates data provided by parents (primarily mothers of kindergarteners through sixth graders) and self-report data provided by children (fourth through sixth graders) to examine various interrelations between children’s and parents’ reactions. Specifically, the study was designed to examine four issues.

1. What is the relation between children’s exposure to the attacks, measured by direct loss and exposure to news coverage of the events, and their stress responses? Does parental monitoring of their child’s news exposure play a moderating role? We hypothesize that higher levels of loss and more time spent viewing TV coverage of the attacks will interfere with children’s adjustment in the months after Sep- tember 1 I . We further hypothesize that associations between TV viewing and postdisaster adjustment will be moderated by parental monitoring.

2. Are children’s reactions associated with their age and gender? We hypothesize that older children and girls will be more negatively affected in the aftermath of the attacks.

3. What is the extent of concordance between parent reports of their children’s reactions to the events of September 11 and children’s self-reported reactions? Is concordance mediated by parents’ own levels of stress and by the extent to which parents and children talk with each other about the attacks? We hypothesize that parents will identify lower levels of child distress compared with their children’s self- reports and that parent’s well-being after the attacks will be associated with poorer child functioning as reported by parents and by the children’s self-reports.

4. What is the contribution of parent-child communication, constructive actions taken by children, and parents’ encouragement of such actions to children’s reactions in the aftermath of the attacks? We

CHILDREN’S RESPONSES TO ATTACKS 513

hypothesize that higher levels of parent-child communication and the extent to which children and parents emphasize constructive actions post-Septem- ber 11 will be associated with more positive adjustment.

Method

Sample and Procedure

During early November 2001, consent forms and questionnaires were mailed to every family with a child in kindergarten through sixth grade at two public elementary schools in Washington, DC, serving primarily middle- to upper-class, non-Hispanic White families. The consent form explained that participation in this study of children’s reactions to the September 11 terrorist attacks was voluntary, all information would remain confidential, and, if the family chose to participate, one parent should complete the questionnaire and return it with the consent form in an enclosed return envelope. For families whose youngest (or only) child was in kindergarten through Grade 3, only the parents completed a questionnaire. Of the 422 families with a child in these grades, I10 (26%) returned the consent form and questionnaire.

For families with a fourth- through sixth-grade student, the consent form included permission for the student to complete a questionnaire during a small group session at school. Of the 345 families whose youngest elementary school-age child was in these grades, 66 (19%) of parents returned the consent form and questionnaire. Of these 66 parents, 47 (71%) agreed to their child’s participation. The children’s questionnaire was administered over the course of three group sessions per school, each of which lasted approximately 15 min. These sessions were held during November and December 2001.

The final sample for this study consisted of 176 parents (90% mothers)’ and 47 students (43% girls), including 47 matched parent-child (Grades 4-6) pairs. The distribution of parents across grade levels ranged from 11% (fifth-grade subgroup) to 21 % (kindergarten subgroup). The age distribution of the child sample was as follows: 26% fourth graders, 34% fifth graders, and 40% sixth graders.

Measures

The parent and child questionnaires’ consisted of 18 and 13 forced-choice questions, respectively, that addressed five broad issues: (a) the child’s exposure to news about the attacks and whether the parents monitored the child’s exposure, (b) whether any family members or close friends were hurt or killed in the attacks (parents, hut not children, were also asked about job impacts), (c) negative emotional and behavioral reactions of the children and their parents in the week after the attacks, including stress responses, (d) the extent of parent-child communication about the attacks, (e) constructive actions taken by the children after the attacks,

and (f) parents’ actions taken to help their children cope in the week after the attack. The children were asked to report their own reactions to the attacks and actions taken in response to the attacks. The parents were asked about their own reactions as well as about their children’s responses and actions.

The specific questions were drawn or adapted from several existing inventories. Items concerning children’s exposure to and parental monitoring of TV, print, and Internet news about the attacks were drawn from the How America Responds survey (Traugott et al., 2001), the work of Pfef- ferbaum (1999), and the New York City protocol (Gershoff et al., 2001; Gould et al., 2001). Questions asking whether any friends or family members were hurt or killed in the attacks and whether the parents’ jobs were affected were based on the New York City protocol as well as on Norris’s (2001) module for research on the terrorist attacks.

Questions about the parents’ and children’s emotional and behavioral reactions in the week after the attacks were drawn from the How America Responds survey (Traugott et al., 2001), the New York City protocol (Gershoff et al., 2001; Gould et al., 2001), and Noms’s (2001) module. The children’s questionnaire also included eight items assessing PTSD from the Diagnostic Interview Schedule for Children Predictive Scales (Lucas et al., 2001), which are also included in the New York City protocol (Gershoff et al., 2001; Gould et al., 2001). The parents’ questionnaire included four of these items that addressed observable behavior (i.e., nightmares, sleep problems, trouble concentrating, avoid- ance of places related to the attacks).

Questions concerning whether the parent or child talked to anyone about the attacks were adapted from the How America Responds survey (Traugott et al., 2001). Questions about constructive actions taken by the children in the aftermath of the attacks (e.g., attending a school assembly, donating money or time to relief efforts, making a patriotic gesture) and by parents to help their children cope (e.g., took extra time to talk with the child, brought the child to candlelight vigils) were drawn from the New York City protocol (Gershoff et al., 2001; Gould et al., 2001) and the How America Responds survey (Traugott et al., 2001), as well as from the National Association of School Psycholo- gists’ (NASP) recommendations for helping school-age children cope with the attacks (NASP, 2001).

Response rates for the parents were 95% to 100% for all questions, with the exception of those regarding their children’s actions in the aftermath of the attacks, for which 6% to 14% of the parents indicated that they did not know the answer. Response rates for the children were 100% with the exception of three items to which at most 2 children did not respond.

’ Significant differences between mothers’ and fathers’ responses to the questionnaires did not exceed the chance level.

The parent and child questionnaires are available from Deborah Phillips.


Results

Descriptive Statistics3s4

Family impacts. More than one third of the children (Grades 4-6) indicated that they knew a family member or friend who was in the World Trade Cen- ter, the Pentagon, or on one of the airplanes that crashed on September 11, as did more than one fifth of all parents (with kindergarten through sixth-grade children) and 13% of the parents of participating fourth through sixth graders. In addition, one third of both the complete sample of parents and the subsample of parents whose children participated in the study indicated that their job or their spouse’s job had been affected by the attacks. The most common impacts consisted of changes in work schedules and increased workload.

Eighty-five percent of the children indicated that the attacks had shaken their feelings of safety and security somewhat (62%) or very much (23%). On average, children indicated that they had experienced 3.8 (SD = 3.60) of the 20 items inquiring about specific negative reactions in the week after the attacks, including 1.9 (SD = 1.82) of the 8 posttraumatic stress items drawn from the Diagnostic Interview Schedule for Children Predictive Scale.’ The range of total items endorsed extended from none (10 children) to 14 items (1 child), and the range of PTSD items endorsed extended from none (13 children) to 7 items ( 1 child). Nearly 73% of the children endorsed at least 1 symptom of PTSD, and 57.4% endorsed 3 or more specific negative reactions.

Corresponding to the literature on young children’s responses to traumatic events, the most common reactions (endorsed by at least 20% of the children) involved intrusive thoughts (e.g., “finding my- self thinking about the attacks when doing other things,” “trying hard not to think about the attacks,” “having trouble concentrating”), nightmares, and hyperarousal (e.g., having “problems falling or staying asleep,” feeling “jumpy or easily startled,” feeling “more short-tempered”). One quarter of the children expressed fears about being alone or harmed. Un- common responses (fewer than 10% of the children) involved symptoms of depression (e.g., “lost interest in doing things,” “stopped thinking about the future’’), eating problems and psychosomatic symptoms, and wanting to avoid school or other regular activities.

Although most (77%) of the parents of kindergarteners through sixth graders indicated that the attacks

Children’s reactions to the attacks.

had left them worried that something would happen to their children, only one third reported that their child had expressed fears of becoming a victim of a terrorist attack. On average, parents indicated that their child had experienced 1.1 (SD = 1.33, range = 0-7) of the 16 items inquiring about specific negative reactions in the week after the attacks, including .32 (SD = .67, range = 0-3) of the 4 PTSD items that were included on the parent questionnaire.6 The most common child reactions reported by the parents were “expressed fears of being separated or harmed” and “showed other signs of being unsettled or upset.” The only other items endorsed by more than 10% of the parents were “had nightmares or bad dreams,” “had problems falling or staying asleep,” and, for kindergarteners through third graders, “engaged in repeti- tive play scenarios related to the attacks.”

Parents were deeply affected; 74% indicated that they found themselves thinking about the attacks very often, and 85% indicated that their sense of safety was very much or somewhat shaken. In addition, 15% of the parents experienced health problems (e.g., headaches, asthma) in the days after the attacks, and 74% experienced intrusive thoughts about the attacks.

News exposure and parental monitoring. Among the fourth- through sixth-grade children, 40% indicated that in the week after the attacks they spent a lot of time watching news about the attacks on TV. All but 1 of the remaining children indicated that they watched some TV news coverage, and most had also read about the attacks. Sixty percent of the children (and 79% of those who watched a lot of news) indicated that they had talked a fair or great amount with their parents about what they were learning from

Parents’ reactions to the attacks.

No school differences were found for any of the measures; the samples from the two schools were combined for all analyses.

Detailed tables of the descriptive statistics are available from Deborah Phillips.

The alpha coefficient was .82 ( N = 47) for the 20 items assessing the children’s total negative reactions to the terrorist attacks and .70 ( N = 47) for the 8 PTSD items.

6The alpha coefficient for the 16 items that parents completed assessing their children’s reactions to the terrorist attacks was .23 ( N = 176) for the full sample and .50 (n = 47) for the parents of participating children. For the 4 PTSD items, the alpha for the full sample was .48 ( N = 176) and .59 (n = 47) for the subsample. Although the alphas for the parents are substantially lower than those for the children, particularly for the full sample, all items were retained in the count of the total number of items endorsed to ensure comparability to the children’s self-reports.


the news. The vast majority of all parents, and of the subset of parents of participating children, took steps to monitor their child’s exposure to news about the attacks. The most common means of monitoring consisted of limiting TV viewing of attack-related news and making a special point of talking with the child about what she or he was learning from the news.

Vir- tually all children (94%) reported that they talked with someone about the attacks, primarily parents and friends. Almost all parents (80% of total sample and 90% of parents of participating children) indicated that they had taken extra time to talk with their children about the attacks. More than one quarter of the children also reported discussing the attacks at school, donating clothes or money or volunteering to help relief efforts, making a patriotic gesture such as displaying a U.S. flag in their window, writing or drawing about the attacks, attending a memorial service, or going to a school assembly. More than half of the parents engaged in at least one of the following constructive action on behalf of their child: making efforts to keep the child’s routine normal, spending more time than usual with their child, involving their child in a patriotic gesture, involving the child in donating clothes or money or volunteering in relief efforts, or attending a memorial service with the child.

Actions taken in the aftermath of the attacks.

Relations Between Children Is Exposure and Reactions to the Attacks

Both parent reports and children’s self-reports were used to assess the relation between the children’s exposure to the terrorist attacks-both direct loss of family members or friends and exposure to news coverage-and their reactions in the week after the attacks. For parents and children, direct exposure was assessed with a dichotomous item asking whether any family members or friends were in the World Trade Center, in the Pentagon, or on any of the airplanes that crashed. For parents, news exposure was assessed with a dichotomous item asking whether their child followed news coverage of the attacks during the week after the attacks. For the children, news exposure was assessed with an item asking, during the week after the attacks, how much time they spent watching TV news about the attacks. The children were divided into two groups: those who watched a lot of TV news and those who watched some or no news.

Analyses of parent and child reports of exposure and reactions. Two sets of one-way multivariate analyses of variance (MANOVAs; with exposure as the between-subjects variable) were used to assess the effects of direct loss and news exposure on (a) parent reports of their children’s (kindergarteners through sixth graders) total number of reactions, posttraumatic stress symptoms, and expressions of fear of becoming a victim of a terrorist attack and (b) children’s reports (fourth through sixth graders) of their total reactions, stress symptoms, and disrupted feelings of security and safety. The MANOVAs for the parent reports of both direct loss and news exposure were nonsignificant. Parents who reported knowing victims and those who reported that their children followed the news closely did not report significantly more negative reactions or expressions of fear on behalf of their children.

The MANOVA for the children’s self-reports of knowing a victim was nonsignificant, but their self- reports of news exposure were significantly associated with their postattack reactions, F( 1,33) = 4.779, p < .01. Univariate analyses of variance (ANOVAs) were examined for the three outcomes. Children who indicated that they watched a lot of TV news about the attacks reported significantly more negative reactions than those who watched none or some TV news, F(1, 45) = 5.738, p < .O1 (Ms = 5.63 and 2.50, respectively), significantly more posttraumatic stress responses, F(1, 45) = 4.554, p < .05 ( M s = 2.63 and 1.23, respectively), and greater feelings of shaken security, F(1, 33) = 4.639, p < .05 (Ms = 2.33 and 1.89, respectively).

To further explore the relation between children’s self-reported extent of TV exposure and postattack reactions, 2 X 2 chi-square analyses were run to examine the association between news exposure (nonelsome or a lor) and responses to the 20 individual items assessing their reactions to the attacks. In the week after the attacks, a significantly larger share of the children who watched a lot of TV news coverage of the attacks, compared with those who watched only some or no TV, reported having sleep problems, ?(l, N = 46) = 5.888, p < .05 (42% and 11%, respectively); having stopped thinking about the future, ?( 1, N = 46) = 6.226, p < .05 (21% and 0%, respectively); becoming more easily annoyed, ,&l, N = 46) = 5.889, p < .05 (42% and 11%, respectively); being more easily startled, ?(l, N = 46) = 4.384, p < .05 (47% and 19%, respectively); and feeling fatigued, g ( 1 , N = 46) = 7.972, p < .O1 (26% and 0%, respectively).

Chi-squares for children’s reports.


Relations between parental monitoring, exposure, and children’s reactions. Parents’ monitoring of children’s TV exposure was negatively but modestly associated with their reports of negative reactions on behalf of their children ( r = -.16, p < .05) but was not associated with children’s self-reported reactions to the attacks. Parents who more closely monitored their children’s news exposure perceived that their children experienced fewer negative reactions. This raises a question about the role of parental monitoring as it affects the relation between the children’s news exposure and their reactions in the week after the attacks. To explore this relationship, the MANOVAs linking exposure and stress reactions described previously were run separately for groups of parents who monitored and did not monitor the children’s news exposure.

The MANOVA for the parent reports of the children’s news exposure and the children’s responses to the attacks was significant for the parents who monitored their children’s news exposure, F( 1, 125) = 2.36, p < .05, and nonsignificant for those who did not monitor their children’s exposure. For the monitoring group, parent reports of news exposure were significantly associated with their reports that their child had expressed fears of becoming a victim, F(1, 125) = 4.03, p < .05 (Ms = 1.56 and 1.24, respectively).

The MANOVA for the children’s self-reports of their news exposure and reactions to the attacks was also significant for those whose parents monitored their news exposure, F(1, 26) = 3.56, p < .05, and nonsignificant for those whose parents did not monitor their exposure. For children whose parents monitored their news exposure, self-reports of amount of TV exposure were significantly associated with self- reported negative reactions, F(1, 25) = 11.05, p < .01 (Ms = 6.38 and 2.86 for those watching a lot and nonehome, respectively) and their self-reported stress symptoms, F(1, 25) = 8.94, p < .01 (Ms = 3.08 and 1.38, respectively). The chi-squares, reported previously, for the individual items assessing the children’s reactions also remained significant only for the children whose parents monitored their news exposure.

Grade and Gender Esfects

Grade level and gender effects were explored for the children’s postattack reactions and the parents’ behaviors toward their children in the week after the attacks. Grade level effects were examined exclusively with parent reports to capture the full sample

of kindergarten through sixth-grade children. Gender effects were examined with both parent reports and the older children’s self-reports.

To examine whether the children’s reactions to the attacks, as reported by their parents, varied by grade level (kindergarten through Grade 6) or child gender, a two-way multivariate ANOVA was performed on the parent reports of their children’s expressed fears of being a victim of a terrorist attack, the total number of reactions the parents reported for their children, and the subset of PTSD symptoms. All multivariate effects were nonsignificant, indicating no differences by grade level or gender for parent reports of their children’s reactions to the attacks.

Grade level and gender differences in parents’ postattack behaviors toward their children were explored using 3 X 2 (Grade Level X Yes-No Re- sponse) and 2 X 2 (Gender X Yes-No Response) chi-square analyses. The children were grouped into three grade levels: kindergarten and first graders, second through fourth graders, and fifth and sixth graders. The dependent variables were the 17 items assessing parent behaviors toward their children.

Parents of younger and older children differed in many of their behavioral responses to their children in the week after the attacks. Specifically, parents of older children were significantly more likely to talk to their children about the attacks, g (2 , N = 176) = 13.465, p < .001, and about news coverage of the attacks, g ( 2 , N = 176) = 25.834, p < .01, encourage their child to talk with others, 2 ( 2 , N = 176) = 10.594, p < .01, and attend a memorial service, 2 ( 2 , N = 176) = 8.962, p < .01, or candlelight vigil, 2 ( 2 , N = 176) = 7.809, p < .05, with their child. Parents of younger children, particularly those with kindergarteners and first graders, were significantly more likely than those with older children to do everything possible to keep their child from learning about the attacks, 2 ( 2 , N = 176) = 18.069, p < .01, and to monitor their child’s exposure to news about the attacks, 2 ( 2 , N = 175) = 9.538, p < .01. Table 1 reports the percent- ages of parents endorsing each of these items for the three age groups.

In contrast, only one gender effect was significant and thus must be interpreted with caution: Parents of daughters (49%) were significantly more likely than parents of sons (34%) to involve their child in donating money, clothes, or volunteering to help relief efforts, 2 ( 1 , N = 176) = 4.149, p < .05. Gender effects were also assessed, using chi-squares, for the older children’s self-reported reactions to the attacks. Only one significant gender difference emerged:


Table 1 Percentage of Parents Reporting Spec@ Behaviors Toward Their Children by Grade Level Groups

Item Grades K-l Grades 2 4 Grades 5-6

N Parent made time to talk to child (%) Parent talked to child about news (%) Parent encouraged child to talk to others (%) Parent and child attended memorial service (a) Parent and child attended candlelight vigil (%) Parent tried to keep child from learning about the

Parent monitored child’s news exposure (%) attacks (%)

60 65 50 10 20 8

20 93

72 83 74 15 33 19

1 79

44 93 90 34 48 43

2 70

Note. Only variables characterized by significant differences across age groups are reported.

Girls (34%) were significantly more likely than boys (26%) to make a patriotic gesture, such as displaying a U.S. flag in one’s room, ?(I, N = 47) = 5.539, p < .05.

Relations Between Parents’ and Children’s Reactions to the Attacks

The central question of whether children’s postattack reactions were affected by their parents’ well- being in the aftermath of September 1 1 was explored using both the parent reports of their children’s reactions and the older children’s self-reports. We then explored the important issue of concordance between parent and child reports of the children’s reactions and its mediation by the parents’ own level of distress and the extent of parent- child communication after the attacks.

Associations between parents’ distress and children’s reactions. Table 2, based on the complete sample of parents (of kindergarten through sixth- grade children), presents the Pearson product-mo- ment correlation matrix for the parent reports of their own reactions and of their children’s reactions. Ta- ble 3, based on the subsample of parents whose fourth through sixth graders participated, presents the correlation matrix for the parent reports of their own (adult) reactions and the children’s’ self-reported reactions.

The results indicate that parents who reported health problems immediately after the attacks also reported more negative reactions and posttraumatic stress symptoms for their children (see Table 2). Parents who thought more about the attacks, felt their own sense of safety had been shaken, and were more womed about their children also reported more negative reactions for their children and were more likely to report that their child had expressed fears of be-

coming a victim of an attack. The children’s self- reports of negative responses were not consistently associated with their parents’ reports of their own (adult) responses (see Table 3), suggesting some degree of bias in the parents’ reporting of the children’s reactions. However, children whose parents experienced more intrusive thoughts about the attacks self- reported significantly more total negative and posttraumatic stress symptoms. In addition, the positive association between parents’ self-reported health problems after the attacks and children’s self-reported PTSD symptoms was of borderline significance ( r = .28, p = .06).

Concordance between parent and child reports. Turning to the question of concordance between the parent (as informant) and child (self) reports of the children’s reactions to the attacks, we examined intercorrelations for the 47 pairs of parents and their

Table 2 Intercorrelations Among Parents’ Own Reactions to the Attacks and Reports of Their Children’s Reactions

Parent report of child’s reactions

Item

Parent reactions Health problems Worried about job Time spent thinking

about the attacks Worried about own

safety Worried about

child’s safety

Child has expressed

fear

.06

.I3

.25***

.22***

.20***

Child’s total

reactions

.32***

.I5

.22***

.27***

.19**

Child’s stress

symptoms

.18**

. I 3

.15*

.18*

. I 1

Note. All Ns = 174. * p < .05. * * p < .01. * * * p < .001


Table 3 Intercorrelations Among Parents’ Own Reactions to the Attacks and Their Children’s Self-Reported Reactions

Child’s self-reported reactions

Safety Total Stress Item shaken reactions symptoms

Parent reactions Health problems -.04 .21 .28 Womed about job - . lo .02 .06 Time spent thinking

Womed about own

Worried about

about the attacks .08 .33* .29*

safety .14 .27 .22

child’s safety .02 .11 .09

Note. All Ns = 47. * p < .05.

fourth through sixth graders (Table 4) among the following parent and child scores: (a) total number of negative reactions and total number of posttraumatic stress reactions experienced by the children, (b) parent reports of the extent to which their child had expressed fears of becoming a victim of an act of terrorism, and (c) children’s reports about the extent to which their feelings of safety and security had been shaken by the attacks.

The parent and child reports of total negative reactions, and of the subset of stress-related symptoms, were significantly associated (m = .38 and S3 , respectively, both p s < .01). The children’s self-reports of total and posttraumatic stress reactions were also significantly associated with parent reports of the child’s expressed fears of becoming a victim ( r = .37, p < .01, and r = .35, p < .OS, respectively). Children who reported higher numbers of overall negative and posttraumatic stress reactions had par-

ents who reported relatively higher numbers of negative reactions for their children.

We then conducted t tests to examine whether the parent and child mean scores for the children’s total negative reactions and subset of posttraumatic stress reactions differed significantly from each other. The significant mean differences, t(47) = 4.819, p < .01, and t(47) = 2.239, p < .05, respectively, are due to the fact that parents reported substantially fewer negative reactions for their children than was indicated by the children’s self-reports. For total reactions, the mean parent score was 1.13 (SD = 1.35) compared with a mean score of 3.83 (SD = 3.60) for their children. For the posttraumatic stress symptoms, the parent mean was .36 (SD = .76) compared with .81 (SD = 1.14) for the children.

To examine whether the relation between parent and child reports differed on the basis of parents’ own level of distress or the extent of parent-child communication about the attacks, the correlations for the total negative reactions were examined separately for (a) children whose parents indicated that they thought about the attacks only sometimes or not at all (n = 11) and children whose parents indicated that they thought about the attacks very often (n = 35) and (b) children who reported that they talked to their parents about the news coverage of the attacks either not at all or a little bit (n = 18) and for children who reported that they talked to their parents a fair amount or a great deal (n = 27). Associations between parent and child reports were not significantly different for children whose parents were more or less preoccu- pied about the attacks (rs = .40 for both groups), but they did differ based on the extent of parent-child communication. Specifically, stronger associations were found between parent and child reports when they spent more time talking to each other about the news ( r = .49, p < .01) compared with the parent-

Table 4 Intercorrelations Among Parent and Child Items Assessing Children ’s Reactions to the Attacks

Item

1. Parent report: total number reactions - .76*** .37** ,38*** .53*** .26 2. Parent report: total stress reactions - .33** .39*** .53*** .20 3. Parent report: child has expressed fears - .37** .35* .33

5. Child report: total stress reactions - .43** 6. Child report: safety shaken

4. Child report: total number reactions - .9l*** .36*

-

Note. feeling shaken (n = 34). * p < .05. * * p < .01. * * * p < ,001.

N = 47 for all correlations with the exception of those with child’s self-report of


child pairs who did not talk as much about the news ( r = .02, ns).

Relations Among Parent-Child Communication, Constructive Actions, and Stress Responses

Parent reports and children’s self-reports were used to assess the relation between the children’s reactions during the week after the attacks, parent- child communication about the attacks, and the extent to which the children engaged in constructive activities, or were encouraged to do so by their parents, after the attacks. For the parent reports, a dichotomous item indicating whether they had taken extra time to talk with their child about the attacks was used as the measure of communication, and a total count of the number of constructive actions taken on behalf of the child was used as the measure of constructive action. For the children’s self-reports, a continuous item inquiring about the extent to which they had talked with their parents about news coverage of the attacks provided the measure of communication. The children also provided a total count of the number of constructive actions they had taken after the attacks.’

Parent- child communication and children’s reactions. One-way MANOVAs, with communication as the between-subjects variable, were used to assess the effects of communication on (a) parent reports of their children’s total reactions, posttraumatic stress, and fears of becoming a victim of a terrorist attack and (b) children’s reports of their total reactions, stress responses, and disrupted feelings of security and safety.

The MANOVA for the parent reports as they affected their assessments of their children’s reactions was significant, F(1, 174) = 5 . 4 6 5 , ~ < .01. Parents who took extra time to talk with their children about the attacks were more likely to report that their child had expressed fears of becoming a victim of an attack, F(I, 174) = 10.057, p < .01, reported more negative reactions, F( 1, 174) = 14.079, p < .01, and experienced more posttraumatic stress symptoms, F(1, 174) = 5.738, p < .05. However, neither the parents’ nor the children’s reports of communication were significantly related to the children’s self-reported reactions.

Supplemental analyses further revealed that parents who indicated that a family member or friend had been hurt in the attacks were significantly more likely to take extra time to talk with their children than parents who did not know anyone who was hurt

(92% and 76%, respectively), g ( 1 , N = 176) = 4.087, p < .05. Parents who reported that their child followed the news closely were also significantly more likely to take extra time to talk with their children about the attacks than those who indicated that their child did not follow the news (93% and 73%, respectively), $(I, N = 176) = 16.721, p < .01. Correspondingly, children who indicated that a family member or friend had been hurt in the attacks were significantly more likely to talk with their parents about the news than were children who did not know anyone who was hurt (75% and 52%, respectively), g(1, N = 45) = 10.714, p < .05, and children who watched a lot of TV news about the attacks were significantly more likely to talk with their parents than were children who indicated that they did not watch a lot of news (78% and 46%, respectively), g(1, N = 45) = 4.919, p < .05.

Constructive actions and children ‘s responses. One-way MANOVAs (with the total counts of constructive actions recoded as a dichotomous variable using scores above and below the mean as the between-subjects variable) were used to assess the effects of constructive actions on (a) parent reports of their children’s total reactions, posttraumatic stress, and fears of becoming a victim of a terrorist attack and (b) children’s reports of their total reactions, stress responses, and disrupted feelings of security and safety.

The MANOVAs for both the parent and child reports of constructive actions were significant: F( I , 172) = 5.398, p < .01, for the parent reports as they affected their own appraisals of their children’s reactions, and F(1, 32) = 4.096, p < .02, for the children’s reports as they affected their self-reported reactions. The parent and child reports, however, tell contrasting stories about the relation between taking constructive actions and children’s reactions to the attacks. Parents who reported taking more constructive actions on their child’s behalf also reported that their child had fewer posttraumatic stress symptoms, F(1, 173) = 6.040, p < .05, and had not expressed fears of becoming a victim, F(1, 173) = 2.929, p < .05. In contrast, children who reported taking more constructive actions experienced greater feelings of

’ The alpha coefficient for the 16 items that constituted the summary count of constructive actions taken by parents on behalf of their children was .S7 ( N = 176) for the full sample and S O (n = 47) for the parents of participating children. The alpha coefficient for the 9 items that constituted the summary count of constructive actions taken by the children was .SO ( N = 47).


shaken safety, F(1, 33) = 8 . 5 0 1 , ~ < .01. The parent reports of constructive actions were unrelated to the children’s self-reported postattack reactions.

Integrated Model of InJEuences on Children’s Postattack Reactions

We have examined each of the hypotheses that guided this study, and thus each of the proposed influences on children’s postattack reactions, in iso- lation from each other. As a final step, hierarchical linear multiple regressions were run to assess the combined effect of exposure, child characteristics, postattack environment, and psychological resources on the children’s postattack reactions. Specifically, parent reports of their children’s total negative reactions and the children’s self-reported negative reactions were regressed on variables representing the full range of influences assessed in this study. Mul- tiple models were evaluated to gain insight into the effects of each set of influences over and above the influence of previously examined influences. The first model examined the influence of the child’s exposure (loss of family members or friends and TV exposure) to the attacks. The second model added the influence of the child’s grade level and gender. The third model included the influence of the postattack environment as assessed by the parents’ own coping and actions taken on behalf of the child (total constructive actions and monitoring of TV exposure). For the children’s self-reported reactions, a fourth model that added children’s psychological resources, as assessed by their own constructive actions and whether they talked with their parents about the attacks, was evaluated.

The results of the regressions (see Tables 5 and 6 for the parent and child reports, respectively) confirm several of the results reported previously. Specifi- cally, the initial models suggested that parent reports of their children’s reactions (kindergarteners through sixth graders) were affected by whether they knew family members or friends who were hurt in the attacks (see Models 1 and 2 in Table 5). However, this influence became nonsignificant once the effects of the postattack environment established by parents, notably their own health problems, constructive actions they took on behalf of their children, and TV monitoring (see Model 3 in Table 5), were controlled. This final model accounted for 21% of the variance in parents’ reports of their children’s postattack reactions.

The children’s self-reported reactions (fourth through sixth graders) were significantly influenced

only by their exposure to TV news about the attacks. Although adding variables reflecting the postattack environment resulted in a significant increment (19%) in total variance accounted for (see Model 3, Table 6), none of the individual variables reflecting the postattack environment achieved statistical significance. This third model accounted for 31% of the variance in children’s self-reported reactions to the terrorist attacks.

Discussion

On September 11, 2001, the Washington, DC, area was shaken by news of the terrorist attacks on the World Trade Centers, followed almost immediately by the attack on the Pentagon. The attacks occurred just as children were settling into school, which was soon disrupted by parents who came to take their children home and the inevitable spread of the news throughout the schools over the course of the day. The following day, the public schools in Washington, DC, were closed, and in the ensuing days and weeks, school assemblies and classroom conversations about the attacks were common.

Children’s and Parents’ Reactions to the Terrorist Attacks

In this context, it is not surprising that this study revealed a high degree of personal impact and exposure to the attacks of September 11 among the participating families. More than one third of the fourth through sixth graders in the study indicated that they had a family member or friend hurt or killed in the attacks, as did one fifth of the parents of the kindergarten through sixth-grade children. Our data cannot decipher whether this discrepancy between parent and child reports is due to over- or underinclusion on behalf of the children or adults. It may, for example, indicate that elementary school-age children cast a more inclusive net of “friends” or use a broader definition of impact than their parents when answer- ing these questions. The children were also active consumers of news about the terrorist attacks and were thus exposed to the attacks indirectly through visual images on TV, in the newspapers, and through other news outlets. As in the national survey (Schus- ter et al., 2001; Stein et al., 2003) based on parent reports and a wider age group of children (5- to 18-year-olds), only a handful of children in the current study avoided the news altogether, and a sizable minority (40%) watched the news extensively. The New York City data revealed even higher rates of


Table 5 Factors Associated With Children’s Negative Reactions to the Terrorist Attacks: Parent Reports

Variable Model 1 Model 2 Model 3

Intercept

SE Exposure

Lost familylfriend

P

P

P

SE TV exposure

SE Child characteristics

Grade level P

P

SE Gender

SE Postdisaster environment (parent coping)

Intrusive thoughts P

P

P

P

P

P

SE Womed about child

SE Shaken securitykafety

SE Health problems

SE Total constructive actions

SE Monitors TV viewing

SE

Model F Adjusted RZ AR2

2.53 2.98 .56 .73

.16* .16*

.26 .27

.13 .15

.19 .22

- .05 .06

- .06 .22

3.54, p = .03 2.00, ns ,032 .025 - ,006

1.84 1.25

.I4

.25

.15

.20

- .03 .06

- .08 .20

.07

.23

. I 1

.17

.10

.20

.19**

.28

-.18* .06

-.17* .27

5 . 1 0 , ~ = .OO .208 .209** *

Note. n = 157. * p < .05. * * p < .01. * * * p < .001

exposure to television news. Seventy percent of first through sixth graders indicated that they watched a lot of news (Gershoff & Kotler, 2003).

Given the unprecedented nature of the Septem- ber 11 attacks, it is of interest that the magnitude and nature of the children’s reactions found in this study correspond to prior research on children and disasters. The children, as a group, reported high levels of feeling shaken and insecure in the aftermath of the attacks, and endorsed, on average, one fifth of the negative reactions that were presented to them on the questionnaire, including two of eight items assessing

posttraumatic stress symptoms. It is possible that children overendorse items when presented with a long list of possible reactions. However, these rates of negative reactions are comparable to those found in other studies of elementary school children’s responses to disasters (see review by Belter & Shan- non, 1993), particularly for those living in heavily impacted areas. The most common symptoms reported by the children-intrusive thoughts, nightmares, and hyperarousal-also correspond to those most commonly found in prior research and in the study of New York City school children after Sep-


Table 6 Factors Associated With Children’s Negative Reactions to the Terrorist Attacks: Child Reports

Variable Model 1 Model 2 Model 3 Model 4

Intercept

SE Exposure

Lost family/friend

P

P

P

SE TV exposure

SE Child characteristics

Grade level P SE

Gender P SE

Postdisaster environment (parent coping/actions)

Health problems P

P

P

P

SE Intrusive thoughts

SE Parent constructive actions

SE Parent monitored TV viewing

SE Child’s psychological resources

Total constructive actions P

P

SE Talked with parents

SE

Model F Adjusted R’ AR’ change

-4.71 3.37

.06 1.08

.48*

.98

S.81 .p = .01 ,179 -

-1.33 4.94

.08 1.10

.5 1 * 1.04

- . I 1 .64

-.I5 1.06

3.40, p = .02 ,179 ,037

8.76 1 1.25

.03 1.07

.47*

.97

-.23 .67

-.17 1 .oo

.I2 1.64

.24 1.14

-.18 .28

-.19 1.17

3.51, p = .01 .314 .18S*

12.85 13.00

.04 1.16

.46* 1 .os

-.25 .7 1

-.16 1.04

. I 3 1.69

.22 1.20

-.I7 .29

-.18 1.22

.10

.28

.01

.65

2.74, p = .02 ,283 ,008

Note. n = 45 * p < .05.

tember 11 (Aber et al., 2003; Applied Research et al., 2002). In both the New York City and Washington, DC, studies, at least 24% of the children reported experiencing these specific symptoms, and more than 70% of the children experienced at least one symptom of PTSD. In the nationally representative sample of parents studied by Schuster, Stein, et al. immediately after September 11 (Schuster et al., 2001; Stein et al., 2003), 78% of the parents reported at least one terrorism-related psychological reaction in their child. It is noteworthy that the strongest reactions

among the New York City children were found among the age groups (fourth and fifth graders) that overlapped with the current Washington, DC, sample.

An important aspect of the study involved explor- ing the association between children’s and parents’ reactions to the terrorist attacks. As hypothesized, the common finding in the existing disaster literature that parents who are more upset by the event also report higher levels of negative reactions on behalf of their children (Belter & Shannon, 1993; Phillips et al., in

CHILDREN’S RESPONSES TO AITACKS 523

press; Schuster et al., 2001; Vogel & Vernberg, 1993) was replicated in the current study. Our data, however, clarify that this association is not exclusively the result of a generalized tendency by distressed parents to report negative reactions on behalf of their children. The children’s self-reports also revealed that, when their parents experienced more intrusive thoughts in the week after the attacks, they experienced significantly more negative reactions and stress responses. This finding is in need of replication given its significance for the kinds of services that are offered to families in the aftermath of disasters. There is a critical need to understand the processes through which children assess and react to their parents’ responses to disasters and how these vary with the age and circumstances of the children.

Although parents’ perceptions of their children are affected by their own coping, our evidence also suggests that they can provide accurate characterizations of children who are more or less distressed (i.e., rank orders). Specifically, parents whose children indicated greater distress after the attacks correspondingly reported more negative reactions for their children. However, they endorsed, on average, only l of the 16 items presented to them as possible reactions of their children in contrast to the average of 4 items endorsed by the children. This hypothesized discrepancy between data on children’s reactions provided by their parents and by the children themselves has also been reported in other studies of parents’ and children’s reactions to disasters (Belter & Shannon, 1993; Burke, Borus, Bums, Millstein, & Beasley, 1982; Earls, Smith, Reich, & Jung, 1988; Vincent, 1998). Although parents may provide an accurate account of which children are experiencing relatively more or fewer negative reactions to disasters, their specific reports of symptoms do not necessarily provide an accurate portrayal of the magnitude or nature of children’s self-reported distress. Why this occurs remains an open question that warrants further investigation given that many studies have, and are likely to continue to, rely on parental reports to obtain information on children’s responses to disasters. Children may not reveal all of their reactions to their parents, parents may have a difficult time perceiving or acknowledging negative reactions on behalf of their children, or some children may overreport their reactions when presented with a list of pos- sibilities on a questionnaire or in an interview. In accord with the first possibility, we found that parent-child pairs who spent more time talking about the attacks also showed stronger associations

between their respective reports of the child’s postattack reactions.

The Contribution of Exposure to TV News

A central goal of this study was to explore the association between news exposure and negative reactions to the attacks in elementary school-age children. As hypothesized, a positive association was found between the children’s news exposure and self-reported negative reactions. This finding repli- cates evidence from a small, but consistent, body of research on the effects of viewing news coverage of disasters on the development of symptomatology in children (Aber et al., 2003; Pfefferbaum et al., 2001; Scbuster et al., 2001; Terr et al., 1997). Television viewing in the aftermath of a disaster may contribute to negative reactions, or, alternatively, children who experience more negative reactions may be drawn to the news. In this study, the link between TV viewing and children’s reactions to the attacks occurred for children who indicated that they watched a lot of TV during the week of the attacks compared with children who watched only some TV, suggesting a threshold effect rather than a simple effect of any news exposure.

As Schuster et al. (2001) found, a substantial share of parents in the current study monitored their children’s news exposure, particularly for younger children. In addition, those who monitored their children’s TV viewing more closely reported less symptomatology in their children, perhaps suggesting a belief in the effectiveness of this strategy. This belief was not, however, confirmed by the children whose self-reported reactions to the attacks were not affected by parental monitoring. Moreover, in contrast to Schuster et al.’s findings, the positive association found between children’s exposure to the news and their negative reactions to the attacks remained significant only for children whose parents monitored their exposure. In the current study, therefore, monitoring the child’s exposure to the news appears to be a reactive strategy adopted by parents who perceive (and have children who report) an association between TV viewing and negative child reactions rather than a response that actually helped to buffer the relation between exposure and stress, as Schuster et al.’s (2001) results suggest. It may also have made the news more salient to the children (i.e., it required monitoring) and, in the process, more stress inducing. In this correlational study, however, these possibili- ties remain purely speculative.


The Role of Grade Level and Gender

Another goal of this investigation was to examine differences in the children’s reactions to the attacks as a function of grade level and sex. Contrary to our hypotheses, as well as to findings regarding Septem- ber 11 (Aber et al., 2003; Stein et al., 2003), this study revealed virtually no grade level or gender variation in children’s reactions in the week after the attacks as self-reported or reported by parents. Grade level did, however, affect how parents responded to their children in the aftermath of the attacks; parents of older children encouraged communication about the attacks and attendance at memorial services and candlelight vigils. Parents of younger children took more protective actions, such as minimizing their exposure to discussions and news about the attacks.

The Contribution of Constructive Actions by Parents and Children

There has been surprisingly little research on types of coping assistance that parents and others offer to children or on constructive actions in which children engage in the aftermath of disasters. The current study reveals relatively high levels of direct emotional processing, primarily through parent-child conversations and, for the younger children, sym- bolic play. These results replicate other studies of the September 11 attacks, which reveal very high levels of communication about the attacks among adults or parents and children (Featherman & Liu, 2003; Ger- shoff & Kotler, 2003; Schuster et al., 2001; Stein et al., 2003; Traugott et al., 2001). It is also of interest that, second only to parents, friends provided an important source of communication about the attacks, as was also found by Prinstein et al. (1996) in the aftermath of Hurricane Andrew and by Gershoff and Kotler (2003) in their study of elementaq school- age children in New York City after September 11.

Schuster et al. (2001) further found that the extent of parent-child communication about the attacks increased with the child’s age, and Stein et al. (2003) found an association between the length of parent- child conversations and parent reports of children’s negative psychological reactions and fears of being a victim of terrorism.. The results of the current study, contrary to our initial hypothesis, replicated this significant association between parents’ special efforts to talk with their children and their reports of greater fear and distress on behalf of their children. Parents and children who reported knowing someone who had been hurt in the attacks and watching a lot of TV

coverage were also more likely to talk with each other. It thus appears, in the current study, that parents considered their child’s age, extent of exposure, and expressions of distress in deciding whether and how much to talk about the terrorist attacks. It is also likely that parents who spend more time talking with their children become more aware of their child’s mental state and thus report more symptoms.

Parents also appear to have taken their children’s postattack reactions into consideration when deciding whether and how to engage their child in constructive actions, such as attending memorial services or donating to relevant charities. Somewhat surprisingly, approximately 4 in 10 of the young children studied became involved in relief efforts or made patriotic gestures. In the New York City study of elementary school-age children, close to 30% became involved in volunteer efforts (Gershoff & Kotler, 2003). Par- ents in the current study who perceived their children to be more distressed were less likely to encourage these types of activities, perhaps as a protective response. In contrast, and contrary to our hypothesis, children who reported engaging in constructive activities of this nature after September 11 reported greater feelings of shaken safety and security. Given the correlational nature of these data, it is not possible to distinguish whether children who experience greater distress seek out constructive activities as a coping strategy or whether these activities exacerbate negative reactions. Longitudinal data are needed to reveal whether, over time, these types of activities undermine or promote effective coping. In view of the interest of teachers, physicians, relief workers, mental health practitioners, and others in understanding the most effective means of supporting children’s coping after the terrorist attacks, research on this topic should be a high priority.

Combined Influences on Children’s Postattack Reactions

When variables reflecting the four domains of influence that the prior literature suggests affect children’s reactions to disasters were considered to- gether, this study confirmed the salient associations between exposure to TV news and the children’s self-reports and between parents’ own postattack reactions and actions taken on behalf of their children and their perceptions of their children’s reactions. It is equally important to note, however, that these influences accounted for less than one third of the variance in the children’s reactions, as self-reported or reported by parents, leaving a large gap in our

CHILDREN’S RESPONSES TO A’lTACKS 525

understanding of factors that contribute to elementary school-age children’s distress or resilience in the aftermath of disasters. This gap may be attributable to our inability to assess the children’s well-being be- fore September l l or to unmeasured aspects of their postattack environments or behavior.

Limitations of the Current Study

Several limitations of the current study are important to note. The sample is relatively small and drawn from only two public elementary schools that serve primarily middle- to upper-class White neighbor- hoods. Response rates, although consistent across grade level and gender of the children, were quite low. The findings emerging from this small self- selected sample must be interpreted with caution pending further replication in larger, more representative samples. If, for example, those children and parents who were most troubled by the attacks were disproportionately motivated to participate in this research, the results would overestimate negative impacts in the population. Alternatively, if particularly distressed families tended to avoid situations in which their responses to the attacks would be probed, the results would underestimate negative reactions.

Moreover, because this study was conducted in the heavily impacted city of Washington, DC, the results should not be generalized to areas of the country that were not as directly affected. Finally, data were col- lected at only one point in time and, although it is encouraging that the general pattern of results reported here corresponds to evidence from the prior literature on children’s reactions to disasters, they cannot provide insights into longer term impacts of the terrorist attacks on children and their parents (for an example of a longitudinal study on reactions to the terrorist attacks, see Phillips et al., 2003). These data also await replication from other studies of children’s responses to the terrorist attacks such as those funded by the National Institute of Mental Health (National Institutes of Health, 2002).

Implications

Several important implications can be drawn from the current study. First, elementary-school personnel, pediatricians, and others who come in regular contact with young children and their families need to rec- ognize that catastrophes can provoke serious negative reactions, including symptoms of posttraumatic stress, in young children even in the absence of immediate impacts. In fact, in the current study,

children who reported knowing a family member or friend who was hurt in the attacks and those who did not experienced comparable levels of negative reactions in the aftermath of the attacks. Thus, rather than attempt to target individual children for school-based and other interventions, a more useful approach would initially encompass all children in a heavily impacted area and subsequently focus on children who exhibit more serious or prolonged symptoms. This will necessarily involve close collaborations between the educational system, which has the children, and the health care system, which has the relevant funding streams and professional expertise.

Second, evidence linking TV news exposure to negative reactions to the attacks supports the advice of major school associations and pediatric organizations to limit young children’s exposure to news about disasters. Although parents of preschoolers and young elementary school children seem to understand this, parents of older elementary school children were significantly less likely to monitor or limit their children’s news exposure. A limited amount of TV viewing may not be harmful, and some children may actually seek out news coverage as a means of coping with their fears, but extensive viewing is clearly associated with more problematic postdisaster reactions by children across the elementary years. Major news organizations also need to be informed about these findings and solicited for their input into efforts to ensure that children’s exposure to TV coverage of disasters does not gratuitously exacerbate their feelings of vulnerability and trauma. In practice, the challenge facing parents, teachers, and other adults is one of enabling children who seek knowl- edge about traumatic events to become informed while also helping them cope with what this study and others suggest are likely to be greater, although not necessarily inappropriate or enduring, levels of distress.

Third, the finding that many of the elementary school-age children in the current study took constructive steps in the aftermath of the attacks, including nearly 50% who volunteered time or donated materials to relief efforts, suggests a possible avenue for efforts of school personnel, psychologists, and staff of disaster relief organizations to provide outlets for even quite young children to respond to the attacks. Although we cannot decipher whether more distressed children are drawn to these activities or whether they exacerbate negative postdisaster reactions, the potential benefits of such constructive efforts are supported by previous research indicating that negative coping, including doing nothing, was


significantly related to negative outcomes (Berman, Kurtines, Silverman, & Serafini, 1996; Dempsey, 2002). Additional research on protective influences, including constructive actions engaged in by children o r encouraged by their parents, is sorely needed.

Fourth, the finding obtained directly f rom the children that their parents’ responses to the attacks influenced their own sense of vulnerability and distress, adds to the extensive evidence for family- and community-level interventions after disasters (LaGreca e t al., 1996; Saylor e t al., 1997). Children’s friends, a s well, provide an important source of postdisaster debriefing and support and need to be explicitly included in intervention efforts (see also Gershoff & Kotler, 2003; Prinstein e t al., 1996).

In conclusion, this preliminary study of elementary school children’s reactions to the terrorist attacks suggests that this catastrophic event evoked similar types and degrees of distress and behavioral reactions a s has been found in studies of other disasters, whether natural or man-made. Emerging evidence f rom studies of school children in New York City, as well as from a nationally representative survey of parents immediately after September 11, also appear to be replicating many of the results found in the current study of children in Washington, DC. The children’s reactions were best understood in the context of their exposure to the events, primarily through TV news, and the reactions of and coping assistance provided by their parents. The more telling evidence, however, will emerge from longitudinal studies that assess the reduction o r persistence of distress in light of h o w children and their families experienced the attacks, responded in their aftermath, and moved ahead into a more uncertain future.

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154, 744-751.

Received January 10, 2003 Revision received August 8, 2003

Accepted October 7, 2003

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