Editorial: Seeking "new normality" after 9/11


Bioterrorism and its aftermath.



Seeking "new normality" after 9/11

By Elizabeth M. Alderman, MD, and Stanford B. Friedman, MD

The terrorist attacks of September 11 are more than three months past as you read this, but the repercussions of what occurred on that day continue to affect the lives of children and adolescents, their families, and their communities—as well as their caregivers. Who among us hasn't witnessed, over and over again, the physical damage of this human-engineered disaster through television news footage and newspaper and magazine photographs? And who hasn't been affected by the emotional fallout of the tragedy? As pediatricians, we occupy the front lines—talking to children, adolescents, and those who care for them about what has been happening in their lives since that ominous day.

Every patient encounter you have had since September 11 might appropriately open with "How are you and your family?" And on the first occasion of seeing a patient and his (or her) parents since that day, you might ask specifically how the terrorist attacks, as well as the ongoing war and anthrax scares, have affected child and family. Although most people (even we who live and work in the New York City area) have not directly lost a loved one or a member of the community, feelings of loss vary. An infant's reaction is mostly a mirror of the reaction and mood of his parents or caretaker; an adolescent's response is much more independent of the reactions of others and mirrors the response of an adult; and the reaction of a school-age child falls in the middle.

All of us have heard about children who have displayed regressive symptoms since September 11, including sleep disturbances, separation anxiety, clinging behavior, school phobia, and bedwetting. Other behaviors that have been observed are more psychological: irritability, inability to concentrate, somatic symptoms such as abdominal pain and headache, and reluctance to engage in familiar activities. These manifestations are all a normal reaction to an abnormal situation. As pediatricians, we can reassure our patients and their parents that, with time, and in a loving and caring environment, these symptoms will probably resolve. Some children may have acted out the events of September 11 during play—crashing a plane into a building-block "Twin Towers," for example. Such behavior is also normal.

By this time, however, most children and adolescents are no longer displaying these symptoms—especially if they are not constantly exposed to reports about, and images of, the war in Afghanistan and news of the terroristic spread of anthrax spores through the US mail. Yet when a child or preadolescent is curious and wants to watch the news, parents should, whenever feasible, sit by his side and watch, ready to answer questions in a factual, succinct way.

A few children and adolescents, after repetitive exposure to the kinds of images that emerged from the September 11 attack, develop posttraumatic stress disorder (PTSD)—a constellation of symptoms that requires intervention by a mental health professional. Clues to whether a child or adolescent has PTSD are recurrent, intrusive recollections of the event; nightmares; and an exaggerated emotional reaction to the event. Children and adolescents affected this way are hyperirritable and may exhibit strong avoidance behaviors.

Pediatricians are also being called on to discuss medical issues related to bioterrorism, such as the treatment of anthrax and the threat of smallpox (to read more about the threat of biological weapons, see "Biological terrorism: Not sci-fi any longer," of this issue). We need to keep abreast of the latest information issued by the Centers for Disease Control and Prevention and our local health departments so that we stand in the vanguard of calm and sound medical practice. In turn, we can aid our communities by being readily available to speak before civic and professional groups.

You should also encourage parents and caregivers to seek out resources beyond the care and concern that you provide. "For parents and children: Relevant resources on the Web," supplies the addresses of pertinent and authoritative Internet destinations for their use.

What happened on September 11 shocked us all. The three months following have revealed a slow determination to get our country back to a semblance of "normal." Yet life will never be the same. As pediatricians, we can acknowledge that fact for patients and their families and help them develop a "new normal"—one that will ensure their optimum mental and physical health.


Friedman, SB, Alderman, EM, Pantell, RH, et al; the American Academy of Pediatrics Work Group on Disasters: Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Rockville, Md., US Department of Health and Human Services, US Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 1995

DR. ALDERMAN is an associate clinical professor of pediatrics at Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, N.Y.
DR. FRIEDMAN is professor of pediatrics at the same institution.
DRS. ALDERMAN and FRIEDMAN are two of several authors of a publication of the American Academy of Pediatrics Workgroup on Disasters, Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician, published in 1995 by the Center for Mental Health Services of the US Department of Health and Human Services.

For parents and children: Relevant resources on the Web

From the AAP


On talking with children about disasters


Information on smallpox and anthrax


Family Readiness Kit (making preparations for disasters)

From other organizations


Coping with the aftermath of terrorism and violence; handling trauma-related stress and anxiety; numerous other resources on related topics


How to talk with children about violence and other complex world issues


Information on smallpox and anthrax and on coping with the September 11 terrorist attacks; each topic is presented in three age-tailored versions—for adults (parents), teens, and younger children


What to say to children about the September 11 attacks, including pearls for parents


Elizabeth Alderman, Stanford Friedman. Editorial: Seeking "new normality" after 9/11. Contemporary Pediatrics 2001;12:9.

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