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The rate of psychiatric illness among children who lost a parent in the Sept. 11, 2001, World Trade Center attack doubled – from about 32 to nearly 73 percent – in the years following the event, according to a new study from researchers at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

More than half (56.8 percent) of the young children studied suffered from some sort of anxiety disorder, including post-traumatic stress disorder (PTSD), which affected nearly three in 10 bereaved children.

The study, which appears in the April issue of Biological Psychiatry, also found chronic, heightened activity of the brain's "stress-response system" in many children who lost a parent on 9/11.

"Continued activation of this system can lead to long-term hypersensitivity to stress as adults and even impact on bone health, since the stress hormone cortisol can harm bone," notes lead researcher Dr. Cynthia Pfeffer, an attending psychiatrist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and a professor of psychiatry at Weill Cornell Medical College.

Dr. Pfeffer's team assessed the long-term mental well-being of 45 children (averaging about 9 years of age) who lost a parent in the 9/11 attacks.

The children – with the informed consent of the surviving parent – were recruited anywhere from four months post-9/11 to three years later, then assessed once every six months over the following two years.

A control group of 34 non-bereaved children, matched for age and socioeconomic background, were also included in the study. The study was conducted at five sites across the greater New York metropolitan area.

"This study is unique because it is one of the few well-controlled studies of child bereavement conducted longitudinally, and also because their loss occurred in such a sudden, devastating way," explains Dr. Pfeffer. "We believe that the nature of bereavement does change depending on the type of loss – for example, after a long illness or suddenly and through no fault of the victim, as happened on 9/11."

During each six-month assessment, the team conducted standard tests checking for a wide range of psychiatric problems. At the same time, they obtained twice-daily samples of saliva, looking for levels of cortisol, the stress hormone.

Levels of psychiatric illness were found to be much higher among bereaved vs. non-bereaved youngsters, despite the fact that many of the bereaved children were receiving psychotherapy to help them cope, Dr. Pfeffer says.

Besides the high rates of PTSD – which was 10 times that seen in non-bereaved children – the researchers found that 27.3 percent of bereaved youngsters suffered from separation anxiety and 25 percent experienced generalized anxiety, double the rate seen in non-bereaved youngsters. The rate of simple phobias in bereaved children was also double that of non-bereaved children (13.6 percent vs. 5.9 percent).

While the rate of major depressive disorder in bereaved children was twice that of non-bereaved children – 13.6 percent compared to 5.9 percent, respectively – Pfeffer was surprised that children didn't suffer more from depression after losing a parent.

"We usually talk about bereavement being closely associated with sadness and depression, but perhaps the sudden loss of 9/11 led to more anxiety, instead," she says.

One particularly worrying finding came from the salivary cortisol sampling. "Salivary cortisol levels are a marker for the activity of the 'hypothalamic-pituitary-adrenal (HPA) axis,' the body's central responder to stress – our 'fight or flight' mechanism," explains study co-author Dr. Margaret Altemus, an associate attending psychiatrist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and associate professor of psychiatry at Weill Cornell Medical College.

"Usually, this system jumps in action in response to a stress, then slowly goes back down to normal," Dr. Altemus explains. "But we saw elevated cortisol levels in many bereaved children throughout the two-year study. That suggests that the HPA axis remained switched on at a relatively high level."

That could lead to problems down the line, Dr. Pfeffer says, because studies have shown that chronic HPA activation in childhood may make individuals hypersensitive to stressors throughout their lifespan. Chronically elevated cortisol levels can also negatively impact bone health and boost risks for insulin-related dysfunction.

The study does suggest that many bereaved children, whatever the nature of their loss, need better monitoring and treatment.

"Bereavement and grief is a natural process, and it is important to note that many of the children we studied did not suffer from psychiatric difficulties beyond normal grieving," Dr. Pfeffer says. "However, a significant number developed anxiety or depressive disorders that might require expert diagnosis and treatment."

"We know that bereavement isn't the same for everyone," the expert adds. "So, we need to get better at identifying how individual children are faring after this type of devastating loss – and then construct interventions that will work for that child."

Co-investigators included Dr. Hong Jiang and Dr. Moonseong Heo, both of NewYork-Presbyterian Hospital/Weill Cornell Medical Center and Weill Cornell Medical College.

This study was funded by the U.S. National Institute of Mental Health.

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NewYork-Presbyterian Hospital/Weill Cornell Medical Center

NewYork-Presbyterian Hospital/Weill Cornell Medical Center, located in New York City, is one of the leading academic medical centers in the world, comprising the teaching hospital NewYork-Presbyterian and its academic partner, Weill Cornell Medical College. NewYork-Presbyterian/Weill Cornell provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine, and is committed to excellence in patient care, research, education and community service. NewYork-Presbyterian, which is ranked sixth on U.S.News & World Report's list of top hospitals, also comprises NewYork-Presbyterian Hospital/Columbia University Medical Center.