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Implementation of CBT for Youth Affected by the World Trade Center Disaster- Matching Need to Treatment Intensity and Reducing Trauma Symptoms

CATS Consortium

This article describes 6-month outcomes from cognitive–behavioral therapies (CBT) provided to 306 children aged 5-21 who experienced trauma as a result of 9/11, and examines implications of providing evidence-based therapies to youth after large scale disasters.

There is a lack of empirically tested treatments for children post-disaster, specifically after terrorist attacks, and no scientific base to convey the techniques. As a result there has been a lot of improvisation or lifting of techniques from other population types as occurred in New York post 9/11.

The Child and Adolescent Trauma Treatments and Services Consortium (CATS Consortium) was formed to supervise and coordinate treatment services. The article examines the use of “a naturalistic and innovative need-based assignment design called regression discontinuity to assess strategies for matching the intensity of treatment services to the level of need in a post-disaster condition with limited resources.” The results of the study are intended to help create a selection process to assign youth with different levels of trauma either trauma-specific CBT or brief CBT skills, and examine 6-month outcomes.

The study compares results in New York from: evidence-based trauma treatment given to youth with moderate to severe symptoms, and a brief CBT skills intervention given to youth with mild symptoms. For those with severe trauma different approaches were taken for patients aged 5-12 and 13-21, in 8-12 treatment sessions. The brief CBT skills intervention for those with mild trauma was a 4-session arc.

The authors say their success suggests that providing evidence-based therapies following large scale disasters can be accomplished, including the field training of therapists in the techniques.


“The CATS Consortium created an efficient infrastructure for implementing and evaluating evidence-based CBT trauma treatments for youth in the aftermath of a major disaster. We hope that the lessons learned from this study can be useful to other communities faced with rapid deployment of mental health services for youth and their families after a disaster.”

Over the past few years there has been an increasing focus on the psychological impact of injury, but not a lot of research on the impact of a parent being injured on children when it is not a war injury. The authors studied the impact of a parent being injured on children, including when the children are injured in the same event. The hypothesis was children wouldn’t recover as well if their parent was also injured than if their parent hadn’t been injured.

Patients were selected from over 6,000 patients admitted to the emergency room at Harborview Medical Center. 175 parent-child (ages 6-17) dyads were recruited meeting four types: both parent and child were injured, the parent was injured but not the child, the child was injured but not the parent, and a control group where at least one person came to the emergency room but no one had a serious injury. Patients were interviewed about two weeks after their hospital visit in part to help set a pre-injury baseline. Parents and children were assessed for their prior circumstances and post-injury status according to a number of different accepted diagnostic tests. This included finding out about prior traumatic events. Follow-ups were by mail or phone at 5 months and 12 months. Results were adjusted for gender, age, and seriousness of the injuries involved.

The authors discuss patient demographics noting that prior depression or substance abuse were highest among the parent injured group, but in general, there were no differences in history of trauma or family function. The both-injured group had the youngest children. Most of the children in the child injured group and not injured group were male, with the reverse true of the other groups. Most of the both-injured group were hurt in car crashes.

For parents, marriages were not affected by the injury circumstances as of 5 and 12 months. The both injured group seemed to be most affected. Injured parents showed more depression. Alcohol abuse declined. Unexpectedly, having an injured child didn’t affect the physical/mental health of the parents, or family circumstances, or alcohol use.

For children, those in the both injured group were the most affected by PTSD. Children who were injured but whose parents were not were back to normal in five months. Uninjured children in the parent injured group were actually better off at 5 and 12 months, though they had more PTSD than in the neither injured group.

Findings showed that having an injured parent had a negative effect on children, including on  those who were injured themselves, including a greater incidence of PTSD. Some of this negative impact was from not having the injured parent as available as previously. There were negative financial effects for lower income families due to high medical bills, including bankruptcies.

The authors focused on their finding of heightened risk of PTSD to uninjured children of an injured parent. This had been seen in military families but in this study the authors found this was true for nonmilitary families as well. They noted that currently few uninjured children are screened for this real problem after a parent’s injury. There are specific tests to screen children for PTSD and more routine screening was suggested. However, while adults respond well to PTSD treatments, these have not proven effective for children, so more clinical studies were recommended. 

The authors listed the limitations of their study but felt their results would approximate circumstances for the general population, as prior injury studies had similar limitations.

They conclude with a recommendation that injured parents as well as uninjured children should be screened initially for PTSD and should have their recovery followed by their primary care providers over the ensuing months.



This article is an attempt to survey longitudinal studies of post-9/11 Post Traumatic
Stress Disorder (PTSD) to find patterns and effectiveness of treatment. The survey targeted
longitudinal studies over time rather than cross sectional studies measuring different populations
at the same time. Searches were conducted among thousands of articles to find suitable studies.
The focus was on the prevalence, trajectory, and treatment of PTSD among populations most
exposed to trauma, who therefore had the highest risk of developing PTSD.

One problem with 911 studies of broad cross sections of populations is that the range in
the percent of people affected by PTSD was highly variable across multiple populations and
variable time periods and so the data was not that useful. Another problem is that data is
collected at one point in time and so can’t be followed over time. PTSD can develop after a
delay, further undermining one-time observations. Relying on data with so many issues can
distort trends, so that PTSD prevalence after large-scale disasters can’t be estimated with
accuracy. A further problem with 911 studies is they haven’t studied treatment effectiveness.

The authors did searches using keywords of peer-reviewed literature on longitudinal
studies of 9/11 PTSD published over 15 years from 2001 to 2016. The articles had to highlight
the most exposed populations such as people who lived or worked near the World Trade Center
on 9/11 and first responders and clean-up workers who were there on 9/11 or soon after. They
had a final list of 20 articles with 13 longitudinal studies and 7 treatment studies. Three different
ways were used to measure PTSD: “Structured Clinical Interview for Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID; First et al. 1995), Clinician-
Administered PTSD Scale (CAPS; Blake et al. 1995), and the PTSD Symptom Checklist (PCL;
Blanchard et al. 1996).”

Eight of the 13 longitudinal studies covered first responders, rescue and recovery
workers. Studies found the rate of PTSD for the first four years for these groups to be between
8%-12%, but increased prevalence after 5-6 years of 7.4–16.5%. A much higher probable rate of
PTSD was found among non-traditional responders, lay people who rushed in to help with little
preparedness and training. Three studies compared traditional and non-traditional responders,
and didn’t all agree, showing different rates and trajectories of PTSD . One study of the 2.5 years
after 9/11 showed PTSD rising from 11.7% to 13.0% for traditional responders compared to
16.4% to 17.2% for non-traditional responders. Another study found probable PTSD rising from
20.2% to 29.6% among lay responders between 3-6 years after 9/11. Another found that PTSD
fell for non-traditional responders from years 3-8 from 24.1% to 22.5%, but went up for
traditional responders from 8.5% to 9.8%. A study of children exposed to 9/11 found PTSD fall
from 30% after four months to 5% after two years. Another study found increases in the rate of
trauma symptoms for NYC and Washington, DC residents over the first year.

The biggest risk factor in the onset of PTSD was degree of trauma exposure, with
intensity correlated with severity of PTSD. Bereavement and traumatic loss were also factors.
Prior traumas, mental history and stress levels contributed to how chronic the PTSD was. A
number of studies found that physical impairment or job loss related to 9/11 were also risk

Two treatment studies found that among children cognitive–behavioral therapy (CBT)
was helpful in relieving symptoms of PTSD, as was trauma-specific CBT and “Tell-Me-A-Story

Narrative Trauma Therapy (TEMAS-NTT).” Studies of adults showed benefits of exposure-
based treatment and prolonged exposure (PE) therapy with paroxetine (an antidepressant) to be
effective, also virtual reality (VR) as a means of exposure. Eye movement and reprocessing
therapy were also helpful for adults, as was CBT.

Generally, the rates of exposure and level of PTSD are very high in the periods following
the attack and decline over a long period of time after the direct experience of trauma. However,
for traditional responders, PTSD was lower overall but rose after 3 years. One reason for this
may be the failure to seek help. For nontraditional responders PTSD rates were much higher,
probably because of their extreme level of exposure with little to no experience or training. Job
loss or physical impairment contribute to chronic PTSD. So does repeated re-exposure in the
media which serves as a frequent reminder.

The findings seem consistent with studies of PTSD after other large-scale disasters,
though there are theories both for enhanced resilience for traditional responders based on
training, and increased risk to traditional responders due to intensity of exposure. There is little
data available regarding the relative strength/influence of resilience factors.

The authors hope their findings highlight the importance of longitudinal studies vs. cross-
sectional studies following disasters, and stress the need for more investment in registries
including for treatment tracking. They also hope there will be a focus in the future on biological
studies vs epidemiological data. Knowledge from longitudinal studies and biomarkers could
really help people exposed to large-scale traumas in the future with respect to PTSD.

Lowell, et al

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