Impact of conjoined exposure to the world trade center attacks and to other traumatic events on the behavioral problems of preschool children

Objectives: To examine the long-term behavioral consequences of exposure to the World Trade Center ( WTC) attacks in preschool children and to evaluate whether conjoined exposure to disaster and to other traumatic events has additive effects. Design: Retrospective cohort study. Setting: Lower Manhattan, New York. Participants: A total of 116 preschool children directly exposed to the WTC attacks. Main Exposures: High-intensity WTC attack - related trauma exposure indexed by the child experiencing 1 or more of the following: seeing people jumping out of the towers, seeing dead bodies, seeing injured people, witnessing the towers collapsing, and lifetime history of other trauma exposure. Main Outcome Measure: Clinically significant behavioral problems as measured using the Child Behavioral Checklist. Results: Preschool children exposed to high-intensity WTC attack - related events were at increased risk for the sleep problems and anxious/ depressed behavioral symptom clusters. Conjoined exposure to high-intensity WTC attack related events and to other trauma was associated with clinically significant emotionally reactive, anxious/ depressed, and sleep-related behavioral problems. Children without a conjoined lifetime history of other trauma did not differ from nonexposed children. Risk of emotionally reactive, anxious/ depressed, and attention problems in preschool children exposed to conjoined high-intensity WTC attack related events and other trauma increased synergistically. Conclusions: Conjoined other trauma exposure seems to amplify the impact of high-intensity WTC attack - related events on behavioral problems. Preschool children exposed to high-intensity events who had no other trauma exposure did not have increased clinically significant behavioral problems. The additive effects of trauma exposure are consistent with an allostatic load hypothesis of stress. More vigorous outreach to trauma-exposed preschool children should become a postdisaster public health priority.