Neighborhood characteristics and psychiatric disorders in the aftermath of mass trauma: A representative study of New York City public school 4th-12th graders after 9/11

George J. Musa, Lupo Geronazzo-Alman, Bin Fan, Keely Cheslack-Postava, Rachel Bavley, Judith Wicks, Michaeline Bresnahan, Lawrence Amsel, Emily Fiano, Glenn Saxe, Erich Kummerfeld, Sisi Ma, Christina W. Hoven

Research output: Contribution to journalArticlepeer-review


Studies of the relationship between neighborhood characteristics and childhood/adolescent psychopathology in large samples examined one outcome only, and/or general (e.g., ‘psychological distress’) or aggregate (e.g., ‘any anxiety disorder’) measures of psychopathology. Thus, in the only representative sample of New York City public school 4th-12th graders (N = 8202) surveyed after the attacks of 9/11/2001, this study examined whether (1) indices of neighborhood Socioeconomic Status, Quality, and Safety and (2) neighborhood disadvantage (defined as multidimensional combinations of SES, Quality and Safety indicators) are associated with eight psychiatric disorders: posttraumatic stress disorder, separation anxiety disorder (SAD), agoraphobia, generalized anxiety disorder (GAD), panic disorder, major depression, conduct disorder, and alcohol use disorder (AUD). (1) The odds ratios (OR) of psychiatric disorders were between 0.55 (AUD) and 1.55 (agoraphobia), in low and intermediate-low SES neighborhoods, respectively, between 0.50 (AUD) and 2.54 (agoraphobia) in low Quality neighborhoods, and between 0.52 (agoraphobia) and 0.65 (SAD) in low Safety neighborhoods. (2) In neighborhoods characterized by high disadvantage, the OR were between 0.42 (AUD) and 1.36 (SAD). This study suggests that neighborhood factors are important social determinants of childhood/adolescent psychopathology, even in the aftermath of mass trauma. At the community level, interventions on modifiable neighborhood characteristics and targeted resources allocation to high-risk contexts could have a cost-effective broad impact on children's mental health. At the individual-level, increased knowledge of the living environment during psychiatric assessment and treatment could improve mental health outcomes; for example, specific questions about neighborhood factors could be incorporated in DSM-5's Cultural Formulation Interview.

Original languageEnglish (US)
Pages (from-to)584-590
Number of pages7
JournalJournal of Psychiatric Research
StatePublished - Jun 1 2021

Bibliographical note

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First, compared to high Quality scores, lower neighborhood Quality was associated with higher odds of 9/11-related PTSD, SAD, and agoraphobia, disorders involving fear and avoidance. However, surprisingly, compared to high Safety scores, lower Safety scores were associated with lower odds of PTSD, SAD, and GAD. This difference between the Quality and Safety indices may be due to the fact that the Quality indicators included in this study are more likely to be experienced directly by children (e.g., disorderly youth, derelict vehicles, lack of parks and playgrounds in acceptable condition), while Safety indicators (e.g., felonious assaults and drug abuse deaths) may be less manifest in their everyday life. Thus, children living in lower-Quality neighborhoods might be more inclined to consider the living environment as a dangerous and unsafe place, compared to children living in lower-Safety neighborhoods; this negative neighborhood perception might be related to SAD symptoms, such as nightmares and wanting to stay home and not going to school/other places without the parents. Similarly, neighborhood factors comprising the Quality index, such as higher levels of noise, and lower availability of streets, sidewalks, parks and playgrounds in acceptable condition, might influence the development and/or maintenance of PTSD symptoms assessed in this study, such as problems falling/staying asleep and avoidance of places and activities, respectively. Finally, in regard to agoraphobia, youth living in lower-quality neighborhoods might experience increased fear/anxiety when outside of the home alone; they may also be more prone to believe that escape from such feared situations might be difficult, and develop the associated avoidance behaviors. Furthermore, compared to their children, parents living in lower-safety neighborhoods may instead have better knowledge of safety-related statistics that comprise the Safety index, and – to compensate – may tend to adopt positive parenting practices/behaviors (e.g., enhanced parental support and positive reinforcement of child behavior) and reduce negative parenting strategies (e.g., harsh, inconsistent practices), which may buffer against PTSD, SAD, and GAD (Lindstrom Johnson et al., 2018). The adaptive calibration model (Del Giudice et al., 2011) offers an additional explanation of why lower Safety scores were associated with lower odds of PTSD, SAD, and GAD. According to this model, individuals who rarely experience strong, sustained activation of the stress response systems, such as those in safe, low-stress environments (high Safety score), develop a sensitive stress responsivity pattern; moderate levels of environmental stress, and repeated activation of the stress response systems in childhood, will instead tend to adaptively down-regulate the stress responsivity, leading to buffered phenotypes and increased resistance to stress. A recent study in urban youth also suggests that blunted stress responsivity, associated with greater exposure to neighborhood violence and adversity, may represent an adaptive physiological buffer against the stressors occurring in their ecological context (Theall et al., 2017).At the individual level, the relevance of contextual factors in psychiatry has recently been formalized in the Cultural Formulation Interview (CFI) (Lewis-Fernandez et al., 2016), introduced as an emerging measure in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). The CFI is a semi-structured interview with clinical guidelines to assess a patient's social, cultural, and contextual background. In the CFI, psychiatric disorders and the patient's perspective and approach to clinical care are understood to be embedded in, and shaped by, the patient's specific cultural and socioeconomic contexts (La Roche and Bloom, 2018; Lewis-Fernandez et al., 2016). However, the current CFI was designed for adults and, thus, there is a paucity of research on youth that incorporates the CFI (La Roche and Bloom, 2018). Furthermore, the current CFI does not specifically inquire about neighborhoods. This may be a limitation, as suggested by the findings of this study and others' findings (see Supplementary Material), and by a recent clinical illustration of the effectiveness of the CFI with youths (La Roche and Bloom, 2018). Thus, the researchers suggest including additional questions to specifically assess the neighborhood context during a mental health assessment. For example, the CFI's incorporated the supplementary module 9, “School-Age Children and Adolescents” (SACA), which can be directly administered to the child (Rousseau and Guzder, 2016). The section of the SACA about “age-related stressors and supports” could easily be integrated with probes about the patient's neighborhood, such as “What do you like/don't you like [SACA questions 8 and 9, respectively] about being a child/youth at home? At school? With friends? In your neighborhood?”. Similarly, instructions to directly probe for stressors in the neighborhood could be included in question 8 in the “stressors and supports” section of the CFI and CFI-Informant Version. More detailed questions can follow up on specific issues if necessary (La Roche and Bloom, 2018). Further research on how culture and neighborhoods influence the perception and experience of both life stressors and illness in youth is needed to improve diagnostic accuracy, treatment specificity, and the clinical and ecological relevance of public health policies. The synthesis of neighborhood and culture into a holistic perspective of the lived milieu may lead to the delineation, in future editions of the DSM, of an approach that systematically and efficiently includes these elements into our understanding of the development and clinical management of childhood and adolescent psychopathology.

Publisher Copyright:
© 2021 Elsevier Ltd


  • Adolescents
  • Children
  • Neighborhoods
  • Psychiatric disorders
  • Trauma


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