54 - 31.19d Impact of Terrorism on Children

31.19d Impact of Terrorism on Children

Teicher MH, Tomoda A, Andersen SL. Neurobiological consequences of early stress and childhood maltreatment: are results from human and animal studies comparable? Ann N Y Acad Sci. 2006;1071:313. Widom CS, Brzustowicz LM. MAOA and the “cycle of violence:” Childhood abuse and neglect, MAOA genotype, and risk for violent and antisocial behavior. Biol Psychiatry. 2006;60:684. Wilson KR, Hansen DJ, Li M. The traumatic response in child maltreatment and resultant neuropsychological effects. Aggress Violent Behav. 2011;16:87–97. Young SE, Smolen A, Hewitt JK, Haberstick BC, Stallings MC, Corley RP, Crowley TJ. Interaction between MAO-A genotype and maltreatment in the risk for conduct disorder: Failure to confirm in adolescent patients. Am J Psychiatry. 2006;163:951. 31.19d Impact of Terrorism on Children In recent years, exposure to mass trauma and terrorism has become an increasing concern regarding the well-being of youth. Mass trauma has occurred directly and by witness through highly publicized traumatic events globally and in the United States, pertaining to terrorism, war, mass killings, and natural disasters. On April 15, 2013, the first major terrorist attack in the United States since 9/11 occurred at the finish line of the Boston Marathon in the mid-afternoon. Two “improvised explosive devices” (IEDs), that is, homemade bombs, detonated 8 minutes apart in the middle of a densely packed crowd of thousands of marathon runners and bystanders, killing three people and injuring about 264 others. Within moments after the blasts, the crowd’s panic and chaos turned to purposeful attention to help others get to emergency medical teams arriving on the scene. Courageously, bystanders ran toward others to give aid rather than dispersing away from the scene in all directions. Runners tore off their own shirts to apply pressure to fellow runners who were bleeding, or to use them as tourniquets. Boston’s emergency response medical teams worked quickly, efficiently, and tirelessly to transport injured runners to hospitals and into operating rooms in order to save limbs, and stop bleeding. The fact that almost all the injured were saved is a tribute to the emergency preparedness and collaboration of law enforcement, medical, and surgical teams carrying out an emergency plan that they had previously been briefed on, as a matter of course. Additional situations in which youth are exposed to severe trauma and terror involve armed conflict around the world, multiple mass school shootings that have taken place across the United States in recent years, and hurricanes, devastating storms, and tsunamis. Of course, more than a decade ago, the youth in the United States experienced the large-scale domestic terrorist attack on September 11, 2001, on the World Trade Center in New York City and the Pentagon in Washington, DC. There is an increasing body of literature on the impact of terrorism on children as well as a variety of other forms of trauma. One predominant and near universal symptom in children in response to these stimuli is anxiety. Young children may cling excessively to their parents, whereas older children may become preoccupied with fear about unrelated issues. Some youth express overt anger, and others experience a sense

of hopelessness, lack of control, and/or depression. Severe traumas, such as experiencing a terrorist event, may be more likely to result in posttraumatic stress syndromes among exposed youth, compared to less severe forms of trauma. The number of traumas experienced by a child, degree of family support provided after the exposure, and the reactions of parents are all important factors in a child’s reaction. According to a national survey after the terrorist attack of September 11th, stress reactions to that disaster were increased by watching repeated media coverage of those events. A similar study evaluating the impact of media versus direct exposure to collective trauma, on acute stress response was undertaken 2 to 4 weeks after the Boston Marathon bombings through surveying 846 people from Boston, 941 people from New York City, and 2,888 people through Internet means. Direct exposure, defined as being at or near the bombings, was compared to media exposure, including footage on television and bombing related stories on the radio, in print, online, and other social media coverage. Because acute stress responses appear within weeks of a traumatic event, this study was able to capture acute stress difference between the two groups. The study found that trauma related to media exposure was associated with acute stress reactions in people from all over the United States who were not directly exposed to the event in Boston. Furthermore, respondents reporting exposure to media coverage of the bombings for six or more hours daily in the week following the bombings were nine times more likely to report high acute stress than those who had minimal exposure to media coverage of the events. In fact, the group who engaged in extensive media coverage had higher levels of acute stress than respondents who had direct exposure in Boston, but who had minimal exposure to media coverage of the bombings. These findings suggest that prolonged media exposure to collective traumatic events may have a strong negative impact on psychological symptoms and acute stress syndromes. However, the study noted substantial resilience in the surveyed population. Researchers have suggested that the effectiveness of Boston’s medical and law enforcement teams in response to the terrorist bombings may have promoted some degree of resilience in the population. A unique aspect of exposure to terrorist-related trauma, as well as school shootings, is the psychological effects of knowing that the trauma was both consciously and purposely perpetrated, and yet also random. The random nature of terrorist attacks appears to lead to especially adverse reactions in children. School shootings are among the most tragic of traumatic events involving youth. On December 14, 2012, in the village of Sandy Hook, in Newtown, Connecticut, a 20-year-old male in black clothing carrying his mother’s rifle, shot his way through a glass window at the front of the Sandy Hook Elementary School, rampaged the school, shooting and killing 20 first-grade students from multiple classrooms and 6 school personnel, and then shot and killed himself. He had shot and killed his mother before arriving at the school. The psychological impact of this massacre on children who survived is moderated by age, gender, and family reactions. Younger children appear to be at higher risk for posttraumatic stress disorder, somatic symptoms, depression, and distress than older children and adolescents. Gender also has been found to influence behavioral symptoms

after exposure to severe trauma or terrorism, with girls experiencing higher levels of posttraumatic stress syndromes and depression, while boys exhibit more external behavior problems. Although the United States has launched a series of initiatives in response to the threats and consequences of terrorism in the form of an act of Congress in 2002 called the Public Health Security and Bioterrorism Preparedness and Response Act, children and adolescents continue to view media exposure to terrorist events throughout the world that reinforces a sense of danger. The concept of terrorist acts is characterized by three distinct features: (1) They produce a societal atmosphere of extreme danger and fear, (2) they inflict significant personal harm and destruction, and (3) they undermine the expectation of citizens that the state is able to protect them. Child and adolescent reactions to exposure to terrorism are mediated by numerous factors, including personal appraisal of persisting danger, the likelihood of recurrent attack, and the perception of the relative safety of one’s family and close friends. Children’s responses to terrorist exposure are influenced by how their parents cope with the trauma and resulting turmoil and how well they understand the situation. PTSD has been studied in adolescents, with and without learning disabilities, who have been exposed to terror attacks. Findings from this study revealed that personal exposure to terror, past personal life-threatening events, and history of anxiety all contributed to the development of posttraumatic stress reactions. In addition, adolescents with learning disabilities who had difficulties in cognitively processing the traumatic events were at higher risk of developing PTSD when this was combined with the other high risk factors, such as being personally exposed to the traumatic events. Table 31.19d-1 identifies the relationship between objective features of danger and subjective features related to exposure to terrorist acts. Table 31.19d-1 Experience of Danger Consequent to Terrorist Acts

The following summarizes data collected after the terrorist attack of the World Trade Center on September 11, 2001. SEPTEMBER 11, 2001 ATTACKS The U.S. Department of Education, through Project SERV, supported the New York City Board of Education in conducting a needs assessment of New York City schoolchildren. A total of 8,000 randomly selected students were surveyed 6 months after the September 11, 2001 attacks. Striking differences were seen among students in the vicinity of Ground Zero as compared with students in the rest of the city, in exposure to smoke and dust, fleeing for safety, problems getting home, and smelling smoke in the days and weeks after September 11. Approximately 70 percent of all children, however, were exposed to one of these factors. Interpersonal exposure through direct victimization of a family member was greater among children attending schools outside the Ground Zero vicinity as compared with those attending school in this area. Media exposure was extensive and prolonged. Signs of heightened security were visible throughout the city. The study used several scales of the Diagnostic Interview Schedule for Children (DISC). Three sets of findings stand out from this study. First a significant degree of persistent separation anxiety was seen, especially among school-age children, but also among adolescents. Second, reflecting an age-related vulnerability to incident-specific new fears (e.g., subways and buses) and avoidant behavior of school-age children, a nearly 25 percent rate of agoraphobia was reported among 4th- and 5th-graders. Care must be taken, however, not to misrepresent incident-specific new fears as agoraphobia, because the course of recovery and intervention strategies may differ. Third, an enormous

reservoir of prior traumatic experiences (more than one half of the total sample) was associated with severity of current PTSD symptoms, emphasizing the need to attend to prior trauma in conducting needs assessments, surveillance, and intervention strategies. Other risk factors, in addition to younger age, included female gender and Hispanic ethnicity. The finding of age-related increases in rates of conduct disorder also needs to be interpreted in light of adolescent response to an ecology of danger in which overly aggressive, reckless, and risk-taking behaviors are well documented and associated with posttraumatic stress reactions. A major strength of this study was the inclusion of selfreported impairment as well as symptoms, setting an important standard for future studies. J. Stuber and colleagues conducted a telephone survey of a random sample of adult residents of Manhattan 1 to 2 months after the September 11th attacks. The sample included more than 100 parents who were asked to describe the experiences and reactions of their children. Not surprisingly, given the time of the incident, most children were at school or day care when the disaster occurred. Many of the parents recalled concern about their children’s safety at the time, and most were not reunited with their children for more than 4 hours. More than 20 percent of the parents studied reported that their children had received counseling related to the disaster. Receiving counseling was associated with male gender, parental posttraumatic stress, and having at least one sibling living in the household. Also using parent report in a New York City telephone survey, researchers assessed predictors of posttraumatic stress reactions in children between the ages of 4 and 17 years, 4 to 5 months after the attacks. Almost 20 percent of children were reported by their parents to have experienced severe or very severe posttraumatic stress reactions, and approximately two thirds had moderate posttraumatic stress reactions. Parental reactions and viewing three or more graphic images of the disaster on television were associated with severe or very severe posttraumatic stress reactions in children. Another study reported that 27 percent of children with severe or very severe posttraumatic stress reactions received some mental health care 4 to 5 months after September 11th. Two surveys of representative samples of adults were conducted after the September 11th attacks; the first between 4 and 5 months and the second between 6 and 9 months after the attacks. Behavior problems were related to the child’s race or ethnicity, family income, living in a single-parent household, disaster event experiences, and parental reactions to the attacks. The results of these surveys were examined in light of findings from a representative survey conducted before September 11th. The rate of behavior problems was lower in the first post-September 11th survey (4 to 6 months after the attacks) than rates in the pre-September 11th survey, but problems returned to preSeptember 11th levels by the second post-September 11th study (6 to 9 months after the attacks). Consistent with findings in studies of Hurricane Andrew, these results suggest that behavior problems may decrease in the months after a disaster or that parents may be insensitive to them, but that they return to pre-disaster levels over time. Media coverage of the September 11th attacks brought renewed debate about its impact, especially on children, even children with no direct exposure. One study reported extensive exposure to television coverage in children throughout the nation, using a representative survey of adults conducted in the first days after the attacks.

Approximately one third of the parents surveyed attempted to limit or to prevent their children’s viewing, but, among those whose parents made no attempt to restrict viewing, the number of hours of disaster coverage watched was related to the number of reported stress symptoms. Using a Web-based, nationally representative sample of adults, another study examined distress in children 1 to 2 months after the attacks by asking parents if their children were upset by the events. Among the children perceived as most upset, 20 percent had trouble sleeping, 30 percent were irritable or easily upset, and 27 percent feared separation from their parents. The mean age of children perceived as most upset was 11 years, with no statistically significant gender differences. The proportion of parents reporting at least one child upset did not differ by community in analysis of data from the New York City metropolitan area, Washington, DC, other major metropolitan areas, and the rest of the country. A strength of these surveys was their examination of representative samples, but earlier work points to concern about assessing children by interviewing their parents. Furthermore, as with the Oklahoma City studies, the samples were composed mainly of indirectly exposed children, and the clinical significance of the findings is unclear. Nine-year-old Jason endured the traumatic loss of his father on the first plane into the World Trade Center. Jason’s father was on board American Airlines Flight No. 11 on a business trip. Jason and his siblings were preparing to leave for school when he, his mother and his siblings learned of the event. Jason watched his mother nearly collapse when she confirmed the presence of his father aboard the aircraft. Jason observed the recurring video segments of the second plane crashing into the second tower several times that morning before his mother limited television access. Jason, the oldest child in his family, had enjoyed an exceptionally close relationship with his father. Almost immediately after the terrorist attacks, Jason’s mother became worried that he was despondent, suicidal and unable to function, just preoccupied with the grisly nature of his father’s death. He was becoming increasingly agitated as he talked constantly about the gruesome way that his father had died. Jason’s mother sought immediate psychological treatment for him, during which he began to ask a continual series of questions about his father’s death, including aspects of burning, fragmentation, pain, blood, and the exact moment of his father’s deaths in comparison with what he had initially observed on television. This became the main theme of Jason’s early treatment, in which he ruminated (i.e., whether this father had been “blown up in a thousand pieces” and the sequence of fire, burning, pain, and death). Jason developed nightmares within days in which he awakened and called for his mother at least three times a night. Jason was unwilling to discuss the content of his dreams with his mother, given his observations of her own serious distress. Jason began to express fears that the “hijackers” would hurt his mother and siblings. He became focused on the concept that “half our freedom is gone,” and he was concerned

that one half of New York City was destroyed. He was preoccupied with enacting in play, repetitive crashing down of creating the World Trade Center. Although after 3 months, he was able to resume sleeping through the night, he reported new troubling dreams with themes of ghosts “popping out” and “everyone is killed, and then I’m killed.” This worsened after the onset of the war in Afghanistan, and his mother had to constantly reassure him that the war was not near their home. Jason told his therapist of his wish that could find a time machine and be transported back in time on board his father’s flight before it crashed. While his therapist could fly the plane, he would overpower the “hijackers” and throw them off the plane, and then the plane would land safely in Boston. Jason continued his wish that after landing, his father and the other passengers tell him “thank you,” and be very happy. After expressing his wish verbally, he appeared to be somewhat comforted and he began to recall many positive activities with his father, and a series of happy, highly detailed memories of his father, which then caused him to suddenly become tearful with profound sadness at the realization that these would be no more. In therapy, Jason alternately expressed rage and anger and confusion about the actions of “Osama Bin Laden.” Over many months, Jason was able to remember and speak about the good things he remembered about his father without immediately breaking down in tears. Jason become a helpful big brother, who often tried to care for his younger siblings, and his mother often told him how proud she was of him. (Adapted from Robert S. Pynoos, M.D. M.P.H., Merritt D. Schreiber, Ph.D., Alan M. Steinberg Ph.D., Betty Pfefferbaum, M.D., and J.D.) To respond to the mental health needs of children and adolescents who have been exposed to terrorism either through personal experience or through exposure to media depicting world-wide terrorism, the adverse psychological reactions listed in Table 31.19d-2 must be considered. Table 31.19d-2 Psychological Disorders Associated with Terrorism

COMPONENTS OF MECHANISMS FOR RECOVERY FROM EXPOSURE TO TERRORISM In order to begin the process of recovery from exposure to mass trauma, an assessment of a child’s current coping must be done. Numerous instruments to measure coping exist. These include COPE, a self-report questionnaire which has 52 items that can be used with children, adolescents and adults; Children’s Coping Strategies Checklist (CCSC), a self-report questionnaire with 45 general coping items used with children 9 to 13 years of age; and How I Coped Under Pressure (HICIPS), which has 45 event specific questions for children in the 4th to 6th grade. Once this assessment has been determined, the next steps can be taken to begin the road to recovery. Perception of Safety The notion of perceived safety is an important protective factor as well as a component of recovery for a child, adolescent, or adult who has been exposed to terrorism. A recent report of symptoms of PTSD, depression, and perceived safety in disaster workers 2 weeks after the September 11th terrorist attacks found that lower perceived safety was associated with increased symptoms of hyperarousal and intrusive fearful thoughts, but not avoidance. An expected diminished sense of safety was found in those individuals who had personally been in greater physical danger, or who had worked with dead bodies compared with others who were physically less exposed. To regain a sense of security, reestablishment of a perception of safety is a necessary first step. Reestablishment or Maintenance of Daily Routines Although it is clearly not always possible to maintain usual daily routines amidst war or exposure to terrorism, a study of Israeli adolescents found that those whose families were able to maintain their usual activities, such as attending school and family functions, were at lower risk for the development of posttraumatic reactions. Proactive Interventions to Enhance Resilience Perceived personal resilience has been shown to be protective against symptoms of posttraumatic stress development. Proactive interventions aimed at enhancing a sense of personal resilience and an ability to cope with the stressful situation may serve to decrease the risk of psychiatric symptoms after exposure to terrorism. Interventions may include regaining a sense of perceived safety through reestablishing routines, altruistic tasks, family preparedness planning, and parental expression of security. REFERENCES Biddinger PD, Baggish A, Harrington L, d’Hemecort P, Hooley J. Be prepared–the Boston marathon and mass-casualty events. N Engl J Med. 2013;368(21):1958–1959. Bourne C, Mackay CE, Holmes EA. The neural basis of flashback formation: The impact of viewing trauma. Psychol Med.

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