Kaplan + Sadock's Synopsis of Psychiatry, 11e

1321

31.19d  Impact of Terrorism on Children

Table 31.19d-1 Experience of Danger Consequent to Terrorist Acts

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 ter- rorist attacks appears to lead to especially adverse reactions in children. School shootings are among the most tragic of trau- matic 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 psychologi- cal impact of this massacre on children who survived is mod- erated 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 chil- dren and adolescents. Gender also has been found to influence behavioral symptoms after exposure to severe trauma or ter- rorism, 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 initia- tives 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 influ- enced 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 disabili- ties, who have been exposed to terror attacks. Findings from this study revealed that personal exposure to terror, past per- sonal life-threatening events, and history of anxiety all con- tributed to the development of posttraumatic stress reactions. In addition, adolescents with learning disabilities who had dif- ficulties 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. The following summarizes data collected after the terrorist attack of the World Trade Center on September 11, 2001.

Objective Features

Subjective Features

Actualized threat Realistic threats False alarms Hoaxes Official risk communication,

Disruption of protective shield Appraisals of threat Fears of recurrence Living with uncertainty Ongoing worries about significant others Modulation of information exposure Safety and protective behaviors Anxious and restrictive behaviors Aggressive and reckless behaviors Categorization over discrimination of threat—risk of intolerance Themes of heroism and patriotism Political ideology — Changes in spiritual schema Parental demoralization

media coverage, and personal exchanges of information

Heightened security Mobilization of prevention and response capabilities Attribution of responsibility Evacuation and rescue efforts Military mobilization War Additional dangers,

terrorist acts, and personal tragedies

(Courtesy of Robert S. Pynoos, M.D. M.P.H., Merritt D. Schreiber, Ph.D., Alan M. Steinberg Ph.D., and Betty Pfefferbaum, M.D., J.D.)

September 11, 2001 Attacks The U.S. Department of Education, through Project SERV, sup- ported 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. Approxi- mately 70 percent of all children, however, were exposed to one of these factors. Interpersonal exposure through direct victim- ization of a family member was greater among children attend- ing 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. Sec- ond, 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 4 th - and 5 th -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 trau- matic experiences (more than one half of the total sample) was