Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.19d  Impact of Terrorism on Children

this assessment has been determined, the next steps can be taken to begin the road to recovery.

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 con- fusion 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 ado- lescents 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. 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 Cop- ing 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 4 th to 6 th grade. Once

Perception of Safety The notion of perceived safety is an important protective fac- tor 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 11 th terrorist attacks found that lower perceived safety was associated with increased symp- toms 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. 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 main- tain their usual activities, such as attending school and family functions, were at lower risk for the development of posttrau- matic 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 ter- rorism. Interventions may include regaining a sense of perceived safety through reestablishing routines, altruistic tasks, family pre- paredness planning, and parental expression of security. R eferences 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. 2013;43:1521–1532. Braun-Lewensohn O, Celestin-Westreich S, Celestin LP, Verte D, Ponjaert-Krist- offersen I. Adolescents’ mental health outcomes according to different types of exposure to ongoing terror attacks. J Youth Adolesc. 2009;38:850–862. Committee on Environmental Health; Committee on Infectious Diseases; Michale WS, Julia AM. Chemical-biological terrorism and its impact on children. Pedi- atrics. 2006;118:1267. Corrigan PW. Understanding Beivik and Sandy Hook: Sin and sickness? World Psychiatry. 2013;22:174. Demaria T, Barrett M, Kerasiotis B, Rohlih J, Chemtob C. Bio-psycho-social assessment of 9/11-bereaved children. Ann NY Acad Sci. 2006;1071:481. Duarte CS, Hoven CW, Wu P, Bin F, Cotel S, Mandel DJ, Nagasawa M, Balaban V, Wernikoff L, Markenson D. Posttraumatic stress in children with first respond- ers in their families. J Trauma Stress. 2006;19:301. Fairbrother G, Stuber J, Galea S, Pfefferbaum B, Fleischman AR. Unmet need for counseling services by children in New York City after the September 11 th attacks on the World Trade Center: implications for pediatricians. Pediatrics. 2004;113:1367–1374. Finzi-Dottan R, Dekel R, Lavi T, Su’ali T. Posttraumatic stress disorder reactions among children with learning disabilities exposed to terror attacks. Compr Psy- chiatry. 2006;47:144. Reestablishment or Maintenance of Daily Routines

Table 31.19d-2 Psychological Disorders Associated with Terrorism

Acute stress disorder PTSD Depression Anxiety Separation anxiety disorder Agoraphobia Phobic disorders

Bereavement Somatization Irritability Dissociative reactions Sleep disturbances Diminished self-esteem Deterioration in school performance Distress when exposed to traumatic reminders Substance abuse