Effect of the incident at Columbine on students' violence- and suicide-related behaviors

Effects of Mass Shootings on the Mental Health of Children and Adolescents

PURPOSE OF REVIEW

To examine mass shootings in youth including mass shooting trends, risk and protective factors for emotional sequelae, mental health, prevention of mass shootings, and the assessment and treatment of survivors.

RECENT FINDINGS

Many youth are exposed to gun violence, with a smaller subset exposed to mass shootings. While youth have varying responses to mass shootings, possibly due to risk and protective factors as well as level of exposure, the mental health outcomes are significant and include posttraumatic stress, suicide, depression, substance abuse, and anxiety. Efforts at developing effective prevention and treatment programs are still underway but generally take a tiered public health approach. Mass shootings have significant mental health outcomes for youth survivors, particularly those with direct exposure or risk factors. Continued efforts are needed to better understand the effects of mass shootings and how to prevent them from occurring as well as how to best address the needs of survivors.

Supporting Children After School Shootings

Anticipatory guidance should be provided to families on identifying and addressing common adjustment reactions after a school shooting. Although adjustment difficulties may be related to post-traumatic and grief reactions, many will not be directly attributable to the school shooting. Understanding how to cope with associated worries and reactions can help children better adjust. Pediatricians can assist with guidance about the development of a reasonable timeline for emotional and academic recovery, traumatic stress/loss, coping strategies, support for students with special needs, identification of students most in need of support, identification of staff who are most likely impacted, and appropriate preparedness activities.

Diffusion of a Peer-Led Suicide Preventive Intervention Through School-Based Student Peer and Adult Networks

Background: Peer-led interventions have been applied to prevent various health behavior problems and may be an important complement to individual-level suicide prevention approaches. Sources of Strength trains student "peer leaders" in secondary schools to conduct prevention activities that encourage other students to build healthy social bonds and strengthen help-seeking norms. Prior work examining diffusion of peer-led programs has focused on youths' closeness to peer leaders but minimally on other factors such as connections to adults and suicidal behavior. Methods: We examined implementation and dissemination of Sources of Strength in 20 schools. Over 1 year 533 students were trained as peer leaders and 3,730 9th-12th graders completed baseline surveys assessing friendships and adults at school, and suicidal thoughts/behaviors; and end-of-year surveys reporting intervention exposure: viewed poster/video, attended presentation, direct peer communication, and activity participation. Chi-square tests compared exposure rates by student and network characteristics. Multi-level logistic regression models tested predictors of exposure across individual and school-level characteristics. Results: Exposure to the intervention varied greatly by school and by individual student characteristics and network position. Training more peer leaders increased school-wide exposure for all modalities except presentation (Bs 0.06-0.10, p's < 0.05). In multivariate models, exposure was consistently higher for students closer to peer leaders in the friendship network (ORs 1.13-1.54, p's < 0.05) and students who named more trusted adults (ORs 1.08-1.16, p's < 0.001); and lower for males (ORs 0.56-0.83, p's < 0.05). In multivariate models, training more students as peer leaders predicted exposure to poster-video and direct peer communication in larger schools (OR = 3.34 and 2.87, respectively). Network characteristics influenced exposure similarly for students with suicidal thoughts and behaviors. Discussion: Our findings confirm prior work showing the importance of personal affiliations to peer leaders and natural networks as a medium for diffusion of peer-led prevention efforts. We build on that work by showing independent effects of closeness to adults at school and number of peer leaders trained. There is a need to strategically select peer leaders to maximize closeness to students school-wide, particularly in larger schools. Additional work is required for Sources of Strength to devise messaging strategies to engage males and students isolated from adults at school.

The Mental Health Consequences of Mass Shootings

Mass shooting episodes have increased over recent decades and received substantial media coverage. Despite the potentially widespread and increasing mental health impact of mass shootings, no efforts to our knowledge have been made to review the empirical literature on this topic. We identified 49 peer-reviewed articles, comprised of 27 independent samples in the aftermath of 15 mass shooting incidents. Based on our review, we concluded that mass shootings are associated with a variety of adverse psychological outcomes in survivors and members of affected communities. Less is known about the psychological effects of mass shootings on indirectly exposed populations; however, there is evidence that such events lead to at least short-term increases in fears and declines in perceived safety. A variety of risk factors for adverse psychological outcomes have been identified, including demographic and pre-incident characteristics (e.g., female gender and pre-incident psychological symptoms), event exposure (e.g., greater proximity to the attack and acquaintance with the deceased), and fewer psychosocial resources (e.g., emotion regulation difficulties and lower social support). Further research that draws on pre-incident and longitudinal data will yield important insights into the processes that exacerbate or sustain post-incident psychological symptoms over time and provide important information for crisis preparedness and post-incident mental health interventions.

Brief report: Examining children's disruptive behavior in the wake of trauma - A two-piece growth curve model before and after a school shooting

School shootings may have serious negative impacts on children years after the event. Previous research suggests that children exposed to traumatic events experience heightened fear, anxiety, and feelings of vulnerability, but little research has examined potential aggressive and disruptive behavioral reactions. Utilizing a longitudinal dataset in which a local school shooting occurred during the course of data collection, this study sought to investigate whether the trajectory of disruptive behaviors was affected by the shooting. A two-piece growth curve model was used to examine the trajectory of disruptive behaviors during the pre-shooting years (i.e., piece one) and post-shooting years (i.e., piece two). Results indicated that the two-piece growth curve model fit the data better than the one-piece model and that the school shooting precipitated a faster decline in aggressive behaviors. This study demonstrated a novel approach to examining effects of an unexpected traumatic event on behavioral trajectories using an existing longitudinal data set.

Sex, race/ethnicity, and context in school-associated student homicides

This study assessed the importance of sex, race/ethnicity, and geographic context for incidents of school-associated student homicides between July 1, 1994 and June 30, 1999, covering 5 academic years. Using data from the Centers for Disease Control and Prevention School Associated Violent Deaths Study (n = 125 incidents), we compared percentages and medians of victim, offender, motive, and school characteristics for incidents by geographic context and race/ethnicity of the offenders. Most incidents involved urban areas (53.6%), Black and Latino offenders and victims, moderately high youth poverty, and male on male violence (77.6%) driven by disputes and gang-related motives. Suburban area incidents (31.2%) often involved offenders and victims of a different race/ethnicity (51.3%). Multiple victims and White offenders were more common in rural areas (15.2%). More than 50% of the rural incidents involved male offenders and female victims. White offender incidents more often included multiple victims and female victims while Black and Latino offenders more often included single victims of the same sex. These results emphasize the utility of an incident-based analysis of school-associated student homicides in highlighting important variations by intersections of sex, race/ethnicity, and geographic context.

Effects of media exposure on adolescents traumatized in a school shooting

This study analyzes the impact of the media on adolescents traumatized in a school shooting. Participants were trauma-exposed students (n = 231) and comparison students (n = 526), aged 13-19 years. A questionnaire that included the Impact of Event Scale and a 36-item General Health Questionnaire was administered 4 months after the shooting. Being interviewed was associated with higher scores on the Impact of Event Scale (p = .005), but posttraumatic symptoms did not differ between those who refused to be interviewed and those not approached by reporters. Following a higher number of media outlets did not affect symptoms.

Suicide patterns and association with predictors among Rhode Island public high school students: a latent class analysis

OBJECTIVES

We analyzed Rhode Island's 2007 Youth Risk Behavior Survey (YRBS) data to investigate suicide patterns and their association with suicide risk predictors among public high school students.

METHODS

We used latent class regression analysis of Rhode Island's 2007 YRBS data (from a random sample of 2210 public high school students) to model latent classes of suicide risk and identify predictors of latent class membership.

RESULTS

Four latent classes of suicide risk were modeled and predictors were associated with each: class 1 (emotionally healthy, 74%); class 2 (considered and planned suicide, 14%) was associated with being female, having low grades, being gay/lesbian/bisexual/unsure, feeling unsafe at school, having experienced forced sexual intercourse, and self-perceived overweight; class 3 (attempted suicide, 6%) was associated with speaking a language other than English at home, being gay/lesbian/bisexual/unsure, feeling unsafe at school, and forced sexual intercourse; and class 4 (planned and attempted suicide, 6%) was associated with the previously mentioned predictors and with being in 9th or 10th grade and currently smoking.

CONCLUSIONS

A single model characterized and quantified 4 patterns of suicide risk among adolescents and identified predictors for 3 at-risk classes. Interventions for high-risk youths may help prevent adolescent suicides.

Adolescent suicide and health risk behaviors: Rhode Island's 2007 Youth Risk Behavior Survey

BACKGROUND

Suicide is the third-leading cause of death among high school students in the U.S.

PURPOSE

This study examined the relationships among indicators of depressed mood, suicidal thoughts, suicide attempts, and demographics and risk behaviors in Rhode Island high school students.

METHODS

Data from Rhode Island's 2007 Youth Risk Behavior Survey were utilized for this study. The statewide sample contained 2210 randomly selected public high school students. Data were analyzed in 2008 to model for each of five depressed mood/suicide indicators using multivariable logistic regression.

RESULTS

By examining depressed mood and suicide indicators through a multivariable approach, the strongest predictors were identified, for multiple as well as specific suicide indicators. These predictors included being female, having low grades, speaking a language other than English at home, being lesbian/gay/bisexual/unsure of sexual orientation, not going to school as a result of feeling unsafe, having been a victim of forced sexual intercourse, being a current cigarette smoker, and having a self-perception of being overweight.

CONCLUSIONS

The strength of associations between three factors (immigrant status, feeling unsafe, and having forced sex) and suicide indicators adds new information about potential predictors of suicidal behavior in adolescents.

Parental exposure to mass violence and child mental health: the First Responder and WTC Evacuee Study

Children's reactions after being exposed to mass violence may be influenced by a spectrum of factors. Relatively unexplored is the extent to which family exposure to mass violence may affect child mental health, even when these children have not been directly exposed. In a representative sample of NYC public school children assessed 6 months after the September 11, 2001 attack on the World Trade Center (WTC), seemingly elevated rates of psychopathology were recorded among children of WTC evacuees. Children of NYC First Responders (police officers, EMTs, and fire fighters) displayed a complex pattern of response to the WTC attack. Overall, the findings from this previous study support putative transmission of trauma to children whose parents were exposed to the WTC attack. The "Children of First Responder and WTC Evacuee Study"-a two-site longitudinal study-is currently underway in the United States (New York City) and in Israel (Tel Aviv area) in an effort to understand the impact of different patterns of mass violence. The NYC sample permits us to examine the impact of a rare instance of mass violence (e.g., WTC attack), while the Israeli sample provides information about repeated and frequent exposure to mass violence brought about by acts of terrorism. In addition, children's exposure to mass violence is considered in the context of their exposure to other potentially traumatic events. This study aims to improve our general understanding of the impact of mass violence on children, especially the psychological effects on children whose parents' work experiences are by nature stressful. Knowledge generated by this study has implications for guiding efforts to meet the needs of children who have, directly or through a family member, been subjected to rare or infrequent mass violent event as well as to children whose exposure to mass violence is part of daily life.

Relationship of anger, stress, and coping with school connectedness in fourth-grade children

BACKGROUND

High trait anger and stress, ineffective patterns of anger expression, and coping are risk factors for the development of disease and negative social behaviors in children and adults. School connectedness may be protective against negative consequences in adolescents, but less is known about this in school-aged children. The purposes of this study were to characterize relationships between trait anger, stress, patterns of anger expression, resources for coping, and school connectedness and to determine if race and gender moderate these relationships in elementary school-aged children.

METHODS

Using self-report, standardized instruments, a convenience sample of 166 fourth graders in 4 elementary schools in 1 US school district was assessed in the fifth week of the school year.

RESULTS

School connectedness was positively associated with social confidence and behavior control and negatively associated with trait anger, anger-out, and stress. In multiple regression analyses to test for interactions, gender did not moderate the effects of school connectedness in any of the models, while race moderated the relationships between school connectedness and both stress and social confidence. Students with higher school connectedness had lower trait anger and anger-out and higher behavior control, regardless of gender and/or race. White students higher in school connectedness had lower stress and higher social confidence.

CONCLUSIONS

Findings indicate the protective effect of school connectedness on trait anger, anger-out, and behavior control in school-aged children, regardless of race or gender. The protective effect of school connectedness on stress and social confidence may depend on race.

Media exposure predicts children's reactions to crime and terrorism

In this study we examined reactions to 3 news events (September 11 terrorist attacks, Summer 2002 kidnappings, and Fall 2002 sniper shootings) in a national, representative sample of children aged 2 to 17. Media exposure was related to increased worry and changes in activities, with September 11 creating the most concern and shootings the least. More signs of stress were apparent among 10- to 13-year-olds, minority children and those of low socioeconomic status, children with prior adversities, and children who lived in close geographical proximity. Girls aged 10 to 17 had more reaction to the kidnappings, suggesting that other features of target similarity may heighten a sense of risk. The results support moderating exposure for both younger and older youth.

Mass-casualty events at schools: a national preparedness survey

OBJECTIVE

Recent school shootings and terrorist events have demonstrated the need for well-coordinated planning for school-based mass-casualty events. The objective of this study was to document the preparedness of public schools in the United States for the prevention of and the response to a mass-casualty event.

METHODS

A survey was mailed to 3670 school superintendents of public school districts that were chosen at random from a list of school districts from the National Center for Education Statistics of the US Department of Education in January 2004. A second mailing was sent to nonresponders in May 2004. Descriptive statistics were used for survey variables, and the chi2 test was used to compare urban versus rural preparedness.

RESULTS

The response rate was 58.2% (2137 usable surveys returned). Most (86.3%) school superintendents reported having a response plan, but fewer (57.2%) have a plan for prevention. Most (95.6%) have an evacuation plan, but almost one third (30%) had never conducted a drill. Almost one quarter (22.1%) have no disaster plan provisions for children with special health care needs, and one quarter reported having no plans for postdisaster counseling. Almost half (42.8%) had never met with local ambulance officials to discuss emergency planning. Urban school districts were better prepared than rural districts on almost all measures in the survey.

CONCLUSIONS

There are important deficiencies in school emergency/disaster planning. Rural districts are less well prepared than urban districts. Disaster/mass-casualty preparedness of schools should be improved through coordination of school officials and local medical and emergency officials.

Trauma, proximity, and developmental psychopathology: the effects of war and terrorism on children

This report summarizes recent literature relevant to the effects of terrorism on children's mental health. The paper addresses three aspects of this topic. In the first section of the paper, data are reviewed concerning the relationships among stress, trauma, and developmental psychopathology. A particular emphasis is placed on associations with indirect forms of trauma, given that terrorism involves high levels of indirect trauma. Second, the paper delineates a set of key principles to be considered when considering ways in which the effects of terrorism on children's mental health can be minimized. Third, data are reviewed from studies in developmental psychobiology. These data are designed to illustrate the mechanisms through which children exhibit unique effects in the wake of traumatic circumstances.

Children's mental health after disasters: the impact of the World Trade Center attack

This paper summarizes the results of systematic studies published in peer-reviewed journals from 1999 to 2002 addressing post-traumatic stress reactions in children after mass disasters. Children's post-traumatic reactions are considered in five different contexts--natural disasters, large-scale human-induced accidents, spree shootings, war, and terrorism. Association of these reactions with gender and age, as well as longitudinal course, is addressed. Other post-traumatic reactions in children after a mass disaster, as well as the comorbidity of these with stress reactions, are reported. With this as background, the most relevant epidemiologic investigations conducted after the World Trade Center attacks are then described. It is expected that new knowledge in the area of children's post-traumatic reactions to disasters will result from the research initiatives launched after September 11, 2001.