Framework for research on children's reactions to disasters and terrorist events

Children's mental health during the COVID-19 pandemic: a population-based cohort study in the United States

PURPOSE

Examine children's mental health symptoms, including changes during the COVID-19 pandemic.

METHODS

The COVID Experiences Surveys, designed to be representative of the U.S. household population, were administered online to parents of children aged 5-12 years (wave 1 (W1), October-November 2020, n = 1561; wave 2 (W2), March-May 2021, n = 1287). We modeled changes in children's symptoms of anxiety, depression, and psychological stress and examined associations between demographic characteristics, COVID-19 related experiences, and protective factors with symptoms across both waves using generalized estimating equations.

RESULTS

Based on parent-report, children's symptoms of anxiety and depression decreased from W1 to W2 (Δ t-score anxiety = -1.8 [95% confidence intervals (CI): -2.5, -1.0]; Δ t-score depression = -1.0 [CI: -1.7, -0.3]). Psychological stress remained consistent. Across waves, older children and children with an emotional, mental, developmental, behavioral, physical, or medical condition were more likely to have specific poor mental health symptoms. Poor mental health symptoms were more likely among children with several contextual stressors (e.g., economic stress, parental emotional strain) and less likely among children with protective factors (e.g., daily routines, neighborhood cohesion).

CONCLUSIONS

Establishing programs that support mental health, improving access to mental health services, and fostering collaborations to advance children's mental health is important.

Associations between Adverse Childhood Experiences and Pandemic-Related Stress and the Impact on Adolescent Mental Health during the COVID-19 Pandemic

Vulnerabilities of adolescents during times of crisis have been previously identified, but little research has investigated the compounding effects of lifetime adversities and pandemic-related stress on adolescent mental health. This study uses adolescent self-report data to model relationships between stress exposures and indicators of poor mental health from the longitudinal COVID Experiences (CovEx) Surveys. These surveys were administered online in English to U.S. adolescents ages 13-19 using the NORC AmeriSpeak® panel, a probability-based panel designed to be representative of the U.S. household population. Two waves of data were collected (Wave 1: October-November 2020, n = 727; Wave 2: March-May 2021, n = 569). Measures included demographics, adverse childhood experiences (ACEs, 8 items), pandemic-related stress (Pandemic-Related Stress Index [PRSI], 7 items), and depression symptoms (Patient Health Questionnaire for Adolescents [PHQ-A], 9 items). Path analyses were conducted to examine pathways between Wave 1 ACEs, Wave 1 PRSI, and Wave 2 PHQ with covariates of sex and race/ethnicity. Females had higher ACEs, PRSI, and PHQ scores than males. The PRSI score at Wave 1 was positively associated with the PHQ at Wave 2 (b = 0.29, SE = 0.14, p < 0.001). ACEs at Wave 1 were positively associated with PRSI at Wave 1 (b = 0.31, SE = 0.03, p < 0.001) and with PHQ at Wave 2 (b = 0.32, SE = 0.12, p < 0.001). The direct effect of ACEs on PHQ (b = 0.23, SE = 0.12, p < 0.001) remained significant even after accounting for the indirect effect of pandemic-related stress (b = 0.09, SE = 0.05, p < 0.001). Pandemic-related stress had a direct, adverse impact on adolescent depressive symptoms and demonstrates a compounding effect of childhood adversity and pandemic-related stress on depression. Findings can aid the design of interventions that promote mental health and support adolescent coping and recovery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-022-00502-0.

Healthcare utilization after mass trauma: a register-based study of consultations with primary care and mental health services in survivors of terrorism

BACKGROUND

Knowledge on healthcare utilization after mass trauma is needed to strengthen the public health preparedness to such incidents. Using register-based data, this study had a unique opportunity to investigate how young survivors' use of primary care physicians (PCP) and mental health services (MHS) changed after a terrorist attack.

METHODS

We examined register-based data on PCP and MHS consultations among 255 survivors (52% male) of the 2011 Utøya youth camp attack in Norway 3 years before and after the attack, and their reason for encounter with the PCP according to the International Classification for Primary Care (ICPC- 2).

RESULTS

The PCP and MHS consultation rates (CR) were higher in female than male survivors both acutely and at long-term. The mean yearly CRs increased from 2.25 to 4.41 for PCP and 1.77 to 13.59 for MHS the year before and after the attack in female survivors, and from 1.45 to 3.65 for PCP and 1.02 to 11.77 for MHS in male survivors. The third year post-attack CRs for PCP were 3.55 and 2.00; and CRs for MHS were 5.24 and 2.30 in female and male survivors, respectively. Among female survivors, 76% consulted PCP and 12% MHS the year preceding the attack; post-attack 93% consulted PCP and 73% MHS the first year; decreasing to 87 and 40% the third year. Among male survivors, 61% consulted PCP and 7% MHS the year preceding the attack; post-attack 86% consulted PCP and 61% MHS the first year, and 67 and 31% the third year. As for PCP consultations, there was a particular increase in psychological reasons for encounter following the attack.

CONCLUSIONS

This study indicates that it is important to anticipate an increased healthcare utilization several years following mass trauma, particularly of MHS. Both PCP and MHS practitioners played important roles in providing healthcare for psychological problems in young survivors of terrorism in a country with universal and largely publicly financed healthcare and a gatekeeping system. The healthcare utilization could be different in countries with other health systems or psychosocial care responses to mass trauma.

Impact of a Terrorist Attack on the Mental Health of Directly Exposed French Adolescents: Study Protocol for the First Step of the AVAL Cohort Study

Background: Several terrorist attacks have recently taken place in France and Europe. Various studies have shown a high prevalence of Post-Traumatic Stress Disorder (PTSD) and other psychiatric disorders among the victims of these attacks. Nevertheless, research in this field is scarce and no cohort study has been conducted yet to evaluate the impact of a terrorist attack on teenagers directly exposed to this type of events. Therefore, we decided to work on the AVAL (Adolescents Victimes de l'Attentat de Londres) cohort study in order to measure the psycho-traumatic impact of this attack and to describe these adolescents' health care pathways. Material and method: The 53 students of a French high school who were directly exposed (criterion A1 of PTSD in DSM-5) to the terrorist attack perpetrated in London on March 22, 2017 constitute the target population of this monocentric cross-sectional observational study. We decided not to include the three students who were physically wounded and, therefore, didn't have the same sensorial exposition. The primary endpoint will be the prevalence of PTSD 12 to 15 months after the attack, measured by the PCL-5 (Post-traumatic stress disorder Check-List for DSM-5) global severity score: the diagnosis of PTSD will be retained when the score is > 32. We will also use an extensive battery of clinical tests to assess the prevalence of anxiety disorders, mood disorders, sleep disorders, addictions, suicide risk, and alterations in social, family, and school functioning 12 to 15 months after the attack. We will also describe these adolescents' health care pathways since the attack and collect data from the clinical evaluation performed during the initial intervention of the medico-psychological emergency cell within 10 days after the attack. Discussion: The findings of this study are intended to provide epidemiological data about the psycho-traumatic impact of a terrorist attack on the mental health of directly exposed adolescents and to describe these adolescents' health care pathways, thus contributing to improve the immediate, post-immediate, and delayed response strategies after a major psycho-traumatic event involving adolescents (and in particular after terrorist attacks), as well as the identification and psychiatric care of the young survivors requiring specialized care. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03493243. Ethics and Dissemination: The regional ethics committee (Comité de Protection des Personnes Ouest IV-Nantes) approved the study protocol (Reference 10/18_3). All participants (and their legal guardians, for minors) must sign the informed consent to participate. The protocol was presented at the French congress of psychiatry in Nantes (France) in November 2018. After study completion, the results will be published and detailed in Marion Grenon's MD thesis in psychiatry.

Assessment Tools for the Mental Health of School-Aged Children and Adolescents Exposed to Disaster: A Systematic Review (1988-2015)

Objectives

In this study, we aimed to conduct a systematic review of studies investigating psychosocial factors affecting children exposed to disasters.

Methods

In total, 140 studies were retrieved. The studies were published from 1988 to 2015. A systematic review was performed using the PRISMA guidelines. MEDLINE, EMBASE, Cochrane Central, Web of Science, PsycINFO, PubMed, and Google Scholar were searched. Each database was searched using the following terms: 'Child,' 'Adolescent,' 'Youth,' 'Disaster,' 'Posttraumatic,' 'Psychosocial,' 'Assessment,' 'Evaluation,' and 'Screening.' The identified studies were subjected to data extraction and appraisal.

Results

The database search identified 713 articles. Based on the titles and abstracts, the full texts of 118 articles were obtained. The findings of this review can be used as a basis for the design of a psychosocial evaluation tool for disaster preparedness.

Conclusion

Given the paramount importance of post-disaster evaluation and the weaknesses of current disaster evaluation tools, the need to develop valid and reliable tools and psychometric evaluations cannot be overstated. Our findings provide current evidence supporting various assessments in children, who are very vulnerable psychologically following disasters.

Development of post-disaster psychosocial evaluation and intervention for children: Results of a South Korean delphi panel survey

OBJECTIVE

This study aimed to administer a Delphi panel survey and provide evidence for the development of a psychological intervention protocol for use after disasters in South Korea.

METHOD

A three-round Delphi survey was conducted. In all rounds, respondents answered open- or closed-ended questions regarding their views on i) the concept of disaster, ii) evaluation, iii) intervention, and iv) considerations in a disaster. Data from Round 1 were subjected to content analysis. In Round 2, items with content validity ratios (CVRs) greater than 0.49 were included, and in Round 3, items with a CVR≥0.38 were accepted.

RESULTS

The response rates for the Delphi survey were high: 83% (n = 15, Round 1), 80% (n = 16, Round 2), and 86% (n = 24, Round 3). The data collected during this survey showed a need for a support system for children; for preventive strategies, including disaster readiness plans; for the protection of children's safety; and for the development of post-disaster psychosocial care.

CONCLUSIONS

The panel experts reached a consensus regarding the steps they considered critical in post-disaster evaluation and intervention. The findings suggest a unified model for advancing the development of the Korean version of an intervention protocol for children and adolescents exposed to traumatic events.

Children exposed to a natural disaster: psychological consequences eight years after 2004 tsunami

BACKGROUND

There is a need for studies that follow up children and adolescents for many years post disaster since earlier studies have shown that exposure during natural disasters constitutes a risk factor for poor psychological health.

AIMS

The main aim was to examine whether there was an association between severity of exposures during a natural disaster experienced in childhood or adolescence and posttraumatic stress symptoms, psychological distress, self-rated health, diagnosis of depression, anxiety or worry, thoughts about or attempted suicide, physical symptoms or daily functioning eight years later in young adulthood. A second aim was to compare psychological distress and self-rated health of exposed young adults with a matched population-based sample.

METHOD

Young adults, who experienced the 2004 tsunami as children between 10 and 15 years of age, responded to a questionnaire eight years post disaster. The results were compared to a matched population sample.

RESULTS

The results showed that the likelihood for negative psychological outcomes was higher for those who had been exposed to several types of exposures during this natural disaster.

CONCLUSIONS

The negative psychological impact on children and adolescents can still be present eight years post-disaster and seems to have association with the type of exposure; loss, physical presence and subjective experience. It is important for clinicians, who meet young adults seeking help, to be conscious about the impact as long as eight years post disaster and to be aware of possible clinical implications associated with severity of exposures.

Research and Evaluations of the Health Aspects of Disasters, Part VI: Interventional Research and the Disaster Logic Model

Disaster-related interventions are actions or responses undertaken during any phase of a disaster to change the current status of an affected community or a Societal System. Interventional disaster research aims to evaluate the results of such interventions in order to develop standards and best practices in Disaster Health that can be applied to disaster risk reduction. Considering interventions as production functions (transformation processes) structures the analyses and cataloguing of interventions/responses that are implemented prior to, during, or following a disaster or other emergency. Since currently it is not possible to do randomized, controlled studies of disasters, in order to validate the derived standards and best practices, the results of the studies must be compared and synthesized with results from other studies (ie, systematic reviews). Such reviews will be facilitated by the selected studies being structured using accepted frameworks. A logic model is a graphic representation of the transformation processes of a program [project] that shows the intended relationships between investments and results. Logic models are used to describe a program and its theory of change, and they provide a method for the analyzing and evaluating interventions. The Disaster Logic Model (DLM) is an adaptation of a logic model used for the evaluation of educational programs and provides the structure required for the analysis of disaster-related interventions. It incorporates a(n): definition of the current functional status of a community or Societal System, identification of needs, definition of goals, selection of objectives, implementation of the intervention(s), and evaluation of the effects, outcomes, costs, and impacts of the interventions. It is useful for determining the value of an intervention and it also provides the structure for analyzing the processes used in providing the intervention according to the Relief/Recovery and Risk-Reduction Frameworks.

BirnbaumML, DailyEK, O’RourkeAP, KushnerJ. Research and evaluations of the health aspects of disasters, part VI: interventional research and the Disaster Logic Model. Prehosp Disaster Med. 2016;31(2):181–194.

Research participation after terrorism: an open cohort study of survivors and parents after the 2011 Utøya attack in Norway

Background

Reliable estimates of treatment needs after terrorism are essential to develop an effective public health response. More knowledge is required on research participation among survivors of terrorism to interpret the results properly and advance disaster research methodology. This article reports factors associated with participation in an open cohort study of survivors of the Utøya youth camp attack and their parents.

Methods

Overall, 490 survivors were invited to two semi-structured interviews that were performed 4–5 and 14–15 months after the attack. The parents of 482 survivors aged 13–32 years were eligible for a complementary study. The study had an open cohort design in which all of the eligible survivors were invited to both waves. Pearson’s Chi squared tests (categorical variables) and independent t tests (continuous variables) were used to compare survivors by participation.

Results

Altogether, 355 (72.4 %) survivors participated: 255 in both waves, 70 in wave 1 only, and 30 in wave 2 only. Compared with the two-wave participants, wave-1-only participants were more often non-Norwegian and reported higher exposure, whereas wave-2-only participants reported more posttraumatic stress, anxiety/depression, and somatic symptoms. In total, 331 (68.7 %) survivors had ≥1 participating parents, including 311 (64.5 %) with maternal and 243 (50.4 %) with paternal participation. Parental non-participation was associated with non-Norwegian origin, somatic symptoms and less social support. Additionally, paternal non-participation was associated with having divorced parents, and maternal non-participation was associated with higher age, not living with parents, posttraumatic stress and anxiety/depression symptoms.

Conclusions

Survivors with initial non-participation had more symptoms than did the other participants. Thus, an open cohort design in post-terrorism studies might improve the participation among survivors with higher morbidity. Because the factors associated with maternal and paternal participation differed, it is important to consider potential disparities in the selection of mothers and fathers when interpreting parental data.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-1873-1) contains supplementary material, which is available to authorized users.

Health service utilization after terrorism: a longitudinal study of survivors of the 2011 Utøya attack in Norway

Background

For effective organization of health services after terror attacks, it is vital to gain insight into survivors’ health service utilization. Following the 2011 Utøya mass shooting in Norway, a proactive outreach programme was launched to prevent unmet help needs. All survivors received health services during the first five months, yet an important minority were not proactively followed-up. This study assessed the prevalence of health service utilization and factors associated with mental health service utilization among the survivors 5–15 months after the attack.

Methods

The study comprised data from interviews using standardised questionnaires performed 4–5 (T1) and 14–15 (T2) months after the attack. Altogether 281 of 490 (57.3%) survivors answered questions on health service utilization at T2 and were included in this study. Users and non-users of mental health services were compared using Pearson Chi Square tests (categorical variables) and independent t-tests (continuous variables). Multivariate logistic regression analyses were conducted to examine the relationship between mental health service utilization at T2 and early (model 1) and concurrent (model 2) posttraumatic stress reactions, mental distress and somatic symptoms. Both models were adjusted for age, gender and predisaster utilization of mental health services.

Results

Altogether 267 (95.0%) of 281 survivors reported contact with health services at T2, including 254 (90.4%) with ≥1 types of primary care services; and 192 (68.3%) with mental health services. In bivariate analyses, mental health service utilization was associated with female gender, injuries, PTSD, mental distress, somatic symptoms, and sleep problems. After multivariate adjustments for early symptom levels (model 1), only mental distress remained significantly associated with mental health service utilization at T2 (OR 2.8, 95% CI 1.2-6.8). In the analysis adjusting for concurrent symptom levels (model 2), only somatic symptoms were associated with mental health service utilization (OR 4.4, 95% CI 1.8-10.8).

Conclusions

The high utilization of both primary and secondary health services among young survivors 5–15 months after the attack underscores the importance of allocating resources to meet the increased demand for services over a longer time period. The results further highlight the need to address somatic symptoms in disaster survivors who receive mental health services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0811-6) contains supplementary material, which is available to authorized users.

Post-disaster stressful life events and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among responders to the World Trade Center disaster

BACKGROUND

The current study examined contributions of post-disaster stressful life events in relation to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning among rescue, recovery, and clean-up workers who responded to the September 11, 2001 World Trade Center (WTC) terrorist attacks.

METHODS

Participants were 18,896 WTC responders, including 8466 police officers and 10,430 non-traditional responders (85.8% male; 86.4% Caucasian; M(age) = 39.5, SD = 8.8) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and who were reassessed, on average, 2.5 years later.

RESULTS

Path analyses were conducted to evaluate contributions of life events to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning. These analyses were stratified by police and non-traditional responder groups and adjusted for age, sex, time from 9/11 to initial visit, WTC exposures (three WTC contextual exposures: co-worker, friend, or a relative died in the disaster; co-worker, friend, or a relative injured in the disaster; and responder was exposed to the dust cloud on 9/11), and interval from initial to first follow-up visit. In both groups, WTC-related posttraumatic stress, depressive symptoms, and overall functioning were stable over the follow-up period. WTC exposures were related to these three outcomes at the initial assessment. WTC-related posttraumatic stress, depressive symptoms, and overall functioning, at the initial assessment each predicted the occurrence of post-disaster stressful life events, as measured by Disaster Supplement of the Diagnostic Interview Schedule. Post-disaster stressful life events, in turn, were associated with subsequent mental health, indicating partial mediation of the stability of observed mental health.

CONCLUSIONS

The present findings suggest a dynamic interplay between exposure, post-disaster stressful life events, and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among WTC disaster responders.

The adolescent emotional coping after an earthquake: a risk factor for suicidal ideation

The study aims to investigate the relationship of suicidal ideation with coping and resilience in a sample of adolescents who survived an earthquake. Three hundred forty-three adolescents who had experienced the L'Aquila earthquake were investigated for a screening distinguishing Suicidal Screen-Negative (SSN) from the Positive (SSP) subjects. Resilience Scale for Adolescents (READ) and Brief Cope were administered. Emotion-focused coping score was significantly higher in SSP subjects. In the SSN but not in the SSP sample the READ total score correlated with problem-focused total score. A positive correlation was seen between emotion-focused and problem-focused scores in both samples, with a higher coefficient in SSP sample. Externalising problems and maladaptive behaviours can arise in adolescents exposed to traumatic events. Attention should be paid in reducing risk factors and in the development of psychological abilities, improving the coping strategies that can protect from emotional despair and suicidal ideation.

Framework for research on children's reactions to disasters and terrorist events

Clinical work and research relative to child mental health during and following disaster are especially challenging due to the complex child maturational processes and family and social contexts of children's lives. The effects of disasters and terrorist events on children and adolescents necessitate diligent and responsible preparation and implementation of research endeavors. Disasters present numerous practical and methodological barriers that may influence the selection of participants, timing of assessments, and constructs being investigated. This article describes an efficient approach to guide both novice and experienced researchers as they prepare to conduct disaster research involving children. The approach is based on five fundamental research questions: "Why?, Who?, When?, What?, and How?" Addressing each of the "four Ws" will assist researchers in determining "How" to construct and implement a study from start to finish. A simple diagram of the five questions guides the reader through the components involved in studying children's reactions to disasters. The use of this approach is illustrated with examples from disaster mental health studies in children, thus simultaneously providing a review of the literature.