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

Trauma-sensitive school concepts for students with a refugee background: a review of international studies

Children and adolescents with a refugee background are at high risk for traumatization. Once they arrive in safe countries, schools are the institutions where teachers are responsible for caring for them sensitively and competently. Furthermore, schools are organized in learning groups consisting of multiple peers of the same age, which provides excellent opportunities for social learning and experiences of social support. In this respect, schools are the appropriate places where preventive concepts can be applied to students with a refugee background. This systematic review summarizes studies that examine or evaluate existing international concepts of trauma-sensitive schools for supporting traumatized students with a refugee background. Based on N = 41 selected articles, 17 relevant concepts of trauma-sensitive schools were identified. In 35.3% of the concepts, traumatized students with a refugee background are explicitly included in the target group of the concept, while 47.1% of the concepts refer to groups of students with trauma as a result of various adverse childhood experiences, which also occur more frequently within the population of refugee children and adolescents 17.6% of the concepts contain specific adaptations for pupils with a refugee background. The majority of these concepts were developed in the United States. Additional concepts can be reported for Australia, the United Kingdom, Turkey, and Cambodia. Based on available empirical data, no significant effectiveness regarding the researched concepts' effects on academic and other school-related data can be determined. Although some studies indicate positive effects concerning school-related target variables, most of the studies have only limited significance due to inadequate research designs and methodological deficiencies. Therefore, there is a great need for further development, careful implementation, and evaluation of trauma-sensitive concepts in schools, especially for the growing group of refugee students.

Fake news during the war in Ukraine: coping strategies and fear of war in the general population of Romania and in aid workers

Introduction

In addition to the health crisis that erupted during the COVID-19 pandemic, the war between Russia and Ukraine is impacting the mental health and wellbeing of the Romanian population in a negative way.

Objectives

This study sets out to investigate the impact that social media consumption and an overload of information related to the armed conflict between Russia and Ukraine is having on the distribution of fake news among Romanians. In addition, it explores the way in which several psychological features, including resilience, general health, perceived stress, coping strategies, and fear of war, change as a function of exposure to traumatic events or interaction with victims of war.

Methods

Participants (N = 633) completed the General Health Questionnaire (GHQ), the CERQ scale with its nine subscales, the Perceived Stress Scale (PSS), and the BRS scale (Brief Resilience Scale), the last of which measures resilience. Information overload, information strain and the likelihood of the person concerned spreading fake news were assessed by adapting items related to these variables.

Findings

Our results suggest that information strain partially moderates the relationship between information overload and the tendency to spread false information. Also, they indicate that information strain partially moderates the relationship between time spent online and the tendency to spread false information. Furthermore, our findings imply that there are differences of high and moderate significance between those who worked with refugees and those who did not as regards fear of war and coping strategies. We found no practical differences between the two groups as regards general health, level of resilience and perceived stress.

Conclusion and recommendations

The importance of discovering the reasons why people share false information is discussed, as is the need to adopt strategies to combat this behavior, including infographics and games designed to teach people how to detect fake news. At the same time, aid workers need to be further supported to maintain a high level of psychological wellbeing.

Weathering within war: Somatic health complaints among Vietnamese older adults exposed to bombing and violence as adolescents in the American war

OBJECTIVE

People living in war may experience deteriorating health via weathering (wear and tear) from long-term exposures to psychosocial and environmental stressors. Weathering embodied in somatic health complaints may illuminate the effects of war on health.

METHODS

We investigate whether wartime stress exposures occurring during adolescence and early adulthood affect weathering in late adulthood via linear regression with data from the Vietnamese Health and Aging Study (VHAS). VHAS is a cross-sectional study wherein investigators surveyed 2447 adults aged 60+ in four districts of northern and central Vietnam in 2018. These same individuals ranged in age from seven to 52 in 1965, with most having been in adolescence or early adulthood at the peak of the American war in Vietnam (1965-1975). The sample used for this study (n = 2254) were participants in the first VHAS wave in 2018.

RESULTS

We find older Vietnamese adults exposed to higher-intensity provincial bombing suffer more numerous somatic health complaints (unstandardized β = 0.005, SE = 0.001, p = 0.001). Additionally, greater health complaints emerge among older adults whose most intense bombing exposures were at younger ages of adolescence (< age 15) as compared to those whose peak exposures were in older ages (19-25) (unstandardized β = 0.62 95%, SE = 0.19, p = 0.01).

CONCLUSION

Our findings suggest that age of exposure to armed conflict is a critical determinant of weathering across the life course.

From mothers to children and back: Bidirectional processes in the cross-generational transmission of anxiety from early childhood to early adolescence

BACKGROUND

Maternal psychopathology and caregiving behavior are linked with child anxiety and these associations may be particularly salient when families face mass trauma together and members influence each other's symptomatology and resilience. Despite the well-known mother-to-child effects, less research addressed the longitudinal bidirectional effects of maternal and child's anxiety symptoms on each other.

METHODS

Mothers and children exposed to chronic war-related trauma from Sderot, Israel, and comparison group were followed at three time-points; Early childhood (T1:N = 232, M_Age  = 2.76 years), late childhood (T3:N = 176, M_Age  = 9.3 years), and early adolescence (T4:N = 110, M_Age  = 11.66 years). At each time-point maternal and child's anxiety symptoms were evaluated via questionnaires and maternal sensitivity was coded from videotaped observations of parent-child interactions. Bidirectional associations were examined using traditional cross-lagged panel model (CLPM) and CLPM with random intercepts (RI-CLPM).

RESULTS

Trauma-exposed mothers and children exhibited more anxiety symptoms and lower maternal sensitivity. Cross-lagged panel models revealed cross-time bidirectional associations between maternal anxiety and child anxiety from early to late childhood. Child anxiety at each time-point predicted maternal anxiety and maternal sensitivity at the next stage; however, maternal sensitivity did not show longitudinal associations with child anxiety, highlighting children's role in shaping caregiving.

CONCLUSIONS

Findings demonstrate bidirectional cross-generational influences of mother and child on each other's anxiety in contexts of trauma and pinpoint early childhood as a sensitive period for such mutual influences. Children's increased anxiety following trauma appears to be further exacerbated via its impact on increasing maternal anxiety and compromising sensitive caregiving, underscoring the potential benefits of parental and mother-child interventions for trauma-exposed populations.

International migration of unaccompanied minors: trends, health risks, and legal protection

The global population of unaccompanied minors-children and adolescents younger than 18 years who migrate without their legal guardians-is increasing. However, as data are not systematically collected in any region, if collected at all, little is known about this diverse group of young people. Compared with adult migrants, unaccompanied minors are at greater risk of harm to their health and integrity because they do not have the protection provided by a family, which can affect their short-term and long-term health. This Review summarises evidence regarding the international migration and health of unaccompanied minors. Unaccompanied minors are entitled to protection that should follow their best interests as a primary consideration; however, detention, sometimes under the guise of protection, is a widespread practice. If these minors are provided with appropriate forms of protection, including health and psychosocial care, they can thrive and have good long-term outcomes. Instead, hostile immigration practices persist, which are not in the best interests of the child.

Mental health consequences of armed conflicts in children and adolescents: An overview of literature reviews

Introduction: Armed conflicts affect the mental health of children and adolescents. Their outcomes in these populations have been documented identifying vulnerability and significant biopsychosocial damage as the most common factors. Objective: To identify and synthesize the mental health consequences of armed conflicts in children and adolescents. Materials and methods: We carried out a comprehensive and systematic search of reviews published until July 2019 in the MEDLINE (Ovid), EMBASE, Cochrane Central Register of Controlled Trials, and LILACS databases, as well as in additional sources. The information was retrieved and analyzed narratively by describing the characteristics and objectives of the studies and the mental health consequences of armed conflicts in three periods of time: pre-armed conflict, during the armed conflict, and post-conflict. Results. Out of 587 potentially relevant studies, we finally selected 72. In the pre-armed conflict period, we described in detail the psychological experiences and the anticipatory somatic symptoms. During the conflict, we identified regressive, behavioral, and cognitive symptoms such as enuresis, fear, sadness, aggression, hyperactivity, and inattention, among others. Direct mental health consequences such as adjustment disorders, depression, anxiety, and post-traumatic stress were also identified. Finally, in the postconflict period, we referred to the transmission of mental health consequences and resilience processes. On the other hand, we reviewed in depth the potential consequences of armed conflicts on biopsychosocial development, morality, identity, culture, education, and society. Conclusion. The development of mental health consequences due to the exposure to armed conflicts in these populations is a complex process that depends on the stage of the exposure, the length of the conflict, and contextual factors.

Posttraumatic stress disorder and growth: Examination of joint trajectories in children and adolescents

Positive health endpoints are not the opposite of negative endpoints. Previous studies examining posttraumatic stress disorders (PTSD) and posttraumatic growth (PTG) trajectories have overlooked the co-existence of PTSD and PTG, making it difficult to accurately distinguish individuals with various posttraumatic presentations, causing the effects of targeted interventions to be discounted. To fill this gap, the current study sought to examine joint PTSD and PTG trajectories in children and adolescents. Eight hundred and seventy-six Chinese children and adolescents were recruited to complete self-report questionnaires 6, 12, and 18 months after the Ya'an earthquake. Multiple-process growth mixture modeling analysis was used to test the study proposal. Five distinct joint PTSD and PTG trajectory types were found: recovery, growth, struggling, resistant, and delayed symptoms. Female students and students who felt trapped or fearful were more likely to be in the struggling group, and students who experienced injury to themselves or family members were more likely to belong to the delayed symptom group. These findings suggest that postdisaster psychological services should be provided to relieve delayed symptoms in individuals who experience injury to themselves or their family members, and individuals in the struggling group should be supported to achieve growth.

The effects of thought stopping on anxiety levels in adolescents living in earthquake-prone areas

The objective of the study is to determine the effect of thought-stopping therapy on anxiety levels in adolescents living in earthquake-prone areas. This study used quasi-experiment pre-post test with control group, conducted in one of the earthquake-prone areas city in East Java. 112 respondents (the control and the intervention group) were included in the research. Both groups received nursing intervention. In addition to the nursing intervention, the intervention group was asked to use thought-stopping techniques. The HAM-A questionnaire was used to determine anxiety levels. A significant decrease in anxiety in both the control and intervention groups was demonstrated in the present study after the intervention. The intervention group experienced a decrease in the anxiety rating of 5.54, compared to the corresponding decrease in the control group of 2.79. Nursing intervention and thought-stopping are recommended as effective in reducing anxiety in adolescents living in earthquake-prone areas.

Childhood Trauma History and Negative Social Experiences in College

While there is literature documenting the association between childhood trauma and later sexual assault or interpersonal violence victimization, less is known about risk of less severe, but still negative, victimization experiences such as sexual harassment, hazing, and bullying in college. The goal of this study was to explore the association between self-reported childhood trauma (both personally experienced and witnessed) and negative social experiences in college-age adults (e.g., sexual harassment, hazing, and bullying), and the role that internalizing difficulties (i.e., depression and stress) plays in this association. A sample of 620 college-aged adults (ages 18-25) was recruited. Structural Equation Modeling (SEM) was used to investigate two models concerning direct and indirect childhood trauma experience. The models demonstrated significant positive relations between experiences of childhood trauma (both direct and indirect) and negative social experiences. Internalizing difficulties (i.e., depression and stress) mediated the relation between indirect childhood trauma and negative social experiences, but it did not significantly mediate the relation between direct childhood trauma and negative social experiences. These findings help to inform prevention efforts and have important implications for both school and community based mental health providers.

Does the Type of Exposure to Workplace Violence Matter to Nurses' Mental Health?

Workplace violence is a prevalent phenomenon in healthcare, particularly among nursing professionals. Exposure to workplace violence may be direct through firsthand involvement, indirect through secondhand witnessing, or both. Even though implications for victims of workplace violence have been well-studied, less is known about the various types of exposure and their effects on nurse mental health. The purpose of this study is to examine the impact of workplace-violence exposure types on the mental health of nurses, while accounting for the intensity of the incident/s. This study employs an exploratory correlational design with survey methods. Nurses from British Columbia (BC), Canada, were invited by the provincial nurses' union to complete an electronic survey in Fall 2019. A total of 2958 responses from direct-care nurses in acute-care settings were analyzed using logistic regression. The results showed that mental-health problems increased with cumulative exposure; even though nurses with solely indirect exposure to workplace violence did not report greater mental-health problems, those experiencing solely direct exposure, or both direct and indirect exposure, were two to four times more likely to report high levels of post-traumatic stress disorder (PTSD), anxiety, depression and burnout compared to their counterparts with no exposure. There is an urgent need for better mental-health support, prevention policies and practices that take into account the type of workplace-violence exposure.

Compassionate Goals Predict Social Support and PTSD Symptoms Following a University Shooting: A Moderated Mediation Analysis

Introduction: Social support is known to buffer posttraumatic stress disorder (PTSD) symptoms, but the stress-buffering properties of striving to help and support others (compassionate goals) have received less attention. Recent research suggests that compassionate goals shape social support processes and dampen stress responses following social threat, but their relevance to trauma have not been examined. The present study tested whether, in the aftermath of a university mass shooting, compassionate goals concurrently and prospectively predicted lower PTSD symptoms indirectly via higher social support, and whether this mediation would be stronger with higher proximity to the trauma.

Method: Participants (N = 369) completed measures four months post-shooting (Time 1), and a subset (n = 85) repeated outcome variables at eight months (Time 2).

Results: As hypothesized, there was a significant moderated mediation, with trauma proximity moderating the indirect effect of compassionate goals on PTSD symptoms at Time 1 (B = −0.88, SE = 0.28, 95% CI [−1.47, −0.37]) and prospectively at Time 2 (B = −1.12, SE = 0.77, 95% CI [−3.16, −0.03]), although not when controlling for Time 1 symptoms. The indirect effects were greatest for those with higher trauma proximity, suggesting particular relevance for individuals most at risk for trauma-related difficulties.

Discussion: These findings suggest the need for further research into compassionate goals and strategies for fostering them, particularly in the context of social or community traumas.

Terrorism and post-traumatic stress disorder: a historical review

Terror is a psychological state. Historically, most studies of terrorism focused on its societal purpose and structural consequences rather than mental health effects. That emphasis began to change shortly before the Sept 11, 2001, terrorist attacks. A vast expansion of research into post-traumatic stress disorder accompanied revisions to the classification of mental health disorders. The effect of terrorist incidents on those people now deemed vulnerable, both directly and indirectly, was actively sought. However, a review of more than 400 research articles (mostly published after Sept 11) on the association between terrorism and mental health reached the largely overlooked conclusion that terrorism is not terrorising-at least not in a way that causes a greater than expected frequency of post-traumatic stress disorder than other traumatic events. This conclusion is surprising given the emphasis on the psychological effects of terrorism in political discourse, media commentary, contemporary culture, and academic inquiry. Authorities might prefer to encourage an interpretation of terrorist incidents that highlights fortitude and courage rather than psychological vulnerability.

Caregiver Self-Reports and Reporting of Their Preschoolers' Trauma Exposure: Discordance Across Assessment Methods

Nearly half of preschool-aged children from low-income families in the United States have been exposed to potentially traumatic events (PTEs), yet few are identified or receive trauma-focused mental health care. Given the critical need to accurately and efficiently identify PTE-exposed individuals, the current study examined discordant caregiver self-reporting of PTE exposure and caregiver reporting of child PTE exposure across two assessment methods: checklist and interview. Research has demonstrated significant cross-method discrepancies among adults reporting stressful life experiences, but examinations of caregiver reporting for their young children have not been conducted. Further, given their possible impact on reporting patterns, caregiver and child characteristics were examined in relation to discordant caregiver reporting by trauma type. Participants were 64 low-income, racially and ethnically diverse caregivers and their preschool-aged children from a Northeastern US city. Caregivers reported self and child PTE exposure via checklist and semi-structured interview. Cross-method discordance for caregiver and child exposure by trauma type ranged from 10.9% to 46.9% (Cohen's kappa =.06-.70). Caregiver race and education were associated with discordant reporting, as were caregiver and child psychopathology. Lower levels of caregiver psychopathology were associated with discordant caregiver reporting of their own exposure, whereas higher levels were associated with discordant caregiver reporting of child exposure. Discordant caregiver reporting of PTE exposure varies by assessment format and trauma type and is differentially related to caregiver demographics and caregiver and child psychopathology. Associations between assessment methods, individual characteristics, and reporting should be considered when assessing PTE exposure to support service engagement and targeted treatment.

Risk Factors for Antisocial Behavior in Low- and Middle-Income Countries: A Systematic Review of Longitudinal Studies

Violent crime is a major cause of social instability, injury, and death in low- and middle-income countries. Longitudinal studies in high-income countries have provided important evidence on developmental precursors of violence and other antisocial behaviors. However, there may be unique influences or different risk factor effects in other social settings. Extensive searches in seven languages and screening of over 60,000 references identified 39 longitudinal studies of antisocial behavior in low- and middle-income countries. Many risk factors have roughly the same average effects as when studied in high-income countries. Stability of aggression over a 3-year period is almost identical across low- and middle-income countries and high-income countries. Dimensions of comorbid psychopathology such as low self-control, hyperactivity, and sensation seeking are associated with antisocial behavior in low- and middle-income countries, but some early physical health factors have consistently weak or null effects.

Are Children or Adolescents More at Risk for Posttraumatic Stress Reactions Following Exposure to Violence?: Evidence From Post-Genocide Rwanda

Whether children or adolescents exhibit higher levels of posttraumatic stress symptoms (PTSS) in response to violence is an unresolved research question. We examine this issue in UNICEF's 1995 National Trauma Survey (NTS) of 8-19-year-olds (n = 942) who survived the Rwandan Genocide and lived and attended schools in the community. PTSS were assessed with a symptom checklist based on DSM-IV indexed using an overall score comprising the sum of scores on all items and mean item scores of each of five distinct factors identified in a factor analysis within this sample. Eighty percent of the sample had witnessed massacres; 25%, rape/sexual mutilation. The overall symptom score among children was significantly (p < 0.05) lower than among adolescents. Among the five separate factors, this direct association of age with symptom levels held for two: re-experiencing (p < 0.001) and dysphoric arousal (p < 0.05), but not for the remaining three: avoidance, numbing, and anxious arousal. This discordance in factorial response to violence may help explain prevailing inconsistencies in the age-PTSS association reported to date.

Global Disability: Empowering Children of all Abilities

Worldwide, children are often not meeting their developmental potential owing to malnutrition, infection, lack of stimulation, and toxic stress. Children with disabilities are more likely to experience poverty, neglect, and abuse, and are less likely to have adequate access to education and medical care. Early childhood developmental stimulation can improve language, learning, and future participation in communities. Therapeutic supports and endeavors to reduce stigma for people of all abilities strengthen communities and allow for human thriving.

Risk and resilience trajectories in war-exposed children across the first decade of life

BACKGROUND

Although the effects of early-onset trauma on susceptibility to psychopathology are well-acknowledged, no study to date has followed risk and resilience trajectories in war-exposed young children over lengthy periods and charted predictors of individual pathways.

METHOD

In this prospective longitudinal study, we followed 232 children, including 148 exposed to repeated wartime trauma and 84 controls, at three time points: early childhood (1.5-5 years), middle childhood (5-8 years), and late childhood (9-11 years). Children were diagnosed at each time point and four trajectories defined: children exhibiting no pathology at any time point, those displaying early pathology that later remitted, those showing initial resilience followed by late pathology, and children presenting chronic pathology across the entire first decade. Maternal behavioral containment during trauma evocation and child social engagement during free play were observed in early childhood and maternal emotional distress self-reported across time.

RESULTS

War-exposed children showed significantly higher rates of psychopathology, with 81% exhibiting pathology at some point during childhood. In middle childhood, exposed children displayed more posttraumatic stress disorders (PTSD), anxiety disorders, and attention-deficit/hyperactivity disorders (ADHD), and in late childhood more PTSD, conduct/oppositional defiant disorders, and ADHD. War-exposed children had more comorbid psychopathologies and number of comorbidities increased with age. Notably, war-exposure increased prevalence of chronic pathology by 24-fold. Maternal factors, including mother's uncontained style and emotional distress, increased risk for early and chronic psychopathology, whereas reduced child social engagement augmented risk for late pathology.

CONCLUSIONS

Early-onset chronic stress does not heal naturally, and its effects appear to exacerbate over time, with trauma-exposed children presenting a more comorbid, chronic, and externalizing profile as they grow older. Our findings demonstrate that responses to trauma are dynamic and variable and pinpoint age-specific effects of maternal and child factors on risk and resilience trajectories. Results highlight the importance of conducting long-term follow-up studies and constructing individually tailored early interventions following trauma exposure.

An application of an ecological framework to understand risk factors of PTSD due to prolonged conflict exposure: Israeli and Palestinian adolescents in the line of fire

OBJECTIVE

Adolescents living in Israel and the Palestinian authority are exposed to political violence. This review examines psychosocial risk factors for posttraumatic stress disorder (PTSD) organized within an ecological framework.

METHOD

Relevant articles were identified through PubMed and PsycINFO. Studies measuring risk and/or protective factors for PTSD in the Palestinian and/or Israeli adolescent populations because of conflict exposure from 1990 to present were included.

RESULTS

A total of 20 studies met inclusion criteria. Greater violence exposure, poor economic resources, living in rural compared with urban areas, poor family and peer relations, and poor coping skills were associated with PTSD symptoms.

CONCLUSIONS

The ecological framework is a useful approach to understanding factors affecting adolescent PTSD. Future research should focus on socioecological levels that have received limited attention. (PsycINFO Database Record

Potentially Traumatic Events, Posttraumatic Stress Disorder, and Depression among Adults in Puerto Rico

The aims of the current study were to examine the prevalence of potentially traumatic events (PTEs), posttraumatic stress disorder (PTSD; data available in males only), and depressive symptoms in a Puerto Rican sample of 678 adult caretakers (50% female) of twins participating in the Puerto Rican Infant Twin Study. The World Health Organization Composite International Diagnostic Interview version 3.0 (CIDI 3.0) was utilized to assess rates of PTEs, PTSD, and depression among male participants while an abbreviated version of the CIDI 3.0 and the Mood and Feelings Questionnaire were administered to females to assess PTEs and depressive symptoms. Significantly more males than females reported exposure to a PTE (76.6% vs. 44.2%, χ(2) = 64.44, p < 0.001). In males, endorsement of multiple PTEs was associated with increased level of PTSD symptomatology (β = 0.33, p < 0.001). With regard to depression, a similar dose-response relationship was found in both males and females, with depressive symptoms increasing as number of PTEs increased (βs = 0.15, 0.16, ps < 0.05). Exposure to an attack with a weapon was significantly associated with increased depression symptoms in both males and females (βs = 0.24, 0.20, ps < 0.01, respectively). These findings highlight the need for identification of putative risk and resilience factors among PTE-exposed individuals in Puerto Rico.

Predictors of violence against children in Tamil families in northern Sri Lanka

Children living in post-conflict settings are not only at high risk of developing war-related psychopathology but also of experiencing maltreatment within their families. However, little is known about the mechanisms of the relationship between war and family violence. In order to investigate the variables associated with the experience and perpetration of child maltreatment, we conducted a two-generational study with Tamil families in the North of Sri Lanka, a region affected by war and Tsunami. We interviewed children and the corresponding family dyads and triads with 359 children, 122 mothers, and 88 fathers on the basis of standardized questionnaires to assess their exposure to adverse life experiences and mental health symptoms. Using multivariate regression analyses, we found that the strongest predictors for children's report of victimization were children's exposure to mass trauma and child psychopathology. Mothers' experiences of mass trauma, family violence and partner violence were each significantly related to mother-reported maternal perpetration as well as child-reported victimization. Likewise, all types of traumatic events reported by fathers were significantly related to child-reported victimization and father-reported perpetration. Fathers' alcohol use was the strongest predictor of father-reported paternal perpetration. These findings provide further support for the transmission of mass trauma into family violence, and emphasize the role of child psychopathology as well as alcohol consumption in this relationship.

Parental care protects traumatized Sri Lankan children from internalizing behavior problems

BACKGROUND

Research in war-torn regions has mainly focused on the impact of traumatic experiences on individual mental health and has found high prevalence rates of psychiatric disorders in affected adults and children. However, little is known about the possible protective factors occurring in children's environments in the aftermath of mass trauma. Therefore, we conducted a cross-sectional study with families in Northern Sri Lanka, a region that had been shattered by a long-lasting civil war and devastated by the Asian tsunami in 2004.

METHODS

Schoolchildren aged 7 to 11 (N = 359) were interviewed on the basis of standardized measures to assess children's exposure to traumatic events, mental health symptoms, and parenting behavior as perceived by children. All interviews were carried out by local senior counselors.

RESULTS

Linear regression analyses identified exposure to mass trauma and family violence as significant risk factors of child mental health whereas parental care emerged as a significant factor associated with fewer behavior problems. In addition, parental care significantly moderated the relationship between mass trauma and internalizing behavior problems.

CONCLUSIONS

Family characteristics seem to be strongly associated with children's mental health even in regions severely affected by mass trauma. This finding is particularly relevant for the development of targeted psychosocial interventions for children and families living in war torn areas.

Consequences of 9/11 and the war on terror on children's and young adult's mental health: a systematic review of the past 10 years

This mixed method systematic review appraises the individual, familial and systemic effect of 9/11 and the war on terror for majority and minority children and youth in North America. The results highlight the broad social consequences of the socio-political transformations associated with the terror context, which cannot be understood only through a trauma focus analysis. The social stereotypes transformed youth experiences of belonging and exclusion. The difference between the consequences for majority and minority youth suggests the need for a broader appraisal of this societal context to support the development of prevention and intervention intersectorial programs.

Evaluating the risks of clinical research: direct comparative analysis

OBJECTIVES

Many guidelines and regulations allow children and adolescents to be enrolled in research without the prospect of clinical benefit when it poses minimal risk. However, few systematic methods exist to determine when research risks are minimal. This situation has led to significant variation in minimal risk judgments, raising concern that some children are not being adequately protected. To address this concern, we describe a new method for implementing the widely endorsed "risks of daily life" standard for minimal risk. This standard defines research risks as minimal when they do not exceed the risks posed by daily life activities or routine examinations.

METHODS

This study employed a conceptual and normative analysis, and use of an illustrative example.

RESULTS

Different risks are composed of the same basic elements: Type, likelihood, and magnitude of harm. Hence, one can compare the risks of research and the risks of daily life by comparing the respective basic elements with each other. We use this insight to develop a systematic method, direct comparative analysis, for implementing the "risks of daily life" standard for minimal risk. The method offers a way of evaluating research procedures that pose the same types of risk as daily life activities, such as the risk of experiencing anxiety, stress, or other psychological harm. We thus illustrate how direct comparative analysis can be applied in practice by using it to evaluate whether the anxiety induced by a respiratory CO2 challenge poses minimal or greater than minimal risks in children and adolescents.

CONCLUSIONS

Direct comparative analysis is a systematic method for applying the "risks of daily life" standard for minimal risk to research procedures that pose the same types of risk as daily life activities. It thereby offers a method to protect children and adolescents in research, while ensuring that important studies are not blocked because of unwarranted concerns about research risks.

Evaluation of trauma characteristics as predictors of attrition from cognitive-behavioral therapy for child victims of violence

Little research has investigated psychotherapy attrition among child victims of violence, and no studies have evaluated the role of trauma characteristics (e.g., level of threat or injury, trauma frequency, perpetrator relationship, victim type, and trauma type). The current study evaluated premature psychotherapy termination with 134 child victims (ages 5-19 years) who were referred for exposure-based cognitive-behavioral therapy. Results indicated that premature treatment termination was associated with children who experienced (a) a single incident of trauma (compared to multiple), (b) neither life threat nor physical injury during the victimization, (c) and an incident that was perpetrated by an older child compared to a parental figure. Certain trauma characteristics may be important factors for identifying children at risk for terminating treatment prematurely.

Mass trauma: disasters, terrorism, and war

Disasters, war, and terrorism expose millions of children globally to mass trauma with increasing frequency and severity. The clinical impact of such exposure is influenced by a child's social ecology, which is understood in a risk and resilience framework. Research findings informed by developmental systems theory and the related core principles of contemporary developmental psychopathology are reviewed. Their application to the recent recommendations for interventions based on evolving public health models of community resilience are discussed along with practical clinical tools for individual response.

Applying risk and resilience models to predicting the effects of media violence on development

Although the effects of media violence on children and adolescents have been studied for over 50 years, they remain controversial. Much of this controversy is driven by a misunderstanding of causality that seeks the cause of atrocities such as school shootings. Luckily, several recent developments in risk and resilience theories offer a way out of this controversy. Four risk and resilience models are described, including the cascade model, dose-response gradients, pathway models, and turning-point models. Each is described and applied to the existing media effects literature. Recommendations for future research are discussed with regard to each model. In addition, we examine current developments in theorizing that stressors have sensitizing versus steeling effects and recent interest in biological and gene by environment interactions. We also discuss several of the cultural aspects that have supported the polarization and misunderstanding of the literature, and argue that applying risk and resilience models to the theories and data offers a more balanced way to understand the subtle effects of media violence on aggression within a multicausal perspective.

Psychological Consequences of Indirect Exposure to Disaster Due to the Haiti Earthquake

Introduction

Few studies have focused on the mental health consequences of indirect exposure to disasters caused by naturally occurring hazards. The present study assessed indirect exposure to the 2010 earthquake in Haiti among Haitian-Americans now living in Miami; these subjects had no direct exposure to the earthquake, but retained their cultural identity, language, and connection to family and friends in Haiti.

Methods

Two months following the earthquake a sample of Haitian-Americans was surveyed inquiring about: (1) their psychological reactions to the quake; (2) types of exposures experienced by their family members and friends in Haiti; and (3) symptom levels of (a) major depression, (b) generalized anxiety disorder, (c) complicated grief, (d) mental health status, and (e) physical health status.

Results

Haitian-Americans living in Miami experienced a broad spectrum of indirect exposures to the 2010 earthquake in Haiti. These exposures were strongly associated with psychological distress, trauma-related mental health consequences, and diminished health status. Most notable was the multiplicity of indirect exposures to the on-scene experiences of multiple family members and friends in Haiti.

Conclusions

Consideration should be given to the psychological impact and needs for support among indirectly-exposed populations with strong affiliation to directly-impacted victims.

Shultz JM, Besser A, Kelly F, Allen A, Schmitz S, Hausmann V, Marcelin LH, Neria Y. Psychological consequences of indirect exposure to disaster due to the Haiti earthquake.Prehosp Disaster Med.2012;27(4):1-10.

Child development in the context of disaster, war, and terrorism: pathways of risk and resilience

This review highlights progress over the past decade in research on the effects of mass trauma experiences on children and youth, focusing on natural disasters, war, and terrorism. Conceptual advances are reviewed in terms of prevailing risk and resilience frameworks that guide basic and translational research. Recent evidence on common components of these models is evaluated, including dose effects, mediators and moderators, and the individual or contextual differences that predict risk or resilience. New research horizons with profound implications for health and well-being are discussed, particularly in relation to plausible models for biological embedding of extreme stress. Strong consistencies are noted in this literature, suggesting guidelines for disaster preparedness and response. At the same time, there is a notable shortage of evidence on effective interventions for child and youth victims. Practical and theory-informative research on strategies to protect children and youth victims and promote their resilience is a global priority.

Attention orientation in parents exposed to the 9/11 terrorist attacks and their children

While trauma affects both parents and their children, minimal research examines the role of information-processing perturbations in shaping reactions to trauma experienced by parents and, in turn, the effect this trauma has on their children. This study examines familial associations among trauma, psychopathology, and attention bias. Specifically, group differences in psychopathology and attention bias were examined in both adults and their children based on trauma exposure. In addition, the association between attention bias in parents and attention bias in their children was examined. Parents exposed to the 9/11 World Trade Center attacks and their children were recruited from the New York City Metropolitan area. Levels of trauma exposure, psychiatric symptoms, and attention bias to threat, as measured with the dot-probe task, were each assessed in 90 subjects, comprising of 45 parents and one of their children. These measures were examined in parents and their children separately; each parent and child was categorized on the presence of high or low levels of trauma exposure. Although trauma exposure did not relate to psychopathology, parents who were highly exposed to trauma showed greater attention bias towards threat than parents with low trauma exposure. However, the children of high trauma-exposed parents did not show enhanced attention bias towards threat, though threat bias in the high trauma-exposed parents did negatively correlate with threat bias in their children. This association between trauma and attention bias in parents was found four-to-five years after 9/11, suggesting that trauma has enduring influences on threat processing. Larger, prospective studies might examine relationships within families among traumatic exposures, psychopathology, and information-processing functions.

Tsunami, war, and cumulative risk in the lives of Sri Lankan schoolchildren

This study examines the impact of children's exposure to natural disaster against the backdrop of exposure to other traumatic events and psychosocial risks. One thousand three hundred ninety-eight Sri Lankan children aged 9-15 years were interviewed in 4 cross-sectional studies about exposure to traumatic life events related to the war, the tsunami experience, and family violence. Symptoms of posttraumatic stress disorder, somatic complaints, psychosocial functioning, and teacher reports of school grades served as outcome measures. A global outcome variable of "positive adaptation" was created from a combination of these measures. Data showed extensive exposure to adversity and traumatic events among children in Sri Lanka. Findings of regression analyses indicated that all 3 event types--tsunami and disaster, war, and family violence--significantly contributed to poorer child adaptation.

Impact of maternal posttraumatic stress disorder and depression following exposure to the September 11 attacks on preschool children's behavior

To evaluate whether conjoined maternal posttraumatic stress disorder (PTSD) and depression are associated with increased behavioral problems among terrorism-exposed preschool children (N = 116; 18-54 months), this study compared clinically significant child behavioral problem rates among the preschool children of mothers with PTSD and depression, depression alone, and neither disorder. Behavioral problems were independently rated by mothers and preschool teachers. Maternal depression and PTSD, relative to maternal depression alone, and to neither disorder, were associated with substantially increased child problems. Notably, maternal depression and PTSD were associated with increased emotional reactivity (relative risk [RR] = 5.9 by mother's and 3.4 by teacher's reports) and aggressive behavior problems (RR = 11.0 by mother's and RR = 5.9 by teacher's reports). This was corroborated by teacher ratings. Implications for intervening with terrorism-exposed preschool children are discussed.

Parenting and temperament prior to September 11, 2001, and parenting specific to 9/11 as predictors of children's posttraumatic stress symptoms following 9/11

Parenting is related to children's adjustment, but little research has examined the role of parenting in children's responses to disasters. This study describes parenting responses specific to the 9/11 terrorist attacks and examines pre-9/11 parenting, child temperament, and 9/11-specific parenting as predictors of children's posttraumatic stress (PTS) symptoms among children geographically distant from the attack locations. A community sample of children and parents (n = 137, ages 9-13 years) participating in an ongoing study were interviewed 1 month following 9/11. Parents reported engaging in a number of parenting responses following 9/11. Pre-9/11 acceptance and 9/11-specific, self-focused parental responses predicted PTS symptoms. Pre-9/11 parenting and temperament interacted to predict PTS symptoms, suggesting that parenting and temperament are important prospective predictors of children's responses to indirect exposure to disasters.

Natural disasters and the neurodevelopmental response to trauma in childhood: a brief overview and call to action

The majority of past research on the neurodevelopmental response to trauma has concentrated on measures of physiology and brain structure in youths who have experienced interpersonal traumas, such as violence and neglect. Natural disaster-related trauma may differ from interpersonal trauma in several ways, but the paucity of disaster-related imaging studies makes it impossible to draw any clear conclusions with regard to this trauma type. This article highlights the literature gap in brain imaging studies of pediatric post-traumatic stress disorder secondary to natural disasters, and presents how research on disaster-exposed youths could enhance our understanding of the neurodevelopmental response to trauma.

Military trauma and social development: The moderating and mediating roles of peer and sibling relations in mental health

We first examined how war-related traumatic events impact on peer and sibling relations, and how the quality of these relations in turn are associated with children’s mental health, indicating a mediation model. Second, we tested the moderating (protective) effects of good peer and sibling relations in attenuating the link between trauma and mental health. The participants were 227 Palestinian boys and girls aged 10—14 years living in the Gaza Strip. They reported\ their exposure to military trauma, evaluated the qualities of peer relationships (loneliness and friendship) and siblingship (warmth, intimacy, conflict and rivalry), and reported symptoms of PTSD, CDI depression and SDQ psychological distress. The results show that exposure to military trauma was associated with intense rivalry in sibling relations and with low friendship quality especially among girls and younger children. The association between military trauma and symptoms was mediated by poor friendship and rivaling sibling relations. Only sibling relations but not peer relations had a moderating effect, as military trauma was not associated with severe symptoms among children who enjoyed considerable intimacy and warmth and lacked rivalry in their siblingships. We discuss theoretical and practical implications of the roles of peer and sibling relations in helping children in traumatic war conditions.

Warfare and children

In 2007, 136 million children were born in the world, and 9.2 million died before they were 5 years old; 99.8% of these deaths were in developing countries, and 8.2 million were unnecessary. This is 23 000 unnecessary deaths every day. Approximately 0.2 million children die from the direct effects of war every year, and at least twice as many die from the indirect effects. However, most child deaths are caused by common childhood infections in communities that are not affected by war. In 2007, overseas development aid totalled only $104 billion, and world military expenditure totalled US$1339 billion. The 49 poorest countries in the world have a population of 1.3 billion; they spent only $27 per person on health in 2006, but the world spent $201 per person on military activity. The five permanent members of the United Nations Security Council account for 90% of weapons sales to developing countries, yet they are the very countries that have accepted responsibility for ensuring world security. Unfortunately, many governments in both rich and poor countries do not want to limit military spending - the vested interests that support military activity are too powerful. War is immensely harmful, but not primarily because of the horrible injuries, nor the large number of deaths it causes indirectly from infection, malnutrition, and social and political disruption. By far, the greatest harm comes from the diversion of huge amounts of money that could be used for beneficial development into harmful and destructive military activity.

Establishing the boundaries and building bridges: a literature review on ecological theory: implications for research into the refugee parenting experience

Currently an ecological model for conceptualizing and capturing the refugee parenting experience is lacking. After an extensive review of the literature related to the usages of Bronfenbrenner's ecological model of child development, a gap was found in knowledge and research centred on describing the environment of pre-resettlement (i.e. pre-flight, flight, migration, camp) contexts and their impact on refugee parents and carer experiences. The culture of the refugee parenting experience may be characterized by disruptions in and alterations to family structure and organization; values and norms; and gender roles. This paper begins by examining the definition and usages of existing ecological frameworks in the 20th and 21st century. Particular attention is drawn to the gaps in the existing literature and an ecological model is offered. The paper concludes with a discussion of the implications for practice. The outcomes of this paper suggest the need for practitioners, policymakers and researchers to engage and develop culturally competent, relevant and appropriate interventions (i.e. reconciling differing beliefs and behaviours concerning child-rearing practices; affirming positive parenting practices of these families during engagement protocols and processes; adopting a strengths-based orientation) in the area of child protection whilst at the same time safeguarding and promoting the welfare of children within pre- and post-resettlement contexts.