Children's symptoms in the wake of Challenger: a field study of distant-traumatic effects and an outline of related conditions

Children's Exposure to Single Incidents of Terrorism: Perspectives Over 25 Years Since the Oklahoma City Bombing

PURPOSE OF REVIEW

This paper traces advances in our knowledge about children's exposure and reactions to terrorist events over the last 25 years, beginning with the 1995 Oklahoma City bombing, and offers observations about cross-cutting issues including implications for services.

RECENT FINDINGS

Direct and indirect interpersonal exposures have been examined in community samples and in samples of children selected because of their event experiences. Despite its present exclusion from the stressor criterion for a diagnosis of posttraumatic stress disorder, considerable research has documented an association between children's initial subjective reaction and outcomes. Few studies have examined the influence of community or distant effects on outcomes, but contact with media coverage has been well studied. This review confirms the central role of exposure in influencing children's reactions to terrorist incidents and supports recent efforts to distinguish specific experiences that constitute children's event exposures.

The Impact of Community Disaster Trauma: A Focus on Emerging Research of PTSD and Other Mental Health Outcomes

This paper reviews community residents' mental health following exposure to a community disaster trauma, with a focus on post-traumatic stress disorder (PTSD) and other mental health outcomes, such as emotional disorders, behavioral problems including addictive disorders, and personality as a maladaptive trait. This review concludes with recommendations to advance the field of community disaster research by exploring how natural and man-made disasters impact community residents across multiple domains. Moreover, this study suggests that residents impacted by community disaster trauma are frequently appropriate targets for mental health assessments or services in a community setting.

The impact of exposure to memorial reports on the 5.12 Wenchuan earthquake on sleep quality among adult survivors ten years after the disaster: Evidence for nonlinear associations

INTRODUCTION

Very few studies have explored the effect of exposure to disaster memorial reports in the media on long-term sleep quality during the recovery period and post-disaster era. This study investigated the relationship between exposure to memorial reports and adult survivors' long-term sleep quality 10 years after the 5.12 Wenchuan earthquake in 2008, and determined whether exposure to memorial reports are associated with poor sleep quality.

METHOD

Using a cross-sectional methodology, we surveyed participants (N = 1000) recruited from six disaster-affected counties. We measured sleep quality using the Pittsburgh Sleep Quality Index questionnaire (PSQI).

RESULTS

After controlling for the effects of demographic factors, socioeconomic status, and earthquake exposure factors, exposure to memorial reports and the PSQI global score had a strong inverted U-shaped relationship. Relationships among three sub-scores of PSQI (subjective sleep quality, sleep latency, daytime dysfunction) were also found to have similar relationships with memorial report exposure. That is, survivors who were exposed to low or high degrees of memorial reports had better sleep quality than those who were exposed to intermediate memorial reports.

DISCUSSION

The curvilinear relationship between media exposure and sleep quality in the post-disaster era reveals that media exposure could be used to identify victims at risk of poor sleep quality. Clinicians and practitioners may consider adopting psychological intervention programs to enhance victims' psychological controllability to overcome mental disorders caused by media exposure.

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.

Threats to security and ischaemic heart disease deaths: the case of homicides in Mexico

Background

Ischaemic heart disease (IHD) ranks as the leading cause of death worldwide. Whereas much attention focuses on behavioural and lifestyle factors, less research examines the role of acute, ambient stressors. An unprecedented rise in homicides in Mexico over the past decade and the attendant media coverage and publicity have raised international concern regarding its potential health sequelae. We hypothesize that the rise in homicides in Mexico acts as an ecological threat to security and elevates the risk of both transient ischaemic events and myocardial infarctions, thereby increasing IHD deaths.

Methods

We applied time-series methods to monthly counts of IHD deaths and homicides in Mexico for 156 months spanning January 2000 to December 2012. Methods controlled for strong temporal patterns in IHD deaths, the unemployment rate and changes in the population size at risk.

Results

After controlling for trend and seasonality in IHD deaths, a 1-unit increase in the logged count of homicides coincides with a 7% increase in the odds of IHD death in that same month (95% confidence interval: 0.04 - 0.10). Inference remains robust to additional sensitivity checks, including a state-level fixed effects analysis.

Conclusions

Our findings indicate that the elevated level of homicides in Mexico serves as a population-level stressor that acutely increases the risk of IHD death. This research adds to the growing literature documenting the role of ambient threats, or perceived threats, to security on cardiovascular health.

Media Effects in Youth Exposed to Terrorist Incidents: a Historical Perspective

PURPOSE OF REVIEW

This paper reviews the evidence on the relationship between contact with media coverage of terrorist incidents and psychological outcomes in children and adolescents while tracing the evolution in research methodology.

RECENT FINDINGS

Studies of recent events in the USA have moved from correlational cross-sectional studies examining primarily television coverage and posttraumatic stress reactions to longitudinal studies that address multiple media forms and a range of psychological outcomes including depression and anxiety. Studies of events in the USA-the 1995 Oklahoma City bombing, the September 11 attacks, and the 2013 Boston Marathon bombing-and elsewhere have used increasingly sophisticated research methods to document a relationship between contact with various media forms and adverse psychological outcomes in children with different event exposures. Although adverse outcomes are associated with reports of greater contact with terrorism coverage in cross-sectional studies, there is insufficient evidence at this time to assume a causal relationship. Additional research is needed to investigate a host of issues such as newer media forms, high-risk populations, and contextual factors.

Media use and insomnia after terror attacks in France

Direct exposure to traumatic events often precipitates sleep disorders. Sleep disturbance has also been observed amongst those indirectly exposed to trauma, via mass media. However, previous work has focused on traditional media use, rather than contemporary social media. We tested associations between both traditional and social media consumption and insomnia symptoms following 2015 terror attacks in Paris France, controlling for location and post-traumatic symptomology. 1878 respondents, selected to represent the national French population, completed an internet survey a month after the Bataclan attacks (response rate 72%). Respondents indicated different media use, post-traumatic stress and insomnia. Controlling for demographics, location and PTSD, insomnia was associated with both traditional (β 0.10, P = .001) and social media use (β 0.12, P = .001). Associations between social media and insomnia were independent of traditional media use. Interventions targeted at social media may be particularly important following mass trauma.

Aftermath of Terror: A Nationwide Longitudinal Study of Posttraumatic Stress and Worry Across the Decade Following the September 11, 2001 Terrorist Attacks

Research conducted in the early years after the September 11, 2001 (9/11) terrorist attacks in New York, Pennsylvania, and Washington, DC demonstrated adverse psychological outcomes among residents of the United States who were exposed to the attacks both directly and indirectly via the media. However, less is known about the impact of this collective trauma over time. Beginning at the end of December 2006, a longitudinal study of a nationally representative sample of U.S. residents (Cohort 2, N = 1,613) examined the long-term effects of 9/11, with annual assessments administered every year for 3 years. We assessed rates of 9/11-related posttraumatic stress (PTS) annually during the first 2 years of the study; during the second and third years of the study, we assessed fear and worry regarding future terrorism. Rates of PTS among participants were compared with those assessed annually in a nationally representative sample between 2002 and 2004 (Cohort 1); results indicated a relatively stable pattern of 9/11-related PTS symptoms for 6 years following the attacks. Five to six years after 9/11, we found an association between 9/11-related PTS and both direct, B = 8.45, 95% CI [4.32, 12.59] and media-based (live television), B = 1.78, 95% CI [0.90, 2.65] exposure to the attacks. Six to 7 years post-9/11, fear and worry regarding future terrorism were predicted by 9/11-related PTS symptoms that had been reported approximately 5 years after the attacks, B = 0.04, 95% CI [0.03, 0.05]. The psychological legacy of 9/11 was perceptible among many U.S. residents throughout the decade that followed.

Stress Symptoms of Two Groups before and after the Terrorist Attacks of 9/11/01

This study investigated stress symptoms before and after the September 11, 2001 terrorist attack on the World Trade Center. Responses to the Smith Stress Symptoms Inventory were compared for Chicago area college students assessed 1 to 5 weeks after 9/11 ( n = 149) and a comparable sample tested up to 5 months prior to 9/11 (n = 320). Post-9/11 participants scored higher on Attention Deficit. Contrary to prior research, post-9/11 participants did not score higher on distress, including Worry, Autonomic Arousal/Anxiety, Striated Muscle Tension, Depression, and Anger. It is suggested that those indirectly exposed to a terrorist attack may display traditional symptoms of distress and arousal (as suggested by previous research). Later symptoms of attention deficit and distancing may emerge. This work was based on independent pre- and post-9/11 samples and must be replicated longitudinally as a test-retest to draw conclusions regarding change over time.

Childhood sleep disturbance and risk of psychotic experiences at 18: UK birth cohort

BACKGROUND

Sleep disturbances are commonly reported in the psychosis prodrome, but rarely explored in relation to psychotic experiences.

AIMS

To investigate the relationship between specific parasomnias (nightmares, night terrors and sleepwalking) in childhood and later adolescent psychotic experiences.

METHOD

The sample comprised 4720 individuals from a UK birth cohort. Mothers reported on children's experience of regular nightmares at several time points between 2 and 9 years. Experience of nightmares, night terrors and sleepwalking was assessed using a semi-structured interview at age 12. Psychotic experiences were assessed at ages 12 and 18 using a semi-structured clinical interview.

RESULTS

There was a significant association between the presence of nightmares at 12 and psychotic experiences at 18 when adjusted for possible confounders and psychotic experiences at 12 (OR = 1.62, 95% CI 1.19-2.20). The odds ratios were larger for those who reported persistent psychotic experiences.

CONCLUSIONS

The presence of nightmares might be an early risk indicator for psychosis.

Trauma-induced insomnia: A novel model for trauma and sleep research

Traumatic events have been increasingly recognized as important precipitants of clinically significant insomnia. Trauma is an extreme form of stressful life event that generates a sustained neurobiological response triggering the onset and maintenance of insomnia. Trauma may disrupt the normal sleep-wake regulatory mechanism by sensitizing the central nervous system's arousal centers, leading to pronounced central and physiological hyperarousal. The central concept of hyperarousal has been linked to both the pathogenesis of insomnia and to the neurobiological changes in the aftermath of traumatic events, and may be a neurobiological commonality underlying trauma and insomnia. This paper presents evidence for trauma-induced insomnia and advances a model of it as an important nosological and neurobiological entity. Trauma-induced insomnia may occur in the absence of full-blown posttraumatic stress disorder (PTSD), and may also be a precursor of subsequent PTSD development. Converging lines of evidence from the neuroscience of insomnia with the neurobiology and psychophysiology of stress, fear, trauma and PTSD will be integrated to advance understanding of the condition. Preclinical and clinical stress and fear paradigms have informed the neurobiological pathways mediating the production of insomnia by trauma. Elucidating the underlying neurobiological substrates can establish novel biological markers to identify persons at risk for the condition, and help optimize treatment of the trauma-insomnia interface. Early identification and treatment of trauma-induced insomnia may prevent the development of PTSD, as well as other important sequelae such as depression, substance dependence, and other medical conditions.

Emergency Mental Health Services for Children After the Terrorist Attacks of September 11, 2001

Much literature documents elevated psychiatric symptoms among adults after the terrorist attacks of September 11, 2001 (9/11). We, however, know of no research in children that examines emergency mental health services following 9/11. We test whether children's emergency services for crisis mental health care rose above expected values in September 2001. We applied time-series methods to California Medicaid claims (1999-2003; N = 127,200 visits). Findings in California indicate an 8.7% increase of children's emergency mental health visits statistically attributable to 9/11. Non-Hispanic white more than African American children account for this acute rise in emergency services.

Childhood parasomnias and psychotic experiences at age 12 years in a United Kingdom birth cohort

STUDY OBJECTIVES

To examine associations between specific parasomnias and psychotic experiences in childhood.

DESIGN

Birth cohort study. Information on the presence of frequent nightmares in children was obtained prospectively from mothers during multiple assessments conducted when children were aged between 2.5 and 9 y. Children were interviewed at age 12 y about nightmares, night terrors, sleepwalking, and psychotic experiences (delusions, hallucinations, and thought interference) occurring in the previous 6 mo.

SETTING

Assessments were completed in participants' homes or a University clinic within the UK.

PATIENTS OR PARTICIPANTS

There were 6,796 children (3,462 girls, 50.9%) who completed the psychotic experiences interview.

MEASUREMENTS AND RESULTS

Children who were reported by their mothers as experiencing frequent nightmares between 2.5 and 9 y of age were more likely to report psychotic experiences at age 12 y, regardless of sex, family adversity, emotional or behavioral problems, IQ and potential neurological problems (odds ratio (OR) = 1.16, [95% confidence intervals (CI) = 1.00, 1.35], P = 0.049). Children reporting any of the parasomnias at age 12 y also had higher rates of concurrent psychotic experiences than those without such sleeping problems, when adjusting for all confounders (OR = 3.62 [95% CI = 2.57, 5.11], P < 0.001). Difficulty getting to sleep and night waking were not found to be associated with psychotic experiences at age 12 y when controlling for confounders.

CONCLUSION

Nightmares and night terrors, but not other sleeping problems, in childhood were associated with psychotic experiences at age 12 years. These findings tentatively suggest that arousal and rapid eye movement forms of sleep disorder might be early indicators of susceptibility to psychotic experiences.

Clinicians and journalists responding to disasters

OBJECTIVE

Mass casualty events pose dilemmas for community clinicians, often challenging their existing clinical toolkits. However, few clinicians were trained to be experts in explaining the unfolding events to the community, creating resources, and interacting with journalists. The objective of this article is to explain knowledge, skills, and attitudes that mental health professionals need to consider when working with journalists, especially those covering children affected by disaster.

METHODS

In service of these objectives, this article reviews controversies, evidence, and best practices to facilitate effective collaborations and consultations with journalists. Advice includes information on how to be a good source to journalists.

RESULTS AND CONCLUSIONS

Clinicians can ethically and effectively help journalists tell accurate and compelling stories about the psychological effects of disasters when they understand and respect the aims, culture, and ethics of journalism.

Stress-related changes in toddlers and their mothers following the attack of September 11

Unlike other forms of disaster, terrorism is not confined to a particular place or time, and recent evidence indicates that the 9/11 terrorist attack was a significant macrolevel stressor affecting the health and mental health of United States citizens. No studies, however, have reported symptoms in toddlers and their mothers both before and after the attacks. To address this gap, we examined the effects of the 9/11 terrorist attacks on mothers and their 33-month-old toddlers. The attacks occurred during data collection at 33 months of a longitudinal study. Thirty-three-month-old toddlers and mothers who were assessed after the attacks were compared with those assessed before the attacks. When changes were examined from a previous wave of data collected at 15 months, those in the after-attack group showed poorer health, lower child acceptance, and marginally more anxiety, and their toddlers cried more and slept less, whereas the before-attack group showed no changes. Our findings contribute to research documenting widespread effects of the 9/11 terrorist attack on stress-related symptoms and suggest that greater attention must be placed on the needs of our youngest citizens and their caregivers.

Worry about terror among young adults living in ongoing security uncertainty

The aim of the current study was to investigate worry about terror as a mediating variable, with the exogenous variables being media viewing, differentiation of self, and trait anxiety, and the endogenous variables being somatic symptoms and perceptions of security-related stress. Participants were divided into two groups by age/academic level: 248 high school students and 191 university students. A pathway correlation model was used to investigate worry about terror as a mediating variable. The central finding was that worry about terror was a significant mediating variable in the relationship between the extent of media viewing following terror events and the level of perception of security-related stress. That is, young people who said they worried a lot reported a high level of stress relating to the terror events they saw covered in the media. In addition, trait anxiety was found to have an effect on stress perception only via the level of worry about terror. This means that high levels of stress are not experienced by all highly trait-anxious people, but only by those who suffer from higher levels of worry about terror.

Defining a moment in history: parent communication with adolescents about September 11, 2001

Parents play an important role in helping their children process and interpret significant sociohistorical events. However, little is known about how parents frame these experiences or the specific social, cultural, and civic messages they may communicate about the event. In this study, we examined self-reported communication of parents from six communities in the United States with their adolescents about the September 11, 2001 terrorist attacks. Parents' (N = 972) open-ended responses about September 11th were analyzed to assess whether communication with their adolescents occurred and for thematic content. Results revealed marked variability in parents' communication and suggest that many parents used September 11th as an opportunity to impart sociocultural, emotional, and civic messages. Identifying the diversity in parents' responses aligns with the tenets of Terror Management Theory and provides insights into the roles of parents in translating pivotal historical moments. Collectively, these findings yield important implications for civic socialization.

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.

The role of verbal threat information in the development of childhood fear. "Beware the Jabberwock!"

Rachman's (Behaviour Research and Therapy 15:372-387, 1977; Clinical Psychology Review 11:155-173, 1991) three pathways theory proposed that childhood fears not only arise as a consequence of direct learning experiences, but can also be elicited by means of threat information transmission. This review looks at the scientific evidence for this idea, which has accumulated during the past three decades. We review research on the influences of media exposure on children's fears, retrospective parent and child reports on the role of threat information in fear acquisition, and experimental studies that explored the causal effects of threat information on childhood fears. We also discuss possible mechanisms by which threat information exerts its influence and the processes relevant to understand the role of this type of learning experience in the origins of fear. Finally, implications for the prevention and intervention of childhood fears are briefly explored, and potential leads for future research will be highlighted.

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.

Posttraumatic growth and reduced suicidal ideation among adolescents at month 1 after the Sichuan Earthquake

BACKGROUND

This study investigated posttraumatic growth (PTG) and reduced suicidal ideation among Chinese adolescents at one month after the occurrence of the Sichuan Earthquake.

METHODS

A cross-sectional survey was administered to 3324 high school students in Chengdu, Sichuan. The revised Posttraumatic Growth Inventory for Children and the Children's Revised Impact of Event Scale assessed PTG and posttraumatic stress disorder (PTSD), respectively.

RESULTS

Multivariate analysis showed that being in junior high grade 2, having probable PTSD, visiting affected areas, possessing a perceived sense of security from teachers, and being exposed to touching news reports and encouraging news reports were associated with probable PTG; the reverse was true for students in senior high grade 1 or senior high grade 2 who had experienced prior adversities. Among the 623 students (19.3% of all students) who had suicidal ideation prior to the earthquake, 57.4% self-reported reduced suicidal ideation when the pre-earthquake and post-earthquake situations were compared. Among these 623 students, the multivariate results showed that being females, perceived sense of security obtained from teachers and exposure to encouraging news reports were factors associated with reduced suicidal ideation; the reverse was true for experience of pre-earthquake corporal punishment and worry about severe earthquakes in the future.

LIMITATIONS

The study population was not directly hit by the earthquake. This study is cross-sectional and no baseline data were collected prior to the occurrence of the earthquake.

CONCLUSIONS

The earthquake resulted in PTG and reduced suicidal ideation among adolescents. PTSD was associated with PTG. Special attention should be paid to teachers' support, contents of media reports, and students' experience of prior adversities.

Reduced hippocampal activity in youth with posttraumatic stress symptoms: an FMRI study

OBJECTIVE

Youth who experience interpersonal trauma and have posttraumatic stress symptoms (PTSS) develop cognitive deficits that impact their development. Our goal is to investigate the function of the hippocampus in adolescents with PTSS during a memory processing task.

METHODS

Twenty-seven adolescents between the ages of 10-17 years (16 with PTSS and 11 healthy controls) encoded and retrieved visually presented nouns (Verbal Declarative Memory Task) while undergoing fMRI scanning.

RESULTS

The PTSS group demonstrated reduced activation of the right hippocampus during the retrieval component of the task. Further, severity of symptoms of avoidance and numbing correlated with reduced left hippocampal activation during retrieval.

CONCLUSIONS

Decreased activity of the hippocampus during a verbal memory task may be a neurofunctional marker of PTSS in youth with history of interpersonal trauma. The results of this study may facilitate the development of focused treatments and may be of utility when assessing treatment outcome for PTSS.

Psychological distress among adolescents in Chengdu, Sichuan at 1 month after the 2008 Sichuan earthquake

A devastating earthquake occurred on May 12, 2008 in Sichuan, China. This study investigated the prevalence and factors in association with psychological problems among secondary school students living in Chengdu (90 km away from the disaster epicenter) in June 2008. In a cross-sectional survey, 3,324 secondary students self-administered a structured questionnaire in classroom setting. Validated scales were used in this study. Among all respondents, 22.3% reported post-traumatic stress disorder (PTSD); 22.6% were probable depression cases; 10.6% reported suicidal ideation; and 14.1% would like to receive psychological counseling. No gender differences were found. While social/emotional support from teachers or peers (OR from 0.40 to 0.78) and exposure to positive news reports (OR from 0.59 to 0.62) were found protective, prior experience of severe mental distress (OR from 1.60 to 2.68) and corporal punishment (OR from 1.31 to 1.58), worry about future aftershocks (OR from 1.64 to 3.11), absence from school when it was not closed (OR from 1.38 to 1.48), exposures to scary or sorrowful disaster media coverage (OR from 1.39 to 2.07), post-disaster visits to affected sites (OR from 1.51 to 1.59), separation from parents (OR = 1.61), etc., were risk factors predictive of some of the aforementioned psychological problems. Negative mental health impacts were prevalent among the respondents. Teachers, parents, and the mass media are all important in maintaining good mental health among adolescents that are indirectly affected by the severe earthquake. The results have important implications for earthquake preparedness and relief work in the future.

"I see what you're saying": intrusive images from listening to a traumatic verbal report

We tested the hypothesis that intrusive visual images could develop from listening to a traumatic verbal report. Eighty-six participants listened to a traumatic verbal report under one of three conditions: while shaping plasticine (visuospatial condition), while performing articulatory suppression (verbal condition), or with no extra task (control condition). Results showed that intrusive visual images developed from listening to the traumatic report. In line with the idea that central executive processes guide encoding of information, intrusion frequency was reduced in both the visuospatial and the verbal condition compared to the no task control condition. Overall, this pattern is similar to intrusive images from a traumatic film as found in earlier studies. This study provides a valuable addition to models of posttraumatic stress disorder and autobiographical memory. Additionally, the results have potential implications for therapists working with traumatized individuals.

Screening for generalized anxiety disorder symptoms in the wake of terrorist attacks: a study in primary care

Little is known about the mental health impact of terrorism beyond posttraumatic stress disorder (PTSD) and depression. The associations between exposure to the September 11, 2001 (9/11) attacks in New York City and generalized anxiety disorder (GAD) symptoms were examined in a sample of 929 primary care patients. After controlling for PTSD, depression, panic and substance use disorders, and pre-9/11 trauma, patients who screened positive (vs. negative) for GAD symptoms were roughly twice as likely to report having a loved one at the 9/11 disaster site, twice as likely to know someone who was killed by the attacks, and twice as likely to know someone who was involved with the rescue/recovery efforts after the disaster. Implications for treatment and future research are discussed.

Using context to treat traumatized children

When treating childhood psychic trauma, context means "putting a perspective to the terrifying experience"--"seeing it in a new light", one might say, or understanding its magnitude and meaning. Of three essential mechanisms behind a young person's psychological recovery from a stress disorder--abreaction, context, and correction-context is the most reflective, cognitive, and conscious of these processes; while abreaction is primarily emotive, and correction is primarily behavioral (involving real or fantasied action). Because context, newly introduced by this author to the psychiatric literature (Terr, 2003), is the most recent and the least well understood of the three mechanisms, it will be the sole focus here.

Posttraumatic stress symptoms and brain function during a response-inhibition task: an fMRI study in youth

Youth who experience interpersonal trauma and have posttraumatic stress symptoms (PTSS) can exhibit difficulties in executive function and physiological hyperarousal. Response inhibition has been identified as a core component of executive function. In this study, we investigate the functional neuroanatomical correlates of response inhibition in youth with PTSS. Thirty right-handed medication-naïve youth between the ages of 10 and 16 years underwent a 3-Tesla Functional Magnetic Resonance Imaging scan during a response-inhibition (Go/No-Go) task. Youth with PTSS (n = 16) were age and gender matched to a control group of healthy youth (n = 14). Between-groups analyses were conducted to identify brain regions of greater activation in the No/Go-Go contrasts. PTSS and control youth performed the task with similar accuracy and response times. Control subjects had greater middle frontal cortex activation when compared with PTSS subjects. PTSS subjects had greater medial frontal activation when compared with control subjects. A sub-group of youth with PTSS and a history of self-injurious behaviors demonstrated increased insula and orbitofrontal activation when compared with those PTSS youth with no self-injurious behaviors. Insula activation correlated positively with PTSS severity. Diminished middle frontal activity and enhanced medial frontal activity during response-inhibition tasks may represent underlying neurofunctional markers of PTSS.

Psychosocial Effects of War Experiences among Displaced Children in Southern Darfur

This study focused on assessing the psychosocial effects of the long standing, high intensity, and guerrilla-style of warfare among displaced children in Southern Darfur. The goal was to better understand the etiology, prognosis, and treatment implications for traumatic reactions, depression, and grief symptoms in this population. Three hundred thirty-one children aged 6–17 from three IDP Camps were selected using a quota sampling approach and were administered a Demographic Questionnaire, Child Post Traumatic Stress Reaction Index, Child Depression Inventory, and the Expanded Grief Inventory. Forty-three percent were girls and 57% were boys. The mean age of the children was 12 years. Results found that children were exposed to a very large number of war experiences with no significant differences between genders for types of exposure, including rape, but with older children (13–17 years) facing a larger number of exposures than younger children (6–12 years). Out of the 16 possible war experiences, the mean number was 8.94 ( SD = 3.27). Seventy-five percent of the children met the DSM-IV criteria for PTSD, and 38% exhibited clinical symptoms of depression. The percentage of children endorsing significant levels of grief symptoms was 20%.

Increased exposure to war experiences led to higher levels of: 1) traumatic reactions; 2) depression; and 3) grief symptoms. Of the 16 war experiences, abduction, hiding to protect oneself, being raped, and being forced to kill or hurt family members were most predictive of traumatic reactions. Being raped, seeing others raped, the death of a parent/s, being forced to fight, and having to hide to protect oneself were the strongest predictors of depressive symptoms. War experiences such as abduction, death of one's parent/s, being forced to fight, and having to hide to protect oneself were the most associated with the child's experience of grief. In addition to Total Grief, Traumatic Grief, Existential Grief, and Continuing Bonds were measured in these children. Although trauma, depression, and grief often exist as co-morbid disorders, the mechanisms and pathways of these is less understood. In this study we used Structural Equation Modeling to better understand the complex interaction and trajectories of these three symptoms evolving from war exposure and loss. This study is the first of its kind to assess the psychosocial effects of war experiences among children currently living in war zone areas within Sudan. It identifies some of the most prevalent war-related atrocities and their varying impact on the children's psychological well-being and overall adjustment. Implications for planning mental health interventions are discussed.

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.

Posttraumatic stress disorder symptoms following media exposure to tragic events: impact of 9/11 on children at risk for anxiety disorders

With the extensive media coverage on September 11, 2001, adults and children indirectly witnessed the terrorist attacks leading to the deaths of almost 3,000 people. An ongoing longitudinal study provided the opportunity to examine pre-event characteristics and the impact of this media exposure. We assessed symptoms of PTSD in 166 children and 84 mothers who had no direct exposure to the 9/11 attacks. The sample included children who had parents with or without anxiety and mood disorders, and who had been assessed for the presence or absence of temperamental behavioral inhibition (BI). We found a 5.4 percent rate of symptomatic PTSD in response to 9/11 in children and 1.2 percent in their mothers. Children's identification with victims of the attack, and for younger children, the amount of television viewing predicted increased risk of PTSD symptoms. Parental depression was associated with higher symptoms, and pre-event levels of family support was associated with a lower risk for PTSD symptoms. BI in children was also linked to lower rates of PTSD symptoms, suggesting that a cautious and fearful approach to novelty may offer protection against exposure to media-based traumatic images. Media viewing of tragic events is sufficient to produce PTSD symptoms in vulnerable populations such as children. Given the links between PTSD symptoms and viewing habits, parental monitoring of media exposure may be important for younger children.

Posttraumatic stress symptoms in London school children following September 11, 2001: an exploratory investigation of peri-traumatic reactions and intrusive imagery

Threatening intrusive images are central to posttraumatic stress disorder. It has been suggested that intrusive imagery in the context of a sense of threat leads to the development and persistence of posttraumatic stress symptoms. This study investigates London school children's (N=76; age 10-11 years) self-reported posttraumatic stress symptoms in response to viewing the attacks of September 11, 2001 on television. Assessments were made at two time points. A minority of participants reported moderate-severe symptoms with functional impairment at 2 months (14.5%) and 6 months (9.2%) after viewing the September 11 events. After controlling for symptom stability, persistent symptoms were associated with peri-traumatic factors, notably perceiving that one's life was in danger. The combined effect of intrusive imagery and peri-traumatic life threat was associated with symptom persistence. Assessments of intrusive image content via checklist and free-report indicated that the images were directly related to September 11 and were fairly stable over time. Implications for treating children's intrusive images following stressful events are explored.

Television watching and the risk of incident probable posttraumatic stress disorder: a prospective evaluation

The relation between viewing television coverage of a mass disaster and the development of posttraumatic stress disorder (PTSD) is poorly understood. A cohort of New Yorkers without baseline probable PTSD (N=1787) was assessed 1 year following the September 11, 2001, attacks. The primary outcome was new-onset probable PTSD assessed through a validated scale, and the primary exposure was number of hours of September 11 anniversary news coverage viewed. A total of 99 (5.6%) of participants had developed probable PTSD at the 1-year follow-up. Watching 12 or more hours of September 11 attack anniversary news coverage was associated with a 3.4-fold increased risk of new-onset probable PTSD (p=0.004). Exposure to television coverage of the September 11 anniversary was associated with new-onset probable PTSD among a cohort of New Yorkers with no probable PTSD at baseline.

Pre-attack stress-load, appraisals, and coping in children's responses to the 9/11 terrorist attacks

BACKGROUND

Appraisal and coping following a disaster are important factors in children's post-traumatic stress (PTS) symptoms. However, little is known about predictors of disaster coping responses. This study examined stress-load, appraisals and coping styles measured prior to the September 11 terrorist attacks as predictors of 9/11-specific appraisals, coping and PTS.

METHODS

A community sample of children and parents (N = 143) participating in an ongoing study were interviewed by phone approximately 1 month following 9/11.

RESULTS

Pre-attack stress-load, appraisal and coping styles predicted children's 9/11-specific appraisals, coping, and PTS. 9/11-specific threat appraisals and avoidant coping predicted higher PTS and mediated the effects of pre-attack stress-load and threat appraisal.

CONCLUSIONS

Pre-disaster stress-load, appraisal and coping styles predict disaster-specific appraisal and coping, which in turn, contribute to PTS. Coping interventions might mitigate PTS symptoms following a disaster.

Terrorism and resilience: adolescents' and teachers' responses to September 11, 2001

This study examined the impact of terrorism on adolescents, who may be resolving developmental issues regarding their vulnerability to death. Approximately 4 months after the September 11th attacks, a survey was given to 973 Upper Midwest adolescents and teachers. Quantitative analyses indicated that adolescents (especially girls) were frightened and upset but also used many coping strategies. Qualitative analyses suggested that adolescents were angry as well as tired of hearing about the events. Teachers discussed the attack's historical significance, student safety, and a desire to resume "normalcy." Adolescence resilience was seen by the making of a coherent narrative of September 11th and by focusing on their daily living.

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.

Terrorism's psychologic effects and their implications for primary care policy, research, and education

This paper examines primary care physicians' (PCP) roles in helping the nation prepare for, respond to, and recover from the psychologic consequences of chemical, biologic, radiologic, or nuclear (CBRN) terrorism. First, we discuss the psychologic consequences of a CBRN attack and PCPs' roles in responding to these consequences. Second, we analyze these roles in light of the known barriers to delivering high-quality, primary care-based, mental health care. Third, we offer recommendations for mitigating these barriers and preparing PCPs to respond to the psychosocial consequences of a CBRN weapon. Importantly, our recommendations provide dual-use benefits to PCPs faced with the daily concerns of primary care mental health, including improved linkages and electronic connectivity with mental health, information technology, and decision support for providers, and needed education and research.

The impact of terrorism on children and adolescents: terror in the skies, terror on television

Terrorist attacks and their aftermath have had a powerful impact on children and their families. Media and television exposure of terrorist events throughout the world has increased during the past few years. There is increasing concern about the effects of this exposure on children who witness these violent images. To develop a proactive and strategic response to reactions of fear, clinicians, educators, and policy makers must understand the psychologic effects of media coverage of terrorism on children. Previous research has focused on media coverage of criminal violence and war. Recent studies have examined the effect of remote exposure of terrorist attacks and have shown a significant clinical impact on children and families.

Pre-attack symptomatology and temperament as predictors of children's responses to the September 11 terrorist attacks

BACKGROUND

The aims of this study were to assess the psychological response of children following the September 11, 2001 terrorist attacks in New York and Washington, DC and to examine prospective predictors of children's post-attack responses.

METHOD

Children's responses were assessed in a community sample of children in Seattle, Washington, participating in an ongoing study. Symptomatology and temperament assessed prior to the attacks were examined as prospective predictors of post-attack post-traumatic stress (PTS), anxiety, depression and externalizing problems.

RESULTS

Children demonstrated PTS symptoms and worries at levels comparable to those in children directly experiencing disasters, with 77% of children reporting being worried, 68% being upset by reminders, and 39% having upsetting thoughts. The most common PTS symptom cluster was re-experiencing, and 8% of children met criteria consistent with PTSD. African-American children reported more avoidant PTS symptoms and being more upset by the attacks than European-American children. Girls reported being more upset than boys. Prior internalizing, externalizing, social competence and self-esteem were related to post-attack PTS; and child inhibitory control, assessed prior to the 9/11 attacks, demonstrated a trend towards an association with post-attack PTS symptoms controlling for prior levels of symptomatology. PTS predicted child-report anxiety and conduct problem symptoms at follow-up, approximately 6 months after 9/11.

CONCLUSIONS

Children experiencing a major disaster at a distance or indirectly through media exposure demonstrated worries and PTS symptoms suggesting that communities need to attend to children's mental health needs in response to national or regional disasters. Pre-disaster symptomatology or low self-regulation may render children more vulnerable in response to a disaster, and immediate post-disaster responses predict subsequent symptomatology. These variables might be used in the identification of children in need of intervention.

The effect of the September 11 terrorist attacks on suicide and deliberate self-harm: a time trend study

Suicide rates may be affected by world news. Our objective was to investigate the possible impact of the terrorist attacks of September 11, 2001, on suicidal behavior in the Netherlands. There was evidence of an increase in rates of suicide and deliberate self-harm in the weeks immediately following the attacks. These findings contrast with Durkheim's (1897) original suggestion that suicide rates decline in times of war and outside threat but are in line with findings of increases in suicidal behavior after media coverage of lethal violence.

Reactions of Indian adolescents to the 9/11 terrorist attacks

OBJECTIVE

There is information about the impact of disasters and trauma on children, but little is known about the effects of terrorism particularly in India. (i) To assess the knowledge of the 9/11 terrorist attacks to the school going adolescents of India who were miles away from the actual incident. (ii) To compare the reactions to this event among the boys and girls.

METHODS

The study used a survey design with a self-report questionnaire administered to 406 students in 6 schools of standards 9-12. The questionnaire was administered within 3 weeks of occurrence of this event. The mean age of the subjects was 16.34 years (SD= 1.22; range= 13-20) and 44.1% were boys.

RESULTS

All the students were aware about this event. Awareness that the twin towers were hit was in 81.06 but only 51.94% knew that Pentagon was also hit. All the children knew who the prime suspect was although only 12.62% were aware about the country to which he belonged. The source of knowledge of the events was the television in 74.7% of the adolescents and 17.95% of them viewed foreign news channels additionally to the Indian channels to gather details about the event. Newspaper, radio and internet were the sources of information in 44.17%, 3.4% and 3.5% children respectively. Of the adolescents who gathered information from the television, 84.7% agreed that there had been an increase in their TV viewing time since the event and it was more than one hour per day in 47.5% of them. None of the students supported the terrorist attacks. The number of students with negative stressors was significantly more than the ones who were unaffected (p 0.0001). The girls were significantly more affected than the boys and while the former expressed anger the latter were more fearful and sad. (p 0.05) The idea of USA going for war against Afghanistan was supported by 69.4% and one third of them believed that such an event might adversely affect India. The adolescents who had witnessed the events on television were more fearful and shocked than the ones who read about the event in the print media (p 0.05).

CONCLUSION

This study emphasizes the adverse reactions in the minds of adolescents in India to terrorist events even though they did not directly witness the events of September 11,2001. The role of media exposure in causing stress is also revealed. Pediatricians should be aware of the adverse effects of terrorism in the minds of the children and should be able to identify and help those who are in need.