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Trauma, Proximity, and Developmental Psychopathology: The Effects of War and Terrorism on Children

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Abstract

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.
Trauma, Proximity, and Developmental Psychopathology:
The Effects of War and Terrorism on Children
Daniel S Pine*
,1,2,3
, Jane Costello
1,2,3
and Ann Masten
1,2,3
1
Section on Development and Affective Neuroscience, National Institute of Mental Health Intramural Research Program, Bethesda, MD, USA;
2
Developmental Epidemiology Program, Department of Psychiatry and Behavioral Sciences, Duke University Medical School, Durham, NC, USA;
3
Institute of Child Development, University of Minnesota, Minneapolis, MN, USA
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.
Neuropsychopharmacology (2005) 30, 17811792. doi:10.1038/sj.npp.1300814; published online 13 July 2005
Keywords: trauma; children; psychobiology; terrorism
INTRODUCTION
The Effects of War and Terrorism on Children
In this summary, we review what can be learned from the
literature on traumatic exposure about the psychological
effects of terrorism on children, and the implications for
prevention and intervention planning. At the outset, it must
be noted that virtually no research examines directly the
psychological effects of terrorism on children. As a result,
implications for prevention and intervention must come
from related research that does not focus specifically on
terrorism.
Three broad areas of research are reviewed. First, we
review the behavioral and psychological effects of various
forms of trauma, focusing particularly on the effects of
‘distant traumas,’ as this form of traumatic exposure
appears most similar in form to the threat of terrorism.
Throughout the review, we compare what is known about
the responses of children to what is known about the
responses of adults. Research generally indicates that most
children recover quickly from exposure to traumatic events
unless they are directly involved in harm to themselves or
their family (Masten and Coatsworth, 1998; Pine and Cohen,
2002). However, a small minority can develop chronic
problems following exposure even to distant trauma. While
severity of traumatic exposure is a strong predictor of
outcome, aspects of the child and the child’s ecology also
play a role (Masten and Coatsworth, 1998). This diversity
of event- and child-related factors provides a range of
potential targets for interventions designed to promote
resilience. In the second section of this review, we
summarize key principles to consider when evaluating the
potential benefits of such interventions. Protective inter-
ventions, whether occurring naturally in the lives of
children or implemented by professionals, can target many
different processes at different system levels, ranging from
cells (eg, medication) to social policy (eg, mandated school
emergency planning). Regardless, many of the adverse
effects of trauma and the moderating effects of protective
factors or interventions are thought to operate by influen-
cing functional aspects of the central nervous system.
Moreover, there are individual and developmental differ-
ences in how the system responds to trauma. Therefore, in
the third section, we review developmental plasticity in
neural systems that are responsive to threats.
STRESS, TRAUMA, AND PSYCHOPATHOLOGY IN
CHILDREN AND ADOLESCENTS
At some point before they reach adulthood, most children
are exposed to one or more traumatic event involving
‘actual or threatened death or serious injury, or other threat
Online publication: 2 June 2005 at http://www.acnp.org/citations/
Npp060205040097/default.pdf
Received 2 March 2004; revised 28 June 2004; accepted 20 July 2004
*Correspondence: Dr DS Pine, NIMH-Building 15-K, Room 110,
MSC-2670, Bethesda, MD 20817-2670, USA,
E-mail: daniel.pine@nih.gov
Neuropsychopharmacology (2005) 30, 17811792
&
2005 Nature Publishing Group All rights reserved 0893-133X/05
$
30.00
www.neuropsychopharmacology.org
to one’s physical integrity’ (Costello et al, 2002). Some of
these events are personal, caused either by accident or by
deliberate violence against the child. Others, like natural
disasters and mass accidents, can involve whole families
or communities. Traumatic events can be placed on a
continuum based on the degree to which a child is exposed
directly to extremely frightening and prolonged stressors
that carry long-term impact on personal well being or
access to social supports. The most extreme traumas involve
high degrees of threat, targeted directly at the child over
long periods of time, that produce a loss of social supports.
For example, one form of extreme trauma might involve
witnessing a period of prolonged violence directed towards
a parent that ultimately culminates in death of a parent.
Alternatively, milder traumas involve exposures that either
are brief in duration, only mildly threatening, or produce an
increase in the availability of social support. For example,
one form of relatively mild trauma might involve brief
exposures to inter parental arguments that culminate in
divorce and an actual decrease in exposure to violence
(Hetherington, 1999).
A wealth of epidemiological studies examine the
association between childhood psychopathology and these
various forms of stress exposure, including direct exposure
to a violent act (Pynoos et al, 1999), as well as relatively
milder and more common stressful life events, such as
breakup of a romantic relationship or relatively mild
illnesses (Steinberg and Avenevoli, 2000; Hetherington,
1999). In general, the types of psychopathology exhibited
by children following what DSM-IV calls ‘extreme stres-
sors,’ as well as less severe life events, show broad
similarities to the types of psychopathologies exhibited by
adults. In particular, there are quite strong predictions
from traumatic stress to emotional disorders, defined in
DSM-IV as mood and anxiety disorders (Pynoos et al,
1999; Breslau, 2002; Pine et al, 2002). Some evidence
suggests that traumatic events in children may also lead to
behavior problems, such as those included in DSM-IV
oppositional defiant disorder, conduct disorder, and
attention deficit hyperactivity disorder (ADHD) (Shaw
et al, 1995). However, these associations emerge with less
consistency. Moreover, since few studies rely on prospec-
tive community-based longitudinal designs, findings in
many available studies may be influenced by biases related
to referral patterns or retrospective recall (Pine and Cohen,
2002; Pine et al, 2002). Therefore, it remains unclear the
degree to which some psychiatric problems that emerged
after a traumatic event might actually represent exacerba-
tions of preexisting problems. For example, pre-traumatic
behavior problems may actually shape the degree to which
a child is exposed to various forms of traumatic stress
(Champion et al, 1995).
Some researchers treat traumatic exposure as a con-
tinuum, from relatively mild to severe, and place more
emphasis on the magnitude of overall stress, or the impact
of moderating factors, than on the precise nature of the
event. This view of trauma suggests that traumatic events
produce a broad, generalized increase in risk for various
forms of psychopathology (Steinberg and Avenevoli, 2000).
From this perspective, the specific psychiatric outcome may
have more to do with characteristics of the child than of the
event.
Other research suggests that different forms of stress may
be associated with different forms of psychopathology.
Research in this area has categorized events based on the
typical reaction produced by such an event in most
children. For example, events that involve exposure to
dangerous circumstances, such as exposure to violent acts,
typically produce characteristic signs of fear in a child,
whereas events that involve exposure to loss of vital
relationships, such as decreased contact with a loved one,
typically produce characteristic signs of dysphoria (Eley and
Stevenson, 2000). Such distinctions between fear- and grief-
related reactions can be made relatively reliably, even
among preschool children (Eley et al, 2003). In this area of
research, events involving fear have been shown to exhibit
close links to anxiety disorders, whereas events involving
loss have been shown to exhibit close links to mood
disorders (Eley and Stevenson, 2000; Kendler et al, 2003). It
would follow from this perspective that the unique features
of terrorism may contribute to risk for specific psycho-
pathology in children.
Beyond the specific aspects of one or another traumatic
event, different forms of trauma may be linked to
psychopathology through the relationship between specific
traumas and correlated patterns of other risk factors. These
associated risk factors, acting in concert with specific
aspects of the trauma, may mediate trajectories in symptom
profiles. For example, parental psychopathology and
disruption in the parent–child relationship might predict
particularly high risks for psychopathology following
exposure to domestic violence. Concerning contributions
from parental psychopathology, considerable research
examines the association between mood and anxiety
disorders in parents and their children, as reviewed
elsewhere (Weissman et al, 1997; Merikangas et al, 1999).
This literature is not reviewed in the current summary,
since few family-based studies have examined directly
interactions between parental psychopathology and the
psychological effects of traumatic exposure. Similarly,
characteristics of the child, including their developmental
stage or aspects of their psychobiology, may moderate the
response to traumatic exposures. These influences are
discussed below.
Defining Exposure to Terrorism and Examining
Associations with Behavior
While exposure to traumatic events is very common during
childhood, terrorism adds unique dimensions to traumatic
exposure. For example, children may become targets of
people who hate them for political rather than for personal
reasons. Such events have the potential to increase
children’s perceptions of the uncertainty and risk in the
world and cause psychological harm, even if experienced
only at second or third hand.
Terrorism is a form of undeclared war that often targets
the civilian population as well as, or instead of, the military.
As such, terrorism often avoids formal engagement in
battles in favor of unannounced attacks, often perpetrated
(or carried out) by small groups operating from within a
society rather than as an external, invading force. Terrorists
can use rumors of potential disasters and traumatic events
as effectively as real acts of terror. Children may face
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DS Pine et al
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Neuropsychopharmacology
particular danger on their own account (eg, as the children
of the President), as members of a specifically targeted
group (eg, families of military personnel), as a vulnerable
class of society (eg, because the death of children is so
horrifying), or simply as randomly selected individuals. It is
perhaps this combination of targeted hate and random
violence that is particularly frightening. Terrorism com-
bines two threats: of deliberate harm to a child’s community
and of random harm to children and their families. These
characteristics pose special challenges to the emotional
balance of a community, and they require unique responses
from communities and care providers.
In other respects, however, terrorism shares key dimen-
sions of other traumas. Features of traumatic events and
experiences can be quantified with respect to their potential
impact on the psychological well-being of individual
children. These features include: (1) the degree of exposure
to the event (victim, member of victimized group; victim of
event’s consequences (eg, famine following war), friend
killed; witness to horrific events; exposure through media);
(2) the amount of family support available during the
experience and in the aftermath (parents killed, parents
psychologically unavailable, parents supportive); (3) the
amount of life disruption (orphan refugee, refugee with
family, home and/or school damaged, little effect on home/
school life); and (4) the amount of social disorganization
(social order collapses into chaos, emergency systems
overwhelmed, or work effectively). Given the dearth of data
examining the psychological effects of trauma in children
and adolescents, data on other traumas provide important
insights on terrorism, particularly given these similarities
between terrorism and other traumas.
While traumatic exposure among children is common,
exposure to some specific types of traumatic events is
uncommon in the United States. Most American children
have been extraordinarily protected from the extreme end
of these dimensions, though there are important exceptions
to this rule. Aside from children growing up in military
families, it is rare for native-born children growing up in
America to be direct victims of war or terrorism, to have
parents killed in such events, or to become refugees as a
result of them. Even so, most American children have been
indirectly exposed to war and terror through media
coverage or effects on family and friends, or effects on
daily life (eg, security procedures). Moreover, the US is
home to growing numbers of child and adolescent refugees
who have been exposed to war and terrorism at first hand
(US Committee for Refugees, 2004). Finally, large sub-
populations of American children have been exposed to
violent acts through circumstances endemic to some
geographic areas in America, such as portions of large
urban areas (Gorman-Smith and Tolan, 1998).
In this section, we briefly summarize literature examining
the possible effects of terrorism on children, emphasizing
what is known about the impact of indirect exposure to war
and terrorism because this is the form of terror most likely
to impact American children. Indirect exposure may occur
through various avenues: (1) children learn about about the
acts of terrorism against their country through coverage on
TV, the internet or other media, and through people they
know talking about it; (2) children respond to how their
parents react to such events; and, (3) events lead to changes
in home or school life, such as increased police presence
or surveillance, economic hardship, increased distrust
of ‘foreigners,’ or even the erosion of civil society. In
discussing such potential effects, Terr et al (1999) proposed
the term ‘distant trauma’ to refer to ‘the reaction (memory,
thinking, symptoms) to a disastrous event, experienced at
the time of the event, but from a remote and realistically
safe distance.
In an attempt to elucidate the risk children face when
exposed to terrorism as opposed to other forms of trauma,
we summarize literature on five different types of exposure,
involving different levels of random violence, aggressive
acts, and targeted hate: (1) personal exposure to war and
terrorism, (2) natural disasters, (3) man-made accidents, (4)
mass shootings, and (5) indirect exposure to war and
terrorism. We do not review the extensive literature on
childhood sexual abuse, as this literature has been reviewed
extensively and appears less relevant to research on
terrorism. Nevertheless, the summary of research in these
five areas is informed by the considerable existing research
on domestic physical and sexual abuse, as summarized
extensively in recent publications (Bremner, 2002; Breslau,
2002; Kitzmann et al, 2003; Pine and Cohen, 2002; Wolfe
et al, 2003; Yehuda, 2002).
Finally, research methods vary considerably across the
five classes of traumatic exposure, and few studies have
been conducted on any single class of event. Moreover, the
current review adopts a broad perspective, focusing on
behavioral outcomes as well as implications for research on
interventions and neurobiology. As a result, the current
summary does not provide a quantitative meta-analysis
of outcome data, but rather broadly reviews exemplary
studies. For interested readers, Pine and Cohen (2002)
recently provided such a semiquantitative review, based on
data in prospective community-based studies of trauma
exposure during childhood. In general, rates of post-
traumatic stress disorder (PTSD) in the reviewed studies
rarely exceed 25% of exposed children, unless large groups
of children are exposed to very high degrees of extreme
trauma. Similarly, the magnitude of the risk in these studies
for any form of psychopathology, including PTSD as well as
other emotional or behavioral disorders, typically involves a
two-to-four-fold increased risk for some clinically impair-
ing condition in the exposed as compared to unexposed
groups.
Personal Exposure to War and Terrorism
The psychological effects on children of war or terrorism
have been studied through research on various events
occurring since World War II. Examples include the
Holocaust (Sagi-Schwartz et al, 2003), the Belfast riots in
Northern Ireland (Lyons, 1979), the Iraqi occupation of
Kuwait (Hadi and Llabre, 1998), the ongoing saga of ethnic
rivalry in Sri Lanka (Chase et al, 1999), the effects of the
current situation in the Middle East (Schwarzwald et al,
1993; Thabet and Vostanis, 1999; Thabet et al, 2004), and
ethnic cleansing in Cambodia (Mollica et al, 1997) or
Rwanda (Dyregrov et al, 2000).
As found in research on adults, virtually all of these
studies find a dose-response effect: the more directly a child
lies in harm’s way, the more severe the risk of PTSD. Similar
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DS Pine et al
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Neuropsychopharmacology
dose gradients have been observed in research on child
maltreatment (Masten and Wright, 1998). Clearly, 50–80%
of children will show at least some signs of PTSD when they
directly experience intense threats, as posed, for example,
by tear-gas attacks (Thabet and Vostanis, 2000), witnessing
the murder or beating of their parents (Chase et al, 1999;
Sack et al, 1999; Thabet and Vostanis, 1999), or by near-
death experiences (Sack et al, 1999). Many studies of trauma
in children have found that direct injury to self, parents, and
other close people is associated with more trauma
symptoms (Pine and Cohen, 2002). Moreover, traumatic
experiences during war rarely occur in isolation, and high
cumulative exposure levels are related to higher symptom
levels, with rates of acute PTSD symptoms surpassing 75%
in some situations (Hubbard et al, 1995; Wright et al, 1997).
The study of children from refugee camps is equivocal
from the viewpoint of ‘distant trauma’. Several researchers
have concluded that events threatening survival of self or
parents are much more likely to lead to PTSD than
experiences related to forced removal from home, as
typically experienced in refugee camps (Sack et al, 1999;
Dyregrov et al, 2000; Mollica et al, 1997; Allwood et al,
2002). However, refugee camps can still be extremely
dangerous environments where children are exposed to
horrifying trauma. Also, the exposure of these children is
real, rather than ‘from a remote and realistically safe
distance.’ On the other hand, these children may be less
exposed to direct trauma than children living in regions
actively involved in a war. The majority of studies in this
area have found relatively high rates of PTSD in refugee
camps, generally exceeding 10% (Allwood et al, 2002;
Papageorgiou et al, 2000; Stein et al, 1999; Weine et al,
1995), and surprisingly low rates of other emotional and
behavioral symptoms (Dybdahl, 2001).
Exposure to Distant Trauma
In this section, we review the literature on the effects of
distant or indirect traumatic exposure to natural disasters,
mass accidents, school shootings, war, and terrorist attacks.
When considering the potential effects of future terrorist
attacks, distant trauma is the most likely type of exposure
for most American children.
Natural disasters. While natural disasters can involve
violence and extreme threat, they lack the element of
targeted hate. Nevertheless, research on natural disasters
informs the potential reactions of children to terrorism
since natural disasters involve indirect traumatic exposure
that can affect large groups of children who are not directly
harmed physically by the event. Considerable heterogeneity
exists in the outcome following such traumatic events. On
the whole, children seem to be remarkably resilient in the
face of natural disasters unless the disaster results in death
or injury to family members, or dislocation of home life
(Masten et al, 1990). However, in a minority of cases,
children can develop chronic psychopathology following
this form of trauma (Pine and Cohen, 2002; Pine et al,
2002).
What factors contribute to the resilience that most
children show, and what predicts the adverse outcomes
that occur in the minority of cases? As noted above, effects
on family members can moderate outcomes of direct
exposures (Luthar, 2003), but few studies examine mod-
erators of associations between childhood psychopathology
and the indirect effects of natural disasters. Asarnow et al
(1999) provide one of the few such studies using a pre–post,
quasi-experimental design; in this study, investigators
assessed participants in a family-genetic depression study
both before and after the 1997 Northridge, California
earthquake. The level of exposure was generally quite mild,
but there was extensive exposure to the media reports of
death and destruction. On the whole, children fared quite
well. Pre-earthquake anxiety disorders, but no other
diagnoses or family characteristics, predicted an increased
level of post-earthquake PTSD scores, over and above the
impact of resource loss.
Mass accidentsFshipwrecks, fires, etc. These events may
be the result of human error or culpable incompetence, but
not of deliberate intent to harm. As in research on the
effects of war, these events show a dose–response effect for
children directly exposed to the trauma (Pine and Cohen,
2002). In terms of indirect exposure, effects on children not
directly implicated appear fairly modest and short-lived,
with odds ratios rarely exceeding, in terms of risk for
psychopathology. For example, Terr et al (1999) examined
the impact of the Challenger disaster on three groups of
children: those who had made the trip to Florida for the
launch, many of whom were third-grade classmates of
astronaut and teacher Christie McAuliffe’s son, students
from Christie McAuliffe’s home town in Concord, New
Hampshire, who watched the launch live on television, and
a group on the West coast who heard about the explosion
later. Children who had the closest relationship to McAuliffe
and saw the explosion live (regardless of whether it was in
person or on TV) tended to suffer the most, suggesting a
psychological ‘dose–response’ effect. There were less severe
PTSD symptoms among the West coast group. Symptoms
diminished sharply by a year later in all groups. Interest-
ingly, contrary to research reviewed later on other traumatic
exposures, children with previous traumatic exposures
tended to react less to Challenger than did other children.
A particular subtype of man-made accident is damage to
nuclear reactors, with its risk of future illness. Given this
unique aspect of the event, one might anticipate a stronger
association with psychopathology, relative to other acci-
dents. However, as of this writing, children also appear
resilient in the aftermath of such accidents. Studies of the
effects of the Three Mile Island near-meltdown in 1981, and
of the Chernobyl disaster in 1986 (Cornely and Bromet,
1986; Bromet et al, 2000) have shown few long-term effects
on indirectly exposed children so far. Bromet and
colleagues also found that the main effects on the children
were mediated by maternal anxiety or depression.
School shootings. Like exposure to terrorist acts, school
shooting incidents contain elements of both randomness
and deliberate intent to harm, as well as being rare events
with large potential impact (Moore et al, 2002). These
incidents also occurred in a setting where adults have been
entrusted by parents with protecting their children. In a
study of the Columbine High school shootings (Brener et al,
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DS Pine et al
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Neuropsychopharmacology
2002), data from the 1999 national Youth Risk Behavior
Survey (YBRS) were used to show that children in the
United States interviewed after the date of the shootings
were more likely to feel too unsafe to go to school, as
compared to those interviewed before the shooting. This
was the case ‘regardless of whether the school was in
an urban, suburban, or rural area, but was especially
pronounced in rural areas where the likelihood of students’
missing school was more than 12 times higher after
Columbine’ (p. 148). There was no increase in any other
symptoms measured in the YBRS.
The risk of imitation poses another disturbing effect of
distant trauma. Kostinsky et al (2001) examined a database
of threats of school violence reported to the Pennsylvania
Emergency Management Agency, Harrisburg, during the 50
days following the Columbine incident. Threats of school
violence numbered 354, far exceeding the one or two threats
per year estimated by school administrators prior to 1999.
The frequency of these threats demonstrated a crescendo–
decrescendo pattern. In all, 56 percent of the threats were
made on or before day 10 after the incident, and more than
one-third occurred on days 8, 9, and 10.
War and terrorism. The current report focuses explicitly on
research relevant to potential future terrorist attacks on
children in the United States. As such, prior studies
examining the direct effects of war on children and
adolescents are not directly relevant to the current report.
Moreover, virtually no studies examine the effects of
terrorism on children, though relevant data are reviewed
immediately below. Among studies examining children
exposed to war or terrorism as ‘distant trauma,’ most are
fairly optimistic. Lyons’ (1979) studies of the impact of the
sectarian terrorism in Ireland on children in Belfast found
that the main complaints were enuresis, fear of being left
alone, and school refusal (details p. 386). The few cases that
came to clinical attention appeared to involve children of
anxious parents, once again suggesting that distal effects of
trauma are mediated by proximal effects on parental
functioning. Among these, younger patients had signifi-
cantly milder symptoms.
Pfefferbaum et al (2003a) studied the effect of the
bombing of the US embassy in Nairobi, Kenya, in which
253 people were killed and over 5000 injured. A survey of
500 children showed that, even among indirectly exposed
children, reactions were more severe among those with a
history of previous trauma, suggesting individual vulner-
ability. This is inconsistent with Terr’s observations after
the Challenger disaster described above, which implicated a
moderating influence of trauma experience in the other
direction, more consistent with an inoculation effect (Terr
et al, 1999). Given these inconsistencies, further research is
needed to clarify the role of vulnerability vs protective
processes that may moderate the associations between prior
trauma and outcome following indirect exposure.
Some studies have noted that pre-exposure psychological
characteristics of children and families moderate the impact
of distant traumatic events on children’s symptoms, as
observed in adults as well as children directly exposed to
trauma (Pine and Cohen, 2002). In Palestinian children,
Thabet and colleagues (1999, 2000, 2004) found that
children with high emotional and behavioral symptoms
scores at the first assessment were the most likely to have
persistent PTSD a year later. Studies of children in occupied
Kuwait (Hadi and Llabre, 1998; Llabre and Hadi, 1997)
found that social support moderated the effect on exposure
on PTSD symptoms in girls, but not boys.
In the United States, the three recent major terrorist
events to involve children are the initial Trade Center
bombing in 1993, the Oklahoma City bombing in 1995, and
the 2001 Trade Center bombing. Pfefferbaum et al (2003b)
discuss all three in terms of direct vs indirect exposure (eg,
through the media). They argue that ‘Examining indirectly
exposed children is important especially in terrorist events,
because a goal of terrorism is to inflict fear in the broader
community’ (p. 97). The general conclusion is that PTSD
reaction scores were relatively low in indirectly exposed
samples, and that children ‘reported minimal impact on
functioning’ (p. 97).
In New York, the effects of the 9/11 Trade Center disaster
appear to have been quite marked even among children
only indirectly affected. Prevalence of psychiatric disorders
in one study was two to three times as high in New York city
school students as it was in closeby urban and suburban
school students tested a year earlier (Hoven et al, 2003),
though it is possible that Manhattan rates were higher
before the bombings as well.
In conclusion, available research on trauma exposure in
children and adolescents examines diverse kinds and
severity of exposure. In terms of direct exposure, a dose-
response relationship with risk for psychopathology
emerges in children as in adults. For indirect exposure,
the impact may be weaker overall. However, for both types
of exposure, outcomes are likely to be heterogeneous, with
relatively few children facing high risk for adverse out-
comes.
TERRORISM RISK AND INTERVENTIONS:
A DEVELOPMENTAL RESILIENCE FRAMEWORK
Preparing to minimize the immediate and long-term
consequences of terror for children and adolescents
requires a developmental perspective on risk, vulnerability,
and resilience. Though the literature specifically addressing
protective factors and recovery of children in relation to
terrorism is limited, there is a more extensive literature on
other adversities that provides surprisingly consistent
conclusions for conceptualizing potential preventive inter-
ventions (Garmezy and Masten, 1994; Luthar and Cicchetti,
2000; Masten, 2001; Norris et al, 2002a, b, Parts 1 and 2;
Rutter, 1990, 2000; Weissberg and Kumpfer, 2003). Lessons
learned to date suggest some fundamental principles for
understanding, researching, and intervening to protect
children in the face of terrorism.
Principle 1: The Nature of the Threat must be
Considered
As noted above, children, like adults, show a dose gradient
in response to direct threat. More severe reactions occur in
response to events that threaten basic security (eg, a parent
is killed, injured, or terrified), body and self-integrity (eg,
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DS Pine et al
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Neuropsychopharmacology
the child is tortured, raped, or injured, or threatened with
such), and to threats perpetrated by human design rather
than natural disaster (for children old enough to under-
stand). Secondary exposure via media and rumors is an
increasing concern for children because of the degree of
exposure to media among children in modern societies and
the intensity of the live coverage that is now commonplace.
Perceived exposure is important; studies find high symptom
levels in children and adolescents who believed they had
been exposed to a toxin but had not.
There is concern at all ages for the potential exacerbation
of psychological reactions through media coverage, but
children present a special case because of their immature
cognitive abilities. Media is a powerful ‘vector’ by which
terror spreads, using the model of infectious disease
epidemiology (Butler et al, 2003). Recent survey data
indicate that 36% of American children under the age of 6
have their own television in their bedroom (Rideout et al,
2003). After Oklahoma City and 9/11, television exposure in
children was associated with more post-traumatic stress
symptoms, at least in the short term (Pfefferbaum et al,
2001; NYC Board of Education, 2002). Some teachers in
Oklahoma City chose to forego class activities in favor of
watching live reports on television in the classroom. In
summary, it is clear that the degree of exposure matters
and that prepared adults could influence the degree of
secondary exposure. While American society values not
concealing things from children, and providing opportu-
nities for them to express their fears and anxieties, there is
strong evidence that younger children, at least, do better if
provided with some protection from the full intensity and
repeated coverage by media of trauma and disaster.
Principle 2: Developmental Timing of the Terrorism will
Influence Child and Family Reactions, Protections, and
Developmental Sequelae
Normative vulnerabilities, capabilities, and protective fac-
tors for processing stress shift during development (Luthar,
2003; Masten et al, 1990; Masten and Coatsworth, 1998).
Infants, for example, are protected from full psychological
‘exposure’ to terrorism by their cognitive immaturity; most
adolescents, on the other hand, are capable of apprehending
the full horror of such events. Yet, infants will be highly
vulnerable to degradation or destruction of caregiver
function as they are totally dependent on adult care.
Adolescents not only are more capable of helping them-
selves, having more developed human capital; they also
have more extensive resources outside the family in the
form of friends, teachers, and other people to go to for help,
representing greater social capital.
After children form attachments to caregivers, they are
highly sensitive to separation and loss, particularly if
frightened (Carlson and Sroufe, 1995). Children gauge
threats based on caregiver responses, a propensity termed
‘social referencing.’ Since terrified parents are terrifying to
children, parents can moderate or mediate the propagation
of terror as a vector for the spread of fear to children. Calm
and functional parents, teachers, and other adults, on the
other hand, can be reassuring to children.
Perceived danger and fear stimulate efforts to increase
proximity to caretakers (Bowlby, 1973); people of all ages
will seek contact with attachment figures, but this response
will be intense in young children. It is also reciprocal, so
that parents will seek physical contact with young children
under conditions of extreme threat. Older children may be
reassured by cell phone contact, but young children will
need physical contact. Separation can be more stressful to
children than the traumatic event itself (Masten et al, 1990).
Though less emphasized in the literature, it is important to
consider the impact of threats to children on the level of
stress experienced by parents. The impact of such stress
may explain particularly the strong effects of major
disasters on mothers of young children (Bromet et al,
2000; Laor et al, 2001). Efforts to prepare the general
population for dealing with terrorism must consider the
developmental range of responses, the possible differential
sensitivity of mothers to dangers and threats to their
children, and the salience of attachment figures for the
psychological protection of children.
Principle 3: The Experiences and Consequences for the
Children in the Context of Terrorism will be Mediated
and Moderated by Family, Peer, and School Systems,
and Particularly by the Quality of Relationships in
these Systems
Given that many effects of terrorism on children can be
indirect, interventions that improve parental functioning
may reduce the transmission of effects to children (eg,
Dybdahl, 2001; Forgatch and DeGarmo, 1999; Wolchik et al,
2002). It is widely assumed that similar effects can be
achieved through interventions with teachers. Generally, in
the event of a terrorist attack, it may be more effective to
target parents, teachers, and other adults close to children
than children themselves, particularly in the case of younger
children. Adults can act to buffer children, avoid worse
situations, and ameliorate suffering. In studies of naturally
occurring resilience, it is clear that effective adults function
as highly adaptable protective systems for children in their
care (Masten, 2001); it is not well-established whether such
general competence can be taught or improved through
intervention, though it is likely that specific strategies for
specific threats can be learned.
Principle 4: Individual Differences in Vulnerabilities
and Capabilities will Influence Child Responses and
Recovery Patterns
As noted earlier, children’s pre-event competence and
symptoms influence how they respond to trauma (Masten
et al, 1990; Norris et al, 2002a, b; Pine and Cohen, 2002).
Children with mental health problems may be particularly
vulnerable in part because of associated inadequacies in
their external protective systems (eg, their parents may be
less capable and protective) and in part due to endogenous
factors. Individual risk factors also can be viewed from the
perspective of protective factors; that is, children who do
not have the risk factor fare better through the traumatic
experience. Norris et al (Part 1) delineate such risk/
protective factors among all ages, including children.
Generally, the predictors of good outcomes among children
following trauma bear a striking resemblance to the ‘short
list’ of strong protective factors in the resilience literature as
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DS Pine et al
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Neuropsychopharmacology
a whole (Masten, 2001, 2004). Children functioning well
prior to the experience and who have more resources
available during the experience manage well under exten-
uating circumstances, reflecting fundamental human adap-
tive systems. Children lacking such protections may face the
highest need for intervention.
Principle 5: Interventions can be Directed at Different
Phases of Terrorism, Different Processes, and Different
Kinds of Children, in Different Situations
Interventions can focus on different systems of the child’s
ecology or the child him/herself. The most severely
threatening situations for children may involve complex
processes, unfolding over time with cumulative impact.
Given this possibility, a comprehensive, ‘cumulative protec-
tion’ model (Yates and Masten, in press; Wyman et al, 2000)
may provide the most effective intervention across the
widest group of children (Masten and Powell, 2003;
Yoshikawa, 1994). Virtually no research examines the
effectiveness of any intervention for large-scale disaster or
terrorism. Clearly, this is a high priority for the nation and
world community.
Preparation-phase (pre-event) strategies widely imple-
mented in the United States for possible traumatic events
include emergency plans in families, schools, and other
community agencies. Schools are a particular focus of
concern because of the proportion of time children spend in
school and the relatively low adult-to-child ratio in schools.
Though research is of necessity constrained in disasters
and emergent situations, available research on violent
incidents (eg, school shootings, Oklahoma City bombing,
9/11, etc) generates recommendations for intervention.
These include the need for: (1) emergency plans for schools,
communities, families, etc, that attend to child/family
issues; (2) training of ‘first responders’ concerning child
and family issues; (3) advising the public about devel-
opmentally appropriate media exposure; (4) effective risk
communication and management or containment of fear/
symptom contagion effects. Nevertheless, more research is
needed on the effectiveness of each of these and on the
utility of assessment tools for triage and evaluation.
Principle 6: Frontline Responders need to Know
Differences between Normal and Pathological
Responses to Traumatic Events as well as
Strategies for Prevention
Frontline responders include police, firefighters, medical
personnel, emergency service providers, teachers, and day-
care providers. These individuals need to recognize who is
at greatest risk and how to differentiate typical from
atypical reactions in children and parents (Pynoos et al,
1999). Sensitivity to separation stress is important, as is
preparing the first responder for dealing with their
reactions to child victims. The most important general
observation about long-term recovery recognizes the
resilience exhibited by most children. Children typically
exhibit good recovery unless major protective systems for
human development are damaged or destroyed (Masten,
2001). On the other hand, there is considerable evidence
that traumatic experiences and disasters can have profound
and lasting effects on some children.
While these general principles can inform initial efforts to
minimize the effects of terrorism, clinicians and scientists
both remain concerned that available research does not
accurately capture the key aspects of children’s responses to
threats in the form of terrorism or other traumas. In
particular, current research generates incomplete conclu-
sions concerning factors that predict particularly good or
dysfunctional outcomes. Moreover, limitations exist on
knowledge of the mechanisms behind the effects of widely
recognized risk or protective factors. Similarly, there are
concerns about the possibility of slow-evolving, deleterious
effects of gradual, but accumulating, impact on brain
development. In each of these areas, recent advances in
neurobiology generate hope that future studies will provide
insights. Therefore, in the final section of this summary,
data are reviewed on the relevance of basic science research
on threat responses.
Developmental Psychobiology
Clinical research considering the potential impact of
traumatic exposure on children’s emotional well-being
generates interest in the potential effects of stress on human
brain development. As of this writing, virtually no research
examines directly the impact of war or terrorism on human
brain development. However, insights on the potential
impact may emerge from the extensive basic science
research on the developmental psychobiology of stress.
Accordingly, the current section reviews research on
developmental aspects of the stress response, with the goal
of informing future studies examining psychobiological
aspects of exposure to war or terrorism.
Research in the basic sciences has raised essential
questions concerning developmental psychobiology and
traumatic exposure. One key question concerns the role of
specific brain systems in mediating a child’s successful or
unsuccessful adaptation to trauma. Another key question
concerns the nature of any potential impact of traumatic
events on the developing brain. While more data address
the second question than the first, both questions arise in
the wake of considerable basic science research document-
ing plasticity in brain systems engaged when mature
organisms process threats.
Studies over the past 20 years precisely delineate the
neural circuitry engaged in a range of mature mammalian
species during the processing of a threatening stimulus or
situation (LeDoux 1998, 2000; Davis and Whalen, 2001).
While much of the initial work in this area focused on fear
conditioning and learned fears (LeDoux, 2000), recent
studies also examine stimuli and situations that produce
fear in the absence of prior experiences with the stimulus
(Davis, 1998; Blanchard et al, 2001). For most threatening
situations, physiologic, cognitive, and behavioral responses
in mature mammals are known to be regulated by a neural
circuit encompassing the amygdala and prefrontal cortex
(PFC), particularly ventral and medial aspects of the PFC
(LeDoux, 1998; Rolls, 1999). For some specific types of
threat, other structures also are involved, such as the bed
nucleus of the stria terminalis and the hippocampus (Davis,
1998).
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Neuropsychopharmacology
Relatively few studies compare the degree to which the
same or different neural structures mediate responses to
threats at distinct stages of development. Synaptic con-
nectivity within the primate amygdala reaches maturity
earlier than afferent connections from the PFC or temporal
cortex (Pine, 2003). As a result, potential developmental
differences in the neural responses to threat have been
presumed to reflect changes in major input pathways to the
amygdala or interconnections among a circuit encompass-
ing the amgydala, PFC, and other neocortical regions, as
opposed to changes within intrinsic amgydala nucleii.
However, lesion studies in non-human primates suggest
that the developmental stage during which intrinsic
amygdala dysfunction occurs strongly effects the degree to
which fear behaviors are altered (Bachevalier et al, 2001;
Prather et al, 2001; Amaral, 2002). As a result, develop-
mental differences in the threat response may reflect both
intrinsic immaturity within specific neural structures, as
well as immaturity in the connections among these
structures. Regardless, the few available studies document
meaningful differences across development in the role of
specific neural structures in modulating responses to
threats. For example, in studies of rodents, adolescent
animals exhibit a higher threshold for stress-related
activation of amygdala circuitry (Kellogg et al, 1998),
whereas in non-human primates, amygdala lesions have
been shown to produce divergent effects on threat
responses among immature as opposed to mature organ-
isms (Amaral, 2002).
In contrast to the limited psychobiological data examin-
ing fear responses in juvenile mammals, a wealth of
research examines the long-term effects of environmental
factors operating early in development on threat response
patterns exhibited by mature organisms (Pine, 2003). For
example, rearing manipulations in rodents during the first
two weeks of life have been shown to produce long-term
alteration in physiology, cognition, and avoidant behavior
that are readily observable in mature rodents (Liu et al,
2000; Meaney, 2001a, b). These associations are very robust,
as they emerge across a range of rearing paradigms, from
many laboratories, using many outcome measures. More-
over, at least for measures of behavior and physiology, other
studies document parallel effects in non-human primates
(Kaufman et al, 2000; Coplan et al, 2001). Finally, more
recent studies in rodents document neural mediators of
these developmental effects. Specifically, rearing manipula-
tions produce long-term alterations in physiology, cogni-
tion, and behavior through effects on a neural circuit
encompassing the amygdala, PFC, and hippocampus
(Meaney, 2001a, b). Neuroscientists have only begun to
consider the relevance of these findings for human
behavior, due to noted cross-species differences in neuro-
physiology (Rolls, 1999). Nevertheless, knowledge concern-
ing plasticity in brain systems engaged by threats has
heightened concerns regarding the potential long-term
deleterious effects of trauma or other stressful experiences
in children.
A few recent basic science findings generate specific
questions about children. First, cross-fostering studies in
rodents suggest that experiential effects on developmental
aspects of the stress response are mediated through effects
on gene regulation (Francis et al, 1999, 2002; Liu et al, 2000;
Champagne and Meaney, 2001). These findings have
generated particular interest on understanding interactions
between the genetic and environmental factors in humans.
Initial efforts to translate these insights to humans have
heightened this interest. Two recent studies suggested that
polymorphisms in genes that regulate serotonin and
catecholamine function moderate the strength of the
association between environmental stressors and risk for
either major depression or behavior problems, respectively
(Caspi et al, 2002, 2003). Second, gene-knockout studies
suggest that genetic factors may exert different effects on
stress reactivity in immature and mature organisms. For
example, inactivation of the 5-HT1a receptor in a juvenile
mouse produces permanent increases in stress reactivity
that are not reversed by re-activation of the receptor during
adulthood; conversely, inactivation of the 5HT1a receptor
only after a mouse has reached maturity produces no
change in stress reactivity (Gross et al, 2002).
As with studies of amygdala lesions in primates, findings
in rodents provide evidence of developmental variation in
the relationship between brain function and stress
reactivity. This has raised questions on the degree to
which humans exhibit developmental variation in the
relationship between neural or genetic factors and stress
reactivity. Behavioral genetic studies in humans note
some parallels with research in developmental neurobio-
logy. For example, genetic factors associated with anxiety
or depression in adolescents or adults exhibit weaker
associations with anxiety or depression in children. Finally,
much of the available research in rodents examines rearing
manipulation’s effects on indices of hypothalamic–pitui-
tary–adrenal (HPA) axis function and cognitive abilities
instantiated in the hippocampus. While these indices
provide relatively indirect measures of neural function,
noninvasive measures of these indices can be acquired in
humans. Thus far, data in human children document some
parallels with data in rodents, non-human primates, or
adult humans (Bremner, 2001, 2002; Essex et al, 2002;
Pine, 2003). However, the inconsistencies across studies of
developing humans, contrasted with non-human primates
and rodents, are more marked than the consistencies
(Pine and Charney, 2002). This has generated considerable
interest in expanding the area of inquiry in psychobio-
logical studies among clinical samples. More direct
measures of brain function in humans may facilitate
efforts to extrapolate between data in humans and rodents
or non-human primates.
Recent technological advances raise hopes that it will be
possible to directly measure neurophysiology in children in
ways that facilitate translational approaches. In particular,
through advances in cognitive neuroscience, experimental
paradigms have been developed that differentiate, at a
behavioral or physiologic level, adult patients with PTSD
from various control groups, including healthy subjects or
subjects exposed to trauma who are free of PTSD symptoms
(Williams et al, 1996; Grillon and Morgan, 1999; Grillon,
2002; Dalgleish et al, 2001). Through advances in fMRI,
similar paradigms have been used to engage specific brain
regions, such as components of the medial PFC, that are
involved in stress regulation among rodents and non-
human primates (Pine, 2003). In neuroimaging studies,
some of the most successful paradigms have used photo-
Developmental psychopathology and terrorism
DS Pine et al
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Neuropsychopharmacology
graphs of standard facial emotional expressions. For
example, the viewing of faces expressing the emotion of
fear consistently engages the amygdala in healthy adults,
whereas the viewing of angry faces engages the ventral PFC
(Haxby et al, 2002). Moreover, differences between adults
with and without PTSD have been demonstrated using such
paradigms (Rauch et al, 2000). Such findings generated
initial interest in extending this line of inquiry to children.
While only preliminary studies examine this issue, findings
in children reveal some differences from findings in adults,
increasing the need for basic developmental studies in
children. Broadly conceptualized, these findings are con-
sistent with data in non-human primates suggesting that
specific neural structures play distinct roles in modulating
fear at different stages of development. For example, in
some face-viewing paradigms, children exhibit greater
amygdala activation to neutral as opposed to fearful faces
(Thomas et al, 2001a, b). These differences may in turn
relate to developmental differences in attention during the
viewing of evocative faces. In adults, attending to emotional
aspects of a face has been shown to facilitate amygdala and
ventral or medial PFC engagement when fear-faces are
viewed (Pessoa et al, 2002). Preliminary evidence from fMRI
studies suggests that this ability to modulate amygdala and
PFC activity matures relatively late (Monk et al, 2003).
Specifically, adults, relative to adolescents, show an
enhanced capacity to regulate PFC and amygdala in concert
with attention demands during the viewing of fear faces.
Conversely, adolescents, relative to adults, show enhanced
amygdala and PFC activation to emotionally evocative facial
displays under conditions when attention is not con-
strained. As such, these findings suggest that the circum-
stances for engaging relevant neural pathways differs in
meaningful ways across development.
Conclusions
More than 50 years of research from around the world can
help the United States to evaluate and prepare for the
possible effects of terrorism on children. Some (hopefully
few) children will be directly exposed to terrorism, and
some of them (though far from all) will experience
symptoms of PTSD as a consequence; most will have
recovered within a year provided their environment is safe.
Effects of direct exposure are likely to affect a relatively
limited number of children. A much larger proportion of
the child population will be indirectly exposed to terrorism,
through the media and other people. Here, too, a dose–
response effect is expected, which argues for adult control
of the amount and content of children’s exposure to the
media (as well as exposure to terrified adults). Some
symptoms, such as bad dreams and clinging, may occur,
particularly among younger children, but these effects are
unlikely to last long. A key, and potentially modifiable,
predictor of children’s outcomes appears to be how adults
behave; parental anxieties have been found to mediate the
effects of distant trauma on children’s fears.
Finally, the most dangerous environments for children
are those where long exposure to war and terrorism has
undermined civil society, as happened in Belfast, Mozam-
bique, and many refugee camps in the late 20th century. As
in massive trauma, when all aspects of a child’s ecology may
have collapsed (as seen in war and natural disasters), the
lives of children may be profoundly affected indirectly by
the effects of the terror on the embedded systems in which
they live (Wright et al, 1997). There is a real danger when
order has disintegrated that frightened children will act to
protect themselves by affiliating with terrorists, forming
delinquent gangs, or emulating the violent behavior of
adults. The undermining of civil society may be more of a
threat to children’s mental health in the long term than the
‘distant trauma’ itself.
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... Novel diseases are traumatic as they give a sense of uncertainty and act as a threat to life, which triggers the fear of illness (Vahedian-Azimi et al., 2020). Extant literature reveals negative mental health outcomes are a sequela of exposure to traumatic events (Pine et al. 2005;Su & Chen 2015). ...
... Several researchers have reported negative mental health during the current pandemic (Abramson 2020;Kumar & Nayar 2020). The findings of these studies provide an insight that indirect exposure to traumatic life situations develops signs of psychological distress, even in the general population (Hsing et al. 2020;Pine et al. 2005). Hence, indirect exposure to COVID-19 related information through media increases perceived distress, which in turn might affect subjective psychological well-being. ...
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A sudden outbreak of diseases poses a serious threat to mental health. Relying on strengths might mitigate negative mental health outcomes and promote positive mental health. Prior research suggests a potential moderated mediation effect between fear of illness and subjective psychological well-being. Based on the Competence-based Model of mental health, this study examined the relationship between fear of illness and subjective psychological well-being through perceived distress moderated by resilience in the context of COVID-19 pandemic. A cross-sectional survey using questionnaires was employed. Data were collected online from 384 participants (270 female and 114 male, age range= 15 to 29 years). The participants had indirect exposure to COVID-19 through information from the media. Results demonstrated that fear of illness significantly predicts subjective psychological well-being both directly and indirectly. In addition, the moderated mediation effect of resilience was confirmed. Resilience moderated the indirect effect between fear of illness and subjective psychological well-being through perceived distress. The magnitude of the indirect effect was contingent on resilience. Further, the effect of perceived distress on subjective psychological well-being is weakened as the level of resilience increases. This study contributes theoretically to a better understanding of the salutogenic effect of resilience on positive mental health during a pandemic. Based on the findings, implications and future directions are discussed.
... Por último, en el posconflicto inmediato, se ha podido establecer que el sufrimiento producto de la guerra no se detiene al trasladarse a un sitio más favorable (65) y que, además, hay una probable transmisión de padres a hijos (25,48,65,76,77). En ese sentido, en el estudio de van Ijzendoorn, et al., en los descendientes infantes y adolescentes de personas que participaron en la II Guerra Mundial, se encontró una menor adaptación al trauma, y psicopatologías producto de las relaciones con los padres y con factores histórico-contextuales (48). ...
... Dichas actividades se asociaron con particularidades del desarrollo de la moralidad en niños de 6 a 11 años, específicamente con la posibilidad de tomar decisiones que justifiquen o no el conflicto armado (9,21,74). Además, se plantea que una moralidad favorable a los conflictos armados entraña el peligro real de que estas personas conformen o se unan a pandillas o grupos delincuenciales, con el fin de justificar comportamientos violentos (49,77). ...
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Resumen Introducción. Los diferentes conflictos armados (CA) dejan consecuencias evidenciables en la salud mental (SM) de la población infantil y adolescente. Se han documentado una serie de desenlaces que tienen como factor común la vulnerabilidad de esta población y las afectaciones significativas a nivel biopsicosocial. Objetivo. Identificar y sintetizar las diferentes consecuencias del CA sobre la SM de la población infantil y adolescente. Materiales y métodos. Búsqueda sistemática exhaustiva de revisiones hasta julio de 2019 en las bases de datos MEDLINE (Ovid), EMBASE, Cochrane Central Register of Controlled Trials, LILACS y recursos adicionales. La extracción y análisis se realizó de forma narrativa describiendo características de los estudios, objetivos y consecuencias en SM en tres momentos: pre-conflicto, durante el conflicto y posconflicto. Resultados. De un total de 587 artículos potencialmente relevantes fueron aceptados un total de 72 estudios. En el pre-conflicto se detallaron experiencias psicológicas y síntomas somáticos anticipatorios. Durante el conflicto, se evidenciaron síntomas regresivos, conductuales y cognitivos como enuresis, miedo, tristeza, agresión, hiperactividad, inatención, entre otros. Adicionalmente, se identificaron consecuencias directas como trastornos de adaptación, depresión, ansiedad y en mayor medida, estrés postraumático. Finalmente, en el posconflicto se encontraron procesos de transmisión de la consecuencia y resiliencia. Por otro lado, se profundizó en consecuencias potenciales sobre procesos de desarrollo biopsicosocial, moralidad, identidad, contexto, cultura, educación y sociedad. Conclusiones. El desarrollo de consecuencias en SM es un proceso complejo que se expresa en función de la etapa evolutiva de la exposición, tiempo del CA y factores contextuales. https://revistabiomedica.org/index.php/biomedica/article/view/5447
... Since worried parents are terrifying to their children, parents can alleviate or mediate the spread of terror as the carrier of the spread of fear to children. Parents, teachers, and other calm, functional adults can encourage children (Pine, 2005). Also, it is not clear whether the same medications should be used in children as in adults with post-traumatic syndrome. ...
... War exposure is an example of mass trauma where large populations are exposed to the same traumatic events at the same time (Masten & Narayan, 2012). Exposure to mass trauma places individuals at a greater risk for adverse psychological outcomes, the most common being posttraumatic stress disorder (PTSD), anxiety, and depression (Halevi et al., 2016;Heim & Nemeroff, 2001;Pine et al., 2005). Mass trauma typically involves exposure of the entire family to the same adverse events, a situation that is thought to trigger a "compound effect" in which family members influence each other's symptoms (Scheeringa & Zeanah, 2001). ...
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... La violence familiale, l'intimidation et les conflits politiques sont des exemples de situations d'exposition à l'adversité (Ungar, 2015). Cette adversité peut se situer sur un continuum selon le degré de sévérité et de chronicité (Pine, Costello, & Masten, 2005;Ungar, 2015). ...
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Chapter
School shootings are traumatic events that have detrimental impacts on children. Studies revealed that after the school shooting children can suffer from traumatic symptoms which cause difficulties in learning and relationships. Traumas negatively affect developing brain structures of the children which can lead to long-term problems. For that reason, the trauma sensitive schools (TSS) model, which aimed to provide safe and secure environments for children, can be helpful to support the children and to improve their well-being after the school shooting.
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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.
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Background. The present study examined biases in visual attention for emotional material in children and adolescents with post-traumatic stress disorder (PTSD) and healthy controls. Methods. The participants carried out an attentional deployment task in which probe detection latency data were used to determine the distribution of visual attention for threat-related and depression-related material. Results. The results showed that children and adolescents with PTSD, relative to controls, selectively allocated processing resources towards socially threatening stimuli and away from depression-related stimuli. This attentional avoidance of depression-related information in the PTSD participants declined with age. Conclusions. The results of the study an interpreted as a consolidation and extension of previous research on attentional bias and emotional disorder in younger participants.
Article
Although most people will gradually recover from the psychological effects of a traumatic event, PTSD will develop in a substantial proportion. PTSD appears to represent a failure to recover from a nearly universal set of emotions and reactions and is typically manifested as distressing memories or nightmares related to the traumatic event, attempts to avoid reminders of the trauma, and a heightened state of physiological arousal. Studies of the biologic mechanisms of PTSD have delineated circumscribed alterations in brain regions, such as the amygdala and hippocampus, that are associated with fear and memory, as well as changes in hormonal, neurochemical, and physiological systems involved in coordinating the body's response to stress. The treatment of PTSD involves educating the patient about the nature of the disorder, providing a safe and supportive environment for discussing traumatic events and their impact, and relieving the distress associated with memories and reminders of the event. A variety of approaches, such as exposure therapy, cognitive therapy, and pharmacotherapy, have been found to be effective in the treatment of PTSD.
Conference Paper
Defense patterns of rats and mice have been characterized in terms of the relationships between the type of defensive behavior (e.g. flight, freezing, hiding, defensive threat/attack, and risk assessment) and particular features of the eliciting (threat) stimulus and the situation in which it is encountered. Because the defense systems of rodents serve as major models for investigating and understanding both the physiology and the behavioral expression of emotional response to aversive stimuli, it is essential to evaluate whether these systems show strong parallels in human responsivity to threat. One hundred and sixty male and female undergraduate students read a set of 12 scenarios involving a present or potential threatening conspecific, and chose a primary defensive response to each. These scenarios were designed to vary features known to influence defensive responding in rodents: magnitude of threat; escapability of the situation; ambiguity of the threat stimulus; distance between the threat and the subject; presence of a hiding place. Male and female responses to the various scenarios were highly correlated, except for yell, scream, or call for help which was frequent for females, rare for males. However, a combination of this response category with 'attack' showed a highly positive (+0.96) male-female correlation, across scenarios. Correlations between manipulated (and rated) features of the threat stimulus and situation, and type of defensive behavior chosen, strongly supported a view that the patterning of defensive behavior is similar for humans and non-human mammals. Significant correlations were obtained relevant to eight specific hypotheses derived from the animal literature, with some support for two additional hypotheses (nonsignificant correlations averaging 0.4 or more in expected direction). While three predicted correlations were not supported in these findings, only a single significant correlation was obtained that had not been predicted on the basis of the animal literature. Although the scenario approach, and this application, have specific limitations, these results provide substantial suggestion of congruence between human and non-human mammal defense systems. (C) 2002 Published by Elsevier Science Ltd.
Article
Background: The amygdala plays a central role in the human response to affective or emotionally charged stimuli, particularly fear-producing stimuli. We examined the specificity of the amygdala response to facial expressions in adults and children. Methods: Six adults and 12 children were scanned in a 1.5-T scanner during passive viewing of fearful and neutral faces using an EPI BOLD sequence. All scans were registered to a reference brain, and analyses of variance were conducted on the pooled data to examine interactions with age and gender. Results: Overall, we observed predominantly left amygdala and substantia innominata activity during the presentation of nonmasked fearful faces relative to fixation, and a decrease in activation in these regions with repeated exposure to the faces. Adults showed increased left amygdala activity for fearful faces relative to neutral faces. This pattern was not observed in the children who showed greater amygdala activity with neutral faces than with fearful faces. For the children, there was an interaction of gender and condition whereby boys but not girls showed less activity with repeated exposure to the fearful faces. Conclusions: This is the first study to examine developmental differences in the amygdala response to facial expressions using functional magnetic resonance imaging.
Book
Childhood resilience is the phenomenon of positive adaptation despite significant life adversities. While interest in resilience has burgeoned in recent years, considerable uncertainty remains regarding what research has revealed about this phenomenon. Integrated in this book are contributions from leading scientists who have studied children's adjustment across risks common in contemporary society. Chapters in the first half of the book focus on risks emanating from the family, and in the second half, on risks stemming from the wider community. The concluding chapter integrates the evidence presented to determine considerations for future research, and directions for interventions and social policies.