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ROCKY MOUNTAIN REGION DISASTER MENTAL HEALTH NEWSLETTER

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Learning From The Past and Planning For The Future

MENTAL HEALTH MOMENT
March 28, 2003

"The sad thing about a shuttle is mission is when you hit the point in your checklist when it says 'bring vehicle home.'"
- Guion S. Bluford, Jr., America's First Black Astronaut

Short Subjects

LINKS

Mental Health Moment Online

CISM/CISD Annotated Links

Gulf War Syndrome

WILDLAND FIRE INFORMATION

CONFERENCES AND WORKSHOPS:

NIMH Meeting Announcements

Rocky Mountain Region

Disaster Mental Health Institute -

SPRING WORKSHOP SERIES

March 22 - Religious Aspects of

Domestic Violence

- Pat Bradley, MA, NACC, LAT

April 23, 24, 25 -

Crisis Counseling, Trauma, and Response:

A Multi-level Approach

- Marguerite McCormack, MA, LPC

May 3 - Suicide Risk Assessment and Risk Reduction:
Tactics For The Trenches

- Jon Richard, PsyD

Disaster Mental Health Services-I (DMHS-I)

(Red Cross Course)

Location: Salt Lake City, UT

Dates: May 6-7, 2003

Contact: Lucy Houser

Email: houserlc@crossnet.org

The Australasian Critical Incident

Stress Association Conference

The Right Response in the

21st Century

Location: Carlton Crest Hotel

Melbourne Australia

Friday October 3, 2003 thru

Sunday October 5, 2003

For further information

please contact the conference organisers:

ammp@optushome.com.au

Conference Website:

http://www.acisa.org.au/
conference2003/

Summer Intensive Program

Graduate Certificate in

Disaster Mental Health

Disaster Mental Health Institute
(University of South Dakota)

Location: Union Building

University of South Dakota Campus
Vermillion, SD

Contact: Disaster Mental Health Institute

University of South Dakota

SDU 114 414 East Clark St

Vermillion, SD 57069-2390

Phone: 605-677-6575 or 800-522-9684

Fax: 605-677-6604

http://www.usd.edu/dmhi/

Third Biennial International Conference

on Intercultural Research (IAIR)

May 16 - 19, 2003

Location: Taipei, Taiwan

Contact: 2003 IAIR International Conference

C/o College of Education

NTNU, PO Box 7-763

Taipei, Taiwan 106

Tel: +(886)2-2321-3142

Fax +(886)2-2394-9243

Email: t14004@cc.ntnu.edu.tw

VIII European Conference

on Traumatic Stress(ECOTS)

May 22 - 25, 2003

Location: Berlin, GERMANY

Contact: Scientific Secretariat

VIII ECOTS Berlin 2003

c/o Catholic University of

Applied Social Sciences

Koepenicker Allee 39-57

D-10318 Berlin

Tel: +49-30-50 10 10 54

Fax: +49-30-50 10 10 88

E-mail: trauma-conference@kfb-berlin.de

Annual Conference Society for

Industrial/Organizational Psychology (SIOP)

April 12 - 14, 2003

Location: Orlando, Florida

USA

Contact: lhakel@siop.bgsu.edu

4th International Symposium on Bilingualism

April 30 - May 3, 2003

Location: Tempe, Arizona, USA

Contact:

4th International Symposium on Bilingualism

Arizona State University

PO Box 870211

Tempe, AZ 85287-0211, USA

Email: isb4@asu.edu

TERRORIST LABELS SHIFT IN POLICY WINDS

Since 2001, terrorism and counter-terrorism have become the most
critical issues in U.S. national domestic and foreign policy,
however, the definitions of terrorism and terrorists often change
depending on the current political scene either in Washington, D.C.,
or other capitals, says a Penn State researcher. In a new book,
"Images of Terror: What We Can and Can't Know About Terrorism,"
Philip Jenkins, distinguished professor of history and religious
studies, notes that defining terrorism is a highly political
phenomenon and a subjective, complex and often self-contradictory
process. "Terrorism is not a scientific formula that would be
understood identically by people in all different societies and
varying eras," says Jenkins. "The idea is shaped by politics, by
bureaucrats and the media. We need to understand how we come to see
certain terrorists as demon figures yet give a free pass to other
groups or nations that are just as dangerous." For the full story by
Vicki Fong, visit http://www.psu.edu/ur/2003/terrorismbook.html

Federal Government Implements Operation Liberty Shield

Operation LIBERTY SHIELD is a comprehensive national plan designed to increase protections for America's citizens and infrastructure while maintaining the free flow of goods and people across our border with minimal disruption to our economy and way of life. Operation LIBERTY SHIELD is a multi-department, multi-agency, national team effort. It includes:

� Increased security at borders

� Stronger transportation protections

� Ongoing measures to disrupt threats against our nation

� Greater protections for critical infrastructure and key assets

� Increased public health preparedness

� Federal response resources positioned and ready

For the full story, go to: http://www.fema.gov/nwz03/nwz03_ridge.shtm

Security Council resumes debate on Iraq

27 March � The United Nations Security Council today resumed its first debate on Iraq since hostilities began on 19 March, with a majority of speakers so far calling for an end to what they called illegal aggression and demanding the immediate withdrawal of invading forces. For the full story, go to: http://www.un.org/apps/news/story.asp?NewsID=6584&Cr=iraq&Cr1=

Local UN staff still working in Iraq to bring relief to civilian population

27 March � United Nations relief agencies reported today that their 3,400 local staff in Iraq were doing all they could to bring relief to the civilian population and perform their functions despite the withdrawal of international personnel on the eve of hostilities. For full story, go to: http://www.un.org/apps/news/story.asp?NewsID=6587&Cr=iraq&Cr1=relief

Annan, Condoleezza Rice hold talks on Iraq and humanitarian situation

25 March � United Nations Secretary-General Kofi Annan met today with United States National Security Adviser Condoleezza Rice to discuss the situation in Iraq, including the humanitarian conditions and the requirements for providing assistance to the Iraqi people. For full story, go to: http://www.un.org/apps/news/story.asp?NewsID=6569&Cr=iraq&Cr1=relief

What Is Shock and Awe?

Shock and Awe is NOT an endorsement of a disregard for civilian casualties. It is an offshoot of the modern US military policy to ensure overwhelming force for any campaign, a tenet of the so called Powell Doctrine. Shock and Awe extends the idea of force to include knowledge of the environment. Technology now allows us almost immediate information about all aspects of the battlefield. This should allow very rapid dominance in such a case. Rapid dominance, in concert with various psychological operations and non lethal weapons used to created confusion (E-bombs), can quickly destroy the enemies will to resist. Indeed, if the appropiate awe is achieved in the enemy very quickly, loss of life for both sides can be reduced. To learn more and find out how to get the book that is behind this concept, go to: http://www.amazon.com/exec/obidos/ASIN/1579060307/qid%3D1048795317/sr%3D11-1/ref%3Dsr%5F11%5F1/002-6790950-0751221

PSYOPS: Psychological Operations

An interesting look at the psychological aspects of warfare from Medscape Psychiatry eJournal Medscape General Medicine 5(1) 2003 Access article online at: http://www.medscape.com/viewarticle/449268

Following are a number of alternative News Links:

British Broadcasting Company:

http://news.bbc.co.uk/2/hi/middle_east/2889635.stm

http://news.bbc.co.uk/2/hi/technology/2888589.stm

http://news.bbc.co.uk/2/hi/middle_east/2873661.stm

Canadian Broadcasting Company:

http://www.cbc.ca/

Mexico:

La Jornada
http://www.jornada.unam.mx/

El Heraldo de Mexico
http://www.heraldo.com.mx/

CHILE - Chilean firms questioned in money laundering for Al Qaeda
http://www.abc.net.au/news/newsitems/s818118.htm

Five-Foot Snowdrifts Snarl Colorado and Wyoming

A blizzard buried parts of Colorado and Wyoming in 5-foot snowdrifts last week, shutting down state governments, stranding thousands of people and tearing the Denver airport's roof.

Gov. Bill Owens called out the National Guard to rescue stranded motorists, and officials in both states warned residents to stay home unless travel was absolutely necessary. One fatal accident was reported in Wyoming. For the full story, go to: http://www.fema.gov/press/ap/ap031903.shtm

RESEARCHERS WORKING ON CONTRACEPTION FOR WILD HORSES

It's a long way -- in terms of miles, habitat and species -- from
domesticated ponies in the verdant meadows of central Pennsylvania to
wild mustangs in the parched high deserts of Arizona, California,
Nevada, New Mexico and Wyoming, but research under way in Penn
State's College of Agricultural Sciences is bringing them closer
together. Researchers hope that contraception methods that seem to
work in a small herd of ponies kept in a lush, partially wooded
pasture at the Penn State Horse Farm not far from Beaver Stadium can
be applied to hundreds of thousands of wild horses out West where
overpopulation is straining habitats and wildlife management budgets.
For the full story by Jeff Mulhollem, visit http://aginfo.psu.edu/News/march03/horse.html

CHILDREN'S RESPONSES TO TERRORISM

Introduction

School shootings. Devastating earthquakes. Severe floods. Deadly motor vehicle crashes.
Terrorist attacks. Many communities and individuals endure these and other extraordinary
experiences so horrifying in their effects that we call them disasters. Over the past two
decades, the world has witnessed an increasing number of disasters involving massive exposure of
the population to radiation, chemical toxins, or other hazardous agents. Terrorist acts such as
that on September 11, 2001 create apprehension about possible further attacks, perhaps with
biological or chemical weapons. The term "ecological disaster" is used to indicate these
incidents, which are often followed by widespread fear of future adverse health effects (Havenaar et al, 2002).
Concerns or worries about health tend to facilitate the appearance of medically unexplained
symptoms or syndromes. This mental health component has received relatively little attention in
the disaster literature. The events of September 11, 2001 highlighted the realities of
terrorism for most Americans and underscored the importance of understanding how children and
adolescents react to disasters and terrorism.

The tragedies of September 2001 and subsequent events are still too recent to have yielded an
empirical perspective on their impact on children, adolescents, and families. LaGreca et al (2002) reviewed the
current state of knowledge regarding children's reactions to disaster and terrorism, and provide
the background and conceptualization needed for framing mental health interventions and future
research efforts. They provide a systematic review of children's and adolescents' reactions to
specific disasters and the factors that contribute to those reactions. They also reviewed the
current state of interventions that have been developed to address children's and adolescents'
mental health needs following disasters.

Background

The recent wave of terrorism affecting the United States and other countries raises concerns about the
welfare of children and adolescents. Prior studies suggest that level of exposure, evidence
of psychopathology before trauma exposure, and disruption in social support networks consistently
emerge as strong predictors of psychopathology following trauma exposure (Pine and Cohen, 2002). Clinicians may wish to
monitor children exposed to trauma most closely when they present with these risk factors. When
combined with other data from open studies and controlled trials in nontraumatized children,
studies suggest that Cognitive Behavioral Therapy (CBT) is an option for children
developing anxiety symptoms following terrorism events (Pine and Cohen, 2002).

There are a number of relevant studies with children following recent terrorist events both within and outside the United States. Nineteen infants and children were killed in the 1995 terrorist bombing in Oklahoma City, and many
were injured. More than 200 children lost 1 or both parents. These casualties focused attention
on children in the disaster response efforts. Pfefferbaum, Call and Sconzo(1999) describe the development and
implementation of a school-based mental health program that provided accessible services to
children affected by the bombing, with an emphasis on normalization. A clinical needs assessment
of all children in the Oklahoma City public school system was carried out, and clinicians
provided emergency and crisis services, counseling, and support groups.

Several thousand children were suddenly bereaved by the terrorist attacks on the United States on
September 11, 2001. The New York Times estimated that possibly 15,000 children lost a father or
a mother who, in many cases, was a single parent. The exact number of missing and dead changed
daily after the disaster, as body parts were retrieved in the rubble and identified through DNA
testing. This was a very slow process, however, and three months following September 11 there were still
3,045 persons reported dead or missing at the New York World Trade Center and 495 death
certificates issued by the medical examiner's office. An additional 1,976 death certificates were
issued at the request of families. At the Pentagon, 189 were dead or missing three months after September
11. In addition there were 246 passengers and crew who perished on the four hijacked planes and
19 hijackers. Several hundred police, firefighters, and other rescue personnel were also among
the victims (Webb, 2002).

Brown (2002) discusses mental health trauma responses to the events of September 11th. He
maintains that like most trauma responses, reactions to the events of September 11th occurred in
three phases: crisis intervention, short-term reactions, and long-term planning. He reflects on
observations as a New York City (NYC) mental health professional, Director of Trauma Services and
Program Evaluation for the New York University Child Study Center's Child and Family Recovery
Program, and as an NYC resident. He concludes that mental health professionals have not yet
begun to understand the mental health impact of September 11th on children in NYC and around the
country. He suggests that as needs are identified, strategies for service delivery must continue to change.

Studies of health care use after the September 11 terrorist attacks complement prior
research on the subject. Hoge, Pavlin and Milliken (2002) used the Electronic Surveillance System for the Early
Notification of Community-based Epidemics (ESSENCE) data base to conduct behavioral health
surveillance among military health system beneficiaries in the Washington, D.C., area following
the September 11 attack on the Pentagon. Diagnostic groups for depression, anxiety, acute and
posttraumatic stress disorders, substance-use disorders, and other behavioral health problems
were defined according to the ICD-9. Although there was no significant increase in the total
number of visits to behavioral health clinics, there were significant increases in the number of
visits for anxiety disorder and acute stress reactions in children and for adjustment reactions
in adults.

The goals of short-term intervention in the setting of a crisis event are to help
children understand and accept the events that have occurred; to identify, express, and
comprehend their emotions; to begin to regain a sense of control and mastery over their life;
and to resume developmentally appropriate activities. Schonfeld (2002) discusses what the developmental-behavioral pediatrics field has learned since September 11,
2001 about the management of posttraumatic symptoms and reactions of children in the setting of
terrorism. He notes that parents and other adults who
support children, such as teachers, often underestimate the extent of childrens' reactions to a
crisis situation, especially those related to internalizing symptoms.

Research

Child-focused disaster research is a relatively new area of study. It has grown
substantially in recent years and will continue to develop in the aftermath of the
September 11th terrorist attacks. The first generation of studies has
focused predominantly on documenting children's and adolescents' reactions to disasters and
identifying factors that correlate with or predict severe disaster reactions. Studies have begun
to examine interventions for children following disasters. However, this line of research is
still in a preliminary stage
(LaGreca et al, 2002). The field has yet to develop empirically supported interventions
for children and youth following disasters. A broadened research agenda is needed to advance our
understanding of how children are affected by disasters, which youth are most at risk, and when
and how to intervene. Key issues include the need for researchers and clinicians in the child
mental health field to help advance knowledge of the effects of disasters on children and youth
and the need to develop and evaluate empirically based treatments for child disaster victims.
Researchers and clinicians need to become advocates for children's needs following disasters and
to become attentive to public policy.

Fields (1979) proposed that persons exposed to terrorism in childhood often develop into adult
terrorists. To explain why this does not occur in every country or period, it is argued
that when institutions and legal codes are an outgrowth of the indigenous culture, they
provide support for the population in times of stress. When the legal system and
institutions are imposed on the population by an alien group, they tend to actively
alienate the young, as has happened in Northern Ireland. Based on experience administering
standardized tests to hundreds of children in Northern Ireland since 1971, Fields
believes that children exposed to terrorism have suffered a severe disruption in the
development of moral judgment. The developmental process of changing from a victim to a
terrorist is discussed in this context.

Ben-Eli and Sela (1980) engaged 60 children in therapy who, as a result of the 1979 terrorist attack on
Nahariya, Israel, evidenced the following symptoms: fear of noise, the dark, and the
seashore; lack of concentration; and difficulty sleeping. Ss were divided into small
groups (6-8 members) that met close to the time of original crisis. Strong emphasis was
placed on catharsis and cognitive reconstruction of the traumatic events. Feelings of
anger, terror, and blame were allowed to be vented freely. Results of this active coping
with the stress situation and application of relaxation and desensitization techniques
indicate that most Ss' school and home functioning improved.

Dreman and Cohen (1982) suggest that much of the trauma precipitated by terrorist activities is a result of
their suddenness, their salience in the public consciousness, and the consequent stigma
they produce toward survivors and/or relatives of victims. A number of specific issues
were common in the 2 case studies presented and in other families affected by terrorism.
These included dealing with the need to be a "superparent" and correcting unrealistic
expectations; teaching effective limit setting, including giving permission to be a
parent and an adult; and dealing with guilt and phobic reactions, and family and network
reorganization. Therapy concentrated on promoting family strengths and coping, and it
deemphasized individual pathology. Common to most families treated was the strong desire
of the victim's children to be treated as normal and not as psychological casualties.
Family therapy proved to be an ideal treatment modality for dealing with the tragic loss.
By focusing on the problems of day-to-day living, the mourning work evolved naturally in
the course of therapy. Specific therapy modalities, such as co-therapy and network
intervention, facilitated family adjustment.

Lahad and Abraham (1983) tested the effectiveness of a program of intervention aimed at preparing teachers and
pupils to cope with the continual acute stress caused by war and terrorist activity. 86
experimental and 82 control 3rd, 5th, 6th, and 7th graders in parallel classes; 8 teachers;
and 3 school staff members were studied. Experimental Ss completed a situation anxiety
scale, a variation of the Q-sorts method, guided observations, and a personal
questionnaire. Teachers completed a personal questionnaire, and observation data were
also obtained on them. Before and after the program there was a simulated alarm, after
which the children stayed in the shelter for 2 hrs. In the shelter, the children's
behavior was observed. After leaving the shelter, the various questionnaires were
administered. Observations were also made of the same children under an authentic alarm
situation. The teachers' preparatory program spanned 2 trimesters of the school year.
The classroom interventions were conducted by the teacher and program leader in 9 weekly
2-hr meetings. Results indicate that the intervention program led to a decrease in
situational anxiety in the experimental classes, whereas in the control classes the
situational anxiety increased. In the experimental classes, changes occurred in the
internal organization of the "self" toward greater openness and readiness to admit
anxiety and to cope with it in sublimated, resourceful ways.

Rigamer (1986) described a 6-mo intervention program conducted for teachers, parents, and 122 children
(kindergarten-22th grade) in an American diplomatic community following the assassination
of the American ambassador in Kabul. Adults' initial response to the effect of the trauma
on the children was denial, a dynamic that had to be addressed before
suggestions could be utilized. Most of the children mastered the psychological effects
of the trauma through repetitive narrations, drawings, and play, activities that seemed
necessary to restore emotional equilibrium. A small number of children appeared to adapt
by shutting out all stimuli emanating from the event.

Koplewicz et al (2002) evaluated children's symptoms three and nine months after the 1993 bombing of the World
Trade Center, and the relationship between parent and child reactions when only the children had
been in the building. Nine children who had been trapped in an elevator, 13 who had been on the
observation deck, and 27 controls completed the Posttraumatic Stress Reaction Index and a Fear
Inventory. Parents completed these measures about the children and comparable measures about
themselves. Exposed children reported posttraumatic stress disorder (PTSD) symptoms and disaster-
related fears; their parents reported experiencing PTSD symptoms. Only parents rated children's
symptoms as decreasing significantly over time. Association between child symptoms and parent
symptoms increased over time. Children's initial distress predicted parents' distress nine months
postdisaster.

Gurwitch et al (2002) describe how the bombing of the Murrah Building in Oklahoma City led to some
of the first investigations of the effects of terrorism on U.S. children. They examined
the prevalence of posttraumatic stress disorder (PTSD) symptoms among children and adolescents
following the bombing and point out how subsequent events related to the bombing (namely, the
constant media attention to the bombing and the later criminal proceedings) took their toll on
the victims and families who lost loved ones. Their findings highlight that the crisis-
intervention model of handling disasters is insufficient. They call for ongoing
involvement by mental health professionals who have expertise in working with traumatized
individuals and communities. Given that most children received no systematic help from a mental
health professional to deal with their reactions soon after the bombing, it is reasonable to
assume that most children also received little or no attention to deal with the events that
occurred subsequent to the bombing (e.g., the trial and the execution). Gurwitch et al (2002) suggest that
the crisis-intervention model is too narrow and too brief, and it fails to recognize the various
psychological experiences that victims likely go through as different phases of the event unfold.

In a previous study, Pfefferbaum et al (2000) describe Posttraumatic Stress Disorder (PTSD) symptomatology in 69 6th-grade youths who
resided within 100 miles of Oklahoma City at the time of the 1995 bombing of the Alfred P.
Murrah Federal Building. These youths neither had any direct physical exposure nor personally
knew anyone killed or injured in the explosion. A survey conducted 2 yrs after the bombing
assessed exposure, PTSD symptoms, and functioning. PTSD symptom frequency was measured with the
Impact of Event Scale-Revised. Criteria for defining PTSD caseness was modeled after Mental
Disorders-IV (DSM-IV) B, C, and D (BCD) criteria requiring 1 reexperiencing, 3 avoidance/numbing, and
2 arousal symptoms for diagnosis. Those who met BCD criteria had significantly higher PTSD
symptom scores than those who did not. Both increased mean PTSD symptom score and meeting the
authors' caseness definition were associated with increased functioning difficulties. Media
exposure and indirect interpersonal exposure (having a friend who knew someone killed or injured)
were significant predictors of symptomatology. Findings suggest that children geographically
distant from disaster who have not directly experienced an interpersonal loss report PTSD
symptoms and functional impairment associated with increased media exposure and indirect loss.

Schlenger et al (2002) assessed psychological symptom levels in the United States following the events of September 11 and
examined the association between postattack symptoms and indices of exposure to the events. One
and two months after the attacks, 2,273 adults, including oversamples of the New York, NY, and
Washington, DC, metropolitan areas, responded to a Web-based survey that included the
Posttraumatic Stress Disorder (PTSD) Checklist and the Brief Symptom Inventory. Outcome measures
included self-reports of the symptoms of PTSD and of nonspecific psychological distress, as well
as adult reports of symptoms of distress among children living in their households. The
prevalence of probable PTSD was significantly higher in the New York City area than in Washington,
DC and the rest of the country. Overall distress levels across the country, however, were within
expected ranges. Sex, age, direct exposure to the attacks, and the amount of time spent viewing
TV coverage of the attacks on September 11 and the few days afterward were associated with PTSD
symptom levels. Sex, the number of hours of TV coverage viewed, and the content of that coverage
were associated with the broader distress measure. Over 60% of adults in New York City households
with children reported that one or more children were upset by the attacks.

Stuber et al (2002) assessed the prevalence and correlates of counseling received by 4-17 yr olds living in
Manhattan for experiences related to the September 11, 2001 terrorist attacks. 112 parents or
primary caretakers were interviewed about their child's level of exposure to the disaster, the
extent of loss, receipt of counseling services, and behavioral reaction. Results show that 22%
of the children had received some form of counseling related to their experiences after the
disaster. 58% of the counseling received was delivered in schools. Predictors of counseling in a
multivariate model were male sex, having a parent with current posttraumatic stress disorder
(PTSD) related to the attacks, and having at least one sibling living in the household. Stuber et al
concluded that parents' own level of posttraumatic stress was associated with whether their
children received counseling related to the attacks.

Dreman and Cohen (1990) reported a 10-yr follow-up of early intervention with four children exposed at ages 6-11 yrs
to the killing of one or both of their parents by terrorists. Ss were aged 20-22 yrs at
follow-up, permitting examination of the effects of trauma and early intervention on long-
term adjustment. Interviews suggested that psychic remnants of trauma may negatively
affect adjustment throughout children's lives. Long term adjustment of three of the Ss had the following
characteristics: fear of loss of control, pessimism, re-enactment behavior, situationally
triggered anxiety, stigma, shame, guilt, denial, impulse control problems, antisocial
behavior, and interpersonal relationship problems.

In a previous study, Dreman (1989) conducted a 10-yr follow-up of Israeli children whose parents were killed in
terrorist activities to determine posttraumatic adjustment. Therapy at the time of the
trauma concentrated on promoting family strengths and coping. Ss, however, demonstrated
considerable psychopathology. Two cases presented, together with previous findings,
suggest that early abreactive intrapsychic intervention may help prevent long-term
pathology, but interpersonal intervention may also be necessary to prevent manipulative
antisocial behavior. In the Israeli context, adjustment is likely to be strongly
influenced by recurring events such as military reserve duty, war, or terrorist activities
that re-trigger or exacerbate existing posttraumatic symptomatology.

Vicarious Stress

Mosse (1977) discusses F. Wertham's work on the mass media, which indicated that TV mainly
provides audiovisual conditioning to violence. Natural and spontaneous actions of
children have been moved toward cynicism, callousness, and indifference. TV has the
potential for aiding viewers to participate in the cultural and intellectual life of
mankind. However, the magnetic pull of violence has led to increased terrorism in the
schools, to race hatred, and to a blunted sense of the horror of violence.

Pfefferbaum et al (2001) examined the influence of bomb-related television viewing in the context of physical and
emotional exposure on posttraumatic stress symptoms--intrusion, avoidance, and arousal--in middle
school students following the 1995 Oklahoma City bombing. Over 2,000 middle school students in
Oklahoma City were surveyed seven weeks after the incident. The primary outcome measures were the total
posttraumatic stress symptom score and symptom cluster scores at the time of assessment. Bomb-
related television viewing in the aftermath of the disaster was extensive. Both emotional and
television exposure were associated with posttraumatic stress at seven weeks. Among children with no
physical or emotional exposure, the degree of television exposure was directly related to
posttraumatic stress symptomatology.

In a related study, Pfefferbaum (2001) examined the influence of exposure on posttraumatic stress disorder (PTSD)
symptomatology in children following the 1995 Oklahoma City bombing. Over 2,000 middle school
students were surveyed seven weeks after the bombing. Initial reaction and emotional exposure were
important predictors of PTSD symptomatology in the full sample. Children/adolescents who reported
no physical or emotional exposure had significantly lower scores than exposed children on
television viewing, initial reaction, and PTSD symptomatology. Within the nonexposed group,
those with high television exposure had significantly more PTSD symptoms.

Both studies suggest that children and
adolescents with strong initial reactions should be followed over time, and disaster-related
television viewing should be carefully monitored. The findings also suggest that television viewing in the
aftermath of a disaster may make a small contribution to subsequent posttraumatic stress
symptomatology in children or that increased television viewing may be a sign of current distress
and that it should be monitored. Future research should examine further whether early symptoms
predict increased television viewing and/or whether television viewing predicts subsequent symptoms.

Schuster et al (2001) assessed the immediate mental health effects of the terrorist attacks on September 11, 2001.
Using random-digit dialing 3-5 days after September 11, they interviewed a nationally
representative sample of 560 US adults about their reactions to the terrorist attacks and their
perceptions of the reactions of their children (aged 5-18 yrs). Forty-four percent of the adults
reported one or more substantial symptoms of stress. Ninety percent had one or more symptoms to
at least some degree. Respondents throughout the country reported stress symptoms. They coped by
talking with others (98%), turning to religion (90%), participating in group activities (60%),
and making donations (36%). Eighty-four percent of parents reported that they or other adults in
the household had talked to their children about the attacks for an hour or more. Thirty-four
percent restricted their children's TV viewing. Thirty-five percent of children had one or more
stress symptoms. Forty-seven percent were worried about their own safety or the safety of
loved ones. They concluded that after the September 11 terrorist attacks, Americans across the
country, including children, had substantial symptoms of stress. They suggest that even clinicians who practice in
regions that are far from the recent attacks should be prepared to assist people with trauma-related symptoms of stress.

The events of September 11, 2001 have affected us in different ways. PTSD symptoms have been
reported in children who have watched TV coverage related to Halloween, war, industrial disaster,
and terrorist bombing. Duggal, Berezkin and John (2002) report the case of an 11-yr-old boy who developed posttraumatic
stress disorder (PTSD) along with major depression after watching the terrorist attacks on the
World Trade Center on TV. The patient was in the 7th grade in a boarding school. Overwhelmed by
the events, he impulsively decided to commit suicide, but was prevented from doing so. This case
demonstrates that a child who is exposed to traumatic events on TV can develop PTSD symptoms and
has implications for media personnel, teachers, parents, and clinicians.

Previously, Vila et al (2000) presented a clinical case of posttraumatic stress disorder (PTSD) by indirect exposure to the
trauma and data from follow-up in a department of child psychiatry of 10 of 29 children who were
taken hostage and their parents. These children (directly exposed to the aggression) and their
parents (indirectly exposed since they were not taken hostage but had a great empathy) were
examined to assess mental disorders using Mental Disorders-IV (DSM-IV) diagnostic criteria.
Children were assessed also with self-administered questionnaires for anxiety and traumatic
stress. Nine pupils presented a PTSD, incomplete or full syndrome. In five families (50%), the
parents had post-traumatic disorders: seven fathers or mothers. One mother had an acute stress
disorder. Another had an adaptation disorder with antidepressive symptoms and symptoms of PTSD.
In conclusion, their results demonstrate the reality of PTSD by indirect exposure. From a nosological
viewpoint, they raise the question of the limits of the concept of traumatic stress. From a
practical point of view, when a child has been directly victim of an aggression, it seems
important to also examine his parents and siblings, who are indirectly exposed and may induce or
maintain post-traumatic disorders of the child, particularly when other risk factors are present.

Pfefferbaum et al (2000) examined effects of traumatic loss on children who reported a friend or acquaintance killed
in the 1995 Oklahoma City bombing of a federal office building. Twenty-seven 3rd-5th grade children who
lost a friend or acquaintance and 27 demographically matched controls were assessed 8-10 months after
the bombing. All but three of the children continued to experience posttraumatic stress symptoms.
Those who lost a friend watched significantly more bombing-related television coverage than those
without losses. Those who lost a friend had significantly more posttraumatic stress symptoms at
the time of the assessment than those who lost an acquaintance. She concluded that parents and
those working with children should be alert to the impact of loss even when it involves nonrelatives.

Following the terrorist bombing in Oklahoma City in 1995, a bombing exposure screening
questionnaire was developed for children and adolescents who lived in Oklahoma City at that time (Peak, 2000).
It was administered throughout the school system and was completed by approximately 3,000
students in grades six through twelve. The purpose of this study was to determine the severity
of PTSD symptoms reported by children and adolescents at seven weeks after the bombing. Relationships
between gender, severity of vicarious exposure, and PTSD severity were also examined. This study
controlled for effects of direct personal exposure by including only those participants who did
not hear or feel the blast (N = 817). Results showed that females reported significantly higher
posttraumatic stress severity scores than males. Additionally, those children and adolescents who
knew someone who was injured or killed by the blast (vicarious exposure) reported higher
posttraumatic stress severity than those who did not. However, no significant interaction of
gender by vicarious exposure for PTSD severity was found. The results of this study suggest that
further research is needed to define how best to assist children and adolescents in processing
their reactions following a traumatic event of this extent.

Cultural Factors

Violence stemming from ethnic and political tensions is a problem of increasing proportions
throughout the world, and many indicators show that large numbers of children are directly or
indirectly exposed to war, political repression, torture, and terrorism. There is growing
evidence to suggest that children are at risk under these conditions, and that the consequences
of growing up amid danger, chaos, and deprivation can be severe (Ladd, 1996).

Since the establishment of the State of Israel in 1948, the civilian population has endured many
terrorist attacks. This reality, together with an expanded network of mental and social services,
has led to the development of extensive interventions directed toward helping those people who
experienced these terrorist attacks. Over a period of many years, Shalif and Leibler (2002) have worked
extensively with children and adults in Jewish communities in Judea and Samaria who have been
subjected to terrorist attacks. They describe how narrative therapy ideas and practices aid
their work. They also present a deconstructive analysis of existing discourses on trauma
and crisis, demonstrating the use of narrative ideas and practices, and present a number of
vignettes of people dealing with the hardships related to ongoing peril and terror.

Melville and Lykes (1992) describe the emotional, social, and cultural effects of government-sponsored terrorism
on 32 Mayan children in Guatemala and 36 Guatemalan children who were exiled in Mexico
(aged 8-16 yrs). The two groups were compared with respect to the negative effects of civil
war and the adaptive capabilities of children who had experienced the trauma of loss of
immediate family members, the witnessing of violent crimes, and displacement from their
homes. Open-ended interviews, observations, taped personal stories, and traditional
psychological instruments were used to examine the Ss' well-being. Ss experiencing the
most fear were in Guatemalan villages. Ss in Mexican refugee camps were less fearful.

Miller (1996)Examined the mental health and psychosocial development of 58 Guatemalan Mayan Indian
children (aged 7-16 yrs) living in two refugee camps in Chiapas, Mexico. Assessment instruments
and semistructured interviews were utilized to gather phenomenological data from Ss regarding
developmental, sociocultural, and political topics. Results show minimal evidence of
psychological trauma in this sample. Various factors are suggested to account for this
finding. A positive relationship between Ss' mental health and the physical and mental health
status of their mothers was found. A strong association between depressive symptomatology in
girls and poor health status in their mothers was also found. Qualitative data from the
interviews are presented, focusing on Ss' understanding of why their families fled Guatemala,
the nature and causes of the violence, and their thoughts and feelings regarding the prospect of returning to Guatemala in the future.

Sack et al (1986) studied 40 Cambodian students (average age 17 yrs) who survived four yrs under the Pol Pot
regime and six age-matched controls who escaped prior to Pol Pot, using home interviews and
school teacher ratings. In their findings, Ss reported more distress with school grades,
peers, and themselves than was observed by their caretakers. Many family members exhibited
similar posttraumatic stress and depressive symptoms. In school, Ss receiving a
psychiatric diagnosis were more likely to be rated by their teachers as withdrawn than as
disruptive. A case vignette of a 16-yr-old girl is presented. Results emphasize the
crucial role of the school and responsibilities and opportunities for ESL teachers in
helping refugee students to make a major and difficult transition.

Kinzie et al (1986) described the psychiatric effects on 40 Cambodian students (average age 17 yrs) in the US
who suffered massive trauma from 1975 to 1979 compared with 6 age-matched refugees who
escaped the Pol Pot regime. Ss endured separation from family, forced labor, and
starvation, and witnessed many deaths. After 2 yrs of living in refugee camps, they
immigrated at about age 14 yrs. Four years after leaving Cambodia, 20 Ss developed
posttraumatic stress disorder; mild, but prolonged depressive symptoms were common.
Psychiatric effects were more common and more severe when Ss did not reside with a family
member.

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ROCKY MOUNTAIN REGION DISASTER MENTAL HEALTH NEWSLETTER

MENTAL HEALTH MOMENT March 28, 2003

CHILDREN'S RESPONSES TO TERRORISM

Helping Children Cope With Disasters and Terrorism