Deconstructing Terrorism: Research Review, Limitations, & Clinical Implications

Valdes-Lopez, Trauma & Development, July 16, 2009

Deconstructing Terrorism: Research Review, Limitations, &

Clinical Implications

Harvard University

Summer School

Sandra Valdes-Lopez

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Discussion Outline Defining our terms & the parameters of our

conversation Survey of Research trends Nationally &

Internationally General Research Trends Individual Study Examinations

Challenges & Limitations Clinical Implications Questions


Class Conversation:

Why & how might one’s understanding of the definition of terrorism impact his or her ability to conduct research and clinically treat people affected by terrorism?


Defining our Terms What is Terrorism?

Terrorism is word that is both politically and emotionally charged

Terrorism expert, Walter Laquer, American historian & political commentator, has counted over 100 definitions and concludes that the “only general characteristic generally agreed upon is that terrorism involves violence and the threat of violence”


What is Terrorism?

US Department of Justice defines terrorism as “the unlawful use of force or violence against persons or property to intimidate or cover as the government, the civilian population, or any segment thereof, in pursuance of political or social objectives” (1996).


Defining our terms cont’d… Alexander and Klein (2003) summarize that

terrorism has the following aims: Creating mass anxiety, fear, and panic; Creating helplessness, hopelessness, and

demoralization; Destroying our assumptions about personal security; Disruption of the infrastructure of society, culture or

city; and Demonstrating the impotence of the authorities to

protect the ordinary citizen and his or her environment


For our intensive purposes…

World Health Organization (WHO) defines disaster as “a severe disruption, ecological and psychosocial which greatly exceeds the coping capacity of the affected community” (WHO, 1992)


Why research in this area? Changing paradigms of conflict, warfare, and

violence (Williams, 2007) Some approximated facts relating data from 1993-

2003(1.) Two million children were killed and six million children

were injured or permanently disabled in war zones(2.) Of war-exposed survivors, one million children were

orphaned and 20 million displaced to refugee camps or other camps.

(3.) Civilians comprise 80 to 90% of all who die or are injured in conflicts--mostly children and their mothers” (Barenbaum, Ruchkin & Schwab-Stone, 2004; Dyregrov, Raundalen, Lwanga, & Mugisha Williams, 2006)


Why research cont’d…

In summary, there is mounting evidence that, with changing paradigms of conflict and war and the rapid emergence of terrorism as a major concern in the early 21st century, children are increasingly involved, directly and indirectly, in mass physical and psychological violence (Williams, 2007).


General Trends: Psychosocial factors & variables Impact and burden: Direct & Indirect effects Developmental level Nature of Trauma Staged or Phased Responses ‘Normal’ reactions Direct impacts on children Acute stress responses PTSD Psychological and emotional factors


Impact & Burden: Direct & Indirect Effects Children can directly and indirectly be impacted

by trauma (e.g., terrorism) Indirect impacts are related to the attitudes,

perceptions, and behaviors of parents, family members, & other caregivers

Note variance: Parents’ sensitivities may be unchanged, reduced, or heightened as a result of the violence (Angold, Messer, Stangl, et al., 1998)


Developmental level There is an evident cognitive variance across

various developmental stages Symptoms are dependent on the development

stage of the child, the level and type of exposure, and the child’s individual vulnerabilities and protective factors (Joshi & Lewin, 2004): Ex 1: Pre-school children are less aware of the nature and

meaning of threat, so they derive “threat” from “parental-referencing”. If emotions and behaviors become disorganized, children may lose of their developmental capacities (e.g., bowel & bladder control) (Shooter, 2005)


Developmental level cont’d…

Ex 2: School-aged children with a greater appreciation of danger may exhibit: Disruptions in sleep & appetite Deviation in academic performance Lapse into anxiety Depressive & somatic disorders (Shooter,

2005)


Developmental level cont’d… Adolescents may show more adult-like

responses, including: Open fear of death Hedonistic resort to impulse Delinquent, sexual, substance misusing behaviors Resistance to sharing feelings Particular dependence on their peer group reaction Possible loss of faith in adult ability to provide

security Possible exhibition of apathetic behavior or attitudes


Nature of Trauma Event Trauma versus Process Trauma

Event Trauma refers to sudden, unexpected occurrences that are limited in time and space

• May produce classical post-traumatic symptoms• Specific fears, anxiety & depressive symptoms• Repetitive and Regressive behaviors• Loss and Grief• Development effects• Changed attitudes to self and others (Shaw & Shaw, 2004)


Nature of Trauma cont’d… Process Trauma is characterized by

continuing exposure to enduring stress• Includes post-traumatic symptoms• Spectrum of developmental, emotional, and

behavioral problems that are “associated with chronic stress and interweaving of the dramatic experiences into the emerging personality” (Shaw & Shaw, 2004)


Staged or phased responses Another consideration is the passage of time

after major violence or traumatic events Adjustment to traumatic events is not linear Therefore, what one may see when looking at

children after episodic or recurrent violence depends on where they are in their personal story that involves responding to the impact, recoil afterwards followed by a longer period of adjustment (Raphael, 1986)


Staged or phased responses… May include:

Stunning and numbness; Anxiety and fear; Horror and disgust; Anger and scapegoating; Paranoia; Loss of trust; Demoralization, hopeless, and

helplessness; Survivor and performance guilt; and False attributions (Alexander & Klein, 2003)


‘Normal’ reactions

Particular patterns of response depend on: Developmental level, Culture, Family and community support (Alexander,

2005)


Fig.1. ‘Normal’ responses; (Alexander, 2005)

Emotional Reactions

DisasterPhysical Reactions

Cognitive Reactions

SocialReactions


Table I. ‘Normal’ reactions to trauma (Alexander, 2005)

Emotional reactions Cognitive reactions

Shock and numbness Impaired memory

Fear and anxiety Impaired concentrationHelplessness and/or Confusion or

hopelessness disorientationFear of recurrence Intrusive thoughtsGuilt Dissociation or denialAnger Reduced confidence

or self-esteemAnhedonia Hypervigilance


Table 1: cont’d…

Social reactions Physical reactionsRegression InsomniaWithdrawal HyperarousalIrritability HeadachesInterpersonal conflict Somatic complaintsAvoidance Reduced appetite

Reduced energyCardiovascular

responses(Gump et al., 2005)


Direct Impacts on children As time passes, children may return to previous

changed patterns of adjustment but they may also develop more enduring symptoms of psychopathology Acute, medium, and longer-term psychopathology

includes:• Acute stress responses;• Chronic stress responses;• Psychiatric disorders including:


Direct impacts cont’d… Psychiatric disorders including:

Emotional anxiety and phobic disorders; Mood and particularly depressive disorders Adjustment disorders; Substance misuse; Conduct disorder Somatoform disorders; Attention deficit hyperactivity disorder; PTSD Affect regulation problems

With trauma, Shaw and Shaw (2004) remind us that co-morbidity is often times the “rule rather than the exception”





Psychological and emotional effects Domains of psychological development:

Affect control Identity Perception of the world Perception of self, self-esteem, and self-efficacy Trust Safety Interpersonal skills Interpersonal relations Moral development (Williams, 2006; Dalgleish et al., 2005; Lubit & Eth,

2003; Ursano & Norwood, 2003; Ursano et al., 2003)


Domains of emotional development (Williams, 2006)

Direct effects Problems with reflecting on and

managing own feelingsPainful memoriesRegressionFearFantasies of retaliationPoor impulse controlPreoccupation with/compulsive

repetition of aggressionSubstance misuseRisk-taking


Domains cont’d… Indirect, or secondary, effects are due to or intensified by:

Failing to meet children’s needs

Loss and grief

Effects of adults’ own distress

Effects of adults’ changed views of the world

Loss of routine

Loss of places of education & social gathering

Effects of circumstances on the pace of social, educational and psychological

development

Magical thinking


Individual Study Examinations

Studies in the US Dominant research has focused on 9/11 Trauma is single-event centered Exposure to trauma tends to be secondary or

indirect (e.g. through the media) Similar methodology often involving child

self-reporting and parent reporting (most often the mother)


What did these studies find? Provided further support for the existence of

secondary trauma: Study 1: Researchers examined children’s media use

(i.e. amount of television & Internet usage) and relationships to children’s perceptions of societal threat and personal vulnerability to world threats (e.g. terrorism, crime).

The sample consisted of 90 community youth aged 7 to 13 from diverse economic backgrounds

Analyses found children’s television use to be associated with elevated perceptions of personal vulnerability to world threats (Comer,et al., 2008)


US Research Findings… Comorbidity is common amongst children

exposed to terrorism Study 2: The impact of exposure to the WTC attack

on children presenting separation anxiety disorder (SAD) 6 months after the attack was studied in a sample of NY city public school students (N= 8,236)

SAD occurred in 12.3% of the sample and was more frequent in girls, young children, and children who had been exposed to traumatic situations


Study 2: SAD was found to be highly comorbid with PTSD Direct exposure to the attack or to television

coverage of the attack was associated with probable SAD or a number of SAD symptoms, whereas proximity to Ground Zero or family member exposure were not (Hoven, et al., 2004)

The identified pattern of associations existed independently of a child having PTSD

Meaning….SAD should be considered among the conditions likely to be found in children after a large-scale disaster


Study 3: Cumulative trauma greatly impacts children’s

responses to terrorism 2.5 years after 9/11, 204 middle school students in an

immigrant community located near Ground Zero were assessed for PTSD

90% of students reported at least one traumatic event other than 9/11 (e.g., community violence) with an average of 4 lifetime events reported

Among students with the lowest number of additional traumas, the usual dose-response pattern of increasing PTSD symptoms with increasing 9/11 exposure was observed


Study 3 cont’d… Among those with medium to high cumulative

life trauma, PTSD symptoms were substantially higher and uniformly so regardless of 9/11 exposure dose

Results suggest that traumas that precede or follow mass violence often have as much if not greater impact on long-term symptom severity than high-dose exposure to the event (Mullet-Hume, Anshel, Guevara, Cloitre, & 2008)


Study 4: Gershoff & Aber (2004)

Background Research Role and Interaction of pre-existing

factors with impact of trauma Role of Indirect Exposure


Taken from Joshi & Lewin (2004)




Gershoff & Aber (2004) Background research from:

Challenger space shuttle explosion (Terr et al., 1999; Wright, Kunkel, Pinon, & Huston, 1989)

Oklahoma City federal building bombing (Pfefferbaum et al., 1999, 2001)

Hurricane Andrew (La Greca, Silverman, Vernberg, & Prinstein, 1996; La Greca, Silverman, & Wasserstein, 1998),

War (Macksoud & Aber, 1996; Macksoud, Aber, & Cohn, 1996)


Pre-existing Factors

Nature Amount Parents’ levels of distress response Previous exposure to trauma

Mullet-Hume, Anshel, Guevara, & Cloitre (2008)

Social Support (family, friends, or religion)


Pre-existing Factors… Coping Skills Demographic characteristics

Age Gender Race or Ethnicity

Previous levels of mental health Depression & Anxiety

Intensity of exposure Direct Indirect media or family exposure to events (“distant

trauma”)


Role of Pre-existing factors & context: Study 5

Gershoff, Ware, & Kotler conducted a longitudinal study examining the effects of exposure to 9/11 as well as exposure to other forms of community violence on change in the mental health & social attitudes of youths in NY city

3/4 of youths reported some form of direct exposure to at least 1 form of media coverage of 9/11


Gershoff, et al. (2004)

Results demonstrated that direct exposure and family exposure to the event did not predict change in any mental health outcomes, but did predict change in levels of social mistrust

Media exposure did predict PTSD symptoms as well


Intensity & Type of Exposure Research confirms the role of media exposure in

causing distant trauma Schuster et al. (2001): Parents reported that children

watched an average of 3 hr of coverage of the terrorist attacks

1/3 of parents restricted their children’s viewing of the coverage

Among parents who did not restrict TV watching, parent reports of children’s TV viewing were significantly associated with child stress symptoms


Intensity & Type of Exposure Research has also shown that exposure to both

negative media images of the attacks (e.g., a plane flying into a building) as well as positive media images (e.g., images of heroics, helping, or rescuing) has been associated with higher levels of PTSD symptoms among children geographically distant from the attacks (Saylor, Cowart, Lipovsky, Jackson, & Finch, 2003)


Study 6: Gil-Rivas, Holman, & Silver (2004) Study included 142 adolescent

participants Short-term & long-term assessment

Participants administered a web-based survey 2 weeks after September 11th

One year later, these adolescents & a randomly selected parent completed a second survey


Gil-Rivas, et al. (2004) Study addressed whether parental factors can

explain variability in adolescents’ well-being 1 year post-attacks

Adolescents assessed how events expressed through: Acute & long-term PTS symptoms Distress levels Positive emotion & daily functioning outcomes


Gil-Rivas, et al. (2004) Parents assessed on 5 domains of parental

influence: Parental PTS symptoms & psychological distress

levels Parental positive affect Parental self-efficacy Perceived Parental support Parent-adolescent conflict


Gil-Rivas, et al. (2004) Adolescents reported mild to moderate acute

stress symptoms shortly after the attacks and few-trauma-related symptoms, low psychological distress and functional impairment, and moderate levels of positive affect 1 year later

Greater parent-adolescent conflict was positively associated with adolescents’ trauma symptoms, distress, and functional impairment at 1 year


Gil-Rivas, et al. (2004): Points of Interest Interaction between Adolescent development &

trauma Adolescent cognitive development fosters greater ability to

think beyond the concrete consequences of the events, to imagine what might have happened, to produce alternative explanations, and to feel invulnerable to the risks that others face (Klaczynski, 1997)

Threat appraisal becomes more differentiated to include appraisals of threat to self, other-related threat, and loss of desired objects and activities (Sheets, Sandler, & West, 1996)

Interaction between Parental influence and Adolescent response to trauma


Gil-Rivas, et al (2004)

Higher levels of adolescent positive affect at 1 year were associated with greater parental positive affect, greater parent support, and higher levels of parenting self-efficacy (parental self-perception of capability to perform the varied tasks associated with parenting)


Study 6: Terrorism, Altruism, & Patriotism--posttraumatic growth? Study focused on whether the letters to Santa have

changed over the years, especially in light of terrorist actions

Results indicated that requests for gifts for other people and the number of patriotic sentiments (e.g., “God bless America;” “Pray for those in the WTC and Pentagon) and drawings increased in 2001 and 2002

Also, compared to the year 2000, fewer gifts were requested in 2001

Santa Claus appears to be conceptualized as part demigod, part social worker, and part grandfather (Slotterback, 2006)


International Studies: Miller (1996)

The Effects of State Terrorism and Exile on Indigenous Guatemalan Refugee Children: Mental Health Assessment and Analysis of Children’s narratives

Pfefferbaum, et al.(2006) Trauma, grief, & Depression in Nairobi children after the 1998

Bombing of the American Embassy Tatar & Amram (2007)

Israeli adolescents’ coping strategies in relation to terrorist attacks

Pat-Horenczyk, et al. (2007) Adolescent Exposure to Recurrent Terrorism in Israel:

Posttraumatic Distress & Functional Impairment


Miller (1996) Study examined the mental health and psychosocial

development of 58 Guatemalan Mayan Indian children living in 2 refugee camps in the Mexican state of Chiapas

Results show minimal evidence of psychological trauma in this sample, and various factors are suggested to account for this finding

Results also show a positive relationship between children’s mental health and the health status (physical and mental) of their mothers

In particular, a strong association was found between depressive symptoms in girls and poor health status in their mothers

Study included both quantitative & qualitative data


Pfefferbaum, et al. (2006) Study describes findings in 156 children who knew

someone killed in the 1998 American Embassy bombing in Nairobi, Kenya

The children were assessed 8-14 months after the explosion

Bomb-related posttraumatic stress was associated with physical exposure, acute response, posttraumatic stress related to other negative life events, type of bomb-related loss, and subsequent loss

Grief was associated with bomb-related posttraumatic stress, posttraumatic stress related to other negative life events, and type of bomb-related loss


Tatar & Amram (2007) Study conducted among 330 Israeli adolescents, examined

coping strategies in relation to terrorist attacks Study found that adolescents utilize more productive than

non-productive coping strategies (Frydenberg, 1997; ACS used) when dealing with terrorist attacks

Coping strategies include: seeking social support; investing in close friends; tension reduction; social action; seeking to belong; not coping; keeping to oneself, etc.

Study found that they rarely seek professional help Male adolescents use more non-productive coping strategies

(e.g., avoidance coping strategies) Female adolescents seek more social support as a coping

strategy.


Pat-Horenczyk, et al. (2007) Study examines the impact of exposure to ongoing terrorism on 695

Israeli high school students Exposure was measured using a questionnaire developed for the

security situation in Israel Posttraumatic symptoms measured using UCLA PTSD Index--

Adolescent version Functional impairment & somatic complaints assessed using items

derived from the Diagnostic Interview Schedule for Children Depression was measured with the Brief Beck Depression Inventory The prevalence of probable PTSD was 7.6% Girls reported greater severity of posttraumatic symptoms, whereas

boys exhibited greater functional impairment in social & family domains Study supported utilized school-based screening model


Challenges & Limitations No Comparison Baseline Less research w/ children and youth Uniqueness of the event Timing Indirect or Distant trauma Consent & Moderated self-reporting Interaction between Terrorism & Other

Trauma (e.g., community violence)


Clinical Implications Parents may play an important role in adolescents’

response to stressful national events (Gil-Rivas, et al., 2004)

Parental sensitivity to child mental health & behavioral problems impact child assessment and treatment (Stuber, et al., 2005)

Parental openness prior to traumatic events and post-events allows & encourages children to express their feelings and discover strategies to cope with distressing events (Lutz, Hock, & Ju Kang, 2007)


Concluding Thoughts…

Questions?

Documents

Deconstructing Terrorism: Research Review, Limitations, & Clinical Implications