Terrorism and war.

Prevalence.

Remarks by Robert Pynoos, M.D., M.P.H., University of California at Los Angeles.

 Dr. Pynoos presented an ecological model on the determinants of long-term postwar adjustment in Bosnian youths and discussed the prewar, wartime, and postwar factors that impact adjustment. He presented a postwar adversities scale that illustrated how the family may be traumatized by the effects of war. This scale illustrates that traumatic events may also occur after the war, while some traumatic events, such as the disappearance of a loved one or the confirmed death of a loved one, may be caused by the war. There are also post-war traumas such as accidents or crime that are not war-related that may affect the family. Together, these events comprise a “postwar trauma variable.” PTSD, depression, and grief can often co-occur after a traumatic event. Dr. Pynoos used these findings to create a general psychological distress factor in his structural model. Postwar trauma reminders, including sudden loud noises, destroyed or damaged buildings, and hearing news of political instability, can have an ongoing impact on a person’s psyche and strongly predict long-term adjustment in adolescents, more so than family environment and refugee experiences. These results suggest that assessment and treatment efforts should address reminders. Studies have found that exposure to traumatic events is also mediated by parenting practices. Lessons from developmental psychopathology suggest that therapeutic approaches should target prewar trauma, trauma exposure, postwar trauma reminders, postwar family adversities, psychological distress, and developmental impact.

Turning to terrorism, Dr. Pynoos discussed the impacts of several high profile events on children. One study of Oklahoma and Nairobi showed that the repercussions of loss were much more devastating than PTSD. In the Three Mile Island incident, pregnant women and their offspring associated with a government zone of evacuation showed higher anxiety levels even though the zone had no correlation to radiation. Eleven percent of children in New York City had a family member or friend exposed to the World Trade Center terrorist attacks. Two-thirds of these children had been exposed to a traumatic event prior to the attack. A high incidence of agoraphobia was reported after the attacks. Dr. Pynoos concluded with a brief discussion of the National Child Traumatic Stress Network, funded by SAMHSA. The mission of the network is to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. The Intervention Development and Evaluation Program of the network is primarily responsible for developing, delivering, and evaluating improved treatment approaches and service delivery models, which are then implemented through the Community Treatment and Service Programs.

 Consequences 

Remarks by Jon A. Shaw, M.D., University of Miami.

 It is estimated over the last decade that two million children have been killed due to war related injuries, four million have been disabled, one million orphaned, and twelve million dislocated from their homes. Yet there are relatively few studies of the effects of war and terrorism on children. There are a number of generally accepted but perhaps questionable truths about the effects of war and terrorism on children. For example, some say children’s responses to stressful conditions are often less intense than might be anticipated. Unlike other forms of violence, there are specific situations associated with war such as torture, bioterrorism, refugee status, pupils of war (children socialized to violence), and distant trauma (experiencing a horrifying event from a relatively remote and safe distance). There have been some studies of children captured and tortured in Mozambique that found that while some children identified with the caretaker, some identified with the soldier. There have also been studies in Bosnia and Cambodia on the impact of refugee status on the child. War can produce a variety of consequences in the child. Biological effects can include malnutrition, starvation, disease, and war-related injuries. There can also be emotional, behavioral, or mental effects, ranging from little or no reaction, to immediate effects such as PTSD, mood disorders, and externalizing behavior. Long-term effects can also result. Developmental effects can appear in the form of decreased academic performance, difficulty concentrating, cognitive impairment, structural changes in the central nervous system, and changes in personality structure.

 These effects can be heightened or lessened by a variety of mediating variables, which can be categorized by: (1) Levels of exposure, (2) disruption in the family system, (3) disruptions in the social support system, (4) child-specific variables, such as developmental age and gender, and (5) cultural factors, including religion. Known protective factors include family and social supports, cultural and religious values, strengths intrinsic in the child, leadership, and anticipatory preparation. There are a number of research gaps in this area of study including determining the most effective treatments for war-exposed children, developing empirically based interventions for children and families experiencing grief, and designing training modules to help non-mental health providers intervene in psychological crises. There is also a need for studies of resilience, determining which acute physiological responses predict long-term consequences, assessing the impact of early parent death on children, examining the role of culture and values as protective factors, and assessing the use of pharmacological treatments in children with PTSD

Respondent 

Remarks by Paramjit T. Joshi, M.D., Children’s National Medical Center 

War and terrorism are abnormal events that occur in usually normal populations, causing acute stress reactions. Irrational fear leads to group compulsion to eliminate neighbors or potential enemies, setting up a cascade of events across the world. This pattern is repeated over and over again in different parts of the world through different generations. In terms of the children affected by these acts, Dr. Joshi agreed with Dr. Shaw’s assertion that we need to know more about “pupils of war.” How do young children get recruited to be soldiers? Dr. Joshi suggested that the developmental trajectory goes off track seeing the death of loved ones. When support mechanisms such as family, community, and religion are gradually taken away, children are increasingly vulnerable to outside influences. Children can be affected by repeated acts of war or terrorism. Retraumatization has cumulative effects, enhancing the intensity and duration of response, and lengthening the recovery period. There are also social effects. For instance, family role reversal may occur. Demoralized fathers may return from war only to find their wives, formerly submissive, assuming the more dominant role. Terrifying experiences can also cause defects in gene regulation. In addition, functional magnetic resonance imaging of people’s brains when they are observing violent scenes may also help us understand whether stress contributes to a constant state of brain activation. We need research to answer this question. On the subject of desensitization, rates of aggression, violence, truancy, and substance use in Israeli youth have implications for inner city youth here. In the United States, the need for appreciation, to be wanted, and to have a purpose in life can often draw children into violent groups. This theory can also apply to motivations of suicide bombers. Tragically, there are lost generations due to the effects of war. Our challenge in the event of war or a terrorist act is how to prioritize and go about developing large-scale interventions that can provide support, outreach, and education, and identify those at greatest risk. D. Discussion There was significant discussion on the subject of ideology. One participant suggested considering the role of ideology, religion, and related forms of thought to distinguish between war and community violence. For example, whereas war typically develops results from differences in ideology, community violence is often the result of multiple more proximal causes such as poverty and housing conditions. There was also discussion about whether having a group ideology was positive or negative for children. Dr. Levy noted that children from refugee camps sometimes fared better if they had a strong ideological orientation. Dr. Pynoos noted that the study of ideology is not so straightforward and that it is hard to know what this means in terms of long-term pyschological and physiological effects. Dr. Phillips noted that ideology and ethnicity often may serve as protective factors for minority children. She also suggested that war and terrorism may not be so different from community violence as one might think and that considering them as having common causes and consequences will move us forward in the research in these areas. Dr. McCloskey agreed with this point, and added that the effect of community violence on black men in the United States could be compared to war considering that one in four black men are in prison by age 25. The breakout group framed their discussion and recommendations by first defining war and terrorism. (See Appendix C for the summary and recommendations presented by the breakout group chairperson). The group used existing Department of Defense (DOD) and Federal Bureau of Investigation (FBI) definitions and then added their own thoughts. Terrorism is the “Unlawful use of threat or force against an individual/government for political or other end with the intent/purpose of imposing one’s will (DOD).” It can also be construed as the “Illegitimate use of force to achieve political, social, or religious objectives, when innocent people are targeted (FBI).” Terrorism is usually played out before a larger audience, is marked by unexpected, recurrent attacks, and is carried out by groups who do not have other means to get their message across. Civilians are often a major target of these attacks. By contrast, war is planned and executed, usually by governments against governments perhaps in self-defense or revenge, and has a defined beginning and end. Civilians are usually secondary targets. 

The main research gap in the area of children exposed to war/terrorism is in understanding the different consequences of exposure to war versus terrorism. This issue entails differences in acute, unexpected (terror) versus chronic, expected (war) exposure. A related issue is that the effects from exposure to terrorism may be different than those from other forms of violence in many ways. 

For example, geographically, people who are distant from a terrorist incident still suffer psychological trauma. Can anticipatory preparedness reduce the level of anxiety? What are the effects of anticipating incidents without being prepared? There is a need to contrast the prevalence of problems associated with war versus terrorism. A comprehensive, three-dimensional matrix is needed, comparing war and terrorism across variables such as interventions and type of phenomena and across various individual risk factors. The cells of such a matrix need to be filled in with research from many studies. One large, all-encompassing study is not recommended. A number of characteristics (besides type of trauma) are important to consider in terms of the research on mechanisms and consequences of exposure to war/terrorism. Consequences need to be considered more broadly, and secondary consequences need to be considered. Terror can influence other behaviors (e.g., if adolescents stop going to malls, the economy can be affected). Studies are needed on the psychological effects of bioterrorism on children and families and on the psychological effects of activities aimed at disaster preparedness on children (e.g., some private schools now do mock school shootings). We need to consider effects from the biological (genetics) to the existential, from neurons to neighborhoods. Another intriguing area for future research is the impact of chronic stress, especially the impact on children, including prenatal effects. There is a need to consider research and models from other fields. A public health (not just mental health) model is needed. Ideally, a modular model would be developed to give to communities. Modular intervention is needed in schools since immediate responses can take place in schools. Various responses need to be tried to see which work better. Medical outcomes such as immune disorders, somatic disorders, and disease need to be examined, as well as the influence of ethnicity and culture. 

To inform intervention strategies, participants discussed the need to understand the longitudinal course of the evolution of psychological morbidity, and the developmental stages and development of psychological neuropsychiatric symptoms. 

For example, is depression related to maternal response to trauma? What are the effects of early parent death, considering variables such as age and gender? Research on measuring and examining resilience first demands answers to the following questions: How can we define resilience? How do we build resilience? What are the coping and adapting strategies that contribute to resilience? There is a need for long-term studies and intergenerational studies (e.g., the effects of loss of fathers on families). Empowerment issues also need to be studied (e.g., confidence that one will prevail and a feeling of control over a situation). Researchers’ challenges need to be considered, such as the ethical dilemmas of doing research on the battlefield (international sphere). How does one remain neutral but empathetic?

 To prevent or treat long-term negative emotional consequences of witnessing war and/or terrorism, research is needed on:

 • Crisis intervention, including the best types; 

• The potential harm and benefit from traumatic reminders of past violence, such as memorials; 

• Social communication, for example, addressing what to say to children on TV about attacks; 

• Individual reactions and helping to reprogram through possible training; 

• Identification of our target audience—should we be training the helpers, such as teachers, religious figures, parents, social workers, etc.? What do the children think would be helpful? 

• Types of therapy that might be effective and their possible outcomes; 

• First responders and their families; 

• Effects of parental factors on children’s symptoms, including intervention strategies for single parents and remaining survivors’ strategies. 

In discussing the type of research needed in the area of preventive interventions models targeted toward at-risk individuals or families, participants believed that analogues for intervention models already exist in other fields (i.e., infectious disease, natural disasters). Rather than reinventing the wheel, attention should focus on effectiveness studies of models for individuals, families, and groups—we especially need to focus on children. Studies are needed on how children respond in relation to their own aggression, including the risk factors for becoming future terrorists. 

For example, what effect does the parental political belief system have on a child? What are the psychological and other effects of quarantine on children and families? What type of anticipatory preparedness is best?