Deconstructing terrorism research review limitations clinical implications
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Deconstructing Terrorism: Research Review, Limitations, & Clinical Implications. Harvard University Summer School Sandra Valdes-Lopez. Discussion Outline. Defining our terms & the parameters of our conversation Survey of Research trends Nationally & Internationally General Research Trends

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Deconstructing terrorism research review limitations clinical implications

Deconstructing Terrorism: Research Review, Limitations, & Clinical Implications

Harvard University

Summer School

Sandra Valdes-Lopez

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


Discussion outline

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

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


Class conversation

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?

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


Defining our terms

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”

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


What is terrorism

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).

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


Defining our terms cont d

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

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


For our intensive purposes

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)

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


Why research in this area

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)

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


Why research cont d

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).

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


General trends psychosocial factors variables

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

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


Impact burden direct indirect effects

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)

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


Developmental level

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)

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


Developmental level cont d

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)

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


Developmental level cont d1

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

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


Nature of trauma

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)

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


Nature of trauma cont d

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)

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


Staged or phased responses

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)

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


Staged or phased responses1

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)

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


Normal reactions

‘Normal’ reactions

  • Particular patterns of response depend on:

    • Developmental level,

    • Culture,

    • Family and community support (Alexander, 2005)

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


Deconstructing terrorism research review limitations clinical implications

Emotional Reactions

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

Disaster

Cognitive

Reactions

Physical

Reactions

Social

Reactions

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


Table i normal reactions to trauma alexander 2005

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

Emotional reactionsCognitive reactions

Shock and numbnessImpaired memory

Fear and anxietyImpaired concentration

Helplessness and/orConfusion or

hopelessnessdisorientation

Fear of recurrenceIntrusive thoughts

GuiltDissociation or denial

AngerReduced confidence

or self-esteem

AnhedoniaHypervigilance

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


Table 1 cont d

Table 1: cont’d…

Social reactionsPhysical reactions

RegressionInsomnia

WithdrawalHyperarousal

IrritabilityHeadaches

Interpersonal conflictSomatic complaints

AvoidanceReduced appetite

Reduced energy

Cardiovascular

responses

(Gump et al., 2005)

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


Direct impacts on children

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:

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


Direct impacts cont d

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”

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


Deconstructing terrorism research review limitations clinical implications

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


Psychological and emotional effects

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)

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


Domains of emotional development williams 2006

Domains of emotional development (Williams, 2006)

Direct effectsProblems with reflecting on and

managing own feelings

Painful memories

Regression

Fear

Fantasies of retaliation

Poor impulse control

Preoccupation with/compulsive

repetition of aggression

Substance misuse

Risk-taking

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


Domains cont d

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

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


Individual study examinations

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)

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


What did these studies find

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)

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


Us research findings

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

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


Study 2

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

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


Study 3

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

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


Study 3 cont d

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)

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


Study 4 gershoff aber 2004

Study 4: Gershoff & Aber (2004)

  • Background Research

  • Role and Interaction of pre-existing factors with impact of trauma

  • Role of Indirect Exposure

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


Deconstructing terrorism research review limitations clinical implications

Taken from Joshi & Lewin (2004)

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


Gershoff aber 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)

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


Pre existing factors

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)

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


Pre existing factors1

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”)

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


Role of pre existing factors context study 5

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

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


Gershoff et al 2004

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

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


Intensity type of exposure

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

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


Intensity type of exposure1

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)

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


Study 6 gil rivas holman silver 2004

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

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


Gil rivas et al 2004

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

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


Gil rivas et al 20041

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

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


Gil rivas et al 20042

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

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


Gil rivas et al 2004 points of interest

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

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


Gil rivas et al 20043

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)

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


Study 6 terrorism altruism patriotism posttraumatic growth

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)

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


International studies

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

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


Miller 1996

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

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


Pfefferbaum et al 2006

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

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


Tatar amram 2007

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.

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


Pat horenczyk et al 2007

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

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


Challenges limitations

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)

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


Clinical implications

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)

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


Concluding thoughts

Concluding Thoughts…

Questions?

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


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