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National Youth Violence Prevention Resource Center

A Federal resource for professionals, parents and youth working to prevent violence committed by and against young people.

Responding to Terrorism and War - Information for Researchers, Health Practitioners, and Other Professionals
(Printable Version)

Risk Factors for Long-Term Mental Health Problems

The growing body of research on children and youth's response to disasters and other traumatic events suggests that a number of factors are likely to determine whether a child or youth will develop long-term psychological problems as the result of a terrorist attack. These include: characteristics of the attack itself, the degree of exposure to the attack, characteristics of the individual child; and the characteristics of the child's environment after the attack, including the availability of social support.

Characteristics of the terrorist attack

When children and youth are exposed to certain types of traumatic events, they are more likely to suffer long-term psychological consequences. Terrorist attacks, by their nature, are highly likely to lead to long-term psychological trauma. They typically involve deliberate mass violence, which studies have found to be extremely disturbing, leading to much more severe impairment than natural disasters or large-scale accidents. In addition, if there is a continued threat of violence by terrorist groups, the trauma may persist long after an initial incident, due to an ongoing sense of uncertainty and lack of control.

Chemical and biological attacks may be particularly traumatizing, because people are likely to be uncertain about the extent of their exposure to potentially toxic agents and unsure about the long-term health effects of exposure. Unlike natural disasters or the attacks on September 11th, there may be no clear beginning or ending to disaster exposure. Some researchers have even asserted that the long-term psychological ramifications of chemical or biological terrorism and war may be more damaging than any physical effects.[1] Researchers have found that concerns or perceptions about exposure to radiation and toxic substances can have a powerful effect on psychological and physical health -- even when there has been no actual exposure.[2]

Research on children and youth's responses to traumatic events suggests that a number of other factors are likely to influence the psychological response to terrorist attacks. Traumatic events are more devastating when they occur suddenly, without warning, when they occur at night, and when the number of deaths and injuries is high and the amount of damage is great.[3,4]

Degree of exposure to attacks

In general, researchers have found that the more direct a child or youth's exposure to a traumatic event, in terms of both physical and emotional proximity, the higher the risk for emotional harm.[5] Physical proximity refers to a child's level of involvement and physical distance from an attack. If a child witnessed destruction, mutilation, or death, if the child's life was in serious danger, or if the child suffered injuries, that child is at a greater risk for long-term psychological harm. In some situations, emotional proximity may be a stronger predictor of posttraumatic response than physical proximity.[6] Emotional proximity refers to the level of emotional involvement with those injured or killed in an attack. Typically, the closer the relationship, the greater likelihood of long-term psychological problems.[7] After the 1995 Oklahoma City bombing, elementary school-aged children who had lost a family member or had a family member injured experienced more post-traumatic stress symptoms than those who merely knew someone injured or killed in the blast.[8]

Most research on psychological trauma has focused on the children and youth who are directly involved in traumatic events, ignoring the psychological effects of disasters on the wider community. However, children and youth can also develop psychological problems as a result of indirect transmission. Indirect transmission can occur through contact with other traumatized individuals, such as family members and peers, through the widespread effects of a traumatic event on a community, and through exposure to repeated media coverage of the event.[9,10]

A study conducted with a group of children living within 100 miles of Oklahoma City found that 19% continued to have bomb-related difficulty in functioning two years after the 1995 Oklahoma City bombing. This finding is dramatic, because none of these children had been in physical proximity to the bombing site, and none knew anyone injured or killed in the attack. Indirect personal exposure (i.e., having a friend or family member who knew a victim) and the level of exposure to media coverage of the attack were both predictive of the amount of long-term psychological trauma experienced by these children.[11] It is clear, then, that while children and youth who are directly involved in terrorist attacks are at greatest risk, other children and youth in the community are also at risk of long-term emotional harm as a result of terrorist violence.

Characteristics of the individual child or youth

A child or youth's response to a traumatic event cannot be reliably predicted by the characteristics of the event nor by the child's level of emotional or physical exposure. Some children and youth are at much greater risk for long-term psychological harm than others. The research shows that girls are typically more adversely affected by disasters then boys. A child's age and developmental level also play an important role, influencing a child's perception and understanding of the trauma, susceptibility to parental distress, quality of response, coping skills, and memory of the event.[12,13,14,15] Personality, coping style, and temperament also play an important role.[16] Other factors that affect a child's risk for long-term consequences include prior exposure to trauma and pre-existing mental health problems.[17]

Prior exposure to trauma
Children and youth that have a history of victimization or exposure to violence, or that have recently experienced some other type of trauma or stress, are more vulnerable and are at greater risk for the development of psychological problems as a result of exposure to traumatic events.[18,19,20] The National Survey of Adolescents suggests that an estimated 15.4 million adolescents in the United States have a history of exposure to violence and other potentially traumatic events. An estimated 5.8 million (or 26% of adolescents) have been victims of physical and sexual violence and an estimated 8.8 million (or 39% of adolescents) have been witnesses to violence.[21] This widespread exposure to traumatic events may put a large percentage of children and youth in the United States at heightened risk for long-term emotional harm as a result of terrorist attacks.

Pre-existing mental health problems
Children and teens that have pre-existing mental health problems are more likely to be suffer long-term emotional harm as a result of terrorist attacks. A recent literature review found that pre-disaster symptoms were almost always among the best predictors (if not the best predictor) of post-disaster symptoms. People with pre-disaster psychiatric histories are disproportionately likely to develop disaster-specific post-traumatic stress symptoms and to be diagnosed with some type of post-disaster disorder.

Characteristics of a child's environment after an attack

Following a terrorist attack, a child or youth may be influenced by an array of secondary stressors and adversities that can increase the risk of developing psychological and psychiatric problems. A terrorist attack may lead to the loss of a home, separation from loved ones, relocation, parental unemployment, family disruption, fears of contamination, disrupted school activities, forced inactivity, and a loss of community/social supports.[22,23]

Exposure to reminders of an attack can also affect a child's recovery. Traumatic reminders in a child's environment or repeated exposure to media coverage can re-traumatize a child, increasing the likelihood of long-term psychological problems.[24,25]

One of the key factors in determining a child's recovery after exposure to traumatic events is the availability of social support. The impacts of trauma are lessened when children and teens have a strong relationship with a parent or another competent caring adult and have at least one place to go where they can feel safe. When children and teens do not have caring, supportive adults in their lives, they are less likely to recover quickly from traumatic events and may have lingering problems.[26] Additionally, if parents are, themselves, traumatized and overwhelmed by the events, their children are much more likely to develop long-term symptoms. A review of disaster research found that parental psychopathology, when measured, was typically the best predictor of child psychopathology following a disaster. Children are highly sensitive to postdisaster distress and conflict in the family. Hence, while a family's reaction can buffer the negative effects of a trauma, providing a source of healing, it can also accentuate potential problems in a child's adjustment and coping after trauma and disaster.[27] In fact, some researchers have concluded that providing care and support to overly stressed parents may be among the most effective ways to provide care and support to the children affected by disasters.

While family support is crucial, peers can also play an important role in the recovery of older children and youth. When children and youth have access to the support of their peers after a traumatic event, they are less likely to suffer long-term emotional harm. If they lose this source of support, due to relocation, school absence, or school closures after an attack, they may be at greater risk for long-term psychological problems.[28,29]

Finally, support from the larger community can play an important role. Children often experience community support indirectly through their parents after a traumatic event. Direct support from teachers, disaster relief workers, community groups, and health professionals is also influential and can affect a child's adjustment.[30]

  1. Wessely, S., Hyams, K.C., & Bartholemew, R. (2001). Psychological implications of chemical and biologial weapons, British Medical Journal, 323, 878-879.
  2. Prince-Embury, S., Rooney, J. (1988). Psychological symptoms of residents in the aftermath of the Three Mile Island nuclear accident in the aftermath of technological disaster. Journal of Social Psychology, 128, 779-90.
  3. Gurwitch, R. H., Sullivan, M.A., Long, P.J.(1998). The impact of trauma and disaster on young children. Child and Adolescent Psychiatric Clinics of North America, 7(1), 19-32
  4. Flynn, B.W., Nelson, M.E. (1998). Understanding the needs of children following large-scale disasters and the role of government. Child and Adolescent Psychiatric Clinics of North America, 7(1), 211- 227.
  5. Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11), 1503-1511.
  6. Gurwitch, R. H., Sullivan, M.A., Long, P.J.(1998). The impact of trauma and disaster on young children. Child and Adolescent Psychiatric Clinics of North America, 7(1), 19-32
  7. Pfefferbaum, B., & Pfefferbaum, R. (1998). Contagion in stress: An infectious disease model for posttraumatic stress in children. Child and Adolescent Psychiatric Clinics of North America, 7(1), 183-194.
  8. Gurwitch, R. H., Sullivan, M.A., Long, P.J.(1998). The impact of trauma and disaster on young children. Child and Adolescent Psychiatric Clinics of North America, 7(1), 19-32
  9. Pfefferbaum, B., & Pfefferbaum, R. (1998). Contagion in stress: An infectious disease model for posttraumatic stress in children. Child and Adolescent Psychiatric Clinics of North America, 7(1), 183-194.
  10. Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11), 1503-1511.
  11. Pfefferbaum, B., Seale, T.W., McDonald, N.B., Brandt, Jr., E.N. (2000). Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry, 63(4), 358-370.
  12. Handford, H. A., Mayes, S.D., Mattison, R.E. et al. (1986). Child and parent reaction to the Three Mile Island nuclear accident. Journal of the American Academy of Child Psychiatry, 25, 346-356.
  13. Realmuto, G.M., Masten, A., Carole, L.F., Hubbard, J, et al. (1992). Adolescent survivors of massive childhood trauma in Cambodia: Life events and current symptoms. Journal of Traumatic Stress, 5, 589-599.
  14. Weisenberg, M., Schwarzwald, J., Waysman, M., Solomon, Z., et al (1993). Coping of school-age children in the sealed room during scud missile bombardment and postwar stress reactions. Journal of Consulting and Clinical Psychology, 61, 462-467.
  15. Terr, L. (1988). What happens to early memries of trauma? A study of twenty children under age five at the time of documented traumatic events. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 96-104.
  16. Shaw, J.A. (2000). Children, adolescents, and trauma. Psychiatric Quarterly, 71(3), 227-243.
  17. Yule, W. (2001). Posttraumatic stress disorder in the general population and in children. Journal of Clinical Psychiatry, 62(suppl 17), 23-28.
  18. Garbarino, J., Kostelny, K., Dubrow, N. (1991). What children can tell us about living in danger. American Psychologist, 46(4): 376-83.
  19. Boney-McCoy, S,, Finkelhor, D. (1995). Prior victimization: a risk factor for child sexual abuse and for PTSD-related symptomatology among sexually abused youth. Child Abuse and Neglect, 19(12): 1401-21.
  20. Duncan, R.D., Saunders, B.E., Kilpatrick, D.G., Hanson, R.F., Resnick, H.S. (1996). Childhood physical assault as a risk factor for PTSD, depression, and substance abuse: findings from a national survey. American Journal of Orthopsychiatry, 66(3): 437-48.
  21. Kilpatrick, D., & Saunders, B. (1997). The Prevalence and Consequences of Child Victimization. Washington, DC: National Institute of Justice.
  22. Shaw, J.A. (2000). Children, adolescents, and trauma. Psychiatric Quarterly, 71(3), 227-243.
  23. Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11), 1503-1511.
  24. Pynoos, R.S., Genjian, A.K. & Steinberg, A.M. (1998). A public mental health approach to the postdisaster treatment of children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 7(1), 195-210.
  25. Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11), 1503-1511.
  26. Osofsky, J.D. (1999). The impact of violence on children, The Future of Children, 9(3), 33-49.
  27. Gurwitch, R. H., Sullivan, M.A., Long, P.J.(1998). The impact of trauma and disaster on young children. Child and Adolescent Psychiatric Clinics of North America, 7(1), 19-32.
  28. Coffman, S. (1998). Children's reactions to disaster. Journal of Pediatric Nursing, 13(6), 376-382.
  29. Flynn, B.W., Nelson, M.E. (1998). Understanding the needs of children following large-scale disasters and the role of government. Child and Adolescent Psychiatric Clinics of North America, 7(1), 211- 227.
  30. Coffman, S. (1998). Children's reactions to disaster. Journal of Pediatric Nursing, 13(6), 376-382.