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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. 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

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  1. Deconstructing Terrorism: Research Review, Limitations, & Clinical Implications Harvard University Summer School Sandra Valdes-Lopez Valdes-Lopez, Trauma & Development, July 16, 2009

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. ‘Normal’ reactions • Particular patterns of response depend on: • Developmental level, • Culture, • Family and community support (Alexander, 2005) Valdes-Lopez, Trauma & Development, July 16, 2009

  20. Emotional Reactions Fig.1. ‘Normal’ responses; (Alexander, 2005) Disaster Cognitive Reactions Physical Reactions Social Reactions Valdes-Lopez, Trauma & Development, July 16, 2009

  21. Table I. ‘Normal’ reactions to trauma (Alexander, 2005) Emotional reactions Cognitive reactions Shock and numbness Impaired memory Fear and anxiety Impaired concentration Helplessness and/or Confusion or hopelessness disorientation Fear of recurrence Intrusive thoughts Guilt Dissociation or denial Anger Reduced confidence or self-esteem Anhedonia Hypervigilance Valdes-Lopez, Trauma & Development, July 16, 2009

  22. Table 1: cont’d… Social reactions Physical reactions Regression Insomnia Withdrawal Hyperarousal Irritability Headaches Interpersonal conflict Somatic complaints Avoidance Reduced appetite Reduced energy Cardiovascular responses (Gump et al., 2005) Valdes-Lopez, Trauma & Development, July 16, 2009

  23. 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

  24. 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

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

  26. 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

  27. Domains of emotional development (Williams, 2006) Direct effects Problems 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. Taken from Joshi & Lewin (2004) Valdes-Lopez, Trauma & Development, July 16, 2009

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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

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