The Mitigation and Recovery of Mental Health Problems in Children and
Adolescents Affected by Terrorism

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height="2.029861111111111in"}

By

Richard F. Mollica, MD, MAR

Professor of Psychiatry

Harvard Medical School

&

Director

Harvard Program in Refugee Trauma

Massachusetts General Hospital

#### April 24, 2003

Assisted by:

Laura McDonald, MALD, Harvard Program in Refugee Trauma

Professor Howard J. Osofsky, MD, Louisiana State University Health
Sciences Center

Jose Calderon-Abbo, MD, Louisiana State University Health Sciences
Center

Victor Balaban, PhD, Center for Disease Control and Prevention

The Mitigation and Recovery of Mental Health Problems

In Children and Adolescents Affected by Terrorism

# 

# Report for submission to The Honorable Tommy G. Thompson,

# Secretary of Health and Human Services

# U.S. Department of Health and Human Services

# I. Introduction

This focus group report provides a basic scientific overview of the
existing knowledge of the mental health impact of terrorism on children
and adolescents in the U.S. and the preparedness of the U.S. health care
system to cope with past and possible future terrorist attacks. Major
gaps in service delivery and treatment interventions are addressed, with
priority given to those policies that are in urgent need of support to
fill existing gaps in order to: 1) maximize the recovery of children and
adolescents affected by terrorism; and 2) "inoculate" them against the
negative mental health consequences of possible terrorist attacks on our
nation in the future.

# II. Magnitude of the Problem

Little scientific evidence exists to date on the mental health effects
of terrorism. The risk and resiliency of children and adolescents can
only be hypothesized from recent post-September 11, 2001 (9/11) studies
undertaken in the U.S. and from the existing studies that have focused
on the mental health impact of mass violence and extreme life situations
related to war and ethnic conflict.

Research has revealed that the psychological effects of terrorism on
adults, who most frequently play the role of primary caregiver, will
certainly have a direct and indirect effect on the mental health and
overall impact of the terrorist event on children and adolescents.

A number of recently published studies have attempted to assess the
mental health impact of terrorist attacks on adult populations. A study
by Schuster et al. (2001) assessed the immediate mental health effects
of 9/11 on a national representative survey of 560 adults living in the
U.S. In this study, 44% of adults reported one or more substantial
symptoms of distress related to the attack. This study was followed by a
study by Galea et al. (2002) for the New York Academy of Medicine. Using
random telephone interviews of 1008 adults living south of 110^th^
Street in Manhattan five to eight weeks after the attacks, they found
that 7.5% of respondents reported symptoms consistent with posttraumatic
stress disorder (PTSD) and 9.7% reported symptoms consistent with
depression. Among respondents who lived south of Canal Street (near the
World Trade Center), the prevalence of PTSD was 20%.

A study by Schlenger et al. (2002) using a web-based epidemiological
approach evaluated the probable presence of PTSD in a national sample of
2,273 adults. Their findings confirm the higher prevalence of PTSD in
those respondents from New York City (11.2%) than other less affected
parts of the country (4.0%). The most recent report by Delisi et al.
(2003) conducted in-person interviews of adults in New York City (1,009)
between December 15, 2001 and February 28,2002. A total of 56.3% of
individuals had some evidence of emotional distress three to six months
after the terrorist attacks.

Although these preliminary studies are not based on culturally validated
psychiatric diagnoses for PTSD and depression, they, however, reveal
rates of mental health stress many times the baseline of PTSD and
depression in non-traumatized U.S. populations of 1 to 3% and 5 to 8%,
respectively (U.S. Department of Health and Human Services 1999). They
are also consistent with earlier studies conducted after the bombing of
the Alfred P. Murrah Building in Oklahoma City in 1995. North et al.
(1999) found that six months after the event, 34% of 182 survivors who
had been in or near the building had diagnosable PTSD. A study by Tucker
et al. (1999) found that many individuals traumatized by the Oklahoma
City Bombing continued to have persistent symptoms despite treatment.

Data on the mental health of children and adolescents following the
September 11 attacks are extremely limited. The study by Schuster et al.
(2001) showed that 35% of children had one or more stress symptoms, and
47% were worried about their own safety or the safety of loved ones. In
the study by Schlenger et al. (2002), more than 60% of adults in New
York City households had one or more children upset by the events of
September 11. In this study, adult reports indicated that 19.8% of the
most upset children were having trouble sleeping, and were described as
"irritable", "grouchy", easily upset and fearing separation from
parents.

Hoge (2002) reported that after 9/11 there were significant increases in
the number of visits by children of military personnel for anxiety
disorders and acute stress reactions at military facilities within 50
miles of Washington, DC, as compared to similar time periods during the
previous two years. Stuber et al. (2002), using the New York Academy of
Medicine study of 1,008 adult residents of New York City, found
substantial levels of exposure among 112 children who lived below
110^th^ Street. For example, 41% of children saw parents crying about
attacks, 32% had parents who had witnessed the disaster in person, more
than 10% of the parents reported that a friend or relative had been
killed and 17% knew a teacher or a coach who lost someone in the
disaster.

Hoven's study for the New York City Board of Education (2002), which
assessed the reactions of 8,266 students in New York City school system
grades 4 through 12 to the New York City attacks, is the most
comprehensive study to-date of the mental health effects of terrorism on
children. The exposure rate of children throughout the city was high.
Virtually all children in Ground Zero (the area of the attacks on the
World Trade Center) schools had been personally exposed to the attacks.
Two-thirds of children in the other areas of the city also experienced
exposure; many fled for safety (26%), continued to smell smoke (41%) and
were having difficulty returning home on September 11, 2001. In the
entire city, 11% of public school children had a family member or close
friend exposed to the attacks, including 1% who had a family member
killed.

In this study, estimates of psychiatric disorders as compared to
pre-9/11 baselines (Shaffer et al. 1996) are demonstrated in Table 1.
These findings are consistent with the survey of 3,000 middle and high
school students approximately seven weeks after the 1995 Oklahoma City
bombing (Pfefferbaum et al. 1999).

**Table 1: Prevalence of Mental Health Problems Post 9/11 Among New York
City School Students Compared to Pre-9/11 Community Estimates, Grades
4-12**

+-----------+--------+------+----------+---------+----------+--------+
|           | ##     | **PT | **Se     | *       | *        | **Alc  |
|           | ###### | SD** | paration | *Agorap | *Conduct | ohol** |
|           | # Depr |      | A        | hobia** | Diso     |        |
|           | ession |      | nxiety** |         | rder\*** | **Abu  |
|           |        |      |          |         |          | se\*** |
+-----------+--------+------+----------+---------+----------+--------+
| ####      | 8%     | 11%  | 10%      | 15%     | 10.9%    | 5.1%   |
| #### NYC  |        |      |          |         |          |        |
| Post 9/11 |        |      |          |         |          |        |
+-----------+--------+------+----------+---------+----------+--------+
| **NI      | 6%     | 2%   | 8%       | 5%      | 4%       | 3%     |
| MH-MECA** |        |      |          |         |          |        |
+-----------+--------+------+----------+---------+----------+--------+

\* Measured for Grades 9-12 only

Scientific studies that have measured the impact of mass violence on the
mental health of children have consistently demonstrated the high
prevalence of symptoms of depression, anxiety and PTSD. As Table 2
reveals, traumatized children in these studies have many times the
prevalence rates of mental health problems as compared to
non-traumatized children in the U.S.

### Table 2: Effects of war and trauma on children and adolescents

+----------------+----------+--------+---------+--------+------------+
|                | **PTSD** | **     | **Total | **SCR  | **SOURCE** |
|                |          | Depres | Problem | EENING |            |
|                |          | sion** | Score % | TOOL** |            |
|                |          |        | in      |        |            |
|                |          |        | C       |        |            |
|                |          |        | linical |        |            |
|                |          |        | Range** |        |            |
+----------------+----------+--------+---------+--------+------------+
| 6 Year follow  | 50% 1984 | 41%    | N/A     | K-     | Sack W et  |
| up of 30 Young |          | 1987   |         | SADS-E | al (1993)  |
| Khmer refugees | 38% 1990 |        |         |        |            |
|                |          | 6%     |         |        |            |
|                |          | 1990   |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 170 Cambodian  | 26.5%    | 12.9%  | N/A     | K-     | Sack WH et |
| adolescent     |          |        |         | SADS-E | al (1996)  |
| refugees       |          |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 480 Croatian   | N/A      | 11.28% | N/A     | CDI    | Zivcic I   |
| refugee        |          |        |         |        | et al.     |
| children       |          |        |         |        | (1993)     |
+----------------+----------+--------+---------+--------+------------+
| 59 Young       | Current  | 19%    | N/A     | S      | Hubbard J  |
| Cambo          | 24%      |        |         | CID-NP | et al      |
| dian-Americans | Lifetime |        |         |        | (1995)     |
|                | 59%      |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 182 Cambodian  | N/A      | N/A    | CBCL    | CBCL   | Mollica R  |
| refugee camp   |          |        | 53.8%   |        | et al.     |
| adolescents    |          |        | YSR     | YSR    | (1997)     |
| and their      |          |        | 26.4%   |        |            |
| parents        |          |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 209 Khmer      | 12       | N/A    | N/A     | SSADS  | Sack WH et |
| Adolescents    | .9-41.2% |        |         |        | al. (1995) |
|                |          |        |         | SCID   |            |
+----------------+----------+--------+---------+--------+------------+
| 99 Cambodian   | Point    | Point  | N/A     | SSADS  | Savin D et |
| refugees       | 31.3%    | 68.4%  |         |        | al (1996)  |
|                |          |        |         | Int    |            |
|                | Lifetime | Li     |         | erview |            |
|                | 37.3%    | fetime |         |        |            |
|                |          | 86%    |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| Cambodian      | Point    | Point  | N/A     | SSADS  | Id.        |
| refugees in US | 28.6%    | 17.1%  |         |        |            |
|                | Lifetime |        |         | Int    |            |
|                | 37.1%    | Li     |         | erview |            |
|                |          | fetime |         |        |            |
|                |          | 37.1%  |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 12 Bosnian     | 25%      | 17%    | N/A     | CTEI   | Weine S et |
| adolescents in |          |        |         |        | al (1995)  |
| US             |          |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 147 Bosnian    | N/A      | 25.90% | N/A     | Self   | Stein B    |
| children       |          |        |         | Report | (1999)     |
| refugees       |          |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 492 Israeli    | 24.9%    | N/A    | N/A     | SRQ    | S          |
| children       |          |        |         |        | chwarzwald |
| during Scud    |          |        |         |        | J et al.   |
| missile        |          |        |         |        | (1993)     |
| attacks        |          |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| 150            | N/A      | N/A    | 58.8%   | CBCL   | Gabarino J |
| Palestinian    |          |        |         |        |            |
| mothers and    |          |        |         |        | et al.     |
| their children |          |        |         |        | (1996)     |
+----------------+----------+--------+---------+--------+------------+
| 234 Children   | Point    | N/A    | N/A     | C      | Thabet AA  |
| in the Gaza    | 40.6%    |        |         | PTS-RI | et al.     |
| Strip          |          |        |         |        | (2000)     |
|                | 1 Year   |        |         |        |            |
|                | 10%      |        |         |        |            |
+----------------+----------+--------+---------+--------+------------+
| Children (US)  | N/A      | Point  | N/A     | DSM    | AACAP      |
|                |          | 2%     |         | -III-R | (1998)     |
|                |          |        |         | Int    |            |
|                |          |        |         | erview |            |
+----------------+----------+--------+---------+--------+------------+
| 9-17 year-olds | 2%       | 6      | N/A     | DI     | Shaffer D  |
| (US)           |          | month  |         | SC-2.3 | (1996)     |
|                |          | 6%     |         |        |            |
+----------------+----------+--------+---------+--------+------------+

> Kiddie Schedule For Affective Disorders And Schizophrenia (KSADS);
> School Children Version Schedule For Affective Disorders And
> Schizophrenia (SSADS); Child Depression Inventory (CDI); Child
> Behavioral Checklist (CBCL); Youth Self Report (YSR); Communal
> Traumatic Experiences Inventory (CTEI); Child Posttraumatic Stress
> Reaction Index (CPTS-RI); Stress Reaction Questionnaire (SRQ);
> American Academy of Child and Adolescent Psychiatry (AACAP).

# III. Terrorism Mental Syndrome: Does it exist?

The mental health symptoms in children and adolescents affected by
terrorism in the U.S. and studies undertaken on populations who have
experienced war and displacement show reactions that are consistent with
the child's level of development. These common trauma reactions by
school age are shown in Table 3. Severe reactions are frequently related
to the American Psychiatric criteria based upon the DSM IV for PTSD,
depression and generalized anxiety (Fazel and Stein 2002).

It is not known whether terrorism has *event-specific* mental health
effects on children and adolescents different from DSM IV. For example,
research has not determined whether a *terrorism mental health syndrome*
exists and what are its specific subjective, personal and behavioral
manifestations at different developmental levels. Physical and somatic
symptoms may also characterize this syndrome in children and adolescents
(Hassett 2002; Norris 2001). More than two decades ago, significant
confusion and debate existed as to whether a unique mental health
syndrome was associated with torture. The concept of a torture syndrome
was eventually abandoned once standard psychiatric diagnoses were found
to adequately define the major symptoms found in torture survivors
worldwide.

#### Table 3. Summary of Common Trauma Reactions by Age

+----------------------+---------------+---------------+--------------+
| ## Reactions         | ## Preschool  | ## School Age | ##           |
|                      |               |               |  Adolescents |
+----------------------+---------------+---------------+--------------+
| ## Fears, worries    | X             | X             | X            |
+----------------------+---------------+---------------+--------------+
| **Physical           | X             | X             | X            |
| complaints**         |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Attention, memory  | X             | X             | X            |
| problems**           |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Nightmares, sleep  | X             | X             | X            |
| problems**           |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Post-traumatic     | X             | X             |              |
| play**               |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Regression,        | X             | X             |              |
| separation anxiety** |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Anger, hostility,  |               | X             | X            |
| aggression**         |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Apathy,            |               | X             | X            |
| withdrawal,          |               |               |              |
| avoidance**          |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Sadness,           |               | X             | X            |
| depression**         |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Sense of           |               | X             | X            |
| foreshortened        |               |               |              |
| future**             |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Survivor Guilt**   |               |               | X            |
+----------------------+---------------+---------------+--------------+
| **Risky, dangerous   |               |               | X            |
| behavior**           |               |               |              |
+----------------------+---------------+---------------+--------------+

Source: The Center for Victims of Torture: Overview and Effects of
Torture on Children and Adolescents

A number of issues must be addressed in order to understand where this
field stands on this issue.

First, existing research has not phenomenologically described the full
range of personal reactions, symptoms and behaviors experienced by
American children exposed to terrorism (Halpern-Felsher et al. 2002)
with a few notable exceptions. A study by Halpern-Felsher et al. (2002)
revealed the heightened perceptions of adolescents of their
vulnerability to death after the 9/11 attacks. A recent study by
Beauchesne et al. (2002) post-9/11 discusses the effects of fear on
children. Koplewicz et al. (2002), after the 1993 bombing of the World
Trade Center, studied children's responses to the Oklahoma City Bombing.
A very unique study by Seidemann et al. (1998) investigated how children
make sense of their traumatic life experience at different levels of
development. This was accomplished by focusing on letters mailed to
injured patients in an Oklahoma City Children's Hospital.

Second, without a phenomenological description of the range of mental
health responses of children and adolescents to terrorism, a threshold
for identifying those children and adolescents at serious risk for
diagnosable mental illness cannot be established. Clearly, the mental
health impact of terrorism must move beyond simple descriptions of
PTSD-like symptoms (North and Pfefferbaum 2002) to in-depth assessment
of changes in personality, physical and social functioning. It is
absolutely essential for public policy and planning of mental health
services to incorporate an assessment instrument that measures
disability caused by terrorism, including disability related to problems
in the family, school and the community. While large numbers of children
may be emotionally affected by terrorism, it is possible that many
children might have serious performance difficulties that are unrelated
to mental health symptoms. The New York City study (Hoven 2002),
unfortunately, did not assess the impact of terrorism on children's
school performance although this information may have been collected.
Ultimately, evidence-based criteria need to be established that can
identify descriptively those children and adolescents in need of
intervention whether or not they have a psychiatric diagnosis.

Third, all phenomenological descriptions of emotional distress in
children and adolescents affected by terrorism must be culturally
validated given the cultural diversity of American communities. It has
been well established that children will express their emotional
distress by emphasizing symptoms of emotional suffering compatible with
their cultural background and the cultural context in which they live.
For example, Mollica et al. (1997) found, in a community study of
Cambodian children living in a refugee camp on the Thai border, that
these children had a high prevalence of symptoms of somatization and
social withdrawal commonly associated with emotional distress in Khmer
adults. This knowledge applied in the context of assessments within
diverse U.S. communities supports the idea that Western diagnostic
criteria for children (e.g. depression and PTSD) must be culturally
validated in non-English speaking populations.

Fourth, the cultural meaning and psychological potency of terrorism
needs to be ethnographically and phenomenologically described for
children of all ages and at all developmental levels. Although children
may develop symptoms consistent with a diagnosis of PTSD following a
terrorist attack, the socio-cultural and subjective response of a child
who lost a parent in a terrorist attack might be extremely different
from the reaction of a child who has witnessed the attack. As Difede et
al. (1997) have pointed out, the PTSD diagnosis often does not capture
major transformations in worldviews caused by extreme life experiences.
Moreover, children and adolescents who live in communities where
violence is routine may also experience terrorism as a less significant
threat in comparison to the more immediate physical and emotional
dangers present or feared in their local communities on a daily basis.

Fifth, accurate and culturally informed descriptions of terrorist-caused
symptoms, behaviors and personal responses, including the assessment of
problems in physical and social functioning, must be defined and
codified in order to establish age-dependent identification and
screening processes. The development of culturally valid and reliable
identification and screening measures that can be easily utilized in
clinic and community settings would be an important first step in a
"call to action" in the effort to help relieve the suffering of children
and adolescents affected by terrorism and its threat.

Sixth, it is essential that children be empowered to provide input into
all aspects of their recovery. This is especially critical as research
has consistently shown on numerous occasions that parents usually
underestimate the violence experienced by their children and provide
different estimates of their children's psychiatric symptomatology as
compared to child reports. The difference in parental perceptions may be
true, in particular, when parents themselves are depressed and feel
hopeless and despairing about their own violent aftermath, thereby,
resulting the projection of their negative feelings onto their children
(Mollica et al. 1997). Finally, the input of children is likely to be a
valuable resource in identification and services development. It should
be noted that even at relatively young ages, children from all cultures
are usually able to articulate the source of their upset and offer
potential solutions.

# Risk and Resiliency Factors

Research on children exposed to mass violence reveals that the
devastating mental health effects on children are in most cases,
primarily due to effects on parents, unmet survival needs and
interference with developmental tasks (UNICEF, UNHCR). In particular,
studies have shown that the greatest effects on children in these
situations occur when parents are killed or injured. The disappearance
of a parent or sibling such as that which occurred on September 11^th^
is especially potent and difficult for the child and surviving family
members to overcome. To date, mental health interventions for children
are based on the unproven but generally accepted premise that maximum
recovery is facilitated by:

1.  Restoration of good parenting

2.  Establishing safety

3.  Reestablishing family and child routines

Once these basic conditions are met, children reveal remarkable
resiliency and recovery from mass violence.

The basic conditions necessary for the mental health and well-being of
children and adolescents in complex emergencies, referring to conflict
and displacement, most likely also apply to children affected by
terrorism, in spite of the fact that U.S. children exposed to terrorist
acts may not be returning to the environments of famine, displacement
and disease that characterize war-affected populations. However, any
future biological, chemical or nuclear attack could seriously disrupt
and threaten the survival of children over longer periods of time.

Risk factors in adults and children that have been identified by
post-9/11 studies on children as having significant association with
mental health outcomes include: female gender, minority status, prior
history of emotional problems and previous experience of violence.
Analysis of risk factors to date, however, has had limited application
for treatment interventions and/or prevention.

Figure 1 illustrates a comprehensive model of risk and resiliency that
needs to be filled in by future scientific research. In this model, a
terrorist event can have direct health and mental health consequences
for children and adolescents. The terrorist event will also effect the
child's existing family context, community environment, school
activities, socio-economic well-being, safety and security. Studies to
date have not focused on the transformation of these macro areas by
terrorism nor the subsequent consequences of trauma-related
transformations on the child's and adolescent's mental health status.
Each of these ecological areas can function as a risk factor (i.e.
making a child more vulnerable) or a resiliency factor (i.e., protecting
children from harm or contributing to their recovery).

> **Figure 1: Contextual framework for mental health action plan for**
>
> **children and adolescents affected by terrorism**

![](media/image2.wmf)

Preliminary results are revealing the potential significance of the
major risk and resiliency factors. For example, Hoven et al.'s study
(2002) of New York City Public School children found that prior to 9/11
nearly two-thirds of the school children had already been exposed to
serious violence including having seen someone killed or injured and/or
experiencing the violent or accidental death of a close friend or family
member. Pre-9/11 violence was a major concern for these children, which
was exacerbated by terrorism. It has been demonstrated that a prior
history of violence compromises the ability of children to cope with
future violence (US Department of Health and Human Services 1999).

Delisi et al. (2003) is the only recent study to address the economic
effects of terrorism. In this study, 28.9% of respondents had their
employment negatively changed by the 9/11 disaster. Little is known of
the respective impact of terrorism on schools, local community
activities and the family, and their impact on the mental health status
of children.

Along these lines, a valuable tool for policy planners that is currently
not available, would be an scientifically based and comprehensive list
of those coping factors that could serve to best "inoculate" U.S.
children and adolescents against the mental health effects of terrorism
(Susser et al. 2002). Recent 9/11 studies suggest that active coping
strategies such as planning or seeking support were found to be the only
methods protective against on-going stress (Schuster et al. 2002); while
the use of avoidance and denial appeared to the least effective
strategies for children and adults (Silver et al. 2002; Whittesley et
al. 1999). These initial findings are compatible with other studies that
have revealed the importance of stress-related coping strategies in the
face of extreme violence (Gidron et al. 1999; Benight et al. 2000;
Tucker et al. 1997; Tucker et al. 2000; Pfefferbaum et al. 2001).

In addition, based on scientific understanding of how best to protect
children and adolescents in the U.S. in the event of another terrorist
attack, a major public health education campaign should be designed
immediately that will ensure efficacy in preparing families and
communities in protecting and preparing children and adolescents. The
U.S. media should play a seminal role in public health education prior,
during and after an attack. Research shows that television exposure may
have had a less than salutary effect on children (Schuster et al. 2001,
Schlenger et al. 2002, Pfefferbaum et al. 1999) after the terrorist
attacks on 9/11 and the Oklahoma City bombing. These results suggest the
potent impact of the media on children and adolescents, and as such,
presents an important role for the media to play in producing positive
mental health outcomes.

# Mental Health Interventions

As Figure 1 demonstrates, the essence of any mental health intervention
to address the impact of terrorism, and its threat, must include an
evidence-based mental health action plan -- one that is built on
existing knowledge and capacity. Unfortunately, outreach and the
availability of psychiatric services are seriously limited and do not
currently have the capacity to reach those who could greatly benefit
from it. Both the U.S. Surgeon General's Report (U.S. Department of
Health and Human Services 1999) and The White House Conference on Mental
Health (1999) highlight existing shortages and limitations. The
Conference document states that, "the Nation is facing a public crisis
in mental health for infants, children and adolescents. The Surgeon
General's Report presents a comprehensive analysis of the state of
scientific knowledge relevant to the treatment of childhood mental
health disorders as well as the causes of the unmet needs of children
remaining high with only 20% of affected children in the U.S. receiving
mental health services." For example, currently there is a dearth of
child psychologists or social workers capable of meeting the mental
health needs of the nation's children (Thomas-Holzer 1999).

The lack of utilization of mental health services has been highlighted
in a number of the studies undertaken following 9/11. Hoven et al.
(2002) found that at least two-thirds of New York City school children
with probable PTSD following the 9/11 attacks had not sought any mental
health services from school counselors or mental health professionals.
Stuber et al. (2002) found that 22% of the children in her New York City
study sample had received some form of counseling related to their
experience after the disaster, primarily from their schools. Delisi et
al. (2003) in their recent report found that only 11.3% of their
respondents in New York City had received and help; only 26.7% of those
(adults) were receiving counseling or psychiatric treatment. The
efficacy of interventions in the previous studies as well as the
barriers to health-seeking behavior and access to mental health services
were not determined.

In spite of the limitations and availability of psychiatric services to
children, the majority of families primarily seek help for
trauma-related suffering from their indigenous healing system (i.e.,
primary health care practitioners, clergy, family members and the school
system). This was found to be the case in the U.S. following the 9/11
terrorist attacks. Schuster et al. (2001), for example, found that over
90% of respondents had coped by consulting their clergy and an equal
number their friends and relatives. This study neglected to focus on the
role of general practitioners as a source of assistance in this context.
Melnyk et al. (2002) conducted a national survey to determine the
relationship between children and adolescents affected by terrorism and
pediatric health care providers. They found that knowing how to cope
with the stresses of recent events was the greatest worry for parents,
children and teens.

The potential for reaching children through the primary care system is
great (Farmer et al. 2003). Each year, for example, it is estimated that
there are more than 150 million pediatric visits to primary health care
providers in the U.S. per year (NAMCS 1998). Primary care practitioners
play an active role in the identification and treatment of children with
mental health disorders (Ringeisen et al. 2002) and are prescribing the
majority of psychotropic drugs to children and adolescents. Children and
adolescents with mental health problems, moreover, would prefer to be
treated by their primary care provider rather than mental health
specialists.

The role of primary care providers and the capacity and presence of
other healers existing within the community in addressing mental health
issues should not be ignored and should be the focus of a mental health
action plan to address the effects of terrorism and the threat of future
events. As international experience in resource poor post-conflict
societies has taught us, a mental health action plan is most effective
if it is centered in a non-stigmatizing environment easily accessible to
all citizens. It should reach out to those public sectors where children
and adolescents are most likely to be identified and readily treated.

# *Best practices for Mental Health Interventions, Curriculum Development and Training*

Evidence-based studies of best practices of mental health interventions
for children and adolescents affected by terrorism are extremely
limited. Similarly, state-of-the-art knowledge of mental health
interventions capable of being effectively used in culturally diverse
populations by local and community practitioners such as primary health
care, school based practitioners and families, has not been codified and
is not therefore available for training and dissemination. Furthermore,
potentially dangerous practices may be on the increase. For example,
while it is likely that there has been an increase in the prescription
of psychotropic drugs by primary care practitioners and mental health
specialists to children and adolescents secondary to an increase in
their distress as a result of terrorism, this information is not
currently available. It is important that all practitioners have
knowledge of the proper use of psychotropic drugs in culturally diverse
communities.

The beginning of any training process must be founded on adequate
knowledge of culturally effective and evidence-based mental health
interventions. Yet, to date, such research-based knowledge does not
exist. An immediate priority is, therefore, for national experts
representing scientific and local communities to build a contemporary
portfolio that can immediately sustain a mental health action plan until
more in-depth research has been conducted and results are made
available. Once these best practices are made available, a major
emphasis must be placed on the training of the indigenous healing
system.

Training lies at the foundation of an effective mental health care
system and is critical in ensuring the effective identification and
treatment of mental health problems in the context of terrorism.
Moreover, the mental health training needs of the existing indigenous
healing system are unknown. For example, it is not known whether
existing mental health training approaches indeed are effective in
modifying provider behaviors or influencing treatment outcomes. A
systematic review of mental health trainings (Beuver et al. 2001) of
primary health care providers of non-traumatized children and
adolescents revealed that case-controlled evaluations were rare. In
addition, few of the reported studies indicated changes in professional
behavior or improvement in patient mental health status as a result of
the trainings. However, standards that have been developed in primary
care medicine working with non-traumatized populations can be applied to
the practitioners within the indigenous healing system working with
individuals who have survived a terrorist event. Systematic assessments
of the efficacy of mental health training related to terrorism for
primary care and school practitioners and families have not yet been
undertaken.

Building the mental health capacity of the existing healing system in
the U.S. will require much more than evidence-based interventions and
science-based training curriculum. Elements of capacity-building must
also include attention to financing and other motivational incentives
(Wells et al. 2002). As Wells et al. have stated, "Achieving deeper
changes in practice structure and function may require policy changes,
particularly more effective formulation and implementation of insurance
coverage mandates that state and federal avenues have already
initiated."

#### RECOMMENDATIONS

Current recommendations for the mitigation and recovery of the mental
health impact of terrorism on American children and adolescents include:

####### ASSESSMENT OF THE MENTAL HEALTH IMPACT OF TERRORISM

Undertaking cross-sectional and longitudinal studies in culturally
diverse communities of the impact of terrorist events on psychiatric
symptoms, personality, disability, and risk and resiliency factors.

Conducting ethnographic and quantitative studies that assess the impact
of terrorist experience on children's and adolescents' psychological
well-being and development over time with specific focus on determining
a *terrorism mental health syndrome*.

####### DEVELOPMENT OF STANDARDS OF EVIDENCE-BASED BEST PRACTICES

Contracting teams of multi-disciplinary and culturally diverse experts,
with input from parents and children, to prepare toolkits of best
practices for mental health interventions for teachers, school
counselors/nurses, primary care practitioners, and families.

Conducting evidence-based research (e.g. RCTs) to assess effectiveness
of training on practitioners and their patients/clients including
objective changes in practitioner behavior, mental health outcomes and
sustainability over time.

####### INTERVENTIONS

Developing culturally valid and reliable screening instruments for the
identification of mental health problems by teachers, school
counselors/nurses, primary care practitioners, and families.

Conducting evidence-based studies (e.g. RCTs) on the effectiveness of
interventions for children and adolescents by teachers, school
counselors/nurses, primary care practitioners, and families.

*PREVENTION ACTIVITIES*

Designing, implementing and studying the efficacy of a public education
campaign to "inoculate" children and adolescents against terrorism using
the national and local media.

####### POLICY

Establishing through national polls the readiness and needs of teachers,
school counselors/nurses, primary care practitioners, and families to
cope with children and adolescents affected by terrorism.

Establishing national guidelines for the proper use of psychotropic
drugs in culturally diverse populations.

Setting guidelines and national standards for the role of television,
radio and written media in preparing families, children and adolescents
at all stages of the crisis.

Determining unit cost of effective evidence-based mental health
interventions in all school, community and health care settings.

Formulating and implementing insurance coverage mandates by state and
federal agencies to guarantee that all affected children receive mental
health coverage, even if uninsured.

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