SAMHSA

Disaster Technical Assistance Center 

Supplemental Research Bulletin

Mental Health Issues and Conditions 

in Children and Youth Exposed to 

Human-caused Disasters

July 2019

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

1–877–SAMHSA–7 (1–877–726–4727) • 1–800–487–4889 (TDD) • www.samhsa.gov
CONTENTS

INTRODUCTION 3

Mass Violence Definitions 3

THE CURRENT CONTEXT 4

MENTAL HEALTH AND SUBSTANCE USE ISSUES AND CONDITIONS IN EXPOSED YOUTH 5

Posttraumatic Stress (PTS) and Posttraumatic Stress Disorder (PTSD) Following Human-caused Disasters 5

Depression 6

Substance Use and Misuse 6

Anxiety Disorders 7

Other Issues and Conditions 7

Physical Consequences and Comorbidities 7

RISK AND PROTECTIVE FACTORS 7

Non-modifiable Risk and Protective Factors 7

Modifiable Risk and Protective Factors 8

Impact of Indirect Exposure to Disaster 8

POST-DISASTER APPROACHES AND INTERVENTIONS 9

CONCLUSION 12

REFERENCES 12

The focus of the Supplemental Research Bulletin is to provide an overview of the current literature on a specific 

topic and make it easy to understand for disaster behavioral health professionals who are not otherwise exposed 

to the research. The product aims to assist professionals and paraprofessionals involved in all-hazards planning, 

disaster behavioral health response and recovery, and/or Crisis Counseling Assistance and Training Program 

grant activities.
| Page 3

INTRODUCTION

This issue of the Supplemental Research Bulletin focuses on mental health and substance use issues and 

conditions in children and youth after human-caused disasters, such as oil spills, radiation disasters, public 

health emergencies, incidents of mass violence, and terrorism. This Supplemental Research Bulletin follows 

on the September 2018 Supplemental Research Bulletin (https://www.samhsa.gov/sites/default/files/srbchildrenyouth-8-22-18.pdf), which covers the effects of natural disasters on children and youth. 

Research has consistently shown that exposure to human-caused disasters in people of all ages, including children 

and youth, increases the chances of having a host of mental health and substance use-related consequences, 

including posttraumatic stress disorder, major depressive disorder (MDD), substance use disorders, and other 

issues and conditions (Goldmann & Galea, 2014; Comer et al., 2010). Potentially traumatic events during a humancaused disaster include exposure (direct or indirect) to death, grief, injury, pain, or loss, as well as direct exposure 

to threats to personal safety (Mann, Farfel, Maslow, Osahan, & Stellman, 2015). Even children and youth who are 

indirectly exposed to disaster-related trauma and stress may exhibit increased rates of functional impairment and 

various psychopathologies (Comer et al., 2010). 

As discussed in the September 2018 Supplemental Research Bulletin, after a natural disaster, children may develop 

symptoms of disorders that may be short-term and not as severe as symptoms that would be necessary to fully 

diagnose a psychiatric disorder. These stress-related symptoms are often able to be helped with natural supports 

such as family, friends, and social groups. Only a small percentage of children and youth will develop mental or 

substance use disorders (Pfefferbaum, Jacobs, Griffin, & Houston, 2015). As with the last issue of the Supplemental 

Research Bulletin, this issue focuses on diagnosable disorders that appear in the Diagnostic and Statistical Manual 

of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013). Most children and youth do 

not develop full psychiatric conditions due to disaster exposure. Please refer to the Common Stress Reactions in 

Children and Youth section on page 5 of the previous Supplemental Research Bulletin (https://www.samhsa.gov/

sites/default/files/srb-childrenyouth-8-22-18.pdf) for more about how children and youth often react to disasters.

The purpose of this publication is to shed light on the mental health and substance use- and misuse-related effects 

of human-caused disasters for some children and youth. In it, we also aim to highlight approaches and interventions 

that may be useful in supporting children and youth, and full disaster-affected communities, after human-caused 

disasters. 

This issue of the Supplemental Research Bulletin is based on literature and scientific publications found through 

the National Center for Biotechnology Information, U.S. National Library of Medicine (PubMed), and Internet 

searches. All research cited in this issue was published in English, and the majority was conducted in the United 

States (with a few exceptions where investigations in other countries proved useful to the topic). We searched for 

literature on human-caused disasters such as incidents of mass violence; terrorist attacks; and chemical, biological, 

radiological, and nuclear disasters. We limited the literature we reviewed to studies of children who were no older 

than 18 years at the time of disaster exposure. We did not include literature on trauma related to living in war 

zones, as the ongoing exposure and associated challenges are different.

Mass Violence Definitions

One type of human-caused disaster we focus on in this issue is mass violence. Because there is no single, agreedupon definition of an incident of mass violence or subtypes of these incidents such as mass shootings, in the 

research literature or elsewhere, it was important to consider how we would define these terms for the purposes of 

this Supplemental Research Bulletin (RAND Corporation, n.d.; U.S. Department of Justice [DOJ], Office of Justice 
| Page 4

Programs [OJP], Office for Victims of Crime [OVC], 2015; Lowe & Galea, 2015; Shultz et al., 2014). DOJ’s OVC 

defines mass violence as follows:

An intentional violent criminal act, for which a formal investigation has been opened by the Federal 

Bureau of Investigation (FBI) or other law enforcement agency, that results in physical, emotional, or 

psychological injury to a sufficiently large number of people to significantly increase the burden of victim 

assistance and compensation for the responding jurisdiction as determined by the OVC Director (DOJ, 

OJP, OVC, 2015).

Many government agencies and research efforts have focused on mass shootings in recent years and developed 

definitions of this type of incident. Definitions vary as to whether they specify or indicate intentionality, where 

incidents occur, how many people are injured and/or killed, whether victims are selected or random, how many 

people perpetrate the violence, and whether some types of incidents are excluded (Bjelopera, Bagalman, Caldwell, 

Finklea, & McCallion, 2013; Krouse & Richardson, 2015; Stanford Mass Shootings in America, courtesy of the 

Stanford Geospatial Center and Stanford Libraries. n.d.; Public Law 112-265, 2013).

For this Supplemental Research Bulletin, we adapted two mass shooting definitions to develop a definition of mass 

violence (Shultz et al., 2014; Stanford Mass Shootings in America, courtesy of the Stanford Geospatial Center and 

Stanford Libraries, n.d.). We defined an incident of mass violence as an intentional, planned event typically carried 

out in a public venue perpetrated by one or two people, involving the use of firearms or other devices to kill or 

injure one or more people. These incidents are unrelated to drugs, gangs, or organized crime.

THE CURRENT CONTEXT

In this issue, we examine the effects of all types of human-caused disasters, including nuclear disasters, oil spills, 

and public health emergencies, as well as incidents of mass violence. Nevertheless, it is important to address 

recent trends in mass violence, and mass shootings in particular. Some investigators have reported an increase in 

frequency of mass shootings in the United States. For example, Lowe and Galea cite a report noting an increase 

in such incidents over time in the United States (Blair & Martaindale, 2013; as cited in Lowe & Galea, 2015). 

Mass shootings in schools have been reported on extensively in the mainstream media. However, these incidents 

remain very rare relative to deaths by firearm in the United States. A team of researchers reports that from 1990 to 

2012, 215 fatal school shooting incidents caused 363 deaths, which amounts to less than 1 percent (0.12 percent) of 

national firearm homicides during that period (Shultz, Cohen, Muschert, & Flores de Apodaca, 2013). Of the school 

shootings in the period they reviewed, only 25 of the 215 incidents fit the definition of mass violence used in this 

Supplemental Research Bulletin. The researchers conclude that “despite the high visibility and notoriety of [school 

shooting massacres], we have demonstrated that the numbers of incidents are few and the numbers of deaths 

represent a minute fraction of total firearm fatalities” (Shultz, Cohen, Muschert, & Flores de Apodaca, 2013, p. 97). 

In response to these incidents, students in public K–12 schools routinely now undergo safety trainings and active 

shooter response drills in preparation for a possible school shooting (U.S. Government Accountability Office, 

2016). In recent years, Federal Government offices and national professional associations have produced guidance 

for school personnel for developing emergency plans for active shooter scenarios and implementing traumainformed drills to create safe learning environments for children (U.S. Department of Education, Office of 

Elementary and Secondary Education, Office of Safe and Healthy Students, 2013; National Association of School 
| Page 5

Psychologists & National Association of School Resource Officers, 2017; National Child Traumatic Stress Network, 

2018).

MENTAL HEALTH AND SUBSTANCE USE ISSUES 

AND CONDITIONS IN EXPOSED YOUTH

As noted, human-caused disasters can affect children and youth in many ways, from distress and symptoms of 

mental and substance use disorders in the short term, to ongoing issues in some over the longer term. Findings 

from two large-scale studies by the Substance Abuse and Mental Health Services Administration (SAMHSA) and 

the Centers for Disease Control and Prevention indicate that more than one-third of parents in the Louisiana and 

Mississippi coastal regions reported physical or mental distress in their children 3 months after the start of the 

Deepwater Horizon oil spill in 2010 (Gould, Teich, Pemberton, Pierannunzi, & Larson, 2015). 

Posttraumatic Stress (PTS) and Posttraumatic Stress Disorder (PTSD) Following Humancaused Disasters

PTS is stress people experience after they have gone through, or seen someone else experience, a life-threatening 

event, such as a disaster, car accident, or sexual assault. PTS symptoms reflect this stress and fall into four 

categories: 

• Intrusive thoughts. These may include nightmares. They may also include flashbacks, or the sense of going 

through the event again. Children may act out the event repeatedly in their play.

• Avoidance of reminders of the trauma. People may avoid situations or other people who remind them of the 

event, or they may avoid talking or thinking about the event.

• Negative changes in thoughts and feelings. People may not experience positive or loving feelings toward 

others. They may forget parts of the event that led to their symptoms. 

• Arousal and reactivity. People may be more reactive to stimuli in their environment. They may react to 

sounds and smells that do not indicate danger as though they were signs of danger. They may feel keyed up 

or on edge, and they may experience increased anger and irritability, have trouble sleeping, and find it hard 

to concentrate (National Center for PTSD, 2019). 

Examples of PTS symptoms in children include acting out the trauma repeatedly in play, limited play, social 

withdrawal, and, in adolescents, misuse of alcohol and other substances (American Psychiatric Association, 

2013; American Psychiatric Association, 2017). If PTS symptoms continue for more than 1 month, the individual 

experiencing them may have PTSD (American Psychiatric Association, 2013). For a diagnosis of PTSD, an 

individual must have at least one intrusion symptom, at least one avoidance symptom, at least two symptoms 

related to negative changes in thinking and mood, and at least two arousal symptoms, all for more than 1 month. 

In children ages 6 years and younger, PTSD may be diagnosed if they have at least one intrusion symptom, at least 

one avoidance symptom or symptom related to negative changes in thinking and mood, and at least two arousal 

symptoms, also for more than 1 month (American Psychiatric Association, 2013).

PTS in children following disaster exposure has been studied extensively. Across studies, there is wide variation 

in prevalence estimates of PTS symptoms and PTSD among children and youth. In a paper on children’s reactions 

to natural and human-caused disasters, the authors note that rates vary depending on the samples, the outcomes on 

which researchers focus, and research methodology used (Pfefferbaum, Jacobs, Griffin, & Houston, 2015). 
| Page 6

It has been estimated that between 28 percent and 50 percent of children exposed to trauma develop PTSD 

(Saraiya, Garakani, & Billick, 2013). In research on children and youth exposed to terrorist attacks, the most 

consistently documented finding has been increased rates of symptoms of PTSD (Comer, Bry, Poznanski, & Golik, 

2016). Six months after the 9/11 World Trade Center attacks, probable PTSD was identified in about 11 percent 

of New York City schoolchildren (Comer et al., 2010). Following the Boston Marathon bombing (2013), about 11 

percent of the marathon-attending youth exhibited likely PTSD symptoms. This proportion of youth with likely 

PTSD was about six times higher among marathon-attending youth than non-attending youth (Comer, Dantowitz 

et al., 2014). In a review of studies on mass shootings, the researchers report that an estimated 30 percent to 40 

percent of children and adolescents exposed to a life-threatening event such as a mass shooting will meet criteria 

for a PTSD diagnosis (Shultz et al., 2014).

Children and youth who develop PTS symptoms or PTSD after a human-caused disaster may be at increased risk 

of other mental and substance use disorders, and symptoms of these disorders, as well as physical health problems. 

Comer et al. report that children and adolescents who develop PTSD symptoms after a terrorist attack are at risk for 

a range of problems such as depression, substance misuse, suicidality, and overall reduced quality of life (2016). 

Some research has highlighted elements or aspects of human-caused disasters that are associated with PTS 

symptoms or PTSD in children and youth. Among adolescents who had been exposed to the 9/11 World Trade 

Center attacks as children, researchers found that PTSD was strongly associated with direct attack exposure; of the 

5.4 percent of their sample with probable PTSD, 92.3 percent reported two or more direct exposures (Mann et al., 

2014). In school-age children affected by the Gulf oil spill (2010), there was a causative association between those 

affected by stress related to the spill and development of PTSD symptoms (Osofsky, Osofsky, Weems, Hansel, & 

King, 2016). 

Depression

A review of recent literature concluded that prevalence of depression among youth after human-caused disasters 

ranges from 2 percent to 34 percent (Boer, Smit, Morren, Roorda, & Yzermans, 2009; Bolton, O’Ryan, Udwin, 

Boyle, & Yule, 2000; as cited in Lai, Auslander, Fitzpatrick, & Podkowirow, 2014). One study found that 6 

months after the 9/11 World Trade Center terrorist attacks, about 8 percent of New York City schoolchildren were 

experiencing MDD (Hoven et al., 2005; as cited in Comer et al., 2010). It is important to note that this percentage is 

not out of the ordinary in general population samples; the DSM-5 reports that 12-month prevalence of MDD in the 

United States is approximately 7 percent across all age groups (American Psychiatric Association, 2013). In another 

study, more than half of students surveyed a year after a mass shooting reported impaired well-being, which 

included anxiety/depression, among other issues, such as sleep problems, PTS, and lower life satisfaction (Stene, 

Schultz, & Dyb, 2018). 

Substance Use and Misuse

Research has found increased rates of substance use and misuse among adolescents affected by human-caused 

disasters. In a needs assessment following the 9/11 World Trade Center terrorist attacks, about 5.4 percent of 

New York City high school students reported starting smoking cigarettes or increasing use, and 10.9 percent 

reported increased alcoholic beverage consumption (Wu et al., 2006). Prior trauma and PTSD were associated 

with increased smoking, and direct exposure to the attack was significantly associated with increased alcohol 

consumption (Wu et al, 2006). 
| Page 7

Anxiety Disorders

Following trauma, younger children may have separation anxiety upon leaving their parents, while older children 

may develop other, unrelated fears (Saraiya et al., 2013). Anxiety disorders other than PTSD were reported in 25.4 

percent of a sample of children in New York City public schools 6 months after the 9/11 terrorist attacks (Comer 

et al., 2010). In addition, high rates of generalized anxiety were found in studies examining area youth in the 

aftermath of the Oklahoma City bombing (1995) and Boston Marathon bombing, and in Washington, DC, youth 

following the 9/11 attacks (Comer et al., 2016). 

Other Issues and Conditions

After exposure to trauma associated with a human-caused disaster, some children may behave aggressively and be 

unable to control anger impulses, while others may struggle with lack of control or sense of hopelessness (de Jong 

et al., 2015; Saraiya et al., 2013). In a paper on the effects of the Exxon Valdez oil spill, the author reported that the 

disaster was linked to a decline in children’s grades in school, as well as declining relations with other children 

in the community, increased fighting, distress upon hearing someone talk about the spill, bedwetting, and fear of 

being left alone (McLees-Palinkas, 1994; as cited in Palinkas, 2012). 

Physical Consequences and Comorbidities

After a trauma, some children may experience physical symptoms such as frequent headaches or stomachaches 

or sleep problems (Saraiya et al., 2013). Researchers found sleep difficulties among children affected by the Exxon 

Valdez oil spill, in addition to the other issues described in the preceding paragraph (McLees-Palinkas, 1994; as 

cited in Palinkas, 2012). In a study involving more than 8,000 children in New York City public schools 6 months 

after the 9/11 attacks, researchers found eight patterns of comorbid psychiatric disorders involving conditions such 

as agoraphobia, separation anxiety, and MDD (Geronazzo-Alman et al., 2018). 

RISK AND PROTECTIVE FACTORS

Children’s vulnerability to stress reactions after disasters involves multiple factors such as level and dose of 

trauma, preexisting psychopathology, coping resources, social support, genetic factors, and socioenvironmental 

adversity (Carpenter et al., 2017). Current literature indicates that some parent-related variables as well as aspects 

of the family environment likely constitute risk or protective factors for children (Cobham, McDermott, Haslam, 

& Sanders, 2016). In a review of research on the effects of mass shootings on children and adolescents, researchers 

report that risk factors for the development of post-disaster psychological disorders include proximity to the scene 

of the incident, degree of exposure, emotional sensitivity, lack of expressive ability, female gender, immigrant 

status, and lack of perceived family and social supports (Shultz et al., 2014).

Non-modifiable Risk and Protective Factors

Children who are from an ethnic minority may be at higher risk for adjustment issues after disaster exposure, but 

this may relate to differences in socioeconomic status between ethnic minorities and non-ethnic minorities, as well 

as less access to needed resources during and after disasters, resulting in more stressful disaster experiences (Mann 

et al., 2015; La Greca & Silverman, 2006; as cited in Pfefferbaum et al., 2015). Lower socioeconomic status and 
| Page 8

poverty have been linked with higher rates of psychopathology among children following an incident of terrorism 

(Comer et al., 2016). Youth with disabilities may also be disproportionately affected by and experience greater 

exposure to disasters (Stough, Ducy, & Kang, 2017). 

Among children who experienced the 9/11 attacks, direct exposures consisting of injury or death of a family 

member were significantly associated with probable mental disorders (Mann et al., 2015). A meta-analysis found 

that mass-fatality disasters (in which more than 100 people lose their lives) are associated with higher PTS levels in 

youth than those with fewer fatalities (Furr, Comer, Edmunds, & Kendall, 2010; as cited in La Greca et al., 2016).

Modifiable Risk and Protective Factors 

Parenting and the family environment are modifiable risk factors, as it is widely supported that children’s 

post-disaster mental health is partially affected by the disaster’s impact on parents, parenting, and the family 

environment (Cobham et al., 2016). Children whose parents had post-disaster or current major depression 7 years 

after the Oklahoma City bombing (1995) were more likely to have any post-disaster psychiatric disorder than 

children whose parents did not have depression (Pfefferbaum, Tucker, North, Jeon-Slaughter, & Nitiéma, 2014). In 

addition, negative trauma-specific appraisals and encouragement of avoidance coping by parents were associated 

with higher child-reported PTS. However, it is recognized that there is limited research related to parental response 

to trauma and the influence of this response on PTS in children (Hiller et al., 2018). Having a parent or a relative 

working in law enforcement and called to participate in the manhunt following the Boston Marathon bombing 

was associated with higher risk of PTSD in children after the attack (Comer, Kerns et al., 2014). Children who had 

family members who were first responders in the 9/11 attacks had a high prevalence of probable PTSD (Duarte et 

al., 2006). In a survey of New York City schoolchildren in grades 4 through 12 after the 9/11 attacks, researchers 

found that children who reported that their parents had restricted their travel after the attacks or that someone in 

their family had lost his or her job as a result of the attacks were significantly more likely to have probable PTSD 

(Comer et al., 2010). 

Impact of Indirect Exposure to Disaster

Exposure to human-caused disaster can have devastating consequences for children and youth. Although not 

as apparent, indirect exposure (exposure to disasters through television, radio, or social media, or parents’ 

discussions) also can have lasting effects. One study found that 20 percent of youth living 100 miles from 

the Oklahoma City bombing attack reported dysfunction related to the attack, including symptoms of PTSD, 

presumably owing to indirect exposure (Pfefferbaum et al., 2010; as cited in Garbarino, Governale, Henry, & 

Nesi, 2015). Other studies have reported that indirect exposure to disasters such as the 9/11 attacks through media 

images or indirect post-attack life disruptions could lead to the development of PTSD or anxiety symptoms in 

children (Comer, Dantowitz et al., 2014; Saraiya et al., 2013). In addition, the amount of television viewing after 

the 9/11 attacks was linked to an increase in PTSD symptoms among young children (Otto et al., 2007). Children 

who watched more than 3 hours of television on the day of the 2013 Boston Marathon bombing were more likely to 

experience PTSD symptoms and conduct problems (Comer, Dantowitz et al., 2014). Evidence of secondhand effects 

of exposure to disaster was reported, with significant association between caregiver distress and various domains 

of child functioning, following the Boston Marathon bombing (Kerns et al., 2014). Another study found that more 

than 75 percent of children whose parents were directly exposed to the 9/11 attacks had at least one disaster-related 

PTS symptom 3 years after the attack, and more than half experienced at least one post-disaster behavior change 

(Pfefferbaum, Simic, & North, 2018). For young children who are indirectly exposed to a human-caused disaster, 

minimizing media exposure may be important (Otto et al., 2007). 
| Page 9

POST-DISASTER APPROACHES AND INTERVENTIONS

A variety of approaches and interventions are available to support children and communities after exposure to 

disasters. For in-depth coverage, see pages 11–14 in the September 2018 Supplemental Research Bulletin (https://

www.samhsa.gov/sites/default/files/srb-childrenyouth-8-22-18.pdf). 

Some research has focused on community-level needs and approaches after human-caused disasters. In an 

assessment of services for children and families after the Sandy Hook Elementary School shooting in Newtown, 

Connecticut, researchers found a need for more evidence-based practices among mental health and substance 

use agencies and medical providers; greater individualization of services; and much greater availability of 

bereavement or grief counseling, which was offered by only one of 28 agencies they interviewed (Hoagwood 

et al., 2017). Following the Deepwater Horizon oil spill, a program was developed with integration of mental 

health and substance use services (Osofsky, Osofsky, Wells, & Weems, 2014). The program placed psychiatrists 

and psychologists in primary care clinics, used a team-based approach with centralized care management to 

coordinate mental health and substance use treatment practitioners in the field, and featured multiple levels of care 

to address the different degrees of need that survivors had. Initial evaluation results, focused on adult survivors, 

were promising. From intake to follow-up at 1 and 3 months, researchers found significant decreases in PTSD and 

anxiety symptoms, as well as significant improvement in somatic symptoms (Osofsky, Osofsky, Wells, & Weems, 

2014).

For children and youth who have experienced trauma as part of human-caused disaster, several interventions have 

been developed. A sampling of these interventions is provided in Table 1.

Table 1. Sampling of Interventions for Children and Youth Who Have Experienced Trauma 

and Traumatic Stress

Intervention Description Publications on Research With 

Child and Adolescent Trauma 

Survivors

Bounce Back Designed for children in elementary 

school, Bounce Back is a group 

intervention to help address 

symptoms of child traumatic 

stress, depression, anxiety, and 

functional impairment associated 

with exposure to traumatic events, 

including disasters (National 

Child Traumatic Stress Network 

[NCTSN], 2017a). It involves 10 

sessions led by a clinician, as well 

as 2 to 3 individual sessions. It 

is an adaptation of the Cognitive 

Behavioral Intervention for Trauma 

in Schools, which is for slightly 

older children (NCTSN, 2017a).

Langley, A. K., Gonzalez, A., 

Sugar, C. A., Solis, D., & Jaycox, L. 

(2015). Bounce back; Effectiveness 

of an elementary school-based 

intervention for multicultural 

children exposed to traumatic 

events. Journal of Consulting 

and Clinical Psychology, 83(5), 

853–865.
| Page 10

Intervention Description Research With 

escent Trauma 

Publications on

Child and Adol

Survivors

Cognitive Behavioral Intervention 

for Trauma in Schools (CBITS)

CBITS is a skills-based group 

intervention designed to help 

students in 5th through 12th 

grades with symptoms of PTSD, 

depression, and general anxiety 

after experiencing trauma, 

including school violence and 

human-caused disasters (NCTSN, 

2012). It comprises 10 sessions 

and includes psycho-education, 

parent education sessions, skills in 

management of emotion, cognitive 

coping skills, and trauma narrative 

development and processing (Cohen 

& Mannarino, 2010).

Kataoka, S. H., Stein, B. D., Jaycox, 

L. H., Wong, M., Escudero, P., Tu, 

W., Zaragoza, C., & Fink, A. (2003, 

March). A school-based mental 

health program for traumatized 

Latino immigrant children. Journal 

of the American Academy of 

Child and Adolescent Psychiatry, 

42(3), 311–318. https://doi.

org/10.1097/00004583-200303000-

00011

Stein, B. D., Jaycox, L. H., 

Kataoka, S. H., Wong, M., Tu, W., 

Elliott, M. N., & Fink, A. (2003). 

A mental health intervention for 

schoolchildren exposed to violence: 

A randomized controlled trial. 

JAMA, 290(5), 603–611. https://doi.

org/10.1001/jama.290.5.603
| Page 11

Intervention Description Publications on Research With 

Child and Adolescent Trauma 

Survivors

Trauma-Focused Cognitive 

Behavioral Therapy (TF-CBT)

“TF-CBT . . . targets both the child 

and a primary caregiver to treat 

youth PTS symptoms (Cohen, 

Mannarino, & Deblinger, 2006). 

TF-CBT involves gradual exposure 

to trauma reminders over three 

phases: (1) stabilization and skillsbuilding, (2) trauma narration and 

processing, and (3) integration 

and consolidation. Outcome trials 

suggest that the involvement of a 

supportive caregiver is an important 

aspect of effective treatment” 

(Yasinski et al., 2016, p. 1068).

Jensen, T. K., Holt, T., & Ormhaug, 

S. M. (2017, November). A 

follow-up study from a multisite, 

randomized controlled trial for 

traumatized children receiving 

TF-CBT. Journal of Abnormal 

Child Psychology, 45(8), 1587–1597. 

https://doi.org/10.1007/s10802-017-

0270-0

de Arellano, M. A., Lyman, D. 

R., Jobe-Shields, L., George, P., 

Dougherty, R. H., Daniels, A. 

S., Ghose, S. S., Huang, L., . . . 

Delphin-Rittmon, M. E. (2014). 

Trauma-focused cognitivebehavioral therapy for children and 

adolescents: assessing the evidence. 

Psychiatric Services, 65(5), 591–

602.

Murray, L. K., Skavenski, S., 

Kane, J. C., Mayeya, J., Dorsey, S., 

Cohen, J. A., Michalopoulos, L. T., 

Imasiku, M., & Bolton, P. A. (2015, 

August). Effectiveness of traumafocused cognitive behavioral 

therapy among children in Lusaka, 

Zambia: A randomized clinical 

trial. JAMA Pediatrics, 169(8), 

761–769. https://doi.org/10.1001/

jamapediatrics.2015.0580

Support for Students Exposed to 

Trauma (SSET)

An adaptation of CBITS that can be 

delivered by school personnel who 

are not mental health professionals, 

SSET is an intervention delivered to 

small groups of 10- to 16-year-old 

students. SSET was developed to 

support children and adolescents 

with moderate to severe PTS 

symptoms after experience of 

natural or human-caused disasters 

and other traumatic events 

(NCTSN, 2017b).

Jaycox, L. H., Langley, A. K., Stein, 

B. D., Wong, M., Sharma, P., Scott, 

M., & Schonlau, M. (2009). Support 

for Students Exposed to Trauma: A 

pilot study. School Mental Health, 

1(2):49–60.
| Page 12

CONCLUSION

Human-caused disasters such as mass shootings, terrorist attacks, and technological disasters may cause children 

and adolescents to experience distress; negative mental health consequences such as anxiety, depression, and PTS; 

physical symptoms; and substance use or misuse. These incidents can cause symptoms of mental and substance use 

disorders in children and youth, particularly in the acute post-disaster period, with a subset of children and youth 

going on to develop diagnosable disorders. Recognizing modifiable risk and protective factors can inform strategies 

and tactics for helping children and their families recover and increase the likelihood that they respond and recover 

effectively after future disasters. Approaches and interventions at community and individual levels have been 

developed to support young people and communities in coping after disasters.

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: 

Author.

American Psychiatric Association. (2017). What is posttraumatic stress disorder? Retrieved from https://www.psychiatry.org/

patients-families/ptsd/what-is-ptsd

Bjelopera, J. P., Bagalman, E., Caldwell, S. W., Finklea, K. M., & McCallion, G. (2013, March 18). Public mass shootings in the 

United States: Selected implications for federal public health and safety policy [Congressional Research Service report 

7-5700, R43004]. Congressional Research Service. Retrieved from https://fas.org/sgp/crs/misc/R43004.pdf

Blair, J. P., & Martaindale, M. H. (2013). United States active shooter events from 2000 to 2010: Training and equipment 

implications. Retrieved from https://rems.ed.gov/docs/UnitedStatesActiveShooterEventsFrom2000to2010.pdf 

Boer, F., Smit, C., Morren, M., Roorda, J., & Yzermans, J. (2009). Impact of a technological disaster on young children: A fiveyear postdisaster multiinformant study. Journal of Traumatic Stress, 22(6), 516–524. https://doi.org/10.1002/jts.20461

Bolton, D., O’Ryan, D., Udwin, O., Boyle, S., & Yule, W. (2000). The long-term psychological effects of a disaster experienced 

in adolescence: II: General psychopathology. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41(4), 

513–523. https://doi.org/10.1111/1469-7610.00636

Bromet, E. J. (2014, February). Emotional consequences of nuclear power plant disasters. Health Physiology, 106(2), 206–210. 

https://doi.org/10.1097/HP.0000000000000012

Bromet, E. J., Havenaar, J. M., & Guey, L. T. (2011). A 25 year retrospective review of the psychological consequences of the 

Chernobyl accident. Clinical Oncology, 23(4), 297–305. https://doi.org/10.1016/j.clon.2011.01.501

Carpenter, A. L., Elkins, R. M., Kerns, C., Chou, T., Green, J. G., & Comer, J. S. (2017). Event-related household discussions 

following the Boston Marathon bombing and associated posttraumatic stress among area youth. Journal of Clinical Child 

& Adolescent Psychology, 46(3), 331–342. https://doi.org/10.1080/15374416.2015.1063432

Chun, T. H., Mace, S. E., Katz, E. R., American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, 

& American College of Emergency Physicians, Pediatric Emergency Medicine Committee. (2016). Evaluation and 

management of children and adolescents with acute mental health or behavioral problems. Part I: Common clinical 

challenges of patients with mental health and/or behavioral emergencies. Pediatrics, 138(3), e20161570–e20161570. https://

doi.org/10.1542/peds.2016-1570

Cobham, V. E., McDermott, B., Haslam, D., & Sanders, M.R. (2016). The role of parents, parenting and the family environment 

in children’s post-disaster mental health. Current Psychiatry Reports, 18(6), 53. https://doi.org/10.1007/s11920-016-0691-4

Cohen, J. A., & Mannarino, A. P. (2010). Psychotherapeutic options for traumatized children. Current Opinion in Pediatrics, 

22(5), 605–609. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3013499

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New 

York, NY: Guilford Press.
| Page 13

Comer, J. S., Bry, L. J., Poznanksi, B., & Golik, A. M. (2016) Children’s mental health in the context of terrorist attacks, 

ongoing threats, and possibilities of future terrorism. Current Psychiatry Reports, 18, 79. https://doi.org/10.1007/s11920-

016-0722-1

Comer, J. S., Dantowitz, A., Chou, T., Edson, A. L., Elkins, R. M., Kerns, C., . . . & Green, J. G. (2014, July). Adjustment 

among area youth after the Boston Marathon bombing and subsequent manhunt. Pediatrics, 134(1), 7–14. https://doi.

org/10.1542/peds.2013-4115

Comer, J. S., Fan, B., Duarte, C. S., Wu, P., Musa, G. J., Mandell, D. J., . . . Hoven, C. W. (2010). Attack-related life disruption 

and child psychopathology in New York City public schoolchildren 6-months post-9/11. Journal of Clinical Child & 

Adolescent Psychology, 39(4), 460–469. https://doi.org/10.1080/15374416.2010.486314

Comer, J. S., Kerns, C. E., Elkins, R. M., Edson, A. L., Chou, T., Dantowitz, A., . . . Green, J. G. (2014). Adjustment among 

children with relatives who participated in the manhunt following the Boston Marathon attack. Depression and Anxiety, 

31(7), 542–550. https://doi.org/10.1002/da.22281

de Arellano, M. A., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Huang, L., ... 

Delphin-Rittmon, M. E. (2014). Trauma-focused cognitive-behavioral therapy for children and adolescents: assessing the 

evidence. Psychiatric Services, 65(5), 591–602.

de Jong, J. T. V. M., Berckmoes, L. H., Kohrt, B. A., Song, S. J., Tol, W. A., & Reis, R. (2015). A public health approach to 

address the mental health burden of youth in situations of political violence and humanitarian emergencies. Current 

Psychiatry Reports, 17(7). https://doi.org/10.1007/s11920-015-0590-0

Duarte, C. S., Hoven, C. W., Wu, P., Bin, F., Cotel, S., Mandell, D. J., Nagasawa, M., Balaban, V., Wernikoff, L., & Markenson, 

D. (2006, April). Posttraumatic stress in children with first responders in their families. Journal of Traumatic Stress, 19(2),

301–306. https://doi.org/10.1002/jts.20120

Furr, J. M., Comer, J. S., Edmunds, J. M., & Kendall, P. C. (2010, December). Disasters and youth: A meta-analytic 

examination of posttraumatic stress. Journal of Consulting and Clinical Psychology, 78(6), 765–780. https://doi.

org/10.1037/a0021482

Garbarino, J., Governale, A., Henry, P., & Nesi, D. (2015). Children and terrorism. Social Policy Report, 29(2). Retrieved from 

https://www.srcd.org/sites/default/files/documents/spr292_web.pdf

Geronazzo-Alman, L., Guffanti, G., Eisenberg, R., Fan, B., Musa, G. J., Wicks, J., . . . Hoven, C. (2018, January). Comorbidity 

classes and associated impairment, demographics and 9/11-exposures in 8,236 children and adolescents. Journal of 

Psychiatric Research, 96, 171–177. https://doi.org/10.1016/j.jpsychires.2017.10.012

Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public Health, 35, 169–183. 

https://doi.org/10.1146/annurev-publhealth-032013-182435

Gould, D. W., Teich, J. L., Pemberton, M.R., Pierannunzi, C., & Larson, S. (2015). Behavioral health in the Gulf Coast region 

following the Deepwater Horizon oil spill: Findings from two federal surveys. Journal of Behavioral Health Services and 

Research, 42(1), 6–22. https://doi.org/10.1007/s11414-014-9441-8

Hiller, R. M., Meiser-Stedman, R., Lobo, S., Creswell, C., Fearon, P., Ehlers, A., . . . Halligan, S. L. (2018). A longitudinal 

investigation of the role of parental responses in predicting children’s post-traumatic distress. Journal of Child Psychology 

and Psychiatry 28(7), 781–789. https://doi.org/10.1111/jcpp.12846

Hoagwood, K. E., Olin, S. S., Wang, N. M., Pollock, M., Acri, M., Glaeser, E., Whitmyre, E. D., Storfer-Isser, A., & Horwitz, 

S. M. (2017). Developing a sustainable child and family service system after a community tragedy: Lessons from Sandy

Hook. Journal of Community Psychology, 45, 748–764. https://doi.org/10.1002/jcop.21890

Hoven, C. W., Duarte, C. S., Lucas, C. P., Wu, P., Mandell, R. D., Goodwin, R. D., . . . & Susser, E. (2005). Psychopathology 

among New York City public school children 6 months after September 11. Archives of General Psychiatry, 62, 545–552. 

https://doi.org/10.1001/archpsyc.62.5.545

Investigative Assistance for Violent Crimes Act of 2012, Public Law 112-265, 112th Congress, 126 Stat. 2435 (January 14, 

2013). Retrieved from https://www.govinfo.gov/content/pkg/PLAW-112publ265/pdf/PLAW-112publ265.pdf
| Page 14

Itagaki, S., Harigane, M., Maeda, M., Yasumura, S., Suzuki, Y., Mashiko, H., Nagai, M., Ohira, T., Yabe, H., on behalf of the 

Mental Health Group of the Fukushima Health Management Survey. (2017). Exercise habits are important for the mental 

health of children in Fukushima after the Fukushima Daiichi Disaster. Asia Pacific Journal of Public Health, 28(2_suppl): 

171S–181S. https://doi.org/10.1177/1010539516686163

Jaycox, L. H., Langley, A. K., Stein, B. D., Wong, M., Sharma, P., Scott, M., & Schonlau, M. (2009). Support for Students 

Exposed to Trauma: A pilot study. School Mental Health, 1(2):49–60.

Jensen, T. K., Holt, T., & Ormhaug, S. M. (2017, November). A follow-up study from a multisite, randomized controlled trial for 

traumatized children receiving TF-CBT. Journal of Abnormal Child Psychology, 45(8), 1587–1597. https://doi.org/10.1007/

s10802-017-0270-0

Kataoka, S. H., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., Zaragoza, C., & Fink, A. (2003, March). A schoolbased mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and 

Adolescent Psychiatry, 42(3), 311–318. https://doi.org/10.1097/00004583-200303000-00011

Kerns, C. E., Elkins, R. M., Carpenter, A. L., Chou, T., Green, J. G., & Comer, J. S. (2014). Caregiver distress, shared traumatic 

exposure, and child adjustment among area youth following the 2013 Boston Marathon bombing. Journal of Affective 

Disorders, 167, 50–55. https://doi.org/10.1016/j.jad.2014.05.040

Krouse, W. J., & Richardson, D. J. (2015, July 30). Mass murder with firearms: Incidents and victims, 1999–2013 [7-5700, 

R44126]. Washington, DC: Congressional Research Service. Retrieved from https://fas.org/sgp/crs/misc/R44126.pdf

La Greca, A. M., Comer, J. S., & Lai, B. S. (2016). Trauma and child health: An introduction to the special issue. Journal of 

Pediatric Psychology, 41(1), 1–4. https://doi.org/10.1093/jpepsy/jsv087

La Greca, A. M., & Silverman, W. K. (2006). Treating children and adolescents affected by disasters and terrorism. In P. C. 

Kendall (Ed.), Child and adolescent therapy: Cognitive-behavioral procedures (3rd ed.) (pp. 356–382). New York, NY: 

Guilford Press.

Lai, B. S., Auslander, B. A., Fitzpatrick, S. L., & Podkowirow, V. (2014). Disasters and depressive symptoms in children: A 

review. Child & Youth Care Forum, 43(4), 489–504. https://doi.org/10.1007/s10566-014-9249-y

Langley, A. K., Gonzalez, A., Sugar, C. A., Solis, D., & Jaycox, L. (2015). Bounce back; Effectiveness of an elementary schoolbased intervention for multicultural children exposed to traumatic events. Journal of Consulting and Clinical Psychology, 

83(5), 853–865.

Lowe, S. R., & Galea, S. (2017, January). The mental health consequences of mass shootings. Trauma, Violence, & Abuse, 

18(1), 62–82. https://doi.org/10.1177/1524838015591572

Mann, M., Li, J., Farfel, M. R., Maslow, C. B., Osahan, S., & Stellman, S. D. (2015). Adolescent behavior and PTSD 6–7 years 

after the World Trade Center terrorist attacks of September 11, 2001. Disaster Health, 2(3–4), 121–129. https://doi.org/10.1

080/21665044.2015.1010931

McDermott, B. M., & Cobham, V. E. (2014). A stepped-care model of post-disaster child and adolescent mental health service 

provision. European Journal of Psychotraumatology, 5(1), 24294. https://doi.org/10.3402/ejpt.v5.24294

McLees-Palinkas, T. (1994). Psychosocial impacts of disasters on families and children: The Exxon-Valdez oil spill. Master’s 

thesis. San Diego, CA: Department of Child Development, San Diego State University.

Murray, L. K., Skavenski, S., Kane, J. C., Mayeya, J., Dorsey, S., Cohen, J. A., Michalopoulos, L. T., Imasiku, M., & Bolton, 

P. A. (2015, August). Effectiveness of trauma-focused cognitive behavioral therapy among children in Lusaka, Zambia: A 

randomized clinical trial. JAMA Pediatrics, 169(8), 761–769. https://doi.org/10.1001/jamapediatrics.2015.0580

National Association of School Psychologists (NASP), & National Association of School Resource Officers (NASRO). (2017). 

Best practice considerations for schools in active shooter and other armed assailant drills. Retrieved from http://www.

nasponline.org/resources-and-publications/resources/school-safety-and-crisis/best-practice-considerations-for-schools-inactive-shooter-and-other-armed-assailant-drills

National Center for Posttraumatic Stress Disorder (PTSD). (2019). PTSD basics. Retrieved from https://www.ptsd.va.gov/

understand/what/ptsd_basics.asp
| Page 15

National Child Traumatic Stress Network (NCTSN). (2012). CBITS: Cognitive behavioral intervention for trauma in schools. 

Retrieved from https://www.nctsn.org/interventions/cognitive-behavioral-intervention-trauma-schools

NCTSN. (2017a). Bounce Back: An elementary school intervention for childhood trauma. Retrieved from https://www.nctsn.

org/interventions/bounce-back-elementary-school-intervention-childhood-trauma

NCTSN. (2017b). SSET: Support for Students Exposed to Trauma: School support for childhood trauma. Retrieved from https://

www.nctsn.org/interventions/support-students-exposed-trauma-school-support-childhood-trauma

NCTSN. (2018). Creating school active shooter/intruder drills. Retrieved from https://www.nctsn.org/resources/creatingschool-active-shooter-intruder-drills

Osofsky, H. J., Osofsky, J. D., Wells, J. H., & Weems, C. (2014, March). Meeting mental health needs after the Gulf oil spill. 

Psychiatric Services, 65, 280–283. https://doi.org/10.1176/appi.ps.201300470

Osofsky, J. D., Osofsky, H. J., Weems, C. F., Hansel, T. C., & King, L. S. (2016). Effects of stress related to the Gulf oil spill on 

child and adolescent mental health. Journal of Pediatric Psychology, 41(1), 65–72. https://doi.org/10.1093/jpepsy/jsu085

Otto, M. W., Henin, A., Hirshfeld-Becker, D. R., Pollack, M. H., Biederman, J., & Rosenbaum, J. F. (2007). Posttraumatic stress 

disorder symptoms following media exposure to tragic events: Impact of 9/11 on children at risk for anxiety disorders. 

Journal of Anxiety Disorders, 21(7), 888–902. https://doi.org/10.1016/j.janxdis.2006.10.008

Palinkas, L. A. (2012). A conceptual framework for understanding the mental health impacts of oil spills: Lessons from the 

Exxon Valdez oil spill. Psychiatry, 75(3), 203–222.

Pfefferbaum, B., Jacobs, A. K., Griffin, N., & Houston, J. B. (2015). Children’s disaster reactions: The influence of exposure 

and personal characteristics. Current Psychiatry Reports, 17(7). https://doi.org/10.1007/s11920-015-0598-5

Pfefferbaum, B., Seale, T. W., McDonald, N. B., Brandt, E. N., Rainwater, S. M., Maynard, B. T., ... Miller, P. D. (2000). 

Post-traumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. 

Psychiatry: Interpersonal and Biological Processes, 63, 358–370.

Pfefferbaum, B., Simic, Z., & North, C. (2018). Parent-reported child reactions to the September 11, 2001 World Trade Center 

attacks (New York USA) in relation to parent post-disaster psychopathology three years after the event. Prehospital and 

Disaster Medicine, 33(5), 1–7. https://doi.org/10.1017/S1049023X18000869

Pfefferbaum, B., Tucker, P., North, C. S., Jeon-Slaughter, H., & Nitiéma, P. (2014). Children of terrorism survivors: 

Physiological reactions seven years following a terrorist incident. Comprehensive Psychiatry, 55(4): 749–754. https://doi.

org/10.1016/j.comppsych.2014.01.002

RAND Corporation. (n.d.). Mass shootings: Definitions and trends. Retrieved from https://www.rand.org/research/gun-policy/

analysis/supplementary/mass-shootings.html

Saraiya, A., Garakani, A., & Billick, S. B. (2013). Mental health approaches to child victims of acts of terrorism. Psychiatric 

Quarterly, 84(1), 115–124. https://doi.org/10.1007/s11126-012-9232-4

Schonfeld, D. J., Demaria, T., Disaster Preparedness Advisory Council and Committee on Psychosocial Aspects of Child and 

Family Health. (2015). Providing psychosocial support to children and families in the aftermath of disasters and crises. 

Pediatrics, 136(4), e1120–e1130. https://doi.org/10.1542/peds.2015-2861

Shultz, J. M., Cohen, A. M., Muschert, G. W., & Flores de Apodaca, R. (2013, April–December). Fatal school shootings and the 

epidemiological context of firearm mortality in the United States. Disaster Health, 1(2), 84–101. 

Shultz, J. M., Thoresen, S., Flynn, B. W., Muschert, G. W., Shaw, J. A., Espinel, Z., Walter, F. G., Gaither, J. B., GarciaBarcena, Y., O’Keefe, K., & Cohen, A. M. (2014). Multiple vantage points on the mental health effects of mass shootings. 

Current Psychiatry Reports, 16, 469. https://doi.org/10.1007/s11920-014-0469-5

Stanford Mass Shootings in America, courtesy of the Stanford Geospatial Center and Stanford Libraries. (n.d.) Mass Shootings 

in America. Retrieved from https://library.stanford.edu/projects/mass-shootings-america

Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., & Fink, A. (2003). A mental health intervention 

for schoolchildren exposed to violence: A randomized controlled trial. JAMA, 290(5), 603–611. https://doi.org/10.1001/

jama.290.5.603
| Page 16

Stene, L. E., Schultz, J. H., & Dyb, G. (2018). Returning to school after a terror attack: A longitudinal study of school 

functioning and health in terror-exposed youth. European Child and Adolescent Psychiatry. https://doi.org/10.1007/

s00787-018-1196-y

Stough, L. M., Ducy, E. M., & Kang, D. (2017). Addressing the needs of children with disabilities experiencing disaster or 

terrorism. Current Psychiatry Reports, 19(4). https://doi.org/10.1007/s11920-017-0776-8

U.S. Department of Education, Office of Elementary and Secondary Education, Office of Safe and Healthy Students. (2013, 

June). Guide for developing high-quality school emergency operations plans, Washington, DC: U.S. Department of 

Education. Retrieved from https://rems.ed.gov/docs/REMS_K-12_Guide_508.pdf

U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime. (2015, August). Tools: Glossary. Helping 

victims of mass violence and terrorism: Planning, response, recovery, and resources. Retrieved from https://www.ovc.

gov/pubs/mvt-toolkit/glossary.html

U.S. Government Accountability Office (GAO). (2016, March). Emergency management: Improved federal coordination could 

better assist K–12 schools prepare for emergencies (GAO-16-144). Retrieved from https://www.gao.gov/products/GAO-16-

144

Wu, P., Duarte, C. S., Mandell, D. J., Fan, B., Liu, X., Fuller, C. J., . . . Hoven, C. W. (2006). Exposure to the World Trade 

Center attack and the use of cigarettes and alcohol among New York City public high-school students. American Journal 

of Public Health, 96(5), 804–807. https://doi.org/10.2105/AJPH.2004.058925

Yasinski, C., Hayes, A. M., Ready, C. B., Cummings, J. A., Berman, I. S., McCauley, T., Webb, C., . . . Deblinger, E. (2016). 

In-session caregiver behavior predicts symptom change in youth receiving trauma-focused cognitive behavioral therapy 

(TF-CBT). Journal of Consulting and Clinical Psychology, 84(12), 1066–1077. https://doi.org/10.1037/ccp0000147

SAMHSA is not responsible for the information provided by any of the web pages, materials, or organizations referenced in 

this communication. Although the Supplemental Research Bulletin includes valuable information and links, SAMHSA does not 

necessarily endorse any specific products or services provided by public or private organizations unless expressly stated. In addition, 

SAMHSA does not necessarily endorse the views expressed by such sites or organizations nor does SAMHSA warrant the validity of 

any information or its fitness for any particular purpose.