Parents' Retrospective Reports of Youth Psychological Responses to the Sniper Attacks in the Washington, DC, Area
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Violence and Victims, Volume 26, Number 1, 2011 Parents’ Retrospective Reports of Youth Psychological Responses to the Sniper Attacks in the Washington, DC, Area Shannon R. Self-Brown, PhD Georgia State University Greta M. Massetti, PhD Jieru Chen, MS Jeffrey Schulden, MD Centers for Disease Control and Prevention A random-digit-dial telephone survey was conducted in May 2003, with 355 parents of children ages 2–17 years old, living in Washington, DC, or in the two surrounding coun- ties during the October 2002 sniper shootings, to examine parent retrospective reports of child event-related psychological distress. An estimated 32% of parents reported that chil- dren experienced at least one psychological distress symptom related to sniper shootings. Older children, females, children with a history of trauma exposure prior to sniper attacks, children whose parents reported routine disruption as the result of attacks, children whose parents perceived them as at great risk for harm from sniper attacks, and those children whose parents reported more traumatic stress symptoms in response to attacks were at greatest risk for reported psychological distress. Keywords: sniper shootings; psychological distress; posttraumatic stress; Washington, DC, area; community traumatic events F rom October 2 to 24, 2002, 14 sniper shootings occurred in Washington, DC, Maryland, and Virginia. Thirteen individuals were shot during this spree, with 10 fatally wounded. Nine of the 14 shootings were concentrated within a roughly 10-mile radius in Washington, DC, and in two neighboring Maryland counties. These attacks caused widespread fear among people for their own safety and for their families. In May 2003, a random-digit-dial telephone survey was conducted, with 1,205 adults living in the communities that had the most concentrated exposure to the shootings. The survey collected data on participants’ behavioral and psychological responses to the attacks. Findings from this survey indicated that following the attacks, 44% reported at least one traumatic stress symptom and 7% reported four or more such symptoms, consistent with a positive screening for posttraumatic stress disorder (PTSD). Women living within 5 miles of any sniper incident were at greatest risk for traumatic stress (Schulden et al., 2006). 116 © 2011 Springer Publishing Company DOI: 10.1891/0886-6708.26.1.116
Sniper Attacks 117 To date, limited information is available regarding how children and adolescents were affected by the sniper shootings. Understanding more about how this unique, prolonged, and intermittent violent event affected youth adjustment could significantly contribute to the literature on community traumatic events (CTE), which typically focuses on the impact of natural/man-made disasters, terrorist attacks, or chronic community violence. Additionally, understanding what individual and family risk factors influence youth outcome following such an event will help delineate the future needs for screening and clinical intervention with youth exposed to similar CTE. Thus, the purpose of this article was to examine a sub- sample of the adults surveyed by Schulden et al. (2006), those who reported to have a child between 2 and 17 years of age living in the home to explore the parent-reported psychologi- cal impact of the sniper shootings on children and adolescents who lived in Washington, DC, and neighboring Maryland counties during the period of the sniper shootings. IMPACT OF COMMUNITY TRAUMATIC EVENTS ON CHILDREN Research indicates that exposure to CTE increases the risk of child and adolescent dis- tress (March, Amaya-Jackson, Terry, & Constanzo, 1997; McDonald & Richmond, 2008; Pfefferbaum, Sconzo et al., 2003; Spell et al., 2008). For instance, children exposed to diverse CTE, such as Hurricane Katrina (Spell et al.) and the World Trade Center attack (Hoven et al., 2005), exhibited increased risk for symptoms of posttraumatic stress, anxiety, and depression. Furthermore, in a recent meta-analysis of 26 empirical articles examining the impact of chronic community violence—another form of CTE—on youth, McDonald and Richmond concluded that there is a clear relationship between youth community vio- lence exposure and depressive symptoms, anxiety, posttraumatic stress, and aggression. Interestingly, recent findings suggest that a child does not have to be a direct victim or witness a CTE to be at risk for deleterious outcomes. There is emerging support that indirect exposure to a CTE by learning about violent death, serious harm, or threat of death to another person through family, peers, or media can result in increased risk for psycho- logical distress (Calderoni, Alderman, Silver, & Bauman, 2006; Pfefferbaum, Seale et al., 2003;Saylor, Cowart, Lipovsky, Jackson, & Finch, 2003). Pfefferbaum and colleagues (2000) described bomb-related PTSD reactions in children residing 100 miles from Oklahoma City, 2 years after the Oklahoma City bombing. Approximately one-fourth of the youth reported moderate to severe CTE-related distress symptoms. Media exposure and having a friend who knew someone killed or injured were significant predictors of symp- tomatology (Pfefferbaum et al., 2000). In addition to terrorist attacks, there is evidence that indirect exposure to other types of CTE can have a similar effect on youth. Following Hurricane Katrina, a sample of schoolchildren living 60 miles from New Orleans in Baton Rouge reported similar levels of PTSD symptomatology as children, matched by age and ethnicity, who were displaced during Hurricane Katrina (Kelley et al., in press). Clearly, children can significantly be affected by CTEs, irrespective of whether they are a direct victim, observer, or otherwise exposed to significant information on the event. Risk Factors for Poor Youth Adjustment Following Community Traumatic Events Several individual and family factors have been identified as risk factors of children’s out- come following exposure to a CTE. In terms of individual characteristics, girls (Goenjian
118 Self-Brown et al. et al., 2001; Hoven et al., 2005; Moses, 1999), children who have preexisting psycho- logical conditions (Asarnow et al., 1999; Earls, Smith, Reich, & Jung, 1988; Weems & Overstreet, 2008), and children who have been exposed to other traumatic events (Hoven et al.; Kelley & Self-Brown, 2009; Pfefferbaum, North et al., 2003) have been found to be at increased risk for psychological distress (anxiety and depressive symptoms). For instance, Pfefferbaum and colleagues (2003) found that the number of lifetime traumas a child experienced predicted bombing-related posttraumatic stress symptoms in children exposed to the 1998 bombing of the American embassy in Nairobi, Kenya. Findings regarding other individual-level characteristics, such as child age at the time of the event, have been inconsistent across different types of CTE (Green et al., 1991; Hoven et al., 2005; Lonigan, Shannon, Taylor, Finch, & Sallee, 1994). One possible reason for this is that most studies have sampled restricted age ranges, thereby limiting the ability to examine differential outcomes across the developmental spectrum in response to the same CTE. Individual experiences during and following the traumatic event can also impact the risk of psychological distress. Children who report higher levels of loss, threat of harm, loss of control, fear from the event (Spell et al., 2008; Vernberg, La Greca, Silverman, & Prinstein, 1996), proximity to the event (Breton, Valla, & Lambert, 1993; Goenjian et al., 2001; Pynoos et al., 1987), and greater exposure to television coverage following the event (Pfefferbaum et al., 2000) are at greater risk for poor mental health outcomes. Additionally, research suggests that the disruption to familiar routines following a CTE can increase trauma-related symptomatology in children (Boyce, 1981; Foy, 1992; Prinstein, La Greca, Vernberg, & Silverman, 1996; Sandler, Gersten, Reynolds, Kallgren, & Ramirez, 1988). Post-disaster clinical materials typically suggest that disruption of family routines be minimized and that standard activities be resumed as soon as possible following a CTE (American Red Cross, 1992; Foy, 1992). Family variables have also been deemed important mitigating factors of youths’ out- comes following CTE (Boney-McCoy & Finkelhor, 1996; Buka, Stichick, Birdthistle, & Earls, 2001; Plybon & Kliewer, 2001). To date, one of the most commonly researched family-level risk factors for CTE-exposed youth is parental distress, with a strong focus on maternal distress versus paternal distress, and this factor has been consistently found to be a strong associate or predictor of poor child outcome in these circumstances (Scheeringa & Zeanah, 2008; Self-Brown et al., 2006; Spell et al.; Swenson et al., 1996). For instance, two recent studies have found maternal distress to be significantly associated with child’s outcome following Hurricane Katrina, such that parents rating higher distress post-hurricane have children who rate higher distress (Scheeringa & Zeanah; Spell et al., 2008). Further, Self-Brown and colleagues found that parental PTSD moderated the rela- tion between community violence exposure and PTSD in a community sample of African American adolescents. Thus, it appears that parent distress is a significant contributor to youth outcome following various CTE. Current Study and Hypotheses The current exploratory study examined the prevalence of parent-reported child psycho- logical distress as well as the impact of child- and family-level factors on parent-reported child psychological distress in response to the sniper shootings. Child and family factors examined were selected based on the existing CTE literature (Foy, 1992; Goenjian et al., 2001; Kelley & Self-Brown, 2009; Self-Brown et al., 2006; Vernberg et al., 1996). This study contributes to the literature in several ways. First, the sniper attacks were a highly
Sniper Attacks 119 unique type of community trauma. The sniper attacks differed from natural/man-made disasters and terrorist attacks that have occurred in recent years in this country (Oklahoma City bombings, 9/11 terrorist attacks) because of the prolonged and intermittent period (3 weeks) on which the events took place. The sniper shootings could certainly be consid- ered a form of community violence, another form of CTE, but research on the impact of community violence on youth has typically studied inner-city populations that are exposed to chronic violence. Thus, the sniper shootings provided an opportunity to examine the unique effects of a violent, acute, but repetitive domestic terror event on youth. Second, child and family factors, deemed important in the current CTE literature, were examined. Often in CTE research, such factors are examined separately, inhibiting our ability to understand the unique and combined effects of mitigating factors across the ecological system. Third, both mothers and fathers were included in this study and the participating parents had children with a wide age range (ages 2–17 years), which allows us to under- stand the potential importance of developmental level on psychological distress following these circumstances. Lastly, the data were weighted to account for the complex sample design and post-stratified to the combined population distribution of the jurisdictions by age, gender, and race/ethnicity, which allowed for the prediction of population-level prevalence rates for youth outcomes. We hypothesized that parents would report youth as experiencing psychological distress in response to the sniper shootings. Demographic-, individual-, and family-level factors were expected to contribute significantly to youth psychological distress. Specifically, at the individual level, we hypothesized that girls, youth who resided in closer proximity to one of the shootings, youth with a history of prior trauma, youth perceived by parents to be at greater risk for harm from the sniper shootings, and those reported to have greater disruptions in normal routines from the sniper attacks would be at increased risk for parent-reported psychological distress. At the family level, we hypothesized that children of parents who report higher levels of psychological distress, as the result of the sniper attacks, would be at risk for greater parent-reported psychological distress. Parent gender was included as a control variable, given that research has indicated that mothers often rate their children as exhibiting higher levels of psychological or behavioral problems than fathers (Duhig, Renk, Epstein, & Phares, 2000). METHODS Data Collection A cross-sectional survey was conducted through RDD telephone interviews from May 2 to 31, 2003; 7 months after the sniper shootings. Survey data were collected from a random sample of 1,205 adult residents living in the following areas during any portion of the period the sniper shootings occurred: Washington, DC; Montgomery County, Maryland; and Prince George’s County, Maryland. These areas were where most of the shootings took place (9 of 14) and where the most concentrated exposure to the shootings occurred (within a 10-mile radius). Interviewers from a survey firm trained in administering health-related surveys conducted computer-assisted telephone interviews in English. All households that had a listed mailing address associated with their telephone number (25.4% of valid records) were mailed a letter informing them of the purpose of the survey several days before the interviews. For adults who were reached by telephone, the computer system selected at
120 Self-Brown et al. random one adult residing in the home to be surveyed. Next, a screening question was com- pleted inquiring about the adults’ location of residence in Washington, DC, or Montgomery County or Prince George’s County, Maryland between October 2nd and 24th of 2002. Those individuals who responded “No” were screened out of the study. Approximately 15% of potential participants contacted by phone were screened out because of being outside the scope of study. Other exclusion criteria included if 15 contact attempts were made with no success, if the respondent was reached by telephone and gave a final refusal, or if the telephone number was invalid. According to the Standard Definitions and formula response rate 4 (RR4), as published by the American Association for Public Opinion Research, the overall response rate for the survey was 56.4%. Adult participants were asked whether a child younger than age 18 was living in the household during October 2002, the period of the sniper attacks. For those adults who responded affirmatively, one child between the ages of 2 and 17 years living in the house- hold was selected at random by the computer system, with equal probability for selection among all the children. Adult participants who were the parent or legal guardian of the selected child were asking questions about the child (n 5 355). Of parents included in this study, approximately 43% were fathers and 57% were mothers. Twenty-seven percent of the children selected as participants were aged 2–5 years, 37.3% were aged 6–11 years, and 35.2% were aged 12–17 years. More than half (52.5%) of the youth were boys. Parents were ethnically diverse, with 36.4% non-Hispanic African American, 48.2% non-Hispanic White, 7.3% Hispanic, and 7.9% other. Primary Outcome Parent-Reported Child Psychological Distress. Psychological distress of the child was assessed using eight items from the Pediatric Emotional Distress Scale (PEDS) through parent report (Saylor, Swenson, Reynolds, & Taylor, 1999). The items included yes/ no responses to questions about whether the child experienced any of the following during the dates of October 2–24, 2002, or after the period of the sniper shootings: had more trouble sleeping than usual; had more bad dreams than usual; seemed more sad or withdrawn than usual; clung to adults or did not want to be alone more than usual; had more temper tantrums or seemed more irritable than usual; acted younger than he or she usually does; seemed more easily startled; or acted more aggressively than usual during the period following the sniper attacks. Responses of “Yes” were summed for a total child distress symptoms score. The PEDS has acceptable psychometric properties, including a coefficient alpha of .72–.78, moderate test-retest and interrater reliabilities, and good discriminant validity (Saylor et al., 1999). Demographics and Risk Factors Demographic Questions. Adult participants were asked about basic demographic characteristics of the minor child, including age and sex, as well as for themselves. For the multivariate analyses, the age variable was divided into three categories: (1) ages 2–5 years (early childhood); (2) ages 6–11 years (middle childhood), and (3) ages 12–17 years (adolescence). Proximity of Residence to Shooting Incidents. Parents were asked to report whether any of the sniper shootings occurred within 5 miles, .5 but within 10 miles, or .10 miles from their home. For analysis purposes, self-reported proximity of residence was collapsed into levels of within 5 miles and .5 miles.
Sniper Attacks 121 Parents’ Perceived Likelihood of Injury From Sniper Shootings. Parents were asked, “How likely did you feel it was that [your child] might be injured by the sniper?” Responses were coded on a 3-point scale (not likely at all, somewhat likely, or very likely). Sniper Shootings’ Interference With Routines. Parents were asked, “To what extent did the sniper shootings interfere with [your child’s] social and recreational activities with family or friends?” Responses were reported on a 3-point scale (not at all, slightly, or extremely). For analytic purposes, this variable was collapsed into a dichotomous variable with values of “Yes” or “No” by combining the responses of slightly and extremely together into the “Yes” category. Child History of Prior Trauma. Parents were asked about their child’s prior history of trauma (“Prior to the sniper attacks, had he or she ever had a major trauma or stress?”). Respondents provided a “Yes” or “No” answer to this question. Adult Psychological Distress. Parents’ posttraumatic stress symptoms were measured using a 7-item screening instrument based on Breslau’s short screening scale for PTSD (Breslau, Peterson, Kessler, & Schultz, 1999). The measure includes items assessing PTSD symptoms (“Did you try to avoid being reminded of the sniper incidents by staying away from certain places, people, or activities?”). Responses on this measure were coded into three categories: no symptoms, 1–2 symptoms, or 3 or more symptoms. Statistical Analyses Statistical analyses were conducted to estimate the prevalence of parent-reported child psychological distress and to determine whether there was significant variation in the number of child distress symptoms among different subgroups following the 3-week period of the sniper shootings. As the outcome of interest was the count of child psychological symptoms, a log-linear regression modeling approach was used to model the count data. Log-linear regression analyses assessed the associations between child distress and each of the potential factors identified by previous research discussed in the literature review and by preliminary analyses. These potential factors included child’s age, sex, and history of prior trauma; parents’ report of the sniper attacks’ interference with routines; parents’ perception of the likelihood that the child would be injured or harmed by the shootings; adult gender; and proximity of residence to any one of the shooting sites. For further ass essing the associations considering parental distress status, a second analysis was conducted to control for parents’ traumatic stress symptoms following the sniper shootings. All analyses were conducted by using SUDAAN software version 10.0 (Research Triangle Institute, Research Triangle Park, North Carolina). Data were weighted to account for the complex sample design, including adjustment factors for selection probabilities, corrections for nonresponse at the household level, and population totals. The data were then post-stratified to the combined population distribution of the jurisdictions by age, gender, and race/ethnicity within county using census data. The weights enabled appropriate vari- ance estimates for the full study population (rather than limited to the survey sample). RESULTS Fifty-six percent of the parents felt that their children were somewhat likely or very likely to be injured by the snipers. Analysis results show that more than three-quarters (75.6%) of parents thought that the sniper shootings interfered with their children’s normal routines,
122 Self-Brown et al. including their social and recreational activities with families or friends. About 1 in 12 (8.4%) children was reported to have experienced major trauma or stress prior to the sniper attacks. An assessment of parents’ psychological reaction indicates that 53.7% of parents reported at least 1 PTSD symptom as a result of the sniper attacks (Table 1). Among children aged 2–17 years old and who resided in the affected areas during the 3-week period, about one in three children (an estimated 32%) were reported to have experienced at least one psychological distress symptom because of the sniper shooting incidents. Preliminary bivariate analyses showed that child age, gender, history of prior trauma, parents’ report of the extent to which the sniper attacks interfered with normal routines, and parents’ perception of the likelihood the child would be injured by the shootings were associated with parent-reported child distress. Multivariable models were then fitted to study these associations simultaneously. Model 1 examined the associations, and Model 2 examined these same associations controlling for adult traumatic stress symptoms. Both models are depicted in Table 2. TABLE 1. Demographic Characteristics and Risk Factors of Study Population Frequency Weighted % (95% CI) Child age 12–17 years 120 35.2% (29.1–41.2) 6–11 years 128 37.3% (31.3–43.4) 2–5 years 87 27.5% (21.8–33.2) Child gender Girl 165 47.5% (41.3–53.8) Boy 170 52.5% (46.2–58.8) Child prior history of trauma Yes 36 8.4% ( 5.1–11.7) No 299 91.6% (88.3–94.9) Sniper shootings’ interference with routines Yes 258 75.6% (70.2–81.0) No 75 24.4% (19.0–29.8) Perceived likelihood of injury from sniper shootings Very likely 29 8.9% (5.1–12.7) Somewhat likely 147 47.1% (40.7–53.5) Not at all likely 151 44.0% (37.7–50.4) Parent traumatic stress 3 1 symptoms 50 16.3% (11.1–21.4) 1–2 symptoms 126 37.4% (31.2–43.6) No symptoms 153 46.3% (40.0–52.7)
Sniper Attacks 123 TABLE 2. Results From Log-Linear Regressions Examining the Associations Between Demographics, Individual, and Relationship Risk Factors and Child Psychological Distress Following the Sniper Shootings Model 1 Model 2 Incidence Ratio Incidence Ratio Risk Factor (95% CI) Significance (95% CI) Significance Child age p , .05 p , .05 12–17 years 3.2 (1.3–8.0) 3.5 (1.5–8.5) 6–11 years 3.7 (1.5–9.3) 4.0 (1.6–9.9) 2–5 years Referent Referent Child gender p , .05 p , .05 Girl 1.7 (1.1–2.5) 1.6 (1.1–2.4) Boy Referent Referent Child prior history of trauma p , .001 p , .001 Yes 2.4 (1.5–3.8) 2.6 (1.6–4.3) No Referent Referent Sniper shootings’ interference with p , .01 p , .05 routines Yes 3.0 (1.3–6.6) 2.4 (1.1–5.3) No Referent Referent Perceived likelihood of injury from p , .001 p , .05 sniper shootings Very likely 3.6 (2.0–6.6) 2.5 (1.4–4.7) Somewhat likely 2.0 (1.3–3.2) 1.7 (1.0–2.7) Not at all likely Referent Referent Parent gender p 5 .83 p 5 .76 Male 1.1 (0.7–1.7) 1.1 (0.7–1.6) Female Referent Referent Proximity to shooting incidents p 5 .23 p 5 .21 Within 5 miles 1.3 (0.8–2.0) 1.3 (0.9–2.0) Greater than Referent Referent 5 miles Parent traumatic stress p , .01 3 1 Symptoms — — 2.5 (1.4–4.6) 1–2 Symptoms — — 1.4 (0.8–2.4) No symptoms — — Referent Note. Model 1 included all risk factors except parent traumatic stress; model 2 included all risk factors.
124 Self-Brown et al. Model 1 indicated significant variation in parent-reported child distress symp- toms among the three age groups examined (p , .001). Contrasted with the youngest group (age 2–5 years old), children in age groups 6–11 and 12–17 years had 3.7 times (95% CI 5 1.5–9.6) and 3.2 times (95% CI 5 1.3–8.0) the number of reported distress symptoms, respectively. Girls had a greater number of distress symptoms compared to boys, with a ratio of 1.7 to 1 (95% CI 5 1.1–2.5, p 5 .01). Children with reported major trauma or stress prior to the sniper attacks had more reported distress symptoms following the sniper shootings than children without a history of trauma. Specifically, an incidence density ratio (IDR) of 2.4 (95% CI 5 1.5–3.8, p , .001) was estimated for children with prior trauma versus children without such a history, indicating a higher rate of child distress symptoms by 140% among children with prior trauma. Children with reported disruption of routines as a result of the sniper shootings displayed more distress symptoms according to their parents than did children with less disruption (IDR 5 3.0, 95% CI 5 1.3–6.6, p 5 .008). Statistically significant variation was also found between parent-reported child distress symptoms and the parent’s perception of the likelihood that the child could be injured by the sniper. Analysis shows that the IDR was 3.6 (95% CI 5 2.0–6.6, p 5 .0001) for children reported to be very likely to be injured by the snip- ers, indicating almost four times the rate of child distress symptoms among this group compared with children whose parents felt that their children were not likely at all to be injured by the snipers. Parents’ gender and proximity of residence to any one of the shoot- ing incidents were not significantly associated with child distress symptoms. To assess the influence of parent traumatic stress on the relationships between the num- ber of parent-reported child distress symptoms and the factors discussed in the previous multivariable model, the model was refitted to control for this factor. Results show that the previously found IDRs are similar in magnitude and the associations remain signifi- cant (Table 2). Furthermore, the parent traumatic stress symptoms factor is significantly associated with child distress symptoms (p 5 .009). Children whose parents reported three or more traumatic stress symptoms were reported to have 2.5 (95% CI 5 1.4–4.6) times the number of distress symptoms compared with children whose parents reported no symptoms. DISCUSSION The current exploratory study sought to identify individual- and family-level vari- ables affecting parent-reported children’s distress symptoms following exposure to the Washington, DC, sniper attacks. This study was a first attempt to document the impact of the sniper attacks on youth using systematic data collection. Study findings are indicative of the substantial impact that CTE can have on children and families. As hypothesized, several individual and family factors increased the risk of parent-reported child distress following this event. Risk Factors Associated With Child Distress Following the Sniper Attacks Girls and older children were at greatest risk for psychological distress following the sniper attacks, according to parent reports. This finding is consistent with other research on risk factors following CTEs, such as chronic community violence (Fowler, Braciszewski, Jacques-Tiura, & Baltes, 2009), terrorist attacks (Hoven et al., 2005), and natural disasters
Sniper Attacks 125 (Spell et al., 2008). Previous findings related to age have been mixed; however, few studies have included samples with the broad age range included in the present sample, limiting comparisons for various age groups who have experienced the same CTE. Children who had a history of exposure to trauma were also at greater risk for parent-reported psycho- logical distress. This finding is consistent with prior research, such as that by Pfefferbaum, North, and colleagues (2003), indicating that prior traumatic experiences are predictive of CTE-distress symptoms. Interestingly, parent reports of youth distress did not differ according to parent gender, which was important to examine because past research has documented only moderate correlations among parent reports of child internalizing prob- lems (Duhig et al., 2000). Parent-reported child experiences during and following the sniper attack also influ- enced the levels of reported child distress. Children who were rated by parents as at greater perceived risk for injury or harm were also more likely to be rated as experiencing higher levels of distress. This is consistent with findings in youth disaster research, indicating that children who experience higher levels of loss and harm are at greatest risk for poor psycho- logical outcomes (La Greca, Silverman, Vernberg, & Prinstein, 1996; Spell et al., 2008). However, it is important to note that risk of harm in the present study was measured as parents’ perceived risk of harm, which is an important distinction from actual risk of harm. Additionally, children who were reported to have more routine disruption following the sniper attacks were at greater risk for distress. In general, the presence of family routines has been found to be related to child health and well-being (Fiese et al., 2002). Although routine disruption has not been extensively studied following CTE, many experts have suggested the clinical importance of reestablishing family routines following such events (American Red Cross, 1992); the findings from the present study support the validity of this clinical insight. Inconsistent with past research (Breton et al., 1993; Goenjian et al., 2001; Pynoos et al., 1987), proximity of family residence to the event was not a significant correlate with youth outcome. Perhaps the intermittent and prolonged aspects of the shoot- ings, as well as the broad radius in which the events took place, led to a more pervasive impact across the affected districts. Lastly, parent distress significantly contributed to parent-reported child distress following the sniper attacks. Interestingly, this family factor was found to be significantly associated with child distress after controlling for other child and family-level factors. Although the literature is replete with studies supporting parent distress as an important contributor to child distress following CTE, such as natural disaster, community violence, and terrorist attacks (Scheeringa & Zeanah, 2008; Self-Brown et al., 2006; Spell et al., 2008; Swenson et al., 1996), this study suggests the importance of parent functioning for child psychological distress following a prolonged, repetitive, and intermittent domestic terror event. Although the results of the current exploratory analyses are an important first step in the field, future work replicating this association with child-reported event experiences and trauma symptoms following such an event is necessary. Strengths and Limitations of the Study There were several strengths of this study. First, this study focused on a unique violence- related CTE and examined risk factors that were established as important during other CTE for youth. Thus, this study allowed us to examine whether such risk factors would general- ize to an event that was quite different in scope and duration than other well-studied CTEs (i.e., natural disasters, community violence, terrorist attacks). This is the only known study
126 Self-Brown et al. to date to explore the potential impact of this domestic terror event on youth. Second, the inclusion of mothers and fathers of children who ranged in age from 2 to 17 years old allowed for an examination of age effects across a broad developmental spectrum, from early child- hood through adolescence, as well as whether parent reports of youth distress significantly differed according to parent gender. Most CTE research focuses exclusively on children in early childhood, youth of elementary school age, or adolescents, which does not allow for direct comparisons of children and youth at different developmental stages following a CTE and how this interrelates with outcome. Third, both child- and family-level parent-reported risk factors were assessed, allowing for a more thorough understanding of how each of these ecological contexts can influence child functioning post-CTE. In addition, the use of sample weights in the present analyses allowed for generation of population-level estimates, which broaden the generalizability of the study beyond the specific study sample. In terms of limitations, the cross-sectional nature of the study did not allow for causal associations to be established. Additionally, there were several limitations related to the methodological approach used for data collection. First, even for children who were old enough to provide accurate self-report information (age 8 and above), no child self-report information was collected either on the event or on the related emotional reactions. A decision was made to collect data this way because of several factors, including the limited resources available, concerns regarding participant burden, and concerns regard- ing human subject protections for interviewing children via telephone regarding traumatic experiences. This data collection method could have significantly affected the results, in that parents may have provided inaccurate reports of children’s psychological distress. This bias in reporting is of greatest concern with parents who report high levels of their own distress. Second, because of time constraints, the child- and family-level factors measured in this study were limited to one question; despite the existence of psychometrically sound measures to assess some of the relevant constructs. Future research should make use of relevant child- and parent-report measures to gain a more full understanding of these associations following CTEs. Additionally, several important individual and family factors were not included in this study that could be critical to the outcome variable such as family closeness or cohesiveness and family emotional support. Future studies could include a more thorough examination of these predictor variables. Third, the survey was not fielded until several months after the shootings and did not include all affected counties (Virginia counties were not included), which may have biased the results found. Fourth, the letter sent to potential participants prior to the calls mentioned that surveys would be about the effect of the sniper shootings. These statements may have biased the sample, because those individuals most affected by the sniper shootings may have been more or less likely to participate in the survey than those who were not affected. Fifth, administration of the interview in English limits the generalizability of findings to only English-speaking families. Sixth, information was obtained from one parent. It would have been useful to investigate the psychological functioning of both parents, when applicable, to allow for further exploration of differential parental influences on poor outcome of youth in these circumstances. Lastly, the sniper attacks occurred 1 year after the 9/11 terrorist attacks, which affected some of the same communities that the sniper attacks impacted. Thus, for many families, this period may have felt like a continuous period of threat. Because no questions were included in the survey specifically inquiring about family exposure to other types of community traumatic events, it is impossible to understand the unique and com- bined effects of the sniper shootings and other CTEs that have affected families residing in the surveyed communities.
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