Parents' Retrospective Reports of Youth Psychological Responses to the Sniper Attacks in the Washington, DC, Area

 
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.
Sniper Attacks                                                                                          127

    Implications for Community Traumatic Events Victims. These exploratory data
su­ggest that an appropriate public health approach for working with children exposed to
co­mmunity traumatic events would be multifocal. Firstly, public health messages following
CTEs should emphasize that children may suffer from psychological distress even if they
are not directly exposed. Parents, other caregivers, and treatment providers should be
informed about the potential impact on children directly and indirectly exposed to CTEs,
and be aware of signs of distress. Assessment with youth exhibiting signs of d­istress
f­ollowing CTEs should include a thorough evaluation of event characteristics, prior trauma,
and changes in child routines, related psychological distress symptoms, and primary care-
givers’ distress symptoms. Girls, older children, children perceived to be more at risk for
CTE harm, children with a history of trauma, and children whose parents are experienc-
ing elevated distress should be considered at greatest risk of distress. Interventions for
CTE-exposed youth should occur at the individual and family level and be consistent with
recommended evidence-based practices for screening and intervention strategies.

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Acknowledgments. The findings and conclusions in this report are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control and Prevention.

Correspondence regarding this article should be directed to Shannon R. Self-Brown, PhD, Georgia
State University, P.O. Box 3995, Atlanta, GA 30302. E-mail: sselfbrown@gsu.edu
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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