ARTICLE

Adjustment Among Area Youth After the Boston Marathon Bombing and Subsequent Manhunt

AUTHORS: Jonathan S. Comer, PhD,a Annie Dantowitz, WHAT’S KNOWN ON THIS SUBJECT: Research in the aftermath of MSW,b Tommy Chou, MA,a Aubrey L. Edson, MA,b R. large-scale terrorist attacks shows that exposed children Meredith Elkins, MA,b Caroline Kerns, MA,b Bonnie Brown, experience numerous negative psychological sequelae, including RN,b and Jennifer Greif Green, PhDb increased emotional difficulties, posttraumatic stress, and aDepartment of Psychology, Florida International University, significant attack-related life disruptions. Miami, Florida; and bDepartment of Psychology, Boston University, Boston, Massachusetts WHAT THIS STUDY ADDS: Most research on terrorism-exposed KEY WORDS youth examines large-scale terrorism. Limited work examines trauma, terrorism, PTSD, mental health, disaster reactions to terrorism of the scope of the marathon attack, and ABBREVIATIONS the extraordinary manhunt and shelter-in-place warning was an — PTSD posttraumatic stress disorder unprecedented experience. Understanding adjustment after these SDQ—Strengths and Difficulties Questionnaire events is critical. Dr Comer conceptualized and designed the study, supervised participant recruitment and data collection, conducted the data analyses, drafted the initial draft of the manuscript, and revised the manuscript in response to internal suggestions; Ms Dantowitz developed the data collection infrastructure, coordinated participant recruitment efforts, helped oversee data collection, and helped prepare data for statistical analysis; abstract Mr Chou, Ms Edson, Ms Elkins, and Ms Kerns helped design the BACKGROUND: The majority of research on terrorism-exposed youth has study and develop the core study survey, helped coordinate examined large-scale terrorism with mass casualties. Limited research participant recruitment efforts, helped prepare data for statistical analysis, reviewed the initial draft of the manuscript, has examined children’s reactions to terrorism of the scope of the and provided suggestions for revision; Ms Brown coordinated Boston Marathon bombing. Furthermore, the extraordinary postattack and oversaw participant recruitment efforts and reviewed the interagency manhunt and shelter-in-place warning made for a truly initial draft of the manuscript and provided suggestions for revision; Dr Green helped design the study and develop the core unprecedented experience in its own right for families. Understanding study survey, helped coordinate participant recruitment efforts, the psychological adjustment of Boston-area youth in the aftermath of helped develop a data analytic plan, and reviewed the initial these events is critical for informing clinical efforts. draft of the manuscript and provided suggestions for revision; and all authors approved the final manuscript as submitted. METHODS: Survey of Boston-area parents/caretakers (N = 460) reporting ’ www.pediatrics.org/cgi/doi/10.1542/peds.2013-4115 on their childs experiences during the attack week, as well as fi doi:10.1542/peds.2013-4115 psychosocial functioning in the rst 6 attack months. Accepted for publication Apr 9, 2014 RESULTS: There was heterogeneity across youth in attack- and manhunt- Address correspondence to Jonathan S. Comer, PhD, Center for related experiences and clinical outcomes. The proportion of youth with Children and Families, Department of Psychology, Florida likely attack/manhunt-related posttraumatic stress disorder (PTSD) International University, 11200 Southwest 8th St, Miami, FL 33199. was roughly 6 times higher among Boston Marathon–attending youth E-mail: jocomer@fiu.edu than nonattending youth. Attack and manhunt experiences each uniquely PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). predicted 9% of PTSD symptom variance, with manhunt exposures Copyright © 2014 by the American Academy of Pediatrics more robustly associated than attack-related exposures with a FINANCIAL DISCLOSURE: The authors have indicated they have range of psychosocial outcomes, including emotional symptoms, conduct no financial relationships relevant to this article to disclose. problems, hyperactivity/inattention, and peer problems. One-fifth of youth FUNDING: Supported by the Center for Anxiety and Related . Disorders Research Fund, the Barlow Research Fund, and the watched 3 hours of televised coverage on the attack day, which was linked Department of Psychology at Boston University, as well as by the to PTSD symptoms, conduct problems, and total difficulties. Prosocial behavior National Institutes of Health (grants K23 MH090247 and K01 and positive peer functioning buffered the impact of exposure. MH085710). Funded by the National Institutes of Health (NIH). CONCLUSIONS: Clinical efforts must maintain a broadened focus beyond POTENTIAL CONFLICT OF INTEREST: The authors have indicated simply youth present at the blasts and must also include youth highly exposed they have no potential conflicts of interest to disclose. to the intense interagency pursuit and manhunt. Continued research is needed to understand the adjustment of youth after mass traumas and large-scale manhunts in residential communities. Pediatrics 2014;134:1–8

PEDIATRICS Volume 134, Number 1, July 2014 1 Downloaded from www.aappublications.org/news by guest on September 28, 2021 In recent years, there have been several suburb, during which ∼300 rounds of pathways of resilience in disaster- high-profile terrorist attacks specifically ammunition were fired, bombs and affected populations,8 as well as re- targeting civilian child and family venues grenades were thrown, a transit officer search identifying social support as a (eg, Russia’s Beslan school hostage crisis, was shot, and 1 suspect was killed. potential protective factor for disaster- Norway’sWorkers’ Youth League camp The second suspect escaped, and an affected youth,4 we also examined attack, Nairobi’s Westgate Mall attack). emergency “shelter-in-place” warning whether prosocial behavior and peer Although research has documented the was enacted for nearly 1 million Boston- functioning moderated associations be- psychological toll of terrorism on youth,1–4 area residents. Transportation and busi- tween traumatic exposure and negative the majority of such work has focused nesses were shut down as helicopters child outcomes. on attacks targeting office buildings of circled overhead and officers searched high symbolic value,3,5–7 where the pres- door-to-door for the remaining suspect. METHODS ence of families has been incidental. That evening, a Watertown resident spot- Design and Participants Much remains to be learned about the ted the suspect. Helicopters using ther- Study procedures were conducted un- reactions of children affected by terror- mal imaging then circled overhead, der approval of the Boston University fi “ ” fi ism speci cally aimed at soft targets followed by heavy gun re and the use Institutional Review Board. English- fl such as family events. Moreover, the ma- of ash bangs. The remaining suspect speaking parents and caretakers of at jority of research on terrorism-exposed was taken into custody in critical least1childagedbetween4and19years youth has examined large-scale attacks condition. After 5 days, the imminent dwelling ,25 miles of the attack site or – with mass casualties (eg, 9/11).2,3,5 7 Min- threat posed by the suspects and the Watertown were recruited between the imal research has examined children’s extraordinary show of interagency force dates of June 15, 2013 and October 15, reactions to high-profile terrorism with was over. 2013 (2–6 months postevent) to com- relatively few fatalities. Understanding the adjustment of Boston- plete an online survey assessing chil- The 2013 Boston Marathon bombing area youth after the marathon bomb- dren’s experiences during the marathon was a high-profile attack that spe- ingandsubsequentmanhuntiscritical attack week, as well as psychosocial cifically targeted a civilian family for informing clinical efforts and for functioning. Recruitment efforts in- event. Two coordinated pressure-cooker improving our understanding of the cluded (a) school-based outreach (eg, bombs were detonated near the fin- impact of high-profile terrorism on superintendents, including the Water- ish line of the heavily attended mara- “soft targets.” Moreover, unlike the town Public Schools superintendent, thon, killing 3 and injuring 264 others aftermath of previous well-studied sent letters home with children encour- (including 16 amputees). The attack and terrorist attacks, the extended imme- aging participation); (b) pediatrician- associated casualties marked the be- diate threat, the extraordinary post- based outreach (study flyers displayed ginning of a highly intense week for attack interagency show of force, the in waiting rooms); (c) community event Boston-area families. Bags abandoned violent and public manhunt, the tem- outreach (study staff attended local by fleeing spectators were treated porary shelter-in-place warning, and family-oriented events, as well as “Bos- as potential explosives, and rumors the extended disruption in daily ac- ton Strong” fundraisers/rallies to dis- spread about additional live bombs. tivities for large numbers of families tribute recruitment flyers); and (d) Transportation was shut down, and not directly exposed to the bombing media-based outreach (eg, local news- the typically bustling 15-block radius made for a truly unprecedented and papers and blogs wrote pieces en- around the attack was closed for a week potentially traumatic experience in its couraging participation). and treated as a crime scene. In addi- own right. Previous terrorism-related Interested caretakers were directed to tion to heavy police and bomb squad research has focused on attack-related contact study staff or visit a study Web presence, uniformed federal and state exposure and cannot speak to the unique site for survey information. Of 1105 agencies descended on the region. aftermath of this event on exposed youth. caretakers initially visiting the Web site Three days postattack, the Federal Bu- We surveyed 460 Boston-area parents or contacting staff, 460 (41.6%) com- reau of Investigation released pictures and caretakers in the first 6 postattack pleted the survey. Interested care- of 2 suspects at large, after which an months about their child’s exposure takersprovidedconsentandcompleted officer was ambushed and killed, fol- tothe2013marathonattackweekevents, surveys through Qualtrics, a secure lowed by a carjacking, and an all-points including media exposure, as well as Web-survey program using server au- bulletin was issued. There was a violent their child’s psychosocial functioning. thentication and data encryption. Care- shootout in Watertown, a residential Given increasing efforts to clarify takers with multiple children between

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4 and 19 years responded about their bombing and manhunt. The parent re- For manhunt exposures data, care- oldest child in the study age range. The port of the Strengths and Difficulties takers reported whether their child (a) survey took roughly 45 minutes to com- Questionnaire (SDQ)10,11 collected reports was under the shelter-in-place warn- plete; caretakers were compensated $30. of children’s (a) emotional symptoms, ing,(b)sawaheavierpolicepresencein Participants were given the option of (b) conduct problems, (c) hyperactivity/ his or her neighborhood during the having their compensation donated di- inattention, (d) peer problems, and (e) manhunt, (c) saw uniformed service rectly to the Boston One Fund. prosocial behavior over the previous persons in his or her neighborhood not Table 1 presents demographic charac- 6 months. A total difficulties score was typically seen in civilian areas (eg, Na- teristics of participating families. Rough- generated by summing SDQ subscales tional Guard, Homeland Security), (d) fi ly half reported household incomes athroughd. saw of cers with guns drawn related to the manhunt, (e) heard manhunt- ,$100 000; the majority of respondents The survey also collected data on chil- related gunshots/explosions, (f) saw were college-educated, biological moth- dren’s attack exposure. Caretakers manhunt-related gunshots/explosions, ers with non-Hispanic white children. reported whether their child (a) (g) saw manhunt-related blood, (h) Approximately 20% lived within 5 miles attended the marathon, (b) was injured had an officer knock on their door re- of the attack, and ∼35% lived within in the attack, (c) directly witnessed in- lated to the manhunt, (i) had an officer 5 miles of Watertown. jured people, (d) directly witnessed dead enteror search their home, (j) knew the bodies, (e) was evacuated during the at- slain officer, and/or (k) knew the in- Measures tack, (f) knew a person injured, and/or (g) jured transit officer. Summing these ’ Childrens posttraumatic stress was knew a person killed. Summing these items yielded a total Manhunt Expo- assessed with the UCLA Reaction Index, items yielded a total Attack Exposures sures Tally, ranging from 0 to 11. Parent-Report Scale, a well-validated Tally,rangingfrom0to7.Inaddition, measure of youth PTSD.9 The Reaction caretakers reported the number of hours RESULTS Index provides a continuous measure of television coverage of the attack their Overall Clinical Outcomes of youth posttraumatic stress; scores child viewed on the day of the bombing $38 indicate “likely PTSD.” Items were and whether they restricted their child’s Table 2 presents overall clinical out- worded to relate specifically to the exposure to television coverage. comes across the sample. Participant survey completion order was not asso- TABLE 1 Demographic Characteristics Among Sampled Boston-Area Youth (N = 460) ciated with outcomes. Scores, on average, Characteristic M SD N % fell within normative ranges, although Child age, y 11.8 3.8 parents of marathon-attending children Child race/ethnicity reported greater posttraumatic stress, Non-Hispanic white 374 81.3 conduct problems, peer problems, and Racial/ethnic minority 86 18.7 Caregiver total difficulties. The proportion of youth Biological mother 351 76.4 with likely attack/manhunt-related PTSD Biological father 78 16.9 was 5.7 times higher among marathon- Adoptive mother 18 3.9 Relative/guardian 7 1.5 attending than nonattending youth. Adoptive father 4 0.9 Children watched an average of 1.54 Foster mother 2 0.4 hours (SD = 2.6) of television coverage Caregiver age, y 43.8 7.8 . Caregiver education on the attack day; 21% watched 3 Completed college 374 81.3 hours. Only 31.0% and 37.7% of parents Did not complete college 86 18.7 attempted to restrict children’sexpo- Household income, USD ,$50 000 71 15.4 sure to coverage of the attack and $50 000–74 999 45 9.8 manhunt, respectively. $75 000–99 999 99 21.5 – $100 000 $199 999 184 40.0 Attack Exposures and Clinical $200 000 61 13.3 Child attended marathon 71 15.4 Outcomes Distance between child’s home and bombing site 10.3 7.0 Table 3 presents the proportion of Child home ,5 miles from attack site 84 18.3 Distance between child’s home and Watertown, MA 9.0 7.2 youth experiencing each attack-related Child home ,5 miles from Watertown, MA 161 35.0 experience; Table 4 presents their Child under shelter-in-place warning during manhunt 238 51.7 associations with clinical outcomes

PEDIATRICS Volume 134, Number 1, July 2014 3 Downloaded from www.aappublications.org/news by guest on September 28, 2021 TABLE 2 Clinical Outcomes Among Sampled Boston-Area Youth (N = 460) and Outcomes slain officer (B = 13.5, SE = 4.2, b =0.2, Associated With Marathon Attendance P , .01), hearing manhunt-related Clinical Outcome Total Child Attending Marathon at Time of Attack gunshots/explosions (B = 6.8, SE = Sample fi b , fi (N = 460) Yes (n = 71) No Signi cance Test 2.4, =0.2,P .01),havinganof cer (n = 389) enter/search the home (B = 8.6, SE = N% N %N% 3.1, b =0.2,P , .01), and seeing Likely PTSDa 16 3.5 8 11.3 8 2.0 x2(1, N = 460) = 15.2, P , .0001 manhunt-related blood (B = 7.7, SE = 3.3, b =0.1,P , .05), F(15 431) = 13.44, M SD M SD M SD P , .001; r2 = 0.32. Children’s manhunt Posttraumatic stress 8.2 10.6 13.5 15.7 7.2 9.1 t(458) = 4.6, P , .001 exposures tally had a medium-to-large Total difficulties 7.8 5.9 9.1 7.2 7.5 5.6 t(446) = 2.2, P = .03 Emotional symptoms 2.0 2.1 2.2 2.5 1.9 2.0 t(447) = 1.0, P = .33 association with PTSD symptoms Conduct problems 1.3 1.5 1.8 2.2 1.2 1.4 t(447) = 3.3, P = .001 (partial r =0.41,P , .001), and small- Hyperactivity/inattention 3.1 2.4 3.3 2.4 3.1 2.4 t(446) = 0.8, P = .44 to-medium associations with total Peer problems 1.4 2.2 1.8 1.8 1.4 1.7 t(447) = 2.1, P = .04 difficulties (partial r =0.24,P , .001), a For comparison purposes, ∼0.4% of the general population meet full diagnostic criteria for PTSD.13 emotional symptoms (partial r =0.20, P , .001), conduct problems (partial r = after accounting for demographic exposure in predicting outcomes found 0.22, P , .001), hyperactivity/inattention covariates. Among marathon attend- TV exposure was associated with PTSD (partial r =0.12,P , .01), and peer ees, the most common attack experi- , symptoms (partial r =0.18,P .001), problems (partial r =0.24,P , .001). ence was being evacuated, followed by conduct problems (partial r =0.14,P , roughly one-quarter seeing injured .01), and total difficulties (partial r = Unique Associations Between people. Seeing dead bodies, relative to 0.13, P , .01). Outcomes and Total Attack Versus other marathon exposures, was most Total Manhunt Exposures strongly associated with outcomes. Manhunt exposures and clinical To examine unique contributions of at- Linear regression analysis entering all outcomes tack versus manhunt exposures in 7 attack experiences and the 4 de- Table 3 also presents the proportion predicting outcomes, regression anal- mographic covariates into 1 predictive of youth experiencing each manhunt yses were conducted for each outcome, model of PTSD symptoms found the experience; Table 4 presents their as- withAttackExposuresTallyandManhunt following were associated with unique sociations with outcomes after ac- Exposures Tally (and the 4 demographic variance in posttraumatic stress: di- counting for demographic covariates. covariates) simultaneously entered rectly saw dead bodies (B = 21.1, SE = The most common manhunt experi- as predictors. When entered simulta- 3.9, b = 0.3, P , .001), knew someone ence was being under the shelter-in- neously, manhunt exposures retained fi killed (B = 9.0, SE = 3.0, b = 0.1, P , .01), place warning. For youth under the signi cant associations with all 6 out- knew someone injured (B = 1.9, SE = warning, the most common experience comes, whereas attack exposures only fi 0.7, b = 0.1, P , .01), and saw injured was seeing a heavier police presence retained signi cant associations with 3 fi people (B = 6.0, SE = 3.0, b = 0.1, P , in his/her neighborhood than typical, outcomes (PTSD symptoms, total dif - 2 .05), F(11 439) = 12.18, P , .001; R = followed by seeing uniformed ser- culties, conduct problems; details of 0.23. Total Attack Exposures Tally had vice persons not typically found in regressions available on request). At- a medium-to-large association with civilian neighborhoods. Seeing or hear- tack and manhunt exposures each posttraumatic stress (partial r = 0.36, ing gunshots or explosions, seeing uniquely predicted 9% of variance in P , .001) and small-to-medium asso- manhunt-related blood, having an offi- posttraumatic stress; manhunt expo- ciations with total difficulties (partial cer enter and search the home, and suresuniquelypredicted3%ofvariance r =0.21,P , .001), emotional symptoms knowing the slain officer tended to in total difficulties, whereas attack (partial r =0.16,P , .001), conduct have the largest associations with experiences predicted only 1.5%. problems (partial r =0.26,P , .001), outcomes. Regression analysis enter- hyperactivity/inattention (partial r = ing all eleven manhunt exposures and Resiliency Factors 0.10, P , .05), and peer problems the four demographic covariates into Children’s prosocial behaviors (SDQ pro- (partial r = 0.16, P , .01). Regression one predictive model of PTSD symp- social behavior scale) and peer function- analysis (controlling for demographic toms found the following experiences ing (SDQ peer problems scale, reverse characteristics) examining the con- were associated with unique variance scored) significantly moderated rela- tributions of television-based bombing in posttraumatic stress: knowing the tionships between attack exposure and

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TABLE 3 Proportions of Boston-Area Youth (N = 460) Exposed to Each of 7 Marathon Attack-Related Experiences and Each of 11 Manhunt Experiences Marathon Attack % Total Sample % Children Attending Manhunt/Shelter-in-Place Experiences % Total Sample % Children Under Shelter-in- Experiences (N = 460) Marathon (N = 71) (N = 460) Place (N = 238) Child attended 15.4 100.0 Under shelter-in-place warning 51.7 100.0 marathon Child injured 1.5 9.9 Saw heavier police presence in 35.0 47.9 neighborhood Child saw injured 4.1 26.8 Saw uniformed service persons not 32.2 45.4 people typicallyfoundincivilianneighborhoodsa Child saw dead 2.4 15.5 Saw officers with guns drawn related to 11.5 17.6 bodies manhunt Child evacuated 6.1 39.4 Heard gunshots/explosions related to 9.8 18.9 manhunt Child knew person 5.7 11.3 Saw gunshots/explosions related to 5.4 10.5 injured manhunt Child knew person 2.6 8.5 Saw blood related to manhunt 3.5 6.7 killed Had officer knock on door related to 5.9 9.2 manhunt Had officer enter/search home as part of 5.2 8.0 manhunt Knew slain officer 2.2 2.5 Knew injured transit officer 2.2 2.9 a For example, National Guard, Homeland Security.

PTSD symptoms (ie, interaction terms association (B = 3.2, SE = 0.51, b = 0.39, sociation (B = 4.0, SE = 0.55, b = 0.49, predicted PTS after accounting for main P , .0001). Similarly, youth high in peer P , .001). effects). Specifically, youth high in pro- functioning showed only a modest as- social behavior showed no association sociation between attack exposure and Interactions Between Attack and between attack exposure and PTSD PTSD symptoms (B = 1.3, SE = 0.48, b = Manhunt Exposures symptoms, whereas youth low in pro- 0.16, P , .01), whereas youth low in Follow-up analyses revealed that Manhunt social behavior showed a moderate peer functioning showed a strong as- Exposures Tally moderated relationships

TABLE 4 Associations Between Child Clinical Outcomes and Attack-Related and Manhunt-Related Exposures Among Boston-Area Youth (N = 460) in the First 6 Months After Marathon Attack Child Experiences Associations With Clinical Outcomesa

PTSD Total Emotional Conduct Hyperactivity/ Peer Symptoms Difficulties Symptoms Problems Inattention Problems Marathon attack experiences Child attended marathon 0.20*** 0.09* 0.04 0.15** 0.03 0.09 Child injured 0.22*** 0.21*** 0.16*** 0.24*** 0.07 0.21*** Child saw injured people 0.30*** 0.18** 0.08 0.14** 0.03 0.14** Child saw dead bodies 0.38*** 0.30*** 0.23*** 0.31*** 0.14** 0.27*** Child evacuated during attack 0.19*** 0.09* 0.07 0.09 0.03 0.12** Child knew person injured 0.18*** 0.10* 0.10* 0.13** 0.07 0.01 Child knew person killed 0.25*** 0.14** 0.10* 0.18*** 0.08 0.09 Manhunt experiences Under shelter-in-place warning 0.01 0.02 0.07 0.02 –0.02 0.01 Saw heavier police presence in neighborhood 0.22*** 0.10* 0.12* 0.09 0.07 0.04 Saw uniformed service persons not typically found in 0.21*** 0.17*** 0.17*** 0.12* 0.11* 0.12* civilian neighborhoodsb Saw officers with guns drawn related to manhunt 0.25*** 0.16*** 0.09 0.15** 0.11* 0.13** Heard gunshots/explosions related to manhunt 0.39*** 0.19*** 0.15** 0.17*** 0.10* 0.21*** Saw gunshots/explosions related to manhunt 0.40*** 0.18*** 0.12* 0.18*** 0.08 0.25*** Saw blood related to manhunt 0.38*** 0.18*** 0.09 0.19*** 0.08 0.29*** Had officer knock on door related to manhunt 0.27*** 0.17*** 0.09 0.16*** 0.10* 0.19*** Had officer enter/search home 0.35*** 0.20*** 0.14** 0.18*** 0.11* 0.26*** Knew slain officer 0.39*** 0.21*** 0.12* 0.23*** 0.10* 0.29*** Knew injured transit officer 0.27*** 0.17*** 0.17*** 0.22*** 0.03 0.22*** * P , .05; **P , .01; ***P , .001. a Partial correlations controlling for household income, child age, race/ethnicity, and respondent education. b For example, National Guard, Homeland Security.

PEDIATRICS Volume 134, Number 1, July 2014 5 Downloaded from www.aappublications.org/news by guest on September 28, 2021 between Attack Exposures Tally and sev- ship between attack exposure and 1 manhunt-related experience (having eral outcomes, such that the effect of at- PTSD symptoms. an officer enter/search the home) tack exposure on emotional symptoms, Children’s manhunt-related exposures accounted for ∼4% of unique variance conduct problems, and peer problems were also significantly related to psy- in children’s posttraumatic stress and varied as a function of manhunt exposure chosocial outcomes, and, when en- represents a more unique and some- (ie, interaction terms were significant tered as simultaneous predictors, what idiosyncratic experience specific predictors after accounting for main manhunt-related exposures showed to the marathon attack aftermath. effects). Specifically, among children with even more robust associations with The present findings are important in greater manhunt exposure, there were outcomes than attack-related expo- documenting that exposure to terror- moderate significant associations be- sures. Findings indicate that clinical ismandits aftermathcan be associated tween attack exposure and emotional efforts must maintain a broad focus with a diverse range of child psycho- symptoms (B = 0.31, SE = 0.11, b = 0.21, beyond simply youth present at the social problems. Elevated rates of P , .01), conduct problems (B = 0.34, blasts and also include youth exposed posttraumatic stress have been the SE = 0.08, b = 0.32, P , .0001), and peer to events related to the intense in- most frequently identified outcome problems (B = 0.34, SE = 0.09, b = 0.27, teragency pursuit. Findings add to among terrorism-exposed populations,2,16 P , .0001), whereas such relationships a growing literature documenting how but this may be in part because it is were nonsignificant among youth with destabilizing terrorism-related experi- PTSD that is most often assessed.17 lower manhunt exposure. ences extend beyond immediate attack Comprehensive surveys assessing a exposure and can include the sub- full range of emotional and behavioral DISCUSSION sequently changed ecology in which problems after terrorism, such as in youth recover.1 this investigation, are needed to opti- The current study suggests that in the There has been speculation in popular mally inform clinical efforts for affected first 6 months after the 2013 Boston press and by some politicians as to youth. Marathon attack and manhunt, there whether the shelter-in-place request The majority of sampled caretakers did was considerable heterogeneity in may have been an overreaction, with not restrict their children’s exposure to attack- and manhunt-related exposures its own emotional toll outside of the television coverage, and ∼1 in 5 chil- and clinical outcomes. Although chil- trauma of the attack itself.12–14 The dren viewed .3 hours of televised dren, on average, showed norma- present findings suggest that from attack coverage on the day of the tive functioning, marathon attendance a children’s mental health perspective, bombing, which in turn was associated and many specific attack-related and the shelter-in-place request itself, and with increased problems. Although manhunt-related exposures were as- the containment of families in their these findings are correlational, they sociated with greater psychopathology homes, was not specifically associated are consistent with growing evidence across youth. In the present sample, with any increased psychosocial diffi- documenting the considerable nega- ∼ 11% of marathon-attending youth culties. Rather, associations between tive impact that such indirect contact exhibited likely PTSD (a rate compara- children’s manhunt experiences and with terrorism can have.2,18,19 Despite ble to that found among NYC school- symptoms were specifically driven by needs for live information during dis- children 6 months after 9/11).3 This seeing/hearing gunshots/explosions, asters, increasing evidence suggests proportion of youth with likely PTSD seeing manhunt-related blood, having parents should minimize children’smedia- was roughly 6 times higher among an officer enter/search the home, and based exposure to whatever extent marathon-attending youth than non- knowing the slain officer. Despite the possible. attending youth. Among attack-related extraordinary and unprecedented ex- Several limitations warrant comment. experiences, seeing dead bodies was perience of 1 million residents being First, because population-based meth- most strongly associated with negative asked to remain indoors, findings ods were not applied, findings do not outcomes, including emotional symp- suggest many of the specific manhunt- reflecttheexperiencesandoutcomesin toms, conduct problems, hyperactivity/ related correlates of outcomes were the general population of Boston-area inattention, and peer problems. Chil- largely similar to experiences com- youth. Although we made attempts to dren’s prosocial behavior and positive monly found to be correlates of trau- recruit a range of parents in affected peer functioning both buffered the im- matic stress and related reactions communities, parents who chose to pact of attack exposure, serving as (eg, witnessing death/injury, knowing participate might have been those with important moderators of the relation- someone who was killed).6,15 However, greater exposure or more distressed

6 COMER et al Downloaded from www.aappublications.org/news by guest on September 28, 2021 ARTICLE children. Furthermore, the survey was design entailed a single time-point posttraumatic stress and other emo- only available online and in English, assessment and cannot speak to pro- tional and behavioral outcomes in the which restricted eligibility to English- spective associations between pre- aftermath of the Boston Marathon at- speaking parents with computer access/ and postattack functioning, nor can it tack and manhunt that can help identify literacy. Concerns about the sample’s speak to trajectories of change in youth in greatest need of clinical at- representativeness are somewhat tem- postattack functioning across time. tention. Attack and manhunt experi- pered by the fact that the demographic Given the unpredictable nature of ter- enceseachuniquelypredicted9%ofthe makeup of the present sample is com- rorism, the vast majority of terrorism- variance in postattack posttraumatic parable to those areas most directly related studies are understandably stress, with manhunt exposures more affected by the marathon and manhunt initiated after the attack, but future robustly associated than attack-related (eg, 84.9% of Watertown residents work will benefit from researchers exposures with a broad range of oth- are white; 74.5% of residents of Back with incidental preexisting data in af- er psychosocial outcomes, including Bay, where the attack occurred, are fected communities collecting post- emotional symptoms, conduct problems, white; 55.6% and 51.3% of families in attack data on their existing samples.2 hyperactivity/inattention, and peer prob- Watertown and Back Bay, respectively, Fourth, information on child gender lems. In the aftermath of terrorism, par- earn ,$100 000 annually).20,21 Second, was not collected in the present sur- ticularly acts targeting children and only 42% of caretakers initially con- vey, and thus the impact of gender families, these findings underscore the tacting study staff consented to par- on study variables cannot be cur- urgency of connecting affected youth ticipation and completed the survey. rently assessed. Finally, data were with mental health care. Furthermore, This participation rate is consistent from parents/caretakers. Future work this study demonstrates that the withrelatedresearchondisaster- using multi-informant, multimethod reach of terror and associated fear is affected youth22,23 and may reflect strategies can offer a more compre- not confined to the boundaries of an unique challenges of research after hensive portrait of children’s func- attack itself2; events and community community traumas. Survey length tioning. responses that follow can also have might have also contributed to the Despite these limitations, the present considerable impacts on children’spsy- participation rate. Third, the present findings highlight key predictors of chological well-being.

REFERENCES

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Adjustment Among Area Youth After the Boston Marathon Bombing and Subsequent Manhunt Jonathan S. Comer, Annie Dantowitz, Tommy Chou, Aubrey L. Edson, R. Meredith Elkins, Caroline Kerns, Bonnie Brown and Jennifer Greif Green Pediatrics originally published online June 2, 2014;

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