Reactions of Indian adolescents to the 9/11 terrorist attacks
http://www.100md.com
《美国医学杂志》
Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Abstract
OBJECTIVE: There is information about the impact of disasters and trauma on children, but little is known about the effects of terrorism particularly in India. (i) To assess the knowledge of the 9/11 terrorist attacks to the school going adolescents of India who were miles away from the actual incident. (ii) To compare the reactions to this event among the boys and girls. METHODS: The study used a survey design with a self - report questionnaire administered to 406 students in 6 schools of standards 9-12. The questionnaire was administered within 3 weeks of occurrence of this event. The mean age of the subjects was 16.34 years (SD= 1.22; range= 13-20) and 44.1% were boys. RESULTS: All the students were aware about this event. Awareness that the twin towers were hit was in 81.06 but only 51.94% knew that Pentagon was also hit. All the children knew who the prime suspect was although only 12.62% were aware about the country to which he belonged. The source of knowledge of the events was the television in 74.7% of the adolescents and 17.95% of them viewed foreign news channels additionally to the Indian channels to gather details about the event. Newspaper, radio and internet were the sources of information in 44.17%, 3.4% and 3.5% children respectively. Of the adolescents who gathered information from the television, 84.7% agreed that there had been an increase in their TV viewing time since the event and it was more than one hour per day in 47.5% of them. None of the students supported the terrorist attacks. The number of students with negative stressors was significantly more than the ones who were unaffected (p 0.0001). The girls were significantly more affected than the boys and while the former expressed anger the latter were more fearful and sad. (p 0.05) The idea of USA going for war against Afghanistan was supported by 69.4% and one third of them believed that such an event might adversely affect India. The adolescents who had witnessed the events on television were more fearful and shocked than the ones who read about the event in the print media (p 0.05). CONCLUSION: This study emphasizes the adverse reactions in the minds of adolescents in India to terrorist events even though they did not directly witness the events of September 11,2001.The role of media exposure in causing stress is also revealed. Pediatricians should be aware of the adverse effects of terrorism in the minds of the children and should be able to identify and help those who are in need.
Keywords: Adolescents; Terrorist attacks; Psychological reactions
The advent of major terrorist assaults has ushered in a sense of insecurity and vulnerability among people in different parts of the world. The terrorist attacks against the United States of America (USA) on September 11,2001 were unprecedented events and the magnitude of loss in terms of life and property was enormous.[1] The shock waves were felt all over the world. Television coverage of the events was immediate and extremely graphic and pervasive.[2] Remarkable video footage showing two airplanes crashing into the World Trade Center and the aftermath of four airplane crashes was included in various newscasts. This event was unique in certain features.[3]
The attack on the World Trade Center killed American civilians outside of wartime, and it killed them on TV, making most of the rest of us unwilling witnesses to a mass murder, and that places it in a context of its own. We watched the towers burn and collapse, in real time. And we watched the bodies drop from the sky- a sight that most of us will never be able to forget.
Understandably, people who are present at a traumatic event often have stress symptoms, but recent evidence indicates that children and adults can have similar symptoms even when they have not been present at the site of disaster. Children exposed to a catastrophe largely through television coverage have been found to be affected, as after the Challenger explosion,[4] the Gulf War,[5] and the Oklahoma City bombing.[6],[7] Significant reactions among children were not limited by the geographic proximity and persisted for years after the event.[8]A probable factor was media exposure.[9] Media coverage was even more intense after the Trade Center and Pentagon attacks with 24-hour cable news services covering the September 11 incidents incessantly.[10]
Several surveys have been conducted in America to measure the reactions of children and adults to September 11.[11],[12],[13],[14],[15],[16] A report to the New York City Board Education presented the results of a direct poll of 8,266 students in grades 4 through 12 where the investigators found that the majority of children were affected by the terror attacks and the responses were not limited to children in the immediate geographic area of the attacks. At the Pediatric Academic Societies conference in May 2002, researchers presented evidence of 9.11.01 related problems among children from Massachusetts and North Carolina.[17] A published report from as far away as Italy also documented the impact of these attacks.[18]
There is information about the impact of disasters and trauma on children, but relatively little data on the effects of terrorism.[19] Moreover the awareness and immediate mental health effects of an international catastrophe experienced from afar especially the one that carried threat of further attacks and a war in retaliation has not been examined amongst adolescents in India. Hence this event provided an opportunity to study the awareness of the event and reactions of adolescents in India to this terrorist attack.
Disaster research perspectives differ by discipline and there is no widely accepted theoretical framework. Given this context, the authors used a framework that characterizes disasters as having the potential for negative and positive responses rather than on identifiable disorders. Thus this study was conducted to assess the knowledge of the 11th September 2001 event of school going adolescents of India who were miles away from the actual incident as well as to compare the reactions among the boys and girls who participated in the survey.
Materials and methods
The present study employed a cross sectional survey design using a 20-minute anonymous self - report questionnaire administered to high school students in the 2001-2002 academic year during usual school hours by an interviewer within 3 weeks of occurrence of this event. All adolescents, both male and female studying in classes IX to XII in 6 government schools who were present on the day of the survey participated in the study. The questionnaire elicited information about the demographic and socioeconomic characteristics of the household to which each of the children belonged and was divided into 3 sectors which dealt with the awareness of the event of the 11th September, 2001 terrorist attacks, source of information and amount of media exposure and reactions to this event and its aftermath. It was pilot tested on a socioeconomically diverse sample of 20 adolescents before administration. Necessary suitable translations into Hindi were made wherever required. The questionnaire was prepared with the questions to be asked to elicit the problem of adolescent violence exposure and its effects in several studies as well as to elicit the knowledgability of the adolescents regarding this event. Demographic information included age, grade level, gender, religion, caste of the child, socioeconomic status of the family. Academic performance of the child was judged on the basis of percentage of marks which he/ she obtained in the last examination. Type and duration of media exposure for gathering information of the events was also included in the study.
Through scaled items, participants were asked to indicate their feelings, perceptions and behaviors in response to this event and to the plan of USA to attack Afghanistan in retaliation. Informed written consent was obtained prior to conducting this interview and the questions were asked in a sensitive manner and strict confidentiality was promised.
Descriptive statistics were used and the data was analyzed using the SPSS 10.0 for Windows statistical computer package. We conducted separate analyses by sex-wise because of known sex differences in reactions to stressful events. We evaluated tests of significance using Chi-square tests and statistical significance was defined as p 0.05
Results
Four hundred and six adolescents completed the survey and their mean age was 16.34 years (SD= 1.22; range= 13-20). 44.1% of the students who participated in the study were males. The sociodemographic characteristics of the study population have been shown in table1. The mean academic percentage achieved by the students in the last examination was 54.66 (S.D.=9.06). All the adolescents interviewed watched television regularly and 60% of them for more than 2 hours per day.
The awareness of the events of the participants as described by them has been depicted in Figure1. The source of knowledge of the events was the television in 74.7% of the adolescents and 17.95% of them viewed foreign news channels additionally to the Indian channels to gather details about the event. Newspaper, radio and internet were the sources of information in 44.17%, 3.4% and 3.5% children respectively. Of the children who gathered information from the television, 84.7% of them agreed that there had been an increase in their TV viewing time since the event and it was more than 1hour per day in 46.5% of them. Among the adolescents who reported increase in their daily viewing hours boys were significantly more in number than girls (94.97% vs 76.65% p 0.0001) Males also had significantly longer viewing hours than the girls per day as depicted in table2.
The prime suspect of this event as Osama bin Laden was known by 99.5% students but only 12.62% could correctly tell the country to which he originally belonged. Eighty-seven percent adolescents knew Afghanistan as the hiding place of the prime suspect. Seventy percent adolescents, of whom boys were more than girls, supported USA's resolution of waging war against Afghanistan. (p 0.05). The reasons cited by them 73.4% for which war was justified was that terrorism needed to be curbed and 10.5% felt that USA needed to show its power and might. For those who did not support the war 63.5% felt that innocent people would die, 34.9% felt that there would be huge loss of human life and property and 17.5% felt that wars would not resolve problems. One third of the students feared that such a war might adversely affect India.
The reactions to this event were described as shocking by 45.07%, 14.5% felt sad, 17.98% felt angry, and 18.47% feared that a similar fate might befall them. Only 4% students stated that the event did not matter to them in anyway. The number of students with negative stressors was significantly more than the ones who were unaffected. (p 0.0001) Among the reactions, anger and revengefulness was expressed by significantly more number of boys than girls (p 0.05) whereas both sexes were equally shocked. The girls felt significantly more sad and fearful than the boys Figure2. The adolescents who had witnessed the events on television were more horrified and shocked than the ones who read about the event in the print media (p 0.05). All students who participated in the survey condemned any type of terrorist attacks.
Discussion
A few days after the September 11 terrorist attacks, nationally representative samples in USA of adults and children revealed a large percentage showing symptoms of stress.[13],[20] No such data is available from India, which has tested this aspect of reaction to such a disastrous world event. In our country, which is also, facing serial terrorist attacks in different parts e.g. the 13th December 2001 attack on the Parliament at Delhi and the serial bomb blasts in Mumbai on the 25th of August 2003, it is vital to know the awareness and reactions of youngsters to such events so that measures can be undertaken both by mental health professionals, physicians and pediatricians dealing with such cases. Our data reveals that even though this terrorist attack occurred miles away most adolescents were aware of this event and had negative stress symptoms. As had been previously described, males were found to react differently than females and the latter are primarily at risk for depression.[3],[13],[20]
The potential for personalizing the September 11 attacks was large, even for those who were thousands of miles away at the time.[13] This has been amply shown by the present study where approximately one fifth of the adolescents who participated in the survey felt that a similar fate might befall them or their country in near future. Adults and children who are not physically present at catastrophes can have a pronounced effect and this may be the greatest when a loved one or acquaintance is harmed, but others who may personalize the event and think of themselves as potential victims can also have similar stress symptoms.[21]
A study on the children's symptoms on the wake of Challenger disaster has made an interesting speculation that distant traumatic exposures play a part in ordinary short-term human development. Distant traumas might be grouped into superstructure of mental conditions involving no personal or direct threats that are commonly encountered in the course of a lifetime.[4] Despite a belief among general public that children should not be studied after upsetting events, author's review shows that considerable mental symptoms are seen even in them and recognizing this fact is important to institute remedial measures.[22]
Consistent with previous research our study also reflects the vividness of awareness and reactions of children who learnt about this event from the television.[23],[24] It has been observed the present in this study that the stressful reactions were more in children who watched the event for longer duration in the television than in those who watched it for shorter hours. For viewers particularly children and adolescents watching television may have exacerbated or caused stress, especially with the repeated viewing of terrifying images.[19],[25] That such events interest the adolescents is seen from the fact that in 84.7% of them there was a definite increase in TV viewing time and it was definitely longer in cases of boys than in girls. For vast majority of people who have had indirect exposure to this event the shocking televised images, and the profound ramifications can cause unprecedented side effects.[11] It is thus recommended by professional bodies that parents should restrict their children's television viewing during a crisis and discuss the event with them.[22] Although the psychological effects of the recent terrorism are often told to have short lasting effects but many attacks, which are felt to be repetitive, can heighten anxiety. Ongoing media coverage of such events may act as traumatic reminders, resulting in persistent symptoms.[11] Even though 68.2% of the students said that their parents stopped them from excessive television viewing but discussion of the event with them was lacking.
Thus children in the present era who are raised from birth with television, the urgency and vividness of the medium seems almost as real and pure, as untouched reality and thus parents and teachers should explain the episodes of violence as well as encourage the adolescents to express their feelings and listen to them without passing judgments.[26], [27]
An interesting finding in the present study was that children who had television exposure had significantly more negative stress symptoms than those who were exposed to print media. This is in contrast to a previous finding where print media exposure has been found to be more strongly associated with enduring posttraumatic stress than broadcast exposure.[9] Thus media exposure to terrorist incidents, in any form either television or print, should be assessed by the pediatricians and monitoring of such exposure should be stressed even in children not directly impacted.
The present study was an opportunistic one and did not include traditional disaster research measures for acute stress or posttraumatic stress disorder limiting our ability to compare results across studies. As this is the only study done on adolescents from another country witnessing the events no such comparison of findings were possible.
Despite limitations, the present study describes the awareness of our adolescents regarding such disastrous international events and also shows the negative stressors, which develop in them following these. In the current global village that is threatened by pervasive terrorism, no community is immune. The challenge of disaster to one community is a challenge to all.[28],[29] Greater awareness is needed among local and national authorities of the importance of metaadaptive systems and of local, national and international networking. Today's youth are well informed and exposed to television about such events, which cause acute stress symptoms, and emergency mental health systems and pediatricians should be equipped to manage such eventualities.[30] By intervening as soon as symptoms appear, pediatricians, psychologists and other clinicians may be able to identify people with stress and help them to take steps to cope effectively. Media exposure to terrorist incidents should be monitored and those working with children should assess exposure and stress this fact even in children who are not directly impacted.
References
1. Williams AD. September 11,2001: the day the world changed. Available at: http://www.september11news.com/DailyTimeline. htm. Accessed September, 2003
2. Barringer F, Fabrikant G. As an attack unfolds, a struggle to provide vivid images to homes. New York Times; September, 2001; 12: A25.
3. Ford CA, Udry JR, Gleiter K, Chantala K. Reactions of young adults to September 11, 2001. Arch Pediatr Adolesc Med 2003; 157: 572-578.
4. Terr LC, Bloch DA, Michel BA, Shi H, Reinhardt JA, Metayer SA. Children's symptoms in the wake of Challenger: a field study of distant traumatic effects and an outline of related conditions. Am J Psychiatry 1999; 156: 1536-1544.
5. Cantor J, Mares ML, Oliver MB. Parents' and children's emotional reactions to TV coverage of the Gulf War. In Greenberg BS, GantzW, eds. Desert Storm and the Mass Media. Cresskill NJ, Hampton Press, 1993; 325-340.
6. Pfefferbaum B. The impact of the Oklahoma City bombing on children in the community. Mil Med 2001; 166: 49-50.
7. Pfefferbaum B, Nixon SJ, Krug RS et al. Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing. Am J Psychiatry 1999; 156: 1069-1074.
8. Pfefferbaum B, Seale TW, McDonald NB et al. Posttraumatic stress two years after the Oklahoma City bombing in youth geographically distant from the explosion. Psychiatry 2000; 63: 358-370.
9. Pfefferbaum B, Seale TW, Brandt EN Jr, Pfefferbaum RL, Doughty DE, Rainwater SM. Media exposure in children one hundred miles from a terrorist bombing. Ann Clin Psychiatry 2003; 15 :1-8.
10. Duggal HS, Berezkin G, John V. PTSD and TV viewing of the World Trade Center (letter). J Am Acad Child Adolesc Psychiatry 2002; 41: 494.
11. Hayez JY. Our children, the Twin Towers and the war. Arch Pediatr 2001; 8 : 1297-1301.
12. DeLisi LE, Maurizio A, Yost M, Papparozzi CF, Fulchino C, Katz CL et al. A survey of New Yorkers after the Sept. 11, 2001, terrorist attacks. Am J Psychiatry 2003; 160 : 780-783.
13. Schuster MA, Stein BD, Jaycox L, Collins RL, Marshall GN, Elliott MN et al. A national survey of stress reactions after the September 11, 2001 terrorist attacks. N Engl J Med 2001; 345 : 1507-1512.
14. Chen H, Chung H, Chen T, Fang L, Chen JP. The emotional distress in a community after the terrorist attack on the World Trade Center. Community Ment Health J 2003; 39 : 157-165.
15. Hoven CW, Duarte CS, Mandell DJ. Children's mental health after disasters: the impact of the World Trade Center attack. Curr Psychiatry Rep 2003; 5 : 101-107.
16. Murphy RT, Wismar K, Freeman K. Stress symptoms among African-American college students after the September 11, 2001 terrorist attacks. J Nerv Ment Dis 2003; 191: 108-114.
17. Irwin Redlener, Roy Grant. The 9/11 terror attacks: Emotional consequences persist for children. Contemporary Pediatr 2002; 9: 43.
18. Apolone G, Mosconi P, La Vecchia C. Post traumatic stress disorder (letter). N Engl J Med 2002; 346: 1495.
19. Pfefferbaum B, Pfefferbaum RL, Gurwitch RH, Nagumalli S, Brandt EN, Robertson MJ et al. Children's response to terrorism: a critical review of the literature. Curr Psychiatry Rep 2003; 5 : 95-100.
20. Silver RC, Holman EA, Mc. Intosh DN, Poulin M, Gil Rivas V. Nation wide longitudinal study of psychological responses to September 11. JAMA 2002; 288: 1235-1244.
21. Dixon P, Rehling G, Shiwach R. Peripheral victims of the Herald of Free Enterprise disaster. Br J Med Psychol 1993; 66: 193-202.
22. Fact Sheet; Helping Children and Adolescents Cope with Violence and Disasters. National Institute of Mental Health, Department of Health and Human Services, September 2001, NIH Publication No. 01-3518.
23. Pfefferbaum B, Nixon SJ, Tivis RD et al. Television exposure in children after a terrorist incident. Psychiatry 2001; 64: 202.
24. Caronna EB, Augustyn M, Zuckerman B. 9/11: Teachers, television and trauma. Pediatr Academic Societies 2002,
Abstract 137.
25. Cantor J. Media violence. J Adolesc Health 2000; 27: 30-34.
26. How to talk to children and parents after a disaster. Washington, D.C. American Academy of Child and Adolescent Psychiatry, 1999. (Accessed September 16, 2003, at http://www.aacap.org/publications/Disaster Response/ cp_disas.htm.)
27. AAP offers advice on communicating with children about disasters. Washington, D.C. American Academy of Pediatrics, 2001. (Accessed September 16, 2003, at http://www.aap.org/advocacy/release /disastercomm.htm.)
28. Laor N, Wolmer L, Spirman S, Wiener Z. Facing war, terrorism, and disaster: toward a child-oriented comprehensive emergency care system. Child Adolesc Psychiatr Clin N Am 2003; 12 : 343-361.
29. Cassimatis EG. Terrorism, our world and our way of life. J Am Acad Psychoanal 2002; 30 : 531-543.
30. Blaschke GS, Lynch J. Terrorism: its impact on primary pediatrics, Part III. Pediatr Ann 2003; 32: 216-217.(Ray Munni, Malhi Prahbhjo)
Abstract
OBJECTIVE: There is information about the impact of disasters and trauma on children, but little is known about the effects of terrorism particularly in India. (i) To assess the knowledge of the 9/11 terrorist attacks to the school going adolescents of India who were miles away from the actual incident. (ii) To compare the reactions to this event among the boys and girls. METHODS: The study used a survey design with a self - report questionnaire administered to 406 students in 6 schools of standards 9-12. The questionnaire was administered within 3 weeks of occurrence of this event. The mean age of the subjects was 16.34 years (SD= 1.22; range= 13-20) and 44.1% were boys. RESULTS: All the students were aware about this event. Awareness that the twin towers were hit was in 81.06 but only 51.94% knew that Pentagon was also hit. All the children knew who the prime suspect was although only 12.62% were aware about the country to which he belonged. The source of knowledge of the events was the television in 74.7% of the adolescents and 17.95% of them viewed foreign news channels additionally to the Indian channels to gather details about the event. Newspaper, radio and internet were the sources of information in 44.17%, 3.4% and 3.5% children respectively. Of the adolescents who gathered information from the television, 84.7% agreed that there had been an increase in their TV viewing time since the event and it was more than one hour per day in 47.5% of them. None of the students supported the terrorist attacks. The number of students with negative stressors was significantly more than the ones who were unaffected (p 0.0001). The girls were significantly more affected than the boys and while the former expressed anger the latter were more fearful and sad. (p 0.05) The idea of USA going for war against Afghanistan was supported by 69.4% and one third of them believed that such an event might adversely affect India. The adolescents who had witnessed the events on television were more fearful and shocked than the ones who read about the event in the print media (p 0.05). CONCLUSION: This study emphasizes the adverse reactions in the minds of adolescents in India to terrorist events even though they did not directly witness the events of September 11,2001.The role of media exposure in causing stress is also revealed. Pediatricians should be aware of the adverse effects of terrorism in the minds of the children and should be able to identify and help those who are in need.
Keywords: Adolescents; Terrorist attacks; Psychological reactions
The advent of major terrorist assaults has ushered in a sense of insecurity and vulnerability among people in different parts of the world. The terrorist attacks against the United States of America (USA) on September 11,2001 were unprecedented events and the magnitude of loss in terms of life and property was enormous.[1] The shock waves were felt all over the world. Television coverage of the events was immediate and extremely graphic and pervasive.[2] Remarkable video footage showing two airplanes crashing into the World Trade Center and the aftermath of four airplane crashes was included in various newscasts. This event was unique in certain features.[3]
The attack on the World Trade Center killed American civilians outside of wartime, and it killed them on TV, making most of the rest of us unwilling witnesses to a mass murder, and that places it in a context of its own. We watched the towers burn and collapse, in real time. And we watched the bodies drop from the sky- a sight that most of us will never be able to forget.
Understandably, people who are present at a traumatic event often have stress symptoms, but recent evidence indicates that children and adults can have similar symptoms even when they have not been present at the site of disaster. Children exposed to a catastrophe largely through television coverage have been found to be affected, as after the Challenger explosion,[4] the Gulf War,[5] and the Oklahoma City bombing.[6],[7] Significant reactions among children were not limited by the geographic proximity and persisted for years after the event.[8]A probable factor was media exposure.[9] Media coverage was even more intense after the Trade Center and Pentagon attacks with 24-hour cable news services covering the September 11 incidents incessantly.[10]
Several surveys have been conducted in America to measure the reactions of children and adults to September 11.[11],[12],[13],[14],[15],[16] A report to the New York City Board Education presented the results of a direct poll of 8,266 students in grades 4 through 12 where the investigators found that the majority of children were affected by the terror attacks and the responses were not limited to children in the immediate geographic area of the attacks. At the Pediatric Academic Societies conference in May 2002, researchers presented evidence of 9.11.01 related problems among children from Massachusetts and North Carolina.[17] A published report from as far away as Italy also documented the impact of these attacks.[18]
There is information about the impact of disasters and trauma on children, but relatively little data on the effects of terrorism.[19] Moreover the awareness and immediate mental health effects of an international catastrophe experienced from afar especially the one that carried threat of further attacks and a war in retaliation has not been examined amongst adolescents in India. Hence this event provided an opportunity to study the awareness of the event and reactions of adolescents in India to this terrorist attack.
Disaster research perspectives differ by discipline and there is no widely accepted theoretical framework. Given this context, the authors used a framework that characterizes disasters as having the potential for negative and positive responses rather than on identifiable disorders. Thus this study was conducted to assess the knowledge of the 11th September 2001 event of school going adolescents of India who were miles away from the actual incident as well as to compare the reactions among the boys and girls who participated in the survey.
Materials and methods
The present study employed a cross sectional survey design using a 20-minute anonymous self - report questionnaire administered to high school students in the 2001-2002 academic year during usual school hours by an interviewer within 3 weeks of occurrence of this event. All adolescents, both male and female studying in classes IX to XII in 6 government schools who were present on the day of the survey participated in the study. The questionnaire elicited information about the demographic and socioeconomic characteristics of the household to which each of the children belonged and was divided into 3 sectors which dealt with the awareness of the event of the 11th September, 2001 terrorist attacks, source of information and amount of media exposure and reactions to this event and its aftermath. It was pilot tested on a socioeconomically diverse sample of 20 adolescents before administration. Necessary suitable translations into Hindi were made wherever required. The questionnaire was prepared with the questions to be asked to elicit the problem of adolescent violence exposure and its effects in several studies as well as to elicit the knowledgability of the adolescents regarding this event. Demographic information included age, grade level, gender, religion, caste of the child, socioeconomic status of the family. Academic performance of the child was judged on the basis of percentage of marks which he/ she obtained in the last examination. Type and duration of media exposure for gathering information of the events was also included in the study.
Through scaled items, participants were asked to indicate their feelings, perceptions and behaviors in response to this event and to the plan of USA to attack Afghanistan in retaliation. Informed written consent was obtained prior to conducting this interview and the questions were asked in a sensitive manner and strict confidentiality was promised.
Descriptive statistics were used and the data was analyzed using the SPSS 10.0 for Windows statistical computer package. We conducted separate analyses by sex-wise because of known sex differences in reactions to stressful events. We evaluated tests of significance using Chi-square tests and statistical significance was defined as p 0.05
Results
Four hundred and six adolescents completed the survey and their mean age was 16.34 years (SD= 1.22; range= 13-20). 44.1% of the students who participated in the study were males. The sociodemographic characteristics of the study population have been shown in table1. The mean academic percentage achieved by the students in the last examination was 54.66 (S.D.=9.06). All the adolescents interviewed watched television regularly and 60% of them for more than 2 hours per day.
The awareness of the events of the participants as described by them has been depicted in Figure1. The source of knowledge of the events was the television in 74.7% of the adolescents and 17.95% of them viewed foreign news channels additionally to the Indian channels to gather details about the event. Newspaper, radio and internet were the sources of information in 44.17%, 3.4% and 3.5% children respectively. Of the children who gathered information from the television, 84.7% of them agreed that there had been an increase in their TV viewing time since the event and it was more than 1hour per day in 46.5% of them. Among the adolescents who reported increase in their daily viewing hours boys were significantly more in number than girls (94.97% vs 76.65% p 0.0001) Males also had significantly longer viewing hours than the girls per day as depicted in table2.
The prime suspect of this event as Osama bin Laden was known by 99.5% students but only 12.62% could correctly tell the country to which he originally belonged. Eighty-seven percent adolescents knew Afghanistan as the hiding place of the prime suspect. Seventy percent adolescents, of whom boys were more than girls, supported USA's resolution of waging war against Afghanistan. (p 0.05). The reasons cited by them 73.4% for which war was justified was that terrorism needed to be curbed and 10.5% felt that USA needed to show its power and might. For those who did not support the war 63.5% felt that innocent people would die, 34.9% felt that there would be huge loss of human life and property and 17.5% felt that wars would not resolve problems. One third of the students feared that such a war might adversely affect India.
The reactions to this event were described as shocking by 45.07%, 14.5% felt sad, 17.98% felt angry, and 18.47% feared that a similar fate might befall them. Only 4% students stated that the event did not matter to them in anyway. The number of students with negative stressors was significantly more than the ones who were unaffected. (p 0.0001) Among the reactions, anger and revengefulness was expressed by significantly more number of boys than girls (p 0.05) whereas both sexes were equally shocked. The girls felt significantly more sad and fearful than the boys Figure2. The adolescents who had witnessed the events on television were more horrified and shocked than the ones who read about the event in the print media (p 0.05). All students who participated in the survey condemned any type of terrorist attacks.
Discussion
A few days after the September 11 terrorist attacks, nationally representative samples in USA of adults and children revealed a large percentage showing symptoms of stress.[13],[20] No such data is available from India, which has tested this aspect of reaction to such a disastrous world event. In our country, which is also, facing serial terrorist attacks in different parts e.g. the 13th December 2001 attack on the Parliament at Delhi and the serial bomb blasts in Mumbai on the 25th of August 2003, it is vital to know the awareness and reactions of youngsters to such events so that measures can be undertaken both by mental health professionals, physicians and pediatricians dealing with such cases. Our data reveals that even though this terrorist attack occurred miles away most adolescents were aware of this event and had negative stress symptoms. As had been previously described, males were found to react differently than females and the latter are primarily at risk for depression.[3],[13],[20]
The potential for personalizing the September 11 attacks was large, even for those who were thousands of miles away at the time.[13] This has been amply shown by the present study where approximately one fifth of the adolescents who participated in the survey felt that a similar fate might befall them or their country in near future. Adults and children who are not physically present at catastrophes can have a pronounced effect and this may be the greatest when a loved one or acquaintance is harmed, but others who may personalize the event and think of themselves as potential victims can also have similar stress symptoms.[21]
A study on the children's symptoms on the wake of Challenger disaster has made an interesting speculation that distant traumatic exposures play a part in ordinary short-term human development. Distant traumas might be grouped into superstructure of mental conditions involving no personal or direct threats that are commonly encountered in the course of a lifetime.[4] Despite a belief among general public that children should not be studied after upsetting events, author's review shows that considerable mental symptoms are seen even in them and recognizing this fact is important to institute remedial measures.[22]
Consistent with previous research our study also reflects the vividness of awareness and reactions of children who learnt about this event from the television.[23],[24] It has been observed the present in this study that the stressful reactions were more in children who watched the event for longer duration in the television than in those who watched it for shorter hours. For viewers particularly children and adolescents watching television may have exacerbated or caused stress, especially with the repeated viewing of terrifying images.[19],[25] That such events interest the adolescents is seen from the fact that in 84.7% of them there was a definite increase in TV viewing time and it was definitely longer in cases of boys than in girls. For vast majority of people who have had indirect exposure to this event the shocking televised images, and the profound ramifications can cause unprecedented side effects.[11] It is thus recommended by professional bodies that parents should restrict their children's television viewing during a crisis and discuss the event with them.[22] Although the psychological effects of the recent terrorism are often told to have short lasting effects but many attacks, which are felt to be repetitive, can heighten anxiety. Ongoing media coverage of such events may act as traumatic reminders, resulting in persistent symptoms.[11] Even though 68.2% of the students said that their parents stopped them from excessive television viewing but discussion of the event with them was lacking.
Thus children in the present era who are raised from birth with television, the urgency and vividness of the medium seems almost as real and pure, as untouched reality and thus parents and teachers should explain the episodes of violence as well as encourage the adolescents to express their feelings and listen to them without passing judgments.[26], [27]
An interesting finding in the present study was that children who had television exposure had significantly more negative stress symptoms than those who were exposed to print media. This is in contrast to a previous finding where print media exposure has been found to be more strongly associated with enduring posttraumatic stress than broadcast exposure.[9] Thus media exposure to terrorist incidents, in any form either television or print, should be assessed by the pediatricians and monitoring of such exposure should be stressed even in children not directly impacted.
The present study was an opportunistic one and did not include traditional disaster research measures for acute stress or posttraumatic stress disorder limiting our ability to compare results across studies. As this is the only study done on adolescents from another country witnessing the events no such comparison of findings were possible.
Despite limitations, the present study describes the awareness of our adolescents regarding such disastrous international events and also shows the negative stressors, which develop in them following these. In the current global village that is threatened by pervasive terrorism, no community is immune. The challenge of disaster to one community is a challenge to all.[28],[29] Greater awareness is needed among local and national authorities of the importance of metaadaptive systems and of local, national and international networking. Today's youth are well informed and exposed to television about such events, which cause acute stress symptoms, and emergency mental health systems and pediatricians should be equipped to manage such eventualities.[30] By intervening as soon as symptoms appear, pediatricians, psychologists and other clinicians may be able to identify people with stress and help them to take steps to cope effectively. Media exposure to terrorist incidents should be monitored and those working with children should assess exposure and stress this fact even in children who are not directly impacted.
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