A guest looks at the Temple of Time, a structure built to serve as a healing place for those affected by the shooting which claimed 17 lives at nearby Marjory Stoneman Douglas High School in Coral Springs, Florida, February 14, 2019, photo by Joe Skipper/Reuters

commentary

(Health Affairs Blog)

July 19, 2019

After School Shootings, Children and Communities Struggle to Heal

The Temple of Time, a healing place for those affected by the shooting at nearby Marjory Stoneman Douglas High School in Coral Springs, Florida, February 14, 2019

Photo by Joe Skipper/Reuters

by Ariella Iancu, Lisa H. Jaycox, Joie D. Acosta, Frank G. Straub, Samantha Iovan, Christopher Nelson, Mahshid Abir

Within days of the one-year anniversary of the Marjory Stoneman Douglas High School shooting, two students at the school died by suicide, further extending the trauma, grief, and suffering beyond the initial tragedy. Research shows that anniversaries of mass casualty incidents can trigger post-traumatic stress disorder (PTSD) symptoms. Given these suicides and the suicides that followed the Virginia Tech, Columbine, and Sandy Hook shootings, we must ask whether enough is being done to support the mental health needs of survivors of school shootings and the schools and communities in which they occur.

We know that the Marjory Stoneman Douglas shooting is not an isolated incident. The students of Marjory Stoneman Douglas are joined by those in more than 30 schools in the United States that have experienced school shootings in the past year alone. School mass casualty incidents scar communities for generations, with the deadliest school attack in US history, in Bath, Michigan, in 1927, still affecting survivors and their grandchildren more than 90 years later.

School massacres leave deep emotional scars and can affect academic performance, such as decreased school attendance and lower test scores.

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Across the country, survivors of school shootings return to their schools to attend classes, date, play sports, and try to define a new sense of normalcy, all the while struggling with grief, survivors' guilt, PTSD, and symptoms of anxiety and depression. School massacres leave deep emotional scars and can affect academic performance, such as decreased school attendance and lower test scores.

How schools handle the aftermath of a shooting varies; in part, because no road map exists for schools to follow. At Santa Fe High School, security increased significantly with bullet-proof glass, metal detectors, and police officers in hallways. At Marjorie Stoneman Douglas High School, students had access to on-call grief counselors and therapy dogs, were exempt from state exams, and saw some academic requirements reduced. The lingering question is whether enough is being done to help impacted students, school staff, and communities recover from these catastrophic experiences.

To be optimally responsive to the needs of survivors and facilitate the road to recovery in impacted communities, existing, evidence-based mental health treatments should be identified and disseminated to schools across the nation—not just in the immediate aftermath, but to also address the complex course of PTSD symptoms that may emerge months and even years after an event. The approach could be multilevel, with tools that help build community resilience—the ability to anticipate and successfully adapt to challenges after a traumatic incident—and coordinated efforts to identify and address gaps in knowledge, resources, and policy.

The Mental Health Toll of Mass Casualty Incidents

Mass casualty incidents, such as school shootings, can lead to grief, depression, addiction, PTSD, and somatic symptomology, in addition to suicide. Without appropriate treatment, these mental health issues can have wide-ranging negative impacts on quality of life and social, emotional, and cognitive functioning. As such, students are vulnerable to negative mental health outcomes after mass casualty incidents. For example, 66 percent of New York City students experienced moderate symptoms of PTSD, and 30 percent of parents (PDF) reported elevated symptoms in a national sample following the 9/11 terrorist attacks. Similar symptoms were observed in students following the 1995 Oklahoma City bombing. These statistics suggest the need for evidence-based mental health resources delivered by appropriately trained professionals to help identify and support young survivors immediately following the incident and over the following months and years.

Evidence-Based Approaches for Addressing the Mental Health Needs of Survivors

While there remains much to learn about how to help students heal following school shootings, considerable progress has been made in addressing mental health needs arising from past mass casualty incidents and disasters, such as 9/11 and Hurricane Katrina.

In the wake of 9/11, with so many students exhibiting PTSD symptoms and a lack of evidence-based treatments for students following mass casualty incidents, the New York State Office of Mental Health founded the Child and Adolescent Trauma Treatments and Services (CATS (PDF)) Consortium to screen children, train professionals, disseminate evidence-based practices, and evaluate successes and barriers across New York City. CATS adapted a technique originally created for child-survivors of sexual trauma, called Trauma-Focused Cognitive Behavioral Therapy. Children enrolled in this therapy showed greater improvement in PTSD symptoms compared to children enrolled in other therapies following 9/11.

Since 2001, there have been considerable advances in similar interventions focused on trauma exposure and cognitive behavioral therapy. Such interventions include advances in trauma-focused therapies and Eye Movement Desensitization and Reprocessing, a technique developed for PTSD in adults that has also been shown to be effective among children. The International Society for Traumatic Stress Studies has published guidelines (PDF) for optimal treatment in children and adolescents following traumatic events. This includes emerging evidence for early preventative interventions, such as online education for caregivers and children, and strong evidence for trauma-focused cognitive behavioral interventions as treatment.

There are also media and policy approaches that could improve mental health and prevent suicides resulting from post-incident trauma. These could include encouraging friends and family members to reach out to a loved one showing distress and media campaigns communicating the risk factors and warning signs that someone may be at-risk for suicide (for example, National Suicide Prevention Lifeline). In addition, established guidelines could assist the media in covering suicides while minimizing contagion. Policy approaches may also prevent suicide via extreme-risk protection orders in which a family petitions for the temporary, safe removal of firearms from at-risk individuals or mental health providers make a safety plan to temporarily remove a firearm from an at-risk individual. However, no such campaigns, media guidelines, or policy and practice interventions exist specifically for the aftermath of school mass casualty incidents.

Implementing Effective Mental Health Treatments Is Challenging and Inconsistent

Although effective interventions exist for students exposed to traumatic events, there are challenges to implementation in the post-incident context.

The accessibility of services within and across communities needs to be considered. Work following Hurricane Katrina showed that schools can provide easy access points for mental health resources and that providing treatment within school buildings leads to higher access and retention, thereby improving treatment success.

The Power of Community Resilience to Ensure Recovery

Past disasters have shown the importance of resilience. Resilience requires communities to come together and collaborate with a diverse community network. Researchers at the RAND Corporation found that to effectively recover from a wide variety of traumatic events (for example, natural disasters, school shootings) all sectors and levels of a community, including individuals, nonprofit or nongovernmental organizations, government, businesses, and other private entities, need to work together. Unlike traditional preparedness models, which are plan-based and risk-focused, community resilience takes a relationships- and strengths-based approach to building community capacity over the long term—critical given that PTSD symptoms can emerge months or even years following a school shooting. Accumulated stress from traumatic events can also overwhelm a community, just as it can overwhelm individuals. Critical actions that can help build resilience in communities with accumulated stress and trauma include building stronger systems, supporting resilient leaders who can successfully lead communities through recovery, encouraging connection among individuals, and ensuring that what matters (for example, mental health, access to services) gets measured.

To effectively recover from a wide variety of traumatic events, all sectors and levels of a community need to work together.

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Santa Monica, California, was one of the first communities to assess and improve community resilience by creating the Wellbeing Project in 2014. The Wellbeing Project worked with the RAND Corporation to identify discrete building blocks for communities to adopt to increase resilience. This work led to the development of a toolkit of resources for communities to employ to develop resilience.

To apply the concepts of community resilience to school shootings, school districts could take the lead in building partnerships with community mental health organizations to help provide education. Education efforts could include training school-based mental health professionals in trauma interventions before a crisis occurs and professional development to improve the mental well-being and self-sufficiency of students and teachers.

Among the most important things schools can do is engage their communities and partner with local organizations now to develop community cohesiveness and set up pre-incident networks. This may involve identifying mental health professionals locally and expanding the network of providers who are willing to offer care following an incident. This could also include expanding the network of community residents who are trained to help identify and refer individuals in need of mental health care.

School leadership and communities have multiple options for building community resilience, but efforts should begin with outreach to engage all levels of their community, education to provide individuals with the skills and supports they need, and building community partnerships.

A Path Forward

School shootings are considered a rare event with minimal existing research and support systems, so there is often little guidance for schools and communities on how to help survivors heal. School staff are often left not knowing what to do and without access to resources.

A path forward may include the following actions to provide students, school staff, and the community with accessible and effective treatment following school shootings:

First, build community resilience through education and professional development. Through education and professional development for students, teachers, school-based mental health professionals, and community members, communities can build resilience before incidents occur. This includes building and strengthening local multisector relationships to prevent and prepare for and respond and recover from school mass casualty incidents. Access to appropriate trauma-focused mental health resources should be increased, especially after an event, by improving community partnerships and educating community members so they have the skills and supports needed after a traumatic incident. Furthermore, communities should support resilient leaders who are trained to work across sectors and build partnerships.

Second, use existing school resources for mental health support to increase access for students. Such support must be accessible in the long term for survivors, their families, and the community. Building onto and integrating with existing school resources can help promote long-term accessibility.

Third, seek funds for implementation and evaluation of high-quality interventions. This will help grow the research evidence base among students who experience school shootings. In addition, although a growing number of providers are trained in evidence-based therapies, access is not equivalent for all communities. Third-party funding can help improve access in lower-resource communities.

Fourth, local health departments may need mechanisms to measure important outcomes around school mass casualty incidents. For example, measuring access to mental health services—and evaluating policies to hold key stakeholders accountable for adverse outcomes in the aftermath of such incidents. Providing high-quality care could be critical, since nearly one of every three people who die by suicide are already receiving care from a mental health professional or physician.

Finally, research could help to develop media guidelines for reporting on school shootings. Guidelines that minimize the negative ramifications of coverage are needed, as are policy and practice interventions that can prevent school mass-casualty incidents.

School shootings leave physical, mental, and emotional wounds that affect students, school staff, families, and communities for years following an incident. Building community resilience, implementing evidence-based mental health support early, and providing access for survivors and the community immediately post-incident and in the long term could help promote healing and prevent more tragedy.


Ariella Iancu is a medical student at the University of Michigan. Lisa Jaycox is a senior behavioral scientist at the nonprofit, nonpartisan RAND Corporation. Joie Acosta is a senior behavioral scientist at RAND. Frank Straub is the director for the National Police Foundation's Center for Mass Violence Response Studies. Samantha Iovan is a policy analyst in the Acute Care Research Unit at the University of Michigan. Christopher Nelson is a senior political scientist at RAND and a professor at the Pardee RAND Graduate School. Mahshid Abir is an emergency physician, director of the Acute Care Research Unit at the University of Michigan and a member of the adjunct staff at RAND.

This commentary was first published on July 19, 2019 on Health Affairs Blog. Copyright ©2019 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.