Reconceptualizing Severe Traumatic Stress Reactions of Children and Young People: A Resilience Perspective

Children and Young People (CYP) who experience severe traumatic stress through terror-related exposure are reported to have interconnected educational, social, and physical healthcare demands that characteristically receive a lack of attention. The nature of these challenges has been defined as wicked problems as they conventionally resist pragmatic or technical solutions due to the complexity of their appearance. Wicked problems are habitually more distinct within a vulnerable population of CYP who are exposed to a diverse scope of risk factors that increase the development of severe traumatic stress. To illustrate, the context of the present theoretical paper aims to focus on Pakistan’s Army Public School terror-related incident, in which a multitude of risk factors, including the disorganization of education, witnessing the significant loss of life, the perceivable deficiency within Pakistan’s psychosocial health system and stigmatized attitude towards mental health integrated themselves into the immediate environment of CYP who were exposed to the attack. In alliance with Bronfenbrenner’s ecological theory, an interaction between proximal and distal elements within an individual’s environment can significantly influence the emergence of protective and risk factors that interplay with each other to either escalate or reduce the probability of a disruptive outcome, such as severe traumatic stress, following CYP’s exposure to trauma. Applying this research to the outlined wicked problem, the following theoretical review aims to address the outcomes that may have been overlooked before proposing a multidimensional intervention that can enhance the resilience of those impacted by future terror-related exposure through alleviation, protective and prevention strategies.

Keywords. Children and young people, severe traumatic stress, Pakistan, resilience, ecological theory

Children and young people who experience mental health challenges are reported to have interconnected educational, social, and physical healthcare demands that are unable to be addressed (NHS Digital, 2021). These challenges have been defined as wicked problems (Termeer et al., 2015), as they characteristically resist pragmatic or technical solutions due to the complexity of their appearance (Geuijen et al., 2016; Head & Alford, 2015). In particular, wicked problems are habitually more distinct within a vulnerable population of young people exposed to diverse risk factors that increase the development of mental health issues. To illustrate, the context of the present review aims to focus on the shooting-related terror attack which transpired on December 16th, 2014, at an Army Public School in Peshawar, Pakistan. 

Through the heinous methods employed by the Tehrik-i-Taliban, 132 children lost their lives, and 121 children were critically wounded. Furthermore, the majority claimed to have experienced severe traumatic stress reactions as a result of the attack (Hussain et al., 2019; Kazmi & Ali, 2015). This was demonstrated by Khan et al. (2018), who found that out of the 205 children that survived the incident, 154 (75.2%) were reportedly exhibiting post-traumatic stress disorder symptoms such as intrusive imagery, hyper-arousal, and avoidance, at a severe level. The event was recorded as having the highest number of child fatality cases in the world because of a single terrorist attack. This incident was substantially covered across national and international media outlets and led to the employment of high-level security measures in all educational institutions across Pakistan, generating extreme tension and fear among children and young people.

Pastrana et al. (2020) argue that despite exhibitions of terror-related attacks, which introduce suffering to families and generates an increased risk for children and young people to encounter psychiatric distress and developmental challenges (Masten & Barnes, 2018; Tol et al., 2013), there is also evidence to suggest that a significant proportion of children can sustain their psychological distress and therefore advance through a normative developmental trajectory (Majumder et al., 2018). This specific population of children who are exposed to severe trauma but ultimately recover in response is known to have formed resilience (Rosshandler et al., 2016). In alliance with Masten and Narayan (2012), children and young people who develop resiliency display high standards of mental health functioning following the traumatic event and, in addition, may even thrive and adapt further to meet future adversities (Southwick et al., 2014). Furthermore, the research literature has defined resilience as an inherent personality attribute that can be determined by the availability of protective factors within an individual's environment (Luthar, 2013). Applying this research to the outlined wicked problem, the following review aims to address the outcomes that may have been overlooked at the time of its occurrence whilst proposing a multidimensional approach that can enhance the resilience of those impacted by future terror-related exposure through alleviation, protective, and prevention strategies.

Pakistan has been the center of continued efforts against terrorism for the past two decades. While the intensity of terrorist movements has fluctuated over the years, the nation itself has endured more than 100,000 fatalities, including 50,000 children and their families (Portal, 2018). As a result of the Army Public School terror-related incident, a multitude of risk factors, including the disorganization of education (Mufti et al., 2019), witnessing the significant loss of life (Khan et al., 2019), the perceivable deficiency within Pakistan's psychosocial health system (Mian & Chachar, 2020) and stigmatized attitude towards mental health (Sandhu, 2012) integrated themselves into the immediate environment or microsystems of those exposed to the attack. Following the Army Public School terror-related incident, pertinent evidence-based interventions were unable to be effectively allocated by governmental and community levels (Stoltenborgh et al., 2015), other than the short supply of mental health professionals and non-governmental organizations that had sufficient training to respond to disasters that showed equivalent levels of similarity. The Institute for Economics and Peace (2022) could provide a plausible explanation as to why the government and community levels failed to implement extensive prevention strategies. Presently, Pakistan is ranking tenth in the list of countries with reportedly high volumes of disaster events that occur in the form of natural disasters, terrorism, and political turmoil. With a child population that surpasses 95.4 million (UNICEF Pakistan, 2021) and an economic loss in the approximate region of $126.79 billion (equal to Rs. 10762.14 billion) due to the impact of terrorism (Zakaria et al., 2019), it is evident that government and community levels are unable to meet the great demand for equal distribution of financial aid. 

An additional challenge that was identified by Abdullah et al. (2015) that prevents children from receiving adequate psychosocial care is the current establishment of Pakistan's disaster management institutions existing at their premature phases. Although operations that are currently active, such as the Command, Control, and Communication Centre, anchor their attention on the advancement of coordination amongst the sector-level subunits, the subsequent production of their attempts maintains a deprivation of collaboration between distinct sectors within disaster management (Khan & Hassan, 2012; Qasim et al., 2017; Shahbaz, 2019). To demonstrate, Sarwar et al. (2016) claim that the foremost duty of disaster management organizations is to manage the outcome of natural disasters and, as a result, are left unequipped to produce significant contributions toward the governance of man-made disasters. 

Furthermore, whilst the response and planning strategies to combat acts of terrorism are solely supervised by representatives of law enforcement (Rafique, 2019), recovery and relief strategies, due to inferior comprehension and resources, are impotent when considering implementation unless governmental and community levels are integrated and fortified (Rafique et al., 2016). Considering this and as previously identified, the non-governmental organizations currently functional within Pakistan largely utilize themselves through independent means (Ali, 2016; Ashraf & Ismat, 2016). As a result of operating in isolation, Ali and Iqbal (2021) suggest that barriers endure whilst attempting to integrate with supplemental public and emergency firms within the disaster response network, which therefore limits children and young people's access to services that support potential symptoms of severe traumatic stress. It is essential from this understanding that for this wicked problem to be effectively addressed to prevent future occurrences, the complexity of children's needs requires a multidimensional approach.

To address this requirement, it may have been beneficial to reconceptualize those exposed to severe traumatic stress from a resiliency framework (Kent et al., 2013; Masten, 2015). In alliance with Bronfenbrenner's ecological theory, an interaction between proximal, such as family, institutional settings and neighbours, and distal elements, such as national government, wars, and economic status, within an individual's environment can significantly influence the emergence of protective and risk factors that interplay with each other to either escalate or reduce the probability of a disruptive outcome following children and young people's exposure to trauma (Bronfenbrenner, 1992). Applying this to the current paper, children and young people are considered to progress in a manner that represents the interactions they engage with in their environment or social settings (Bronfenbrenner, 2005; Bronfenbrenner & Bronfenbrenner Ceci, 1994). The ecological theory proposes that this process of interaction occurs between four distinct systems. To illustrate, the first and arguably the most influential sphere that children and young people interact with is referred to as the microsystem, which includes family, health services, religious organizations, and academic structures. Resiliency progression is also affected by the next sphere, known as the mesosystem. This system represents how the different sections of children and young people's microsystems collaborate with each other. It also describes the associations or scarcity of such cohesiveness between children and young people's microsystems, such as the relationships between home and work or school environments. Successive to this is the exosystem level, which emphasizes the effect of individuals and locations where children and young people may not interact closely but can still have a significant impact on them, such as government agencies, mass media, the economic status of the household, etc. The final level of the ecological model is the macro system which is situated in the outermost area of the framework and comprises the largest, most remote set of individuals, organizations, and values, including cultural attitudes and ideologies, which have a cascading influence on children and young people.   

In the current context and as a result of Pakistan's substantial economic decline through terrorist activity, Shahbaz et al. (2013) reported that the sharp incline of employment became more evident, which caused it to be a predominant factor in explaining the shortfall of spending power utilized within a child's microsystem. This process can be exhibited through the incorporation of Pakistan's economic system into the outer spheres of children and young people's exosystem, which produced a cascading effect into the interacting microsystems that encompassed the child's family and school environments (Bronfenbrenner, 1979). Consequent to the irreversible impact orchestrated by previous efforts of terrorism, which led to a reduction in financial aid, non-governmental organizations instead aimed their concentration on developing psychosocial interventions which targeted children and young people's school environment, which resides in the microsystem (Qouta et al., 2012). 

Psychosocial interventions that are tailored toward children who have been exposed to terrorism are available in abundance (Brown et al., 2016; Tol et al., 2014), and the majority of them initiate their programs for restorative purposes so that potential psychiatric disorders and their symptoms are prevented whilst optimal health and development are promoted (Kangaslampi et al., 2015). Through these methods, the objective is to improve a child's resilience by being attentive to individual features, which include essential coping tactics, problem-solving competence, and effective cognitive-emotional synchronization (Peltonen et al., 2012). Fernando and Ferrari (2016) additionally emphasized the importance of strengthening social support and family resources within a child's microsystem to successfully acquire these resilience-based skills. Despite these efforts, research that attends to intervention implementation has yet to address resilience as a principal outcome within the population of vulnerable children and young people and instead upholds symptom reduction as their leading outcome to attain (Graham et al., 2017; Salloum & Overstreet, 2012).

To demonstrate this, the Coping-Enhancement Protocol, which was utilized on a population of terrorism-affected Israeli children, concentrated on elevating resilience, coping strategies, and optimal emotion modulation by implementing practices of sharing and reorganizing traumatic material, psychoeducation, and narrative-based play tasks (Hamiel et al., 2013). Following its inclusion, the protocol was concluded to be most effective in symptom reduction rather than resilience building (Berger et al., 2016). A further display of how interventions can be integrated into the school environment of a child's microsystem is through Class-Based Interventions (CBIs). As observed in the research literature, CBIs have been widely administered for terrorism-affected children who reside in low-and middle-income countries (Jordans et al., 2016). Similar to the aforementioned protocols, the influence of CBIs within a child's school environment intends to encourage resilience that elicit innate coping strategies to prevent potential mental health issues. The efficacy of CBIs can be attributed to their cost-effectiveness and, as a result, is becoming a growing area of intervention implementation in many southeast Asian countries (Newnham et al., 2018). Despite this salient feature, the research identified that although mental well-being and post-traumatic stress-related symptoms had been alleviated through CBI interventions in response to terrorism, many children and their parents reported that their natural recovery had been undermined (Tol et al., 2013). In other LMIC countries, including Palestinian territories and Nepal, it was found that the introduction of CBI methods was not associated with improvements in PTSD, anxiety, or depression symptoms (Morina et al., 2017). The lack of potency when interventions were applied in other LMICs could have been explained by the lack of attention given to the psychological connectedness between a child and their immediate family within a certain cultural context (Cassidy & Shaver, 2018; Kim & Choi, 2014).

The importance of this connectedness, which employs the nonverbal methods of touch (same gender), empathy, and hugs in maintaining severe traumatic stress symptoms and building resilience, was found through a local NGO called Horizon that participated in psychological engagement with the children and families who were directly exposed to the APA terror-related attack in the city of Peshawar, Pakistan (Hoven et al., 2020). Although the WHO (World Health Organization, 2013), typically advises against utilizing such methods due to the lack of evidence that psychological debriefing or intervention has promising benefits in reducing symptoms of traumatic stress (Davies, 2020; Roberts et al., 2019), Horizon found that the majority of children often favoured direct participation through the debriefing techniques of nonverbal communication within counselling sessions that employed empathic touch. As a result of this, Horizon concluded that it was more constructive to support the child's psychological resilience in association with their immediate family environment before addressing and implementing measures at the school level of a child's microsystem.

Taking this into consideration, most of the research which promotes family-based trauma interventions has been conducted in the west (Cooper, 2016). This translates into a limited comprehension of child trauma and its management from a non-western frame of reference. As a result, it can be considered irrelevant for application within the cultural and religious contexts upheld by Pakistan (Shukla et al., 2012). Successive to the Army Public School terror-related incident, it was therefore perceivable that an urgent demand existed for culturally sensitive measures to increase the level of understanding of the severe traumatic stress reactions of the children so that reliance-based interventions could be developed. In acknowledgment of its religious context, Pakistan is considered an Islamic state and is listed as the second most populous Muslim country in the world after Indonesia (Zaman, 2018). Following its partition with India (Khan, 2017), the practice of Islam has been deeply rooted in Pakistan's history and has since remained a significant factor regarding the country's policymaking and the society's widely held beliefs revolving around mental health (Naveed et al., 2017).

Although basic acceptance of psychological distress is on the rise within Pakistan, the standard that continues to be practiced is for parents to either consult with religious community leaders or to keep their issues private from their children (Ali & Gul, 2018). To illustrate this process from children and people's macro system, and more specifically from Pakistan's cultural perspective, the development of mental health is believed to be associated with supernatural causes which originate from witchcraft and the evil eye (Choudhry et al., 2018; Sharma et al., 2020). For this reason, barriers to developing resilience are formed and are used as an internalized reason for parents' inability to access mental health outlets in Pakistan. Furthermore, Ciftci et al. (2012) claim that parents often consider mental health as a punishment from God and, as a result, aim to perform more religious actions, such as prayers, to treat the disease instead of communicating their exposure to psychological distress to their children. This generates an increase in individual restraint from inquiring and ultimately accessing mental health outlets. In light of this, the lack of awareness within the family level of the microsystem may influence the child's overall perception of mental health services which creates a further barrier to potential access (Rana & Sharma, 2013). In support of this statement, Ali (2016) revealed that because of the lack of awareness that exists within the immediate family environment, children and young people reported that they had limited or no knowledge of family-based therapy, such as family-based cognitive behavior therapy and admitted to referring themselves to general physicians or conferring with friends if they experienced mental health concerns rather than their family members. In recognition of Horizon's research, drawing upon the religious and cultural contexts established within Pakistan can help further understand the reasoning as to why the children of the Army Public School disaster responded so effectively to the nonverbal techniques of empathic touch. This approach may have encouraged psychological connectedness and, thus, the initial stages of resilience to develop through the form of comfort, which informed the child that their trauma was being acknowledged, a form to which the children may not have previously been exposed.

In acknowledgment of Pakistan's cultural contexts, another model of resilience that could of having been applied when considering treatment interventions for those exposed to the Army Public School terror-related attack is the constructivist self-development theory (McCann & Pearlman, 1990). It was introduced as an interdisciplinary personality theory that expresses the impact of a traumatic event on the individual's overall development. Through the unification of psychoanalytic (Eagle, 2013), social learning (Rosenthal & Zimmerman, 2014) and cognitive developmental (Kazi & Galanaki, 2019) construct coupled with constructivist thinking (Mahoney & Lyddon, 1988), the constructivist self-development theory may be a useful tool to uphold whilst considering future occurrences of terror-related incidents in addition to what could have been incorporated shortly after the Army Public School attack. Its effectiveness can be perceived by including an individual's cultural and social context in which the traumatic event occurred. Through this lens, the constructivist self-development theory accentuates the importance of the developmental approach by claiming that the individual's early stages of development are central to their current methods of communicating with the self and others. Within these early stages, the closeness of the child-caregiver dyad forms an essential part of establishing innate resilience toward their exposure to the traumatic material. Therefore, if the child can establish a secure base or attachment with their caregiver, they are more likely to integrate coping strategies that act as a resilient barrier when experiencing thoughts or feelings that could threaten the integrity and protection of the self. 

Taking the multitude of risk factors presented within the Army Public School children's macrosystem, exosystem, and microsystem into consideration, perhaps the most practicable strategy to utilize for future terror-related events is to apply horizontal integration within Pakistan's existing primary health care system, which would aid in strengthening the current system, instead of constructing a parallel mental health care structure. The implementation of this intervention would mean uniting professionals, services, and organizations that would otherwise function independently. Horizontal health care can be constructed again through the facilitation of the ecological model and could be used to organize and assess relationships between community infrastructures and between the community and the wider macrosystem to measure economic and other resources that have a role in determining the resilience of children and young people.

Despite the lack of qualified clinical psychologists and psychiatrists that exist within the psychosocial health system (World Health Organization, 2009), Pakistan is known for its cohesive Community Health Workers program (Khalid et al., 2022). This network of community health workers is often regarded as essential in enhancing access to mental health outlets so that individuals can achieve health-related goals. As previously mentioned, the constrictions in Pakistan's finance distribution due to terrorist activity create an expectation for community health workers to do more without securing the appropriate aid (Rahman et al., 2019; Scott et al., 2018; Zakaria et al., 2019). In response to this, the Lady Health Worker Cadre and similar groups were formed (Hafeez et al., 2011) to supply the required primary health care resources that promoted health, elimination of disease, therapeutic and rehabilitative services in addition to assistance in family planning within the individual's community level. Community health workers receive the necessary amount of training, including 18 months of coaching and 12 months of practical experience. These community health workers are chosen from their communities, which benefits the proposed intervention implementation as they have a greater understanding of society and are each accountable for supervising 200 individuals. 

In support of integrating various support systems, each community health worker would be aligned to a particular government health establishment, from which they would be provided with sufficient coaching and a small allowance. In recognition of their influential status, the proposed intervention would also aim to incorporate a networking system between community health workers and religious leaders within the community to achieve a holistic and horizontal healthcare system. As explored, the ecological theory is an application framework of investigation to assess children and young people's resilience. Research repeatedly reports that resilience development has strong associations with proximal and distal factors (Ungar et al., 2013). The utilization of this framework in unison with children and young people in Pakistan would validate the importance of the influences existing in their microsystem, mesosystem, exosystem, and macrosystem upon their resilience. Findings can then be integrated into the development of future policies and intervention construction as the ecological model can stipulate where these areas will have the largest impact on building children's and people's resilience to future man-made disasters. Suppose the identified factions were trained in providing mental health services through the recognition of risk and protective factors in association with the ecological model and the recommendations of the constructivist self-development theory by emphasizing the role of a secure attachment between traumatized children and young people and immediate family members. In that case, it could become a very effective system in delivering mental health resources within the affected community. With the government and community levels acting in unison with the religious community leaders and community health workers, an integrated framework of support and understanding could exist, despite the limited financial resources, to employ alleviation, protective, and prevention methods through a constructivist self-development theory lens that would encourage the growth of resilience in children and young people within Pakistan.


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