Terror leaves adolescents behind: Identifying risk and protective factors for high-school completion among survivors of terrorism

Terror exposure increases the risk of somatic and psychological health problems in survivors. Yet, knowledge of how such exposure affects survivors’ ability to stay in school is lacking. This study examined whether exposure to the 2011 Utøya terrorist attack in Norway impacted survivors’ ability to complete high school. Further, it aimed to identify important peri- and posttraumatic risk and protective factors. Interview data from the Utøya study, collected 4–5 months postterror, were linked to individual educational registry data for 265 survivors. Chi-square tests and ordinal logistic regression analyses were used to examine (a) high school completion among younger survivors (n = 185, age range: 13–18 years, 52.4% female) compared to both older survivors (i.e., who had the possibility of completing high school before the terror attacks; n = 80, age range: 19–21 years, 40.0% female) and the national average and (b) associations between high school completion and physical injury, posttraumatic stress symptoms (PTSS), somatic symptoms, and social support among younger survivors. Younger survivors were significantly less likely to complete high school on time. Among younger adolescents, physical injury, aOR = 0.36, 95% CI [0.16, 0.81]; higherlevel PTSS, aOR = 0.54, 95% CI [0.33, 0.88]; and somatic symptoms, aOR = 0.51, 95% CI [0.29, 0.91], lowered the likelihood of on-time completion. Terror exposure in adolescence adversely affects long-term educational functioning in young survivors, which can severely hamper their future prospects. These findings reinforce the need for trauma-sensitive teaching and educator-provided support for adolescents exposed to trauma

Violence in adolescence and later work marginalization? A prospective study of physical violence, sexual abuse and bullying in 15-year olds and marginalization from work in young adulthood

Background The long-term consequences of childhood exposure to physical abuse, sexual abuse, and bullying are of great public health concern, both at the individual and the societal level. The World Health Organization (WHO) has also acknowledge this as new evidence has documented the economic and societal costs associated with abuse in terms of substantial health care, social welfare, and lost productivity. Research has documented the negative outcomes associated with abuse and bullying in terms of severe physical and psychological health problems. However, epidemiological studies focusing on both abuse and bullying are lacking, and few studies have examined the long-term implications for the level of functioning, such as work participation. Most research on exposure to bullying and abuse has focused on the individual predictors of school functioning rather than the social context. The school climate and the person’s level of social support are important factors that may attenuate or increase the risk of impaired academic performance and subsequent work marginalization. Thus, it may be important to study the interrelationship between individual predictors and their social context to capture the complexity of the long-term consequences associated with exposure to abuse and bullying. Objectives and research questions 1. The main objective of the thesis was to gain knowledge about the long-term consequences of exposure to physical abuse, sexual abuse and bullying in terms of subsequent marginalization from work and education. In addition, we investigated whether school-level factors and support from the person´s immediate setting, in interplay with the exposure would influence this association. More specifically, the research questions were: - Do adolescents exposed to abuse or bullying (exposed) in junior high school perform worse academically compared with adolescents not exposed (nonexposed) to these types of adversities? Does the school climate have a stronger impact on academic achievement for the exposed adolescents versus the nonexposed adolescents? (Paper I). - Is exposure to physical abuse, sexual abuse and/or bullying in junior high school associated with subsequent marginalization from work and education in young adulthood? Does high-school completion have a mediating effect on this potential relationship (Paper II)? - Is exposure to physical abuse, sexual abuse and/or bullying in junior high school associated with receiving long-term welfare benefits in young adulthood? Does social support moderate this relationship (Paper III)? Materials and Methods This is a prospective cohort study that follows the same individuals for an extended time period. The baseline data consists of questionnaire data from the Youth Health Survey, which were conducted by the Norwegian Institute of Public Health between 1999 and 2004 with 15, 966 adolescents in 400 schools from six counties in Norway. The baseline data were linked to highquality Norwegian registries, such as the Historical Event Data Base (FD-Trygd) and the National Education Data Base (NUDB), which provide information about each person’s sick leave, unemployment benefits, social benefits, medical and occupational rehabilitation benefits, disability pension and level of education. This allowed us to follow each person’s work and educational progress up to the age of 26 years. Multilevel analyses, linear regression, ordinal logistic regression and Cox regression were used to examine exposure to abuse and bullying and their associations with academic achievement and work marginalisation. Of the baseline participants, 88% (14, 063) permitted the linking of data. Self-reported measures were used for academic achievement (grades), sociodemographics and the exposure variables. Participants were asked about their last 12 months’ exposure to physical abuse from youth, adults or both, sexual abuse and bullying. High-school completion and work marginalization outcomes were measured using registry data. Results In the first paper, we found that exposure to physical abuse, sexual abuse and bullying was associated with lower grades. School climate was of importance as high levels of bullying in a school resulted in lower academic performance regardless of the individual’s previous exposure to abuse. In the second paper, we found that reduced work participation in young adulthood was predicted by previous exposure to abuse and bullying in junior high school. Additionally, a negative dose– response relationship was observed between exposure to abuse and completing high school within five years. The respondents reporting three types of abuse (including bullying) had the highest frequency of not completing high school. Exposure to physical abuse and bullying increased the odds of lower work participation, independent of high-school completion. In the third paper, we found that exposure to abuse and bullying in junior high school increased the risk of receiving long-term welfare benefits in young adulthood. A cumulative association of abuse was observed in which multiple types of abuse led to a higher likelihood of receiving welfare benefits compared with the cases of single types of abuse and no abuse. However, the risk of receiving long-term welfare benefits was reduced with family support and good classmate relationships. Conclusion The results of the three papers indicate that the ability to participate in work is formed early in life. Individuals exposed to life adversities such as sexual and physical abuse and/or bullying in junior high school have a greater risk of poorer achievement in school, dropping out of high school and poorly integrating in work in young adulthood. Furthermore, exposure to multiple types of abuse increases this risk. The school climate and the person’s immediate setting present both risk and protective factors that may affect these outcomes. High levels of bullying in a school represent a threat to the academic achievement of all individuals at a school, while family support and good classmate relationships may serve as a protective factor for vulnerable individuals in regards to work participation outcomes in young adulthood. This thesis emphasizes that preventative efforts at an early age are crucial for successful integration of young adults. Moreover, further investigations of the long-term consequences of exposure to sexual abuse, physical abuse and bullying are needed

But were you drunk? Intoxication during sexual assault in Norway

Background: Sexual assault often occurs when victims are intoxicated. Rape myth research indicates that intoxicated assaults are sometimes seen as less severe or not as ‘real’ assaults; however, it is unclear if victims of intoxicated sexual assaults differ from victims of non-intoxicated assaults in terms of health and functioning. Objective: We investigated possible differences in mental health, social support and loneliness between intoxicated and non-intoxicated sexual assault victims. Methods: Participants were 1011 young adults (505 exposed to childhood violence and 506 non-exposed) selected from a community telephone survey (T1), and a follow-up survey 12–18 months later (T2). Analyses include one-way ANOVA with Tamhane post hoc tests. Results: There were no significant differences in mental health, social support and loneliness between victims of intoxicated and non-intoxicated sexual assault, although both groups differed significantly from those who did not report sexual assault. Conclusions: These results indicate that intoxicated sexual assaults are no less clinically important than non-intoxicated assaults

The mediating role of shame in the relationship between childhood bullying victimization and adult psychosocial adjustment

Background: Psychological distress following experiencing bullying victimization in childhood has been well documented. Less is known about the impact of bullying victimization on psychosocial adjustment problems in young adulthood and about potential pathways, such as shame. Moreover, bullying victimization is often studied in isolation from other forms of victimization. Objective: This study investigated (1) whether childhood experiences of bullying victimization and violence were associated with psychosocial adjustment (distress, impaired functioning, social support barriers) in young adulthood; (2) the unique effect of bullying victimization on psychosocial adjustment; and (3) whether shame mediated the relationship between bullying victimization and these outcomes in young adulthood. Method: The sample included 681 respondents (aged 19–37 years) from a follow-up study (2017) conducted via phone interviews derived from a community telephone survey collected in 2013. Results: The regression analyses showed that both bullying victimization and severe violence were significantly and independently associated with psychological distress, impaired functioning, and increased barriers to social support in young adulthood. Moreover, causal mediation analyses indicated that when childhood physical violence, sexual abuse, and sociodemographic factors were controlled, shame mediated 70% of the association between bullying victimization and psychological distress, 55% of the association between bullying victimization and impaired functioning, and 40% of the association between bullying victimization and social support barriers. Conclusions: Our findings support the growing literature acknowledging bullying victimization as a trauma with severe and long-lasting consequences and indicate that shame may be an important pathway to continue to explore. The unique effect of bullying victimization, over and above the effect of violence, supports the call to integrate the two research fields

Health care needs, experiences, and satisfaction after terrorism: a longitudinal study of parents of survivors of the Utøya attack

Abstract Background There is scarce knowledge on the health care follow-up of parents of terror attack survivors. This study focused on the mothers and fathers of survivors and examined (1) their perceived health care needs relative to their psychological reactions, physical health problems (unmet health care needs), and adaptation to work; (2) whether sociodemographic characteristics, health problems and social support were associated with unmet health care needs; and (3) how unmet health care needs, sociodemographic characteristics, and experiences with health services associated with overall dissatisfaction during the health care follow-up. Methods Interview and questionnaire data from three waves of the Utøya parent study were analyzed (n = 364). Chi-square tests and t- tests were used to compare unmet physical and psychological health care needs, sociodemographic factors and post-terror attack health reported by mothers and fathers. Logistic regression analyses were used to examine whether sociodemographic characteristics, unmet health care needs, and health care experiences were associated with overall dissatisfaction among mothers and fathers of the survivors during the health care follow-up. Results Among the mothers, 43% reported unmet health care needs for psychological reactions, while 25% reported unmet health care needs for physical problems. Among the fathers, 36% reported unmet health care needs for psychological reactions, and 15% reported unmet health care needs for physical problems. Approximately 1 in 5 mothers and 1 in 10 fathers reported “very high/high” needs for adaptation to work. Poorer self-perceived health, higher levels of posttraumatic stress and anxiety/depression symptoms, and lower levels of social support were significantly associated with reported unmet psychological and physical health care needs in both mothers and fathers. Parents with unmet health care needs reported significantly lower satisfaction with the help services received compared to parents whose health care needs were met. Low accessibility of help services and not having enough time to talk and interact with health care practitioners were associated with overall dissatisfaction with the help received. Conclusions Our findings highlight that parents of terror-exposed adolescents are at risk of having unmet psychological and physical health care needs and thus need to be included in proactive outreach and health care follow-up programs in the aftermath of a terror attack

Adolescent abuse victims displayed physical health complaints and trauma symptoms during post disclosure interviews

Aim We investigated whether adolescents who had recently disclosed sexual abuse or family violence displayed more psychological trauma symptoms and physical health complaints than unaffected controls. We also investigated to what degree physical health complaints were associated with trauma symptoms in these abuse victims. Methods Abuse, trauma symptoms and physical health complaints were assessed during face‐to‐face interviews with 40 sexual abuse victims and 35 family violence victims aged 10‐18 years. They had all attended forensic interviews at the Barnehus in Oslo, a specialised Norwegian police unit where evidence is gathered in adolescent‐friendly surroundings, from October 2016 to November 2018. Their symptoms were compared with 41 controls from the general population. Linear regression analyses investigated associations between trauma symptoms and physical health complaints. Results Sexually abused adolescents displayed higher levels of post‐traumatic stress reactions, depression, dissociation and physical health complaints than unaffected controls. Family violence victims displayed higher levels of post‐traumatic stress reactions. Trauma symptoms were associated with physical health complaints, and these were most prominent in the adolescents with the highest burden of symptoms. Conclusion Based on the high burden of symptoms revealed, clinical examinations of abused adolescents should include a systematic assessment of trauma symptoms and physical health complaints

The mediating role of posttraumatic stress reactions in the relationship between child abuse and physical health complaints in adolescence and young adulthood

Background: Child abuse is associated with physical health problems in adolescence and adulthood, but the mechanisms involved are unclear. A possible mediating effect of posttraumatic stress reactions (PTSR) linking child abuse with later physical health complaints has not been fully investigated. Objective: The current study investigated whether PTSR could be a potential mediator in the relationship between child abuse and physical health complaints in adolescents and young adults. If so, we also investigated whether this was the case for different child abuse types alone or in combination. Method: The study sample comprised 506 adolescents and young adult victims of child abuse and 504 unexposed matched controls aged 16–33 from a community sample. We measured child abuse retrospectively and current PTSR at wave 1 (2013), and current physical health complaints at wave 2 (2014/15). We tested a model of PTSR as a possible mediator between child abuse and physical health complaints and conducted causal mediation analysis to estimate direct and indirect pathways. Each child abuse type was studied in isolation and in combination with other abuse types. Results: PTSR had a notable, significant mediating effect on the relationship between child abuse and physical health complaints in our overall model (average causal mediation effect; ACME = 0.14, p < 0.001), accounting for 85% of the total effect. The mediated pathway was also significant in analyses of the different child abuse types. The mediating effect of PTSR was most prominent in individuals reporting exposure to more than one child abuse type. Conclusions: The current study indicates that PTSR may be an important mediator in the relationship between child abuse and physical health complaints. Health professionals should be aware of the important role that PTSR may have in maintaining or exacerbating physical health problems in child abuse victims. However, a reverse model could not be tested in this study and the results need confirmation in future prospective studies