Treating Traumatized Children: Risk, Resilience, and Recovery

Ruth Pat-Horenczyk, Ph.D.Director, Child and Adolescent Clinical

Services

Best Practices In Disaster Mental Health and Resilience: What Is, What Could Be!

New Orleans,

March 19, 2009

Presentation Goals:

• Part I: Risk and Protective Factors– Consequences of exposure to trauma:

Posttraumatic symptoms and related distress– Focus on school children

• Part II: Resilience– Building resilience within the school system

• Part III: Recovery– Guiding principles for school-based

interventions

Part I: Risk Factors

The Search for Risk and

Protective Factors in Childhood

PTSD: From

Variables to Processes

Terror in New York

Findings from United States:report of the Ministry of Education,

(New York City, 6.5.02)

• Survey of needs following 9/11• A sample of 8,266 school children in New

York• Students from the 4th to 12th grade, some were

near the twine tower, some were in more distant places

• Was completed six months after 9/11• With the cooperation of Columbia University

Ministry of education report: risk factors for the development of PTSD

• Physical exposure to the attack• Exposure of a family member to the

attack• Loss of family member in the attack• Exposure to trauma prior to the attack• High exposure to T.V.

Consequences of exposure

• Post Traumatic Symptoms and disorder

USA:– Oklahoma- 29% of exposed youth had

at least some PTSD symptoms even two years after the bombing (Pfefferbaum et al., 2000)

– 9/11- 11% of New York children and adolescents met the criteria for PTSD six month after the attack on the WTC (Hoven et al., 2003)

Consequences of exposure

• Depressive symptoms

– Children and youth exposed to trauma also show high levels of depressive symptoms, anxiety, fears and worries (Joshi, 2003; Shaw, 2003)

– 9/11- 8% of the New York children and adolescents experienced major depression (Hoven et al., 2003)

Consequences of exposure• Alcohol consumption

– Although acknowledged as possible consequence- hardly investigated (Katz et al., 2002; Joshi, 2003)

Report from the Ministry of Education, New York City: Referral for treatment

Most of the students (66%) with posttraumatic symptoms did not turn or were referred to treatment either within the school or in by mental health professionals in the community

Terror in Israel (Second intifada, 2000- )

Café Hillel – September 9, 2003

The Goals of Terrorism(From the New York Times editorial by

Thomas Friedman wrote, February 23, 2003)

• Terrorism aims to weaken the social and economic structure of society.

• Defense against terrorism means also strengthening the social structure of society.

Natural disastersKatrina, New Orleans

Also true for… terrorism and natural disasters

• Because societies under threat tend to counteract planning services in the midst of ongoing trauma, preparedness must involve establishing plans ahead of time

• Social resilience requires enhanced communication, collaboration and integration among policy makers, mental health and education systems, and among service providers

• Understanding and utilizing the human need to help and to bond in ongoing trauma can enhance social resilience

Part II: Resilience

Building Resilience in schools:Identifying and treating traumatized

children

Ruth Pat-Horenczyk, Ph.D., Naomi Baum, Ph.D., & Danny Brom, Ph.D.

Best Practices In Disaster Mental Health and Resilience: What Is, What Could Be!

New Orleans, March 19, 2009

School - Based Intervention In Israel:Conceptual Model

Ecological ApproachComprehensive school based program takes into account intervention at all levels

Developmental ApproachPrograms are planned based on developmental needs

Dual ApproachCommunity and Clinical perspectives

Dynamic Interactive ProcessTailoring the program to the unique needs of each school

Process Workshop for school staff Parent meeting Information and consent regarding screening Screening - administration of self report questionnaires

by teachers and research assistants in the classroom Classroom debriefing with teacher and research

assistant Feedback of results to school counselors Counselor interview to validate screening results Meeting with parents and identified child for decision

making and referral to school or community based services

Start a whole school resiliency program More specialized school based programs after follow- up

Screening Instruments

• Israeli Trauma Exposure (Pat-Horenczyk et al. 2002)• UCLA PTSD Reaction Index-Adolescent Version (Rodriguez,

Steinberg & Pynoos, 1999)or Posttraumatic Diagnostic Scale (PDS) Foa, Cashman, Jaycox, & Perry, 1997

• Functional Impairment Taken from the Diagnostic Predictive Scales (DPS), based on the Child Diagnostic Interview Schedule (Lucas et al.,2001)

• Brief Beck Depression Inventory (Beck & Beck, 1972)• Somatization Scale Taken from the Diagnostic Predictive

Scales (DPS), based on the Child Diagnostic Interview Schedule (Lucas et al.,2001)

• Protective factors: social support, self efficacy, ego resilience, flexibility, optimism, etc

Why Screen Traumatized Students?

One night several years ago, I saw men shooting at each other, people running to hide. I was scared and I thought I was going to die. After this happened, I started to have nightmares. I felt scared all the time. I couldn’t concentrate in class like before. I had thoughts that something bad could happen to me. I started to get in a lot of fights at school and with my brothers. Martin, 6th grader

The Posttraumatic Clusters

1. Re-experiencing of the event 2. Avoiding from the stimuli connected to the traumatic event 3. Symptoms of hyper-arousal

4. Functional impairment

Alertness and constant sense of emergency

Memories, pictures and thoughts appearing during sleep and wake

Numbness, cutback of interest in the exterior world

Impairment in learning, social or family functioning

Why Screen Traumatized Students?

One night several years ago, I saw men shooting at each other, people running to hide. I was scared and I thought I was going to die. After this happened, I started to have nightmares. I felt scared all the time. I couldn’t concentrate in class like before. I had thoughts that something bad could happen to me. I started to get in a lot of fights at school and with my brothers.

Martin, 6th grader

Findings from the Israeli screening project (N=5610): Gender differences

Full PTSD 3.8% 4.0%

Partial PTSD 5.5% 6.3%

Depressive symptoms 5.4% 7.3%

Somatic complaints 6.2% 7.1%

Functional impairment 22.2% 20.9%

Significant differencesP<.05

GirlsBoys

Risk-Taking Behaviors in Israeli Youth Living Under the Continuous Threat

of Terrorism

Ruth Pat-Horenczyk, Ph.D., Osnat Doppelt, M.A., Tomer Miron, B.A., Naomi

Baum, Ph.D.& Danny Brom, Ph.D.

Israel Center for the Treatment of Psychotrauma, Herzog Hospital

The Hebrew University of Jerusalem

FACT: There is evidence of an increase in substance abuse, violence, reckless driving, and other risk-taking behaviors (RTB) among Israeli adolescents in the last few years

(Statistical Yearbook of the Council for the Welfare of the Child, 2003)

Question: Does the exposure to ongoing terrorism influence risk-taking behaviors?

Cliff - Roulette

“It was scary…one after the other the children ran to the edge of the cliff, stopping a few millimeters before the edge. I think it is a new type of `Russian Roulette` game - the `Cliff Roulette` ”

“Some things that seem “not dangerous” can be deadly, like taking a bus to school, and some things that are considered “dangerous” may be harmless…”

“If life is short, then we should make the most of it,” is understood as “let’s take chances”

“I prefer to decide what to do with my life and not let them decide for me…”

Theoretical Explanations

Risk-taking behaviors satisfy the need to re-experience the trauma through “re-enactment”

Trauma influences perceptions of the world and future orientation

Trauma leads to hyper-arousal and thus may promote sensation seeking

Risk-taking behaviors can also be perceived as a way for adolescents to cry for help and express personal distress

Dangerous games

What Risk Taking Behaviors do Adolescents with Full or Partial PTSD Present?

Total

(n=42)

Girls

(n=21)

Boys

(n= 21)

34.2% 16.6% 54.2%

Fights 42.3% 43.8% 40.4% Smoking cigarettes

12.5% 9.2% 16.1% Using drugs

18.1% 10.1% 27.1% Dangerous driving

15.6% 9.7% 22.4% Unprotected sex

61.6% 53.0% 71.4% Drinking alcohol

8.6% 3.7% 14.1% Dangerous roulette games

68.5% 60.8% 77.1% Disobey school

64.1% 61.8% 66.7% Disobey parents

66.7% 23.8% 45.2%

66.7%61.9%

14.3%28.6%

64.3%

21.4%

28.6% 14.3% 21.4%

19.0%33.3% 26.2%

81.0%81.0% 81.0%

9.5%23.8% 16.7%

90.5%76.2% 83.3%

85.7% 66.7% 76.2%

Most frequent explanations provided by adolescents:

– You only live once (37.7%)– To get attention (34.0%) – There will be no bad consequences (33.3%) – It is “cool” (29.8%)

– They want to create the thrill of danger for themselves (23.7%)

These were the five explanations most frequently reported by both boys and girls.

How do Adolescents Explain the Risk-Taking Behaviors?

Sensation seeking

a partnership of

Israel Center for the Treatment of

Psychotraumaof Herzog Hospital

Center for Development in

Primary Health Care(CDPHC)

Al Quds University

JDC-Middle East Program

(JDC-Israel, Myers-JDC-Brookdale Institute, AJJDC)

Ashalim

,

CHERISH-Child Rehabilitation Initiative for Safety and Hope

Similar findings on both sides:• More PTS among youth reporting greater exposure• Higher co-morbidity (more functional impairment, depressive

symptoms and somatic complaints) among youth with PTSD • Girls reported more depression, hopelessness, somatic complaints

Israeli Adolescents Palestinian Adolescents

6.8% adolescents reported on full PTSD and 8.6%% on partial PTSD

35% adolescents reported on full PTSD and 11.7% on partial PTSD

Girls reported more posttraumatic distress No gender differences

APPLIED PSYCHOLOGY: AN INTERNATIONAL REVIEW, 2008

Posttraumatic Symptoms, Functional Impairment,and Coping among Adolescents on Both Sides

of the Israeli–Palestinian Conflict:A Cross-Cultural Approach

Ruth Pat-Horenczyk,1,2 Radwan Qasrawi,3 Roseanne Lesack,1 Muhammad Haj-Yahia,2 Osnat Peled,1 Mohammed Shaheen,3

Rony Berger,4 Danny Brom,1,2 Randi Garber,4 and Ziad Abdeen,3

*

1The Israel Center for the Treatment of Psychotrauma, Israel2Hebrew University of Jerusalem, Israel

3Al Quds University, West Bank4JDC-Middle East Program, Israel

The Second Lebanon War:Under Missiles Attack

July 2006

The Second Lebanon War:Under Missiles Attack

July 2006

Second Lebanon War (summer 2006)

• War lasted 33 days • About 4,000 rockets were fired at northern

Israel, with about 900 hitting inhabited areas• 45 civilians where killed• About 2,000 civilians where injured• About 300,000 people left their home

Exposure to the Second Lebanon War

Almost all subjects were expose directly (e.g. present during a missile attack) or indirectly (e.g. through a family member)

• 34.7% of the adolescents and 26.2% of the children were separated from their parents.

• 81.2% of the adolescents and 80.5% of the children left their home.

Post Traumatic Distress and Anxiety Elementary Schools

2007 (N = 481) 2008 (N = 368)

Post Traumatic Distress and DepressionJunior High

2007 (N = 581) 2008 (N = 382)

Seeking help:Can adolescents tell when they are

distressed?

• Adolescents may have attempted to look strong to ‘save face’(Tatar & Amram, 2007)

Girls reported more utilization of seeking out support

Seeking Help• Less studied• Who and when will adults ask for help?

(Kaniasty & Norris, 2000; Hurricane Andrew, and non emergency situations)– Emergency encourages help-seeking

behavior; unblock barriers for articulating one’s needs.

• Parental encouragement to seek help and advice from others was associated with more distress for adolescents following 9/11 (Gil-Rivas et al., 2007)

• Girls reported more utilization of seeking out support. It is explained by females greater stress, fear and anxiety, which leads them to turn to those surrounding them for help (Komiya et al ., 2000; Zeidner, 1993)

A conceptual model For the Present Presentation

Functioning

Post Trauma

Anxiety

Exposure, Socio Demographic, Negative life events

Help/support seeking

– Can their help seeking behavior serve as a diagnostic tool ?

Seeking Help:Do children know when they need help?

Q: Do you want someone from school to help you?(Elementary schools, 2007)

Teachers’ Resilience in the Wake of the Second Lebanon

War

Naomi L. Baum, Ruth Pat-Horenczyk, Rami Ben-Benishti, Miriam Schiff, and Danny Brom

Israel Center for the Treatment of PsychotraumaHebrew University

Jerusalem

Purpose of Teachers’ Survey

• To assess teacher’s perceptions of:– Themselves and their families– Their students– Their school– Their personal and professional needs

• Adjunct to student survey• Undertaken in June, 2007 – ten months

post war

PTSD in Teachers

Teachers: Results

• 32.9% of teachers reported a decrease in their students' motivation to learn after the war

• 44.3% noted that students experienced an increase in difficulties learning and focus in the classroom.

• 30% of teachers reported more absences due to illness

• 36.1% reported more behavioral problems after the war.

• Positive changes were also reported by teachers:– There was an increase in social support and class

cohesion (30.5%)…– as well as an increase in volunteerism and readiness to

help others

Part III: Recovery

Three Modules of School-Based Interventions

Ruth Pat-Horenczyk, Ph.D. Naomi Baum, Ph.D.Danny Brom, Ph.D.

Definitions of Resilience

• “The capability of a strained body to recover its size and shape after deformation caused especially by compressive stress” (Merriam Webster)

• An ability to recover from or adjust easily to misfortune or change

The Spinal Cord: A Metaphor for Resilience

Treatment Module 1:

Professional Staff Needs

• Time out to explore:

– personal distresses and traumas

– coping and resources

• Knowledge about trauma and recovery

• Skill Development

• Self Confidence

Plan of Action: Three Phases

• Phase one- Focus on staff member

• Phase two-simulation of classroom activities

• Phase three-classroom application

Stage One: Focus on the Teacher• Mindedness training• Development of self awareness:

– Attitudes– Current coping styles– Life stresses

• Psychoeducation Unit: Normal Reactions to Stress and Trauma

Stage Two: Expressing Emotions• Emphasis on Fear• Creative Modalities• Builds Understanding and Empathy

Stage Three: Resourcing• Mapping current coping

resources– Belief Imagination– Affect Cognitive– Social Physical

(Basic-Ph Model (Lahad & Ayalon)

• Expanding and deepening existing resources

Stage Four: The Existential Piece

• Meaning Making We can discover this meaning in life in three

different ways: (1) by doing a deed; (2) by experiencing a value; and (3) by suffering.... Victor Frankl

• Hope

Teacher Evaluations (N=550)

Significance Post Pre

T(560)=-8.210 P=.000

3.20(.821)

2.59(.874)

KnowledgeM(SD)

T(459)=-6.381 P=.000

2.87(.653)

2.48(.753)

SkillsM SD)

T(547)=-3.335 P=.001

3.02(1.06)

2.71(1.00)

BehaviorM (SD)

Intervention and Treatment Continuum

Module no. 3

Module no. 1

Module no. 2

Students with posttraumaticrelated distress (7%)

Students with PTSD symptoms(5%)

Individual psychotherapy

The whole school community (100%)

Treatment Module 2:

• Psycho-education• Cognitive Restructuring• Increasing Awareness• Relaxation and Guided Imagery• Social Support and Validation

Group intervention for students with posttraumatic related distress

“ A Minute for Yourself”:Mindfulness exercise ((Based on Ford, TARGET)

• Slow down your body and your thoughts“Try to slow down your body and your thoughts, let your mind relax, and pay attention to the natural rhythm of your breathing…You may close your eyes if you wish for a few seconds, take a slow deep breath. Reflect on each thought separately.”

• Focus on yourself"Try and focus yourself in space and pay attention to what you feel, what you're doing, on the space around you, and what is in the room. You can remind yourself that you are in a safe and protected place where you can learn about yourself and about others.“

• Rate yourself"Try and estimate the amount of stress you feel according to the stress meter, the amount of control you feel according to the control meter, and your ability to cope according to the coping meter."

MetersRight now I feel 1 2 3 4 5 6 7 8 9 10Very stressed Mildly stressed Relaxed

Right now I feel 1 2 3 4 5 6 7 8 9 10Very stressed Mildly stressed Relaxed

Right now I feel my coping ability is 1 2 3 4 5 6 7 8 9 10Very low Moderate High

Stress Meter

Control Meter

Coping Meter

Pre-Post assessment of the Journey to resilience workshop (5 groups)

15.18 15.42

11.21

14.88

12.97

9.55

0

2

4

6

8

10

12

14

16

18

General Anxiety

Seperation Anxiety

Functional Impairment

pre

post

• Less functional impairment and less separation anxiety following the workshop.

*

*

Treatment Module 3: Group Treatment for PTSD Symptoms

Integration of Psychological Treatment Techniques: Psycho-education CBT exercises Prolonged Exposure

(imagery) Building narrative Relaxation and guided

imagery Increasing social

supports

Session Format

Opening ritual and self check Psycho-education Guided imagery Cognitive exercises Narrative work Closing ritual and self-check

Opening and closing rituals* Each session has an opening and closing ritual that reflect the main motif of the session (e.g.,: internal weather report – cloudy, sunny, rainy, stormy) Rituals : Establish a common group language Enhance group solidarity and create an atmosphere of mutual support and cooperation Create feelings of belonging Give the group leader a sense about each participant’s current state

*Based on TARGET - Trauma Adaptive Recovery Group Education and Therapy (Ford et. al., 2001)

What I would do with 1,000,000$

The story behind

my clothes

Person I admireInternal weather

How are you? Self-check*

Assessment of emotional, behavioral, and cognitive aspects associated with processing the trauma

Rationale: Develops self-awareness Clarifies emotions Increases the capacity for self-appraisal, Enhances self-control and self-regulation Promotes dual attention

• Adapted from the S.O.S procedure in TARGET - Trauma Adaptive Recovery Group Education and Therapy (Ford et. al., 2001).

Self CheckHow much I was bothered by the stressful event this week?

Little 1 2 3 4 5 Very much

How much did I avoid activities that remind me of the event?

Didn’t avoid 1 2 3 4 5 many times

How tense was I?

Not tense 1 2 3 4 5 Very tense

What was my fear level this week?

Didn’t fear 1 2 3 4 5 High level of fear

How was my general functioning this week?

Excellent 1 2 3 4 5 Couldn’t function

How did I feel this week?

Excellent 1 2 3 4 5 Not very well

Pre-Post assessment of Module 3 (“Magnet”) Posttraumatic symptoms and Functional

Impairment

0

0.5

1

1.5

2

2.5

3

Functional imapirment

pre

post

0

10

20

30

40

50

60

Posttraumatic symptoms

pre

post

*

Treatment groups: Pre-Post assessment of PTS

0

2

4

6

8

10

12

14

16

18

Re-experiencing Avoidance Hyper arousal

pre

post*

Concluding Comments

• Children are particularly vulnerable when they are exposed to terrorism, although only a minority of children develop pathological responses, such as PTSD

• A major challenge in implementing these school based programs is to make them sustainable within the local community

• Future challenge is to provide evidence for the effectiveness of resilience building interventions designed to strengthen protective factors and to mitigate the posttraumatic distress, so that policy makers and practitioners will be able to confidently adopt these programs system-wide

In spite of everything I still believe that people are really good at heart. I simply can't build up my hopes on a foundation consisting of confusion, misery and death.

Anne Frank

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