Systems of Care for Traumatized Children: The Example of a School-Based Intervention Model

Chart 7.1

The continuum of services

The chart shows the need to think in multiple dimensions in the development of services. The first dimension is the time in relationship to traumatic events. Ideally, resilience-building interventions should be done before people are exposed to traumatic events so that they can cope better. The services during, immediately after, and long-term after will differ from each other in goals and techniques used. A second dimension is the target group for intervention. Are we talking about general population, high-risk groups, highly exposed groups, clinical populations, young children, adolescents, adults, elderly? A third dimension is the content and aims of the intervention. Some interventions might aim at strengthening the sense of community, others aim at showing victims that society cares, and yet others aim at speeding the coping process. The last dimension is the decision about who can and should execute the chosen intervention. Emergency and trauma-related interventions attract a large amount of volunteer and NGO work and philanthropy is often easy to recruit for this kind of work. NGOs are often also much more flexible and can respond to emergencies quicker than established systems of care that are not designed for emergency interventions. Strategically, however, it is important to make sure that trauma care will not be isolated and will not compete with the existing system of care.

Traumatized Children in Society: A Model of Care

We present a comprehensive model for building resilience in school communities that have been exposed to the trauma of terrorism and war. We will describe the various levels of intervention beginning with the principal and the leading teams in the school, and then highlight our resilience-building workshops for teachers. The guidelines for school-based screening for identifying posttraumatic distress will be clarified followed by three different modules of school-based treatment interventions. We conclude with challenges for implementation and future directions based on our experience.

Children Exposed to Mass Trauma

In the aftermath of war and terrorism, children may downplay or deny their symptoms for fear of overtaxing their already overburdened parents, and adolescents may avoid, ignore, or numb their symptoms either to assert their independence or simply to move on (Hoven, Duarte, & Mandell, 2003). After the Oklahoma bombing in 1995, Pfefferbaum et al. (2003) found that only 5 % of 2,720 children surveyed after the Oklahoma bombing in 1995 received counseling. Further, after 9/11, a large school-based screening conducted by the NYC Board of Education 6 months after the attacks, reported that 2/3 of children identified with posttraumatic distress were not referred to any type of treatment (Hoven et al., 2003). Such findings highlight the need to actively reach out and provide screening and treatment resources for children and adolescents suffering in silence from war- and terrorism-related traumas.

Increasing evidence suggests that when students are directly asked to report their own reactions and behaviors, they tend to express their posttraumatic distress (Pat-Horenczyk, Abramovitz, et al., 2007). Similarly, adolescents clearly indicate when they feel they need help, and these reports have a strong correlation with their answers on questionnaires about symptoms (Schiff et al., 2010). This underscores the importance of simply asking the proper questions to elicit responses that can help identify child and adolescent postwar and post-terrorism syndromes.

Most individuals exposed to traumatic experiences seem to cope well or even thrive in the aftermath of traumatic events. There are various ways to conceptualize what constitutes resilience and what constitutes a “resilience factor.” Such factors could include a combination of protective characteristics, such as competence or self-efficacy (Garmezy, 1991; Masten & Coatsworth, 1998), or the underlying processes of coping that an individual adopts in the face of adversity (Luthar, Cicchetti, & Becker, 2000). Discussions abound regarding what constitutes a resilient response to trauma. Most agree that resilient individuals can still experience some difficulty or distress in the course of coping with traumatic events, but they also must be able to draw on their resources to resume normal functioning.

Bonanno (2004) claims that resilient individuals maintain a degree of equilibrium during their traumatic experiences and “generally exhibit a stable trajectory of healthy functioning across time” (p. 21), which separates them from individuals who “recover” from psychopathological episodes consequent to adversity. Our working definition of resilience is based on the formulation suggested by Masten (2001), which regards resilience as “ordinary magic,” in contrast to extraordinary behavior in the face of adversity.

School-Based Intervention Model

Schools are natural venues for intervention following trauma, where the goal is to strengthen resilience and assess and treat posttraumatic distress, functional impairment, and related distress. Children spend most of their active daytime hours in school, making it a natural venue for developing mental-health initiatives. It has been argued that providing mental-health services in schools can minimize the stigma surrounding psychological care, and thus encourage students to seek care and incorporate therapeutic techniques in their lives (Kataoka et al., 2003). Situating mental-health programs in schools also makes health care more physically accessible and immediately available, which is an important factor, when one considers how many diagnosed cases of trauma-related symptoms remain untreated. On a practical level as well, schools are an excellent venue for intervention because they are already structured in a way conducive to program development and maintenance. Resources already embedded in the school systems, many of which are underutilized, can be used to create an effective and financially feasible mental-health response.

Not all school interventions target the same groups or aim for similar outcome measures. The Institute of Medicine (1994) delineated three different models of intervention that aim to improve the mental health of students: universal, selective, and indicated. In each of these categories, students with different profiles are slated for intervention. Universal interventions focus resources for all students; selective interventions are addressed only towards high-risk students; and indicated interventions address the needs of students on the brink of risk, when signs of problem behavior begin to emerge (Power, 2003). Inherent in these three models is the desire to promote health and resilience, on one hand, and the necessity to intervene and possibly offer treatment in the case of risk or psychopathology, on the other. The distinction between preventative and curative interventions for child mental health necessitates the assessment of the differential needs of students.

Often, in work with trauma, selective interventions in schools aim to identify children with PTSD, acute stress disorder, or depression, and then initiate group or individual treatment to alleviate these symptoms (Amaya-Jackson et al., 2003; Caplan, 1974; Cohen & Mannarino, 2004; Stein et al., 2003). Selective interventions usually borrow heavily from cognitive-behavioral models, where identified students are given a mixture of counseling, psycho-education, and techniques to alleviate stress, identify maladaptive cognitions, and process traumatic experiences (Amaya-Jackson et al., 2003; Caplan, 1974; Cohen & Mannarino, 2004; Stein et al., 2003). In contrast, universal interventions target entire student bodies indiscriminately, focusing less on psychopathology or at-risk children, and more on creating individual and community resources so that all students can become more resilient. Universal interventions often involve multiple levels of school and community contributions to the program, such as parental involvement and teacher training (Berger, Pat-Horenczyk, & Gelkopf, 2007).

There is evidence to support the benefits of both selective and universal school interventions following a variety of traumatic experiences, including natural disasters and hurricanes (Chemtob, Nakashima, & Hamada, 2002; La Greca, Silverman, Vernberg, & Prinstein, 1996; Norris, Friedman, Watson, & Byrne, 2002), war (Laor et al., 1997; Saltzman, Pynoos, Layne, Steinberg, & Aisenberg, 2001; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ), terrorism (Baum, 2005; Berger et al., 2007; Hoven et al., 2003; Koplewicz et al., 2002; Pat-Horenczyk, 2004; Pfefferbaum, 2001) and violence in communities and schools (Stein et al., 2003). However, while studies indicate that school-based screenings and interventions can be used to mitigate the effects of exposure to trauma (or potential exposure, in the case of resilience-building), many questions remain. A particular concern is the long-term validity of intervention programs and their ability to ensure long-term benefits to students. Additionally, at this early stage of development, there are still uncertainties regarding which critical ingredients of intervention are central to a program’s success. Intervention must thus remain in constant dialogue with the theoretical and evidence-based currents in the field, and the strengths and weaknesses of its current programs must be assessed so as to create better practices (Power, 2003).

There are many practical constraints inherent in school-based work. School systems are vast and complex, involving multiple layers of organization and players. Thus, often even the best of programs can falter in the realm of implementation. It has been argued that mental-health objectives in schools often do not succeed, or at least are not sustainable, because there is a disconnect between the education and mental-health orientations, where educators focus on competence and achievement and mental-health practitioners focus on psychopathology and social and emotional growth (Masten, 2003). Political, economic, and cultural barriers can also be expected when intervention takes place in any real-life setting, and there will be particular demands at each research site that require additional resources (Kratochwill & Shernoff, 2004). Such concerns are of primary importance for programs where teachers and administrators, rather than researchers, become the key conduits of conveying mental-health programs.

The Building Resilience Project, in fact, pairs these two factors into a holistic model, bringing both selective and universal elements into one integrative process in schools. The resilience workshop is the first element of the model, which helps administrators, teachers, and other school personnel to acquire a basic understanding and practice of resilience, including trauma awareness education and building coping strategies. The trained personnel are guided to apply this experience and conduct resilience training in the classroom, teaching students through modeling and hands-on activities how to develop strengths that can buffer trauma. Parents also are involved in this program and attend informational seminars and workshops.

The second element is a comprehensive school screening program to identify those students who require individual and group treatment for trauma-related symptoms. Students identified through the screening ideally receive treatment from practitioners who work within the school setting, transforming schools into centers of immediate mental health care. Both elements work together; the nuance is not so much the bridging of two different models, but rather the unique character the program acquires as the two models work together in synergy.

Furthermore, while many interventions introduce outside protocols and procedures and “intervene” in the organic school environment, our model works to embed the solution, skills, and procedures of resilience development into the school system itself. This is the second unique feature of the program—namely, its sensitive approach to effecting change on a systems level. The first order of change involves structural concerns, such as including the Ministry of Education and local boards of education, reviewing program protocol, mapping an organizational framework, and identifying key players who can help make the program a success. Furthermore, since each school is a complex system in its own right, cultural concerns about school ideals and priorities must be addressed. Through the combination of teacher-training workshops, screening, and treatment, we aim to educate school personnel and bring mental-health concerns to the forefront of the educational discourse. In so doing, the program encourages educators to begin thinking in terms of students’ social and emotional development, and thus inspires a reorientation of school culture and a redirecting of educational priorities. Training school-based mental health professionals furthers the empowerment of the local system, and builds capacity for professional trauma treatment and intervention in local schools.

In our experience, this model changes the way educators view their personal role in supporting the mental-health needs of their students, and empowers them to become the agents of this change. Staff training workshops focus on the teacher’s experience and provide tools for intervention, thus challenging school personnel to take part in developing their own school-wide mental health program. By involving school personnel in the long-term goals of the program, and also ensuring that the school infrastructure can support the program, we help secure the long-term sustainability of mental health interventions in schools.

There are six major components of the model:

Preparing the School System

In order to ensure proper implementation of the program, including its sustainability after the initial intervention and implementation, strong working relationships need to be established with municipalities, supervisors of boards of education, and principals in individual schools. Creating a core of committed professionals ensures the continuation of the resilience-building work in the school setting long after the completion of the initial intervention. In this first component of the model, the goal is empowering the local school communities. Working from the top down, after meeting and gaining commitment from municipal education leaders and policy makers in the Ministry of Education, we involve all levels of school administration, staff, and parents in training about trauma and stress and the role of resilience. Their commitment to the program is critical in effecting change on all levels of the school community.

First we identify the key players in the school system. We ask: Which teachers are most excited about this project? Which administrators will oversee its proper implementation? Who will be the internal school contact who can help coordinate concerns from the field? During this initial phase, we also meet with the principal and leading school team (which may consist of the guidance counselor, psychologist, head teachers, or division heads) to assess the school’s trauma history, including how both national and local traumatic events have affected the school atmosphere and the students’ health. Such questions may include: Has the school sustained any losses (students, teachers, parents)? Were any of the students’ family members wounded or killed in war? Did any students or faculty lose their houses during recent events? Has a student or teacher ever died in a car accident or of cancer? All of this information is necessary to tailor the program to the specific needs of the school. After a working relationship with the principal and the leading team has been established, the program is then explained and a timeline set up, with expectations and responsibilities for both sides. This element is critical, as it ensures that both external and internal parties are involved, as well as coordinated in their efforts to construct the school mental-health intervention.

Training Mental-Health Professionals

School mental-health professionals often lack the confidence and the specific tools needed to provide appropriate interventions in the wake of trauma. In addition, the system is often eager to show that everything is “back to normal” and so encourages professionals to go about their daily work. By helping the mental-health professionals acknowledge existing needs as well as empowering them to implement interventions, we aim to strengthen the mental-health system in the schools.

In the Israeli system, school psychologists and school guidance counselors address different mental-health needs. Psychologists play the dual role of consultant to school personnel including the principal and teachers, as well as treating children with a variety of psychological disorders. As such, the model trains psychologists to facilitate teacher resilience workshops, as well as provides training for the specialized treatment of severe manifestations of trauma exposure and posttraumatic stress disorder in a school-based group setting.

Guidance counselors are also key players, acting as the mental health advocates in school, helping direct school resources and energies in the changing environment that trauma creates. Guidance counselors can be trained to conduct post-screening interviews and refer children for individual or group therapy. They are also trained in the six-session protocolized program for reducing anxiety and posttraumatic symptoms that we will describe later.

Building Resilience with Teachers

Teachers are natural partners in developing resilience within the student body. Rather than relying on sporadic visits of outside experts, our program works with teachers to develop their skills so as to embed mental-health objectives in each classroom. The in-service workshop enhances the teachers’ ability to cope with stress and trauma, and increases their resilience by expanding their understanding of trauma, self-awareness, and skill base for dealing with emotions in the classroom. By becoming aware of how they are coping on a personal level, teachers can more effectively communicate with their students about traumatic events and develop the confidence to work with children normatively after exposure to trauma. Furthermore, they learn to identify overt and subtle symptoms of posttraumatic stress disorder, and learn what referral services are available for them and their students, thus enhancing their ability to identify students who need these services and increasing the students’ treatment prospects. Developing the teachers’ repertoire of classroom activities, involving emotions and resilience-building activities, round out the intervention.

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