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Hamiel article on prevention

  1. 1. NEW RESEARCH Preventing Children’s Posttraumatic Stress After Disaster With Teacher-Based Intervention: A Controlled Study Leo Wolmer, M.A., Daniel Hamiel, Ph.D., Nathaniel Laor, M.D., Ph.D. Objective: The psychological outcomes that the exposure to mass trauma has on children have been amply documented in the past decades. The objective of this study is to describe the effects of a universal, teacher-based preventive intervention implemented with Israeli students before the rocket attacks that occurred during Operation Cast Lead, compared with a nonintervention but exposed control group. Method: The study sample consisted of 1,488 students studying in fourth and fifth grades in a city in southern Israel who were exposed to continuous rocket attacks during Operation Cast Lead. The intervention group included about half (53.5%) of the children who studied in six schools where the teacher-led intervention was implemented 3 months before the traumatic exposure. The control group (46.5% of the sample) included six schools matched by exposure in which the preventive intervention was not implemented. Children filled out the UCLA-PTSD Reaction Index and the Stress/Mood Scale 3 months after the end of the rocket attacks. Results: The intervention group displayed significantly lower symptoms of posttrauma and stress/mood than the control group (p .001). Control children had 57% more detected cases of postraumatic stress disorder (PTSD) than participant children. This difference was significantly more pronounced among boys (10.2% versus 4.4%) and less among girls (12.5% versus10.1%). Conclusions: The teacher- based, resilience-focused intervention is a universal, cost-effective approach to enhance the preparedness of communities of children to mass trauma and to prevent the development of PTSD after exposure. J. Am. Acad. Child Adolesc. Psychiatry, 2011;50(4):340 –348. Key words: teacher-based intervention, school, disaster, PTSDD uring the winter of 2008 –2009, a three- The growth in professional and social aware- week armed conflict in the south of Israel ness in regard to these effects has been accompa- and the Gaza Strip took place—Operation nied by efforts to alleviate the pathological re-Cast Lead. Hundreds of rocket and mortar at- sponses, which, in some children may last fortacks were launched at Israeli civilian popula- years.4-9 The larger the population affected by thetions. Whole families spent hours and days in traumatic event, the greater the need to imple-shelters, experiencing a continuous existential ment evidence-based group interventions thatthreat. are cost effective and reach masses of affected The psychological effects that exposure to individuals, with similar professional resources.mass trauma has on children have been amply Postdisaster group interventions are generallydocumented in the past decades. Natural and implemented by trauma expert clinicians. How-human-made traumatic events display a great ever, when massive disasters result in thousandsimpact on the well-being of children in the areas of affected individuals, any society will faceof health, cognition, and mental health.1-4 limited clinical resources, overwhelming the mental health system. Therefore, endorsing a public health approach based on ecological and This article is discussed in an editorial by Dr. Joan Rosenbaum systemic principles is in order, one based on Asarnow on page 320. professional mediators available for training and Supplemental material cited in this article is available online. responsible for the implementation of clinically informed programs.10 For children, teachers are JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY340 www.jaacap.org VOLUME 50 NUMBER 4 APRIL 2011
  2. 2. TEACHER-LED INTERVENTION AND PTSD PREVENTIONundoubtedly the main natural mediator, operat- Usually, the process starts with an educationaling within the community (see Jaycox et al. for a phase that helps individuals to better understandrecent teacher-delivered pilot program for chil- the nature of stress and its effects, and increasesdren exposed to trauma).11 a sense of predictability and control by providing Such an approach was tested for the first time accurate expectations regarding the stress envi-in Turkey after a major earthquake that resulted ronment and the stress reactions. This is followedin more than 30,000 deaths.12 Results of this by a skill acquisition and rehearsal phase totwice-a-week, eight-session, trauma-focused in- develop and practice a repertoire of coping skillstervention showed an immediate significant de- to reduce anxiety and enhance the capacity tocrease of approximately 50% in the prevalence of respond effectively in the stressful situation. Fi-severe posttraumatic symptoms and long-term (3 nally, the coping skills are applied in conditionsyears) better adaptive functioning compared that approximate the criterion environment acrosswith a nontreated control group.13 increasing levels of stressors (e.g., imagery, behav- The same clinically informed and ecological ioral rehearsal, modeling, role playing, and gradedprinciples were used to develop a universal in vivo exposure).17teacher-based intervention for thousands of Is- Developmental studies with primates suggestraeli children affected by the Second Lebanon that the hypothalamic–pituitary–adrenal (HPA)War.14 The protocol used in this model focused axis may provide a neural basis for programmingon resilience building rather than directly ad- stress resistance in the developing child throughdressing trauma symptoms (see Method). Results manageable exposure to moderately stressfulof this intervention revealed a significant symp- events.15 This exposure seems to temporarilytom decrease. Moreover, compared with a wait- activate the HPA axis but permanently altering list control group, the percentage of children neuroendocrine sensitivity to subsequent stres-with moderate and severe symptoms of post- sors by fostering the acquisition of coping strat-trauma was 50% lower in participating children. egies that safeguard against the development of Clinical research under conditions of trauma stress-related disorders.and disaster is a complex endeavor. It requires Research with stress inoculated monkeysassessment efforts in parallel to the implementa- shows that they more readily self-regulate arousaltion of clinical relief, overcoming the resistance of and engage in more exploration than noninocu-individuals and institutions. Difficulties intensify lated monkeys, apparently stimulating the devel-when clinical researchers wish to endorse a pro- opment of larger prefrontal cortical volumes affect-spective approach with communities at risk to be ing cognitive control of behavior, emotionaltraumatically exposed. Such approach invites an regulation and curiosity in humans and monkeys.18”inoculation” perspective, one that prepares the Adults have been found to cope better withindividual to face the traumatic exposure, pro- stressful events such as spousal loss, illness, andcess it effectively, shorten the period of rehabili- major accidents if they have previously copedtation, and minimize the damage while empha- with stressors in childhood.19 Therefore, in hu-sizing growth and development. mans, too, stressful events that are not over- whelming, but challenging enough to elicit emo- tional activation and cognitive processing, mayStress Inoculation make subsequent coping efforts more efficient. AIn addition to its known negative consequences, meta-analysis of 37 studies showed SIT to bestress may potentially enhance future compe- effective to reduce performance and state anxi-tence, provided that the type and degree of stress ety, and enhance performance under stress.16are not excessive. Parker et al. stated that mod-erate stress, when overcome, provides a chal-lenge that produces competence in the manage- SIT in Schoolsment of, and increased resistance to, future When considering the essential elements of im-stressful circumstances.15 mediate and mid-term mass trauma interven- By providing training in effective coping skills tions, Hobfoll et al. regarded techniques based onbefore exposure, interventions within a stress SIT as a public health tool.20 The school setting isinoculation training (SIT) approach aim at pre- a critical factor within such a public health ap-paring individuals to cope more favorably with proach. For example, school counselors couldstressful events while enhancing performance.16 emphasize proactive interventions that promoteJOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 50 NUMBER 4 APRIL 2011 www.jaacap.org 341
  3. 3. WOLMER et al.TABLE 1 Description of Schools in the Intervention and Control Groups School Group N % Girls SES Religiosity I1 Intervention 155 49.7% High Secular I2 Intervention 68 36.8% Heterogeneous Religious I3 Intervention 170 56.5% Heterogeneous Religious I4 Intervention 89 53.4% Low Secular I5 Intervention 80 46.3% High Secular I6 Intervention 186 47.3% Heterogeneous Secular C1 Control 140 44.3% High Secular C2 Control 140 56.1% Heterogeneous Secular C3 Control 89 51.7% Low Religious C4 Control 128 52.8% Heterogeneous Secular C5 Control 49 44.9% Heterogeneous Religious C6 Control 186 48.9% High Secular Note: SES socioeconomic status.children’s preparedness for coping with daily a city in southern Israel exposed to continuous rocketstress and major life events, expecting that inoc- attacks during Operation Cast Lead. The interventionulation training for a specific stress may be group included half (50.3%) of the children (n 748,transferred unto others.21 In this study, we view 50.5% boys, 43.7% in fourth grade) who studied in six schools where the teacher-led intervention was imple-SIT in its narrow scope, implemented before mented before the traumatic exposure. These schoolsrather than after traumatic exposure. were selected by the local authorities according to We have witnessed several times the experience location (those closer to the Gaza Strip) and potentialreported by Chemtob et al. that the dominant collaboration (Table 1).attitude following a disaster is to “get the disaster The control group included 740 children (49.7% ofbehind us,” an attitude that may leave the needs of the sample; 49.8% boys, 56.2% in fourth grade) study-children whose recovery has not proceeded apace ing in six schools matched by location (to ensureunrecognized and unaddressed.22 similar exposure and socio-economic background) in The objective of this study is to describe the which the preventive intervention was not imple-effects of a universal, teacher-based, preventive mented. The distribution of boys and girls was similar,intervention implemented with Israeli students but there were more children in fourth grade in the control group ( 2 21.8, df 1, p .001). One schoolbefore the rocket attacks that occurred during in each group belongs to a neighborhood of lowOperation Cast Lead, compared with a noninter- socio-economic status (SES), three are of heteroge-vention but exposed control group. The sporadic neous SES, and two are of high SES. Two schools in theexperience of mortars and the stress of an immi- intervention group (n 145, 20.5% of the subsample)nent military operation that might result in mas- and two schools in the control group (n 126, 20.3% ofsive bombardment represent a moderate stressor the subsample) are religious. All children had beenprocess through the intervention within a SIT exposed to repeated daily sirens starting about 1approach. To the best of our knowledge, this is minute before the missiles hit, in which they had tothe first report of such a preventive approach find shelter and remain covered until the emergencywith children exposed to severe trauma. Our ended. In both intervention and control schools, coun-hypothesis was that, 3 months after the rocket selors provided support, but large-scale mental health interventions were not provided.attacks, children in the intervention group wouldreport lower levels of symptoms and fewer casesof possible posttraumatic stress disorder (PTSD). Measures Children filled out two scales. The first was the UCLA- PTSD Reaction Index, a self-report scale with 21 items derived from the DSM-IV PTSD criteria of symptomsMETHOD (Intrusive Recollection, Avoidance/Numbing and Hy-Participants perarousal) and Associated Features (e.g., new fears,The study sample consisted of 1,488 Jewish students guilt).23 Children indicated how frequently they expe-studying in fourth and fifth grades (55 classrooms) in rienced each symptom during the last month on a JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY342 www.jaacap.org VOLUME 50 NUMBER 4 APRIL 2011
  4. 4. TEACHER-LED INTERVENTION AND PTSD PREVENTIONfive-point Likert scale ranging from 0 (not at all) to 4 (a dedicated to preparation, supervision, and qualitativelot). The internal consistency for the Hebrew version of check of protocol fidelity. Supervisors monitoredthis scale was highly satisfactory (Cronbach’s 0.90, weekly protocol adherence and reported it as high.n 754).14 The recommended score of 38 was used as The classroom meetings were held during the weeklya cut-off for possible PTSD.23 spot dedicated to the Life Skills Program that deals The second scale, the Stress/Mood Scale, includes with structured lessons involving discussions with theeight items concerning fears, stress and mood (e.g., students about their experience with developmental“Different children are afraid of different things, do tasks, identity, sexuality, risk taking, and various lifeyou have frightening thoughts?” “How stressed or situations. Control schools continued with the regularafraid are you in general?”) who showed satisfactory curriculum. The process of program implementationinternal consistency in a previous study (Cronbach’s starts with meetings with the school principal and the0.68).14 Also, information was gathered concerning school staff to build working alliance and ensurechildren’s school, grade, gender and religiosity (reli- necessary resources. Children are encouraged to sharegious versus nonreligious school). and exercise the coping skills learned with their fam- ilies. Session 1 provides psychoeducation and proposes aProcedure contract of respect and confidentiality. Sessions 2 to 5Parents were asked by the city’s Education Depart- deal with identifying emotions and working throughment to sign an informed consent form agreeing that positive and negative experiences, and identifying andtheir children will fill-out a self-report questionnaire to balancing bodily tension (slow breathing and muscleassess their needs after the rocket attacks. Parents in relaxation). Sessions 6 and 7 focus on when and how tothe control group were informed that their children act inside (internal balancing, managing fears) or out-will participate in the intervention at a later stage. All side (actual coping, dealing with actual risks andchildren in the study group participated in the inter- challenges). Session 8 centers on identifying and bal-vention that started 9 months before the rocket attacks. ancing negative thoughts. Session 9 highlights theHowever, only students whose parents signed the power of positive experiences and session 10 the effectagreement form were assessed 3 months after the of humor as coping and ways to control attention.intervention. A Masters Degree–level mental health Session 11 works with imagery to enhance the abilityprofessional supervised the assessment in the class- to make decisions, the feeling of internal balance androom and clarified questions to the children. No diffi- integrative rehearsal of coping skills. Session 12 dealsculty appeared during the assessment. The study was with coping through empathic and assertive interper-approved by the Ministry of Education’s institutional sonal communication. Session 13 concentrates on emo-review board. tional processing and regulation of strong emotions (fear, anger and sadness). Session 14 emphasizes theIntervention power of the group and creating a vision for the future.Within a SIT framework, the type of skills training The contents of the intervention are introducedused varies according to the specific training require- through letters sent by an imaginary character namedments. However, it often includes modules focusing Adam, who had gone through similar events. Throughon cognitive control or cognitive restructuring tech- his letters, Adam shares with the students his experi-niques that train the individual to regulate negative ences and skills learned, legitimizing and verbalizingemotions and distracting thoughts, and on relaxation complex feelings. Adam also guides the children andtraining aimed at enhancing physiological control proposes activities to practice and internalize newly(awareness, muscle tension, breathing), rehearsed acquired skills.through the use of mental imagery.16 These are in Our approach supplements the traditional SIT,accordance with Zohar et al., who marked that the among others, with a view of teachers as “educators”essence of acute distress management should be to (role transformation), an emphasis on processing basichelp traumatized individuals contain and attenuate emotions and on executive skills and attention regula-emotional reaction, regain emotional control, and re- tion. More importantly, the intervention is led withinstore interpersonal communications, and to encourage frameworks that constitute a gradational mix of realitythe return to full function and activity.24 (teacher’s instructions) and imagination (Adam’s let- Our manualized protocol consists of fourteen 45- ters), on which children are invited to reflect critically.minute didactic modules delivered weekly (Supple- The contents of the program are drawn also fromment 1, available online). It espouses a salutogenic classroom stressful daily life events such as examina-framework rather than aiming at the elimination of tions or interpersonal conflicts. This way, skills ac-pathology. School counselors received a 20-hour train- quired during the program continue to be assimilateding and bi-weekly supervision. All teachers in the and practiced throughout the school year under theselected schools and grades received a 4-hour basic teacher’s guidance according to specific guidelines.training and weekly meetings with these counselors These stressful situations (fights, examinations, inter-JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 50 NUMBER 4 APRIL 2011 www.jaacap.org 343
  5. 5. WOLMER et al.personal conflicts, anger bursts, and events such as Genderroad accidents, death of a parent, or news about 3.41 1.41 3.53 3.37 1.65 3.41 Grouppossible rocket attacks) are the stressors that serve toapply during the assimilation stage the coping skills Univariate Effects F1,1319learned and practiced in the former stages, includingdealing with failure/feeling of being overwhelmed by 23.43*** 34.87*** 57.20*** 38.17*** Genderintense emotions (information concerning manual 9.60§ 3.02availability can be obtained from the authors).Statistical Analyses 12.70*** 22.56*** 11.75*** 23.52*** 15.90*** 18.04***Group differences (treatment– control) in symptom Groupexpression and their interaction with gender, age, andreligiosity were computed with multivariate analysisof variance (MANOVA, two-tailed). Differences in thedistribution of children meeting or exceeding theUCLA PTSD-RI cut-off score by group were calculated Entire Group 2.36 (0.72) 21.1 (12.6) 1.20 (0.90) 1.02 (0.73) 1.35 (0.85) 1.12 (0.91) (N 702)with 2 2 2 tests.RESULTSPsychological Responses by Group, Gender, and Control Group 2.43 (0.73) 22.5 (12.5) 1.34 (0.91) 1.02 (0.72) 1.40 (0.83) 1.22 (0.92) 354)ReligiosityAccording to MANOVA with the two symptom Girlsmeasures as dependent variables, we found sig- (nnificant group (F2, 1389 11.62, p .02), gender(F2, 1389 14.12, p .001), and SES differences 2.29 (0.71) 19.8 (12.6) 1.07 (0.87) 1.03 (0.74) 1.31 (0.87) 1.01 (0.89) 348)(F4, 2780 3.00, p .02). Univariate tests revealed Boyssignificantly lower symptoms of posttrauma andstress/mood among the intervention group (p (n Range 0 to 84; a score of 38 was used as a cut-off for possible posttraumatic stress disorder (PTSD)..008), boys (p .001) and children with low SES Means (SD) of Symptom Scales According to Group and Gender(p .02). The multivariate group gender (p Entire Group.05) and group SES (p .008) interactions were 2.22 (0.71) 17.9 (12.3) 1.03 (0.89) 0.83 (0.70) 1.17 (0.80) 0.91 (0.85) (n 700)significant. Boys in the intervention group re-ported fewer symptoms than girls but similar togirls within the control group (Table 2). Also,high SES children in the intervention group re- Intervention Groupported fewer symptoms of stress/mood com- 2.34 (0.70) 20.6 (12.6) 1.27 (0.93) 0.90 (0.69) 1.27 (0.80) 1.11 (0.83) 345) Note: aRange 1 to 5; a score of 3 represents moderate symptoms.pared with the other subgroups (means 2.08, Girls2.28, and 2.34 for low, heterogeneous, and high (nSES, respectively). We found no group genderSES interactions. When we analyzed the four domains of the 2.10 (0.71) 15.3 (11.4) 0.81 (0.78) 0.77 (0.71) 1.07 (0.79) 0.72 (0.83) 355)PTSD-RI, a similar pattern of group and gender Boysmain effects emerged (multivariate F4, 1313 7.12and 21.57, respectively, both p .001), with (nsignificantly fewer symptoms for the interven-tion group and for boys within the four clusters. p .005; ***p .001. PTSD-Reaction IndexbIn addition, marginal group gender univariate Avoidance/numbing Associated featuresinteractions (p .067) for Avoidance/Numbingand Hyperarousal and the associated features Stress/mooda Hyperarousalindicated that the group differences were more Intrusionpronounced among boys (Table 2). TABLE 2 According to the recommended PTSD-RI cut- § boff score of 38, 7.2% of the children in the JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY344 www.jaacap.org VOLUME 50 NUMBER 4 APRIL 2011
  6. 6. TEACHER-LED INTERVENTION AND PTSD PREVENTIONFIGURE 1 Percentage of children with probable trauma and stress/mood. Also, the percentage ofposttraumatic stress disorder (PTSD), by group and children meeting the cut-off criteria for PTSDgender. was similar in religious and nonreligious schools in the intervention (7.1% and 7.6%, respectively) and the control groups (11.1% and 11.9%, respec- tively) (both 2 0.07, p .05). DISCUSSION In recent years, there have been increasing efforts to develop effective mental health interventions that can be delivered within community settings where children and adolescents are active. For many children, schools have been the de facto provider of mental health services.25 The case of mass trauma, requiring the use of clinical medi- ators to cope with large needs, emphasizes the central role that schools can play. The present study focuses on one of such possible psycho-intervention group met criteria for likely PTSD, educative missions: to provide children effectivecompared with 11.3% of the children in the preparedness to cope with traumatic events andcontrol group ( 2 6.66, df 1, p .008). When with continuous stress.boys and girls were analyzed separately, we This study demonstrated that a teacher-found no significant difference in the percentage mediated, protocol-based intervention focusedof girls from the intervention and the control on resilience enhancement is an effective methodgroups meeting or exceeding the cut-off score to grant students coping skills to help them face(10.1% and 12.5%, respectively; 2 0.97, df 1, daily stressors and transfer the knowledge top .05). However, significantly more boys from cope with severe life events, process them, andthe control group met criteria for likely PTSD recover swiftly to regain normal routine. Thecompared with boys from the intervention group current results add to former studies demonstrat-(10.2% and 4.4%, respectively, 2 8.31, df 1, ing the effect of teacher-based interventions afterp .004) (Figure 1). The numbers needed to treat traumatic exposure.12,13,26,27 However, to the bestto prevent one additional adverse outcome were of our knowledge, this is the first study to inves-24, 17, and 42 for the whole sample, for boys, and tigate the implementation of the teacher-basedfor girls, respectively. intervention as preventive strategy before actual Younger children (fourth grade) reported exposure. Other strengths of this study includehigher symptoms of posttrauma and stress/ the use of a large sample, a matched controlmood (multivariate F2, 1400 13.12, p .02). group, and validated measures.Within the RI clusters, fourth graders reported The main result of our study is the significantsignificantly more symptoms of Avoidance/ difference in symptoms of posttrauma andNumbing and Hyperarousal compared with fifth stress/mood among participant and control chil-graders. The group grade interaction was not dren. The mean scores of both scales were lowerstatistically significant (F4, 1315 0.33, p .05). among participants (although a 3.2-point averageOne-way ANOVA followed by Duncan tests difference in the Reaction Index might be consid-revealed significant school differences among six ered of low clinical significance) and the percent-(four experiment) schools with lower PTSD age of children meeting or exceeding the ac-symptoms and three (two control) schools with cepted cut-off score for PTSD was significantlyhigher symptoms (F11, 1408 4.35, p .001). lower, although mostly among boys. Children We found no multivariate or univariate main with low SES reported more symptoms of botheffects for religious affiliation, no group religi- scales than those with moderate and high SES.osity interaction and no group religiosity Also, it seems that the program had a somewhatgender interaction (F2, 1310 0.66, 1.13, and 0.64, better effect on children in the intervention grouprespectively, all p .05) for symptoms of post- with high SES, who reported fewer symptoms ofJOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 50 NUMBER 4 APRIL 2011 www.jaacap.org 345
  7. 7. WOLMER et al.stress/mood. As a group, control children had in women (calmed by the ventilation) and in-57% more detected cases than participants. How- creased right and reduced left frontal activity inever, this difference was significantly more pro- men (whose left prefrontal activity is reduced bynounced among boys (4.4% versus 10.2%) and the logic and verbal processing of psychologicalless among girls (10.1% versus 12.5%). Although inoculation). Future empirical research compar-the rate of PTSD may seem low given the trau- ing the approach described with others facili-matic exposure, similar rates of severe PTSD tating more expression ought to elucidate( 10%) had been documented in Israeli youth whether, in the absence of actual traumaticafter continuous terrorist attacks during the Inti- exposure, boys assimilate skills better thanfada, suggesting a high level of resilience among girls or they are able to implement them morethe Israeli population.28 effectively during and after exposure. A question that arises out of these findings is It has been stated that the majority of childrenthe difference in response rates across genders. It are resilient and able to cope with psychologicalmay be that boys usually report fewer symptoms distress after a disaster and, therefore, that only aof posttrauma than girls.3 However, if that expla- small proportion of children exhibiting pre-nation was correct, we would have expected to existing vulnerability require structured, inten-find a similar gender difference also in the con- sive intervention.32 Our results and those oftrol group. A second explanation might be re- others clearly demonstrate that many childrenlated to the gender of the protocol’s “main hero,” might require some kind of structured interven-Adam. Perhaps boys could identify more easily tion, and that stress inoculation as a way ofthan girls with the character of Adam, a boy, and primary prevention might be a cost-effectivecould incorporate more effectively the contents strategy.33,34 One needs to consider that the ef-of the intervention. Yet, other important charac- fects of the teacher-delivered intervention goters in the protocol are female (Adam’s teacher, beyond reduction in trauma symptoms and in-friends). clude the enhancement of coping and adaptation A third explanation concerns the coping in general. For example, 3 years after such anmechanisms provided by the intervention. It is intervention after a major earthquake, childrenwell known that boys use more externally were assessed by raters blinded to the interven-oriented strategies, whereas girls use more tion as displaying significantly better academic,internally oriented ones.29,30 It might be that social, and behavioral adaptation compared withthe skills incorporated during the intervention control children.13to process traumatic exposure, emphasizing an Hobfoll et al. emphasized the restoration ofinternal orientation (e.g., stress management, the school community as an essential step inemotional processing, image control, thought re-establishing a sense of self-efficacy throughcorrection), benefitted more boys by enriching renewed learning opportunities, engagement intheir repertoire of coping skills with those used age-appropriate, adult-guided memorial rituals,more “naturally” by girls. To note, when this and school-initiated, pro-social activity.20 Theyintervention was implemented after traumatic also summarized five intervention principles thatexposure, boys reported lower preintervention have empirical support to guide evolving inter-PTSD symptoms, and the symptom decrease vention practices and programs following disas-was more pronounced for girls, reaching ter and mass violence: to promote a sense ofpostintervention levels similar to those for safety, calm, self- and collective efficacy, connect-boys.14 Also, qualitative information gathered edness, and hope.throughout the process did not support any In accordance with these principles, ourgender difference in regard to motivation, par- teacher-based intervention aimed at enhancingticipation, or identification with Adam. children’s resilience by the following: (1) provid- Recently, Farchi and Gidron found that psy- ing psychoeducation to understand and normal-chological inoculation was more beneficial for ize stress reactions; (2) addressing (identifyingmen, and ventilation for women in reducing and replacing) dysfunctional thoughts and be-helplessness in citizens exposed to continuous liefs that mediate development of psychologicalwar threats.31 The authors suggest that these symptoms, for example that the world is com-gender differences in response to a stressor might pletely dangerous; (3) learning to manage anxietybe explained through enhanced limbic activation and regulate emotions, and understanding and JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY346 www.jaacap.org VOLUME 50 NUMBER 4 APRIL 2011
  8. 8. TEACHER-LED INTERVENTION AND PTSD PREVENTIONbetter controlling the interrelationship between respond to disasters is an important determinantthoughts, feelings and behavior; (4) teaching in recovery.37 The accumulated clinical andproblem-focused coping and imaginal exposure research experience with the teacher-based(to develop perspective taking, self-talk, and pos- resilience-focused intervention, a universal ap-itive imagery); (5) encouraging students to in- proach to enhance the preparedness of commu-crease activities that foster positive emotions; (6) nities of children, seems to represent an impor-facilitating social support and sustained attach- tant asset in such an effort.ments (to build on and enhance existing sup- The study’s main limitation is the lack ofport and lasting relationships, e.g., effective baseline information concerning children’s psy-listening); and (7) instilling hope to counteract chological functioning. Such information wouldthe shattered worldview and the vision of a have allowed the comparison of symptoms inshortened future characteristic of mass trauma regard to both pre–post intervention and to inter-(see also Skills Training in Affect and Interper- vention– control baseline differences. Although as-sonal Regulation).35 sessing symptom levels of children before By focusing on building resiliency and strength- traumatic exposure may provide valuable infor-ening resources, rather than on the direct pro- mation, its implementation seems complex andcessing of traumatic experiences, our approach requires awareness and flexibility within the ed-avoids the difficulties in program adherence ucation system. Using a large sample in whichand need for individual attention that can be the intervention and the control group wereencountered when classroom-based interven- composed of schools matched by location (SEStions are applied in regions where exposure to and exposure), religiosity, age, and gender, weterror and war is direct, intense, and wide tried to overcome the lack of baseline data,ranging.26 assuming that pre-exposure and preintervention Southwick et al. asserted that it may be possi- symptom levels were comparable.ble to enhance stress resilience in at-risk or al- A second limitation is the lack of informationready symptomatic individuals by providing from additional sources such as parents or teach-nurturing caregiving environments.36 These psy- ers, whose report on children’s adaptation maychosocial resilience factors include the following: add an important aspect regarding children’spositive emotions, which tend to decrease auto- functioning besides pathological responses. Par-nomic arousal and to broaden one’s focus of ent report or the addition of clinical evaluation inattention with reliance on creativity, exploration, a sample of children would add to the validity ofand flexibility in thinking; cognitive flexibility;spirituality; social support; and active coping the assessment. Unfortunately, the conditionsstyle. The authors agree that children are likely to under which this study was implemented (immi-benefit from moderate stressors that they can nent rocket attacks) required us to emphasizemaster successfully, resulting in stress inocula- swift program implementation at the expense oftion and stress resilience to subsequent stressors. more rigorous methodology. Encounters with stress and adversity are un- Also, control schools received less attentionavoidable and stress resistance cannot reasonably and no training or supervision of teachers thatreside in the avoidance of risk experiences but, would have helped them cope better with theirrather, in successful engagement with and mas- own stress and perhaps generate a systemictery of them. However, even mild stressful inoculation. Although the control group imple-events may increase vulnerability to the effects of mented an alternative program (Life Skills), thesubsequent stressors if they supersede the devel- use of a waiting-list paradigm or a control thatoping organism’s ability to cope with them.15 includes similar time for training and supervi-Therefore, the type, timing, duration, and sever- sion would strengthen the validity of the results.ity of a given stressor within a given species are Finally, the present study did not assess pre-likely to be important factors in determining vious cumulative traumatic experiences and typewhether early experiences ultimately produce a of exposure. Studies showed that teacher-basedprotective or deleterious outcome. interventions performed after a disaster are less Social-ecological resilience, particularly the effective in children with previous multiple trau-ability of communities to mobilize assets, net- mas, who might require a combined universal-works and social capital both to prepare for and specific approach.12 Future studies may need toJOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 50 NUMBER 4 APRIL 2011 www.jaacap.org 347
  9. 9. WOLMER et al.elucidate whether such vulnerability is also rele- We deeply thank Tali Versano, Mor Aram and Maya Faians of thevant to a preventive approach. & Cohen-Harris Center and Shlomo Agmon of the Ashkelon School Psychol- ogy Services for their contribution to the program implementation and data Accepted January 5, 2011. management. Mr. Wolmer and Dr. Hamiel contributed equally to this article. Disclosure: Mr. Wolmer, and Drs. Hamiel and Laor report no biomed- Mr. Wolmer and Drs. Hamiel and Laor are with Tel Aviv-Brull ical financial interests or potential conflicts of interest. Community Mental Health Center and Donald J. Cohen & Irving B. Correspondence to Leo Wolmer, MA, Director of Psychology Harris Resilience Center for Trauma and Disaster Intervention, Associ- Research, Tel-Aviv Community Mental Health Center, 9 Hatzvi ation for Children at Risk, Israel. Dr. Laor is also with Sackler Faculty of Street, Tel-Aviv, 67197 Israel; e-mail: tlv_cmhc@netvision.net.il Medicine, Tel-Aviv University, Israel, and Child Study Center, Yale University, CT. 0890-8567/$36.00/©2011 American Academy of Child and Adolescent Psychiatry This work was supported by grants from the Pritzker Family Foundation and the Irving Harris Foundation. DOI: 10.1016/j.jaac.2011.01.002REFERENCES 1. Chu AT, Lieberman AF. Clinical implications of traumatic stress 20. Hobfoll SE, Watson P, Bell CC, et al. Five essential elements of from birth to age five. Annu Rev Clin Psychol. 2010;6:469-494. immediate and mid-term mass trauma interventions: empirical 2. Kar N. Psychological impact of disasters on children: review of evidence. Psychiatry. 2007;70:283-315. assessment and interventions. World J Pediatr. 2009;5:5-11. 21. Israelashvili M. Preventive school counseling: a stress inoculation 3. Laor N, Wolmer L. Children exposed to disaster: the role of the perspective. 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  10. 10. TEACHER-LED INTERVENTION AND PTSD PREVENTIONSUPPLEMENT 1 Session 7: Progressive muscle relaxationThe Meetings’ Protocol: Building a Coping Measuring stress with thermometer and balloon Puzzle “stressometer” Adam’s letter: Integration, introduction of “Si-Session 1: Introduction and processing positive mon says” experiences Puzzle 5—Thermometer and balloon “stressom-Adam’s letter: Introduction, verbalization, legiti- eter” mization Slow breathing exercise and reassessment usingProcessing a positive experience: Demonstration both methods by teacher Progressive muscle relaxation exercise and “Si-Processing a positive experience in pairs mon says” gameSharing the examples in the classroomA worksheet for personal positive processing Reassessment using both methodsWriting in personal diary Puzzle 6 —Progressive muscle relaxation Puzzle 7—“Simon says”Session 2: Slow breathing using soap bubbles Writing in personal diaryAdam’s letter: PsychoeducationBreathing exercise to manage stress and regain Session 8: “Uncle Harry’s positive experience control bag”Puzzle 1—Slow breathing Rehearsing the game “Simon says”Writing in personal diary Adam’s letter: The “positive experience bag” Collecting positive thoughts to the bagSession 3: Breathing and processing unpleasant A guided imagery exercise using the “positive experiences experience bag”Rehearsing slow breathing Puzzle 8 —The positive experience bagProcessing an unpleasant experience Writing in personal diaryAdam’s letter: Unpleasant experiencesAssessing one’s stress with emotions balloons Session 9: The power of communication: ActivePuzzle 2—Emotions balloons listening and cooperationA worksheet for personal unpleasant processing Breathing exercise and imageryWriting in personal diary Adam’s letter: ListeningSession 4: Adaptive and maladaptive tension Group puzzleBreathing exercise Discussion about the power of cooperationAdam’s letter: Adaptive and maladaptive tension Puzzle 9 —Listening and communicationThe arm test: Demonstrating maladaptive tension Session 10: Perspective taking, distancing, andThe “fight or flight” reaction: Experiencing and humor processing Breathing exercise and imageryWriting in personal diary The “Zoom” exercise: Taking perspective andSession 5: Correcting negative thoughts distancingBreathing exercise Puzzle 10 —Zoom: Perspective taking and Dis-Adam’s letter: Identifying negative thoughts tancingThe Three Steps Model: A technique to identify Adam’s letter: Humor and correct negative thoughts Creating humor: Cartoons on the wall and chil-Puzzle 3—Correcting thoughts dren’s humoristic reactionsWriting in personal diary Laugh meditation/yogaSession 6: A safe place: Enlisting the “dwarf- Puzzle 11—Humor friend” Writing in personal diaryShort breathing exercise and rehearsing thought Session 11: Rehearsing and integrating coping correcting technique techniquesAdam’s letter: The dwarf-friendGuided imagery: Creating our “dwarf-friend” Slow breathing, correcting negative thoughts,Puzzle 3—Dwarf-friend positive thoughts bag, progressive muscleWriting in personal diary relaxation, active listening, zoom and humorJOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 50 NUMBER 4 APRIL 2011 www.jaacap.org 348.e1
  11. 11. WOLMER et al.Measuring with thermometers and “stressom- Session 13: An integrated balance exercise and eters” before and after a distraction exercise SMBIAWriting in personal diary An integrated balance exercise Adam’s letter: The five-step method to effectiveSession 12: Violence: Connecting between reaction stress, tension, and aggression SMBIA: Stop–muscle– breath–image–actionAdam’s letter: Stress, anger, and aggression Puzzle 13—SMBIAVisual signs indicating ineffective reactions to Writing in personal diary anger situationsIdentifying the sign that best describes our reac- Session 14: Conclusion: The power of the tion in a state of anger groupSuggesting alternative ways to deal with anger Adam’s letter: Summary, goodbye situations Positive changes that derive from a crisisDiscussion: The connection between stress, ten- Puzzle 14 —“Finding good in evil?” sion, and aggression Summary exercise: Measuring temperature bio-Puzzle 12—The new anger images feedback with the whole classWriting in personal diary Festive releasing of balloons JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY348.e2 www.jaacap.org VOLUME 50 NUMBER 4 APRIL 2011