Terrorism and Disasters: Crisis Recovery

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Terrorism and Disasters Crisis Recovery

• Marleen Wong
• Director, Crisis Counseling and Intervention
  Services
• Los Angeles Unified School District
• Director, School Crisis and Intervention
• National Center for Child Traumatic Stress
• UCLA and Duke University

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Todays Agenda

• What Is Child Trauma
• What We Have Learned From School Related Violent
  Incidents
• What We Have Learned From the Impact of Terrorism
• Establishing Partnerships with Mental Health and
  Social Service Agencies
• Restoring the Learning Environment

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National Child Traumatic Stress Network
NCTSNet.org

• The mission of the National Child Traumatic
  Stress Network (NCTSN) is to raise the standard
  of care and improve access to services for
  traumatized children, their families and
  communities throughout the United States.

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Range of Traumatic Events

• Trauma is embedded in the fabric of daily life
• Child Abuse and maltreatment
• Domestic violence
• Community violence
• Medical trauma
• Natural disasters
• Terrorist attacks

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What is TRAUMA?

• Trauma is an acute stress response that one
  experiences when confronted with sudden,
  unexpected, unusual human experience.
• Trauma occurs because the event poses a serious
  threat to the individuals life or physical
  integrity or to the life of a family member or
  close friend, or to ones surrounding
  environment.
• Individuals who may have witnessed the event are
  also at risk to develop a trauma stress response.

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War in America - September 11, 2001 8 million
witnesses to violence in NYC 1.2 million
students-New York City Public Schools
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Gender and Ethnicity of NYC School Survey
Participants Grades 4-12 (N 8,266)
Gender
Ethnicity
8.1
12.3
28.2
46.9
53.1
13.5
37.9
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Numbers of NYC Students in Grades 4-12 Estimated
to Have a Probable Disorder with Impairment6
Months After the 9/11 Attack
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Behavior is an Iceberg

• --------------------------------------------------
  ------
• Filters and Foundations

Behavior
Childs Crisis or Problem
Individuals Personality and Mental Health
Youth Culture
School and Community Environment
Child Development/Family Influences
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Link between Violence Exposure and Chronic PTSD
with

• Substance Abuse
• Reckless Behavior
• High-risk Sexual Behavior
• Gang Participation
• Disturbances in Academic Functioning

(Kilpatrick, Saunders Resick, 1998)
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IOM Report -Preparing for the Psychological
Consequences of Terrorism

• Range of emotional, behavioral and cognitive
  effects
• e.g., Insomnia
• Sense of
• Vulnerability
• e.g., Change in Travel
• Patterns, Smoking,
• e.g., PTSD Alcohol Use Major
  Depression
• Anxiety Disorders

Distress Responses
Behavioral Changes
Psychiatric Disorders
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Students with significant post-traumatic stress
symptoms after an event

• 3-7 Days 1-3 Months
  Assessment from the date of the
  incident

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Secondary Adversities Compound Trauma

• Loss of home, car, cherished belongings
• Loss of social, personal, or familial ties
• Loss of self-esteem, control over ones life
• Loss of resources such as food, money, physical
  abilities

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Symptoms of Posttraumatic Stress Disorder

• Reexperiencing
• themes in play
• generalized nightmares
• Avoidance
• may not understand numbing
• subject to the avoidance of adults
• implications for development
• Emotional Arousal - Evident in school
• Functioning

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Flashbacks

• 1.      Have you had upsetting thoughts or images
  about the event that came into your head when you
  didnt want them to?
• Not at all
• Once in a while
• Half the time
• Almost always
•   

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Traumatic Reminders

• 2. Have you been acting or feeling as if the
  event was happening again (for example, hearing
  something or seeing a picture about it and
  feeling as if you were there again)?
• Not at all
• Once in a while
• Half the time
• Almost always

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Emotional Arousal

• 3.      Have you been feeling upset when you
  think about or hear about the event (for example,
  feeling scared, angry, sad, guilty, etc.)?
• Not at all
• Once in a while
• Half the time
• Almost always

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Avoidance

• 4.      Have you been trying not to think about,
  talk about, or have feelings about the event? 
• 5.      Have you been trying to avoid activities,
  people, or places that remind you of the event
  (for example, not wanting to play outside or go
  to school)?
• Not at all
• Once in a while
• Half the time
• Almost always

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Emotional and Physical Arousal

• 6.      Have you been feeling irritable or having
  fits of anger? 
• 7.      Have you been jumpy or easily startled
  (for example, when someone walks up behind you)?
• Not at all
• Once in a while
• Half the time
• Almost always

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CHILDRENS REACTIONS

• Not all reactions are abnormal or pathologic
• Children may experience distress even if
  diagnostic criteria for a disorder are not met

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Adult Issues That Affect Children

• Adults may not recognize distress in children
• Children may be compliant in the aftermath of an
  event
• Adults may be preoccupied with their own issues
• Adults may deny childrens reactions

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Multi-Level Intervention Options

• Tier 1 General School-Based Interventions
• Psychoeducation
• Coping Skills
• Support
• Tier 2 Specialized School-Based Interventions
• Trauma / Grief - Focused Counseling
• Group, Individual, Family
• Short-Term
• Tier 3 Specialized Community-Based
  Interventions
• Referral to On or Off-Site MH Services

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Grief and Trauma

• TRAUMA
• Generalized reaction TERROR
• Pain triggers tremendous terror, sense of
  powerlessness and loss of safety
• Guilt may focus on It was my fault. I could
  have prevented it. It should/could have been me.
• Dreams are about the self as the potential victim
• Often involves grief reactions (sadness, etc.) in
  addition to trauma reactions flashbacks, startle
  reactions, hypervigilance, numbing, etc.

• GRIEF
• Generalized reaction SADNESS
• Pain is the acknowledgement of the loss
• Guilt may focus on I wish I would/would not
  have
• Dreams tend to be of the deceased
• Generally grief reactions stand alone and do not
  involve trauma reactions

From Trauma Debriefing by William Steele
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Tolerance in the Recovery Environment
Among those with different personal, family, and
school levels of impact, courses of recovery, and
levels of ongoing concern
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Violence and Trauma affects School Performance

• Children with life threatening violence exposure
• Lower GPA
• More negative comments in permanent record
• More absences
• Children with Depression and Posttraumatic Stress
  Disorder
• Even Lower GPA
• More absences

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Desirable Qualities For School Crisis Team
Members

• Understanding of school culture/mission
• A sense of responsibility beyond routine
• Ability to establish rapport quickly
• Ability to listen to difficult feelings and
  experiences of others
• Clear about feelings thoughts biases
• Maintain confidentiality
• Aware of limitations
• Aware of the need for self care

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First and Most Important

• Every Adult on Campus Plays an Important
  Role
• Your Attitude and Actions Make All the
  Difference

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Mental Health Objectives in School Settings

• Restore the Learning Environment
• Re-establish Calm Routine
• Assist with Coping and Understanding of Reactions
  to Danger and Traumatic Stress
• Re-unite Students with Caregivers ASAP
• Support the Emotional Stabilization of Teachers
  and Parents

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Secondary Adversities Compound Trauma

• Loss of home, car, cherished belongings
• Loss of social, personal, or familial ties
• Loss of self-esteem, control over ones life
• Loss of resources such as food, money, physical
  abilities

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Advantages of School Based Programs

• Schools are de facto mental health system for
  many children
• Large numbers of at Risk/disadvantaged children
• Existing Specialized Education Programs
• SED/ED students with counseling mandated by IEP
• School-based health clinics
• Co-location of community mental health providers
• Expanded school mental health programs
• Surgeon Generals National Action Agenda for
  Childrens Mental Health and Presidents New
  Freedom Commission call for increase in school
  mental health programs

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Obstacles to School Based Programs

• Difficulty of Entry
• Less than Ideal Clinical Conditions
• (Flushing Meadows)
• Overcoming Mission Creep
• Motivating and Educating Educators
• Tailoring the program for schools
• (Bell Schedules, Tracks, Pupil Free Days)

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Impact of Trauma on Schools

• Change of Teacher Role by State Law? Public
  Safety/Disaster Workers
• Academic achievement Deans/Chairs of
  Departments
• Grades and standardized tests
• Average Daily Attendance (ADA)-Counselors in the
  Attendance Office
• Decreased attendance means less money
• Special Education Students and IDEA
• Special Needs and Common Needs
• Classroom and School Behavior-Increased Rates of
  Suspension, Expulsion, High Risk Behaviors
  including Suicidal Thoughts and Behaviors

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Violence and Trauma affects School Performance

• Children with life threatening violence exposure
• Lower GPA
• More negative comments in permanent record
• More absences
• Children with Depression and Posttraumatic Stress
  Disorder
• Even Lower GPA
• More absences

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From the Field of Brain Research

• In order for children to learn
• Eliminate Threat from the Environment
• Eliminate Threat from Childrens Hearts and Minds
• Enrich the Learning Environment

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Compassion Fatigue Traumatic stress affects
both victim and caregivers

• There is a cost to caring. We professionals
  who are paid to listen to the stories of fear,
  pain, and suffering of others may feel,
  ourselves, similar fear, pain and suffering
  because we care.
• Compassion fatigue is the emotional residue of
  exposure to working with the suffering,
  particularly those suffering from the
  consequences of traumatic events.
• Charles R. Figley, Ph.D.

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Dr. Pamela Cantor, Childrens Mental Health
Alliance, New York

• The shock, trauma and complexity of our
  societies dont permit the establishment of
  working alliances within 60 days. This was the
  most significant limiting factor in mobilizing an
  effective response in New Yorkschools and
  communities (must) know that collaborative
  relationships need to be forged, meetings held,
  and procedures developed well before an event
  occurs and the immediate phase begins.  

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Dr. Mary Courtney, New York University

• It has been my experience that people typically
  fall back on the most familiar, over-learned,
  conceptual framework at times of stress and
  ambiguity. After 9/11, for example, most
  educators were primarily concerned with getting
  the educational process back on track, preferring
  to focus only on preset roles/structures, and
  freely admitting that they felt too overwhelmed
  to enter the unfamiliar territory of mental
  health. Safety officers tightened safety
  enforcement and did not feel able to address the
  mental health repercussions of either the
  disaster or their response to the disaster.
  Because of this completely human response to
  crises, it is necessary to build the mental
  health response system and the network of
  relationships that support it before any crisis
  occurs.

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Recovery in Summary

• Promote Mental Health Education Effects of
  Trauma and Exposure to Violence Course of
  Recovery
• Assessment of Child and School Recovery
• Look at the Calendar
• Form Partnerships Now
• Be Aware of Your Own Need for Care

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Cognitive Behavioral Intervention for Trauma in
SchoolsCBITS

• Group and individual sessions
• 11-15 yo
• Significant symptoms of PTSD or depression
• Trauma type community violence
• Screening includes follow-up with a personal
  interview an confirmed by a clinician.
• Estimated that 20 of children in inner city
  schools could benefit from intervention

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CBITS Protocol

• Group Session 1, Introductions
• Group Session 2, Education and Relaxation
• Individual Session 1, Imaginal Exposure to Stress
  or Trauma
• Individual Session 2, Imaginal Exposure to Stress
  or Trauma
• Individual Session 3, Imaginal Exposure to Stress
  or Trauma
• Group Session 3, Introduction to Cognitive
  Therapy
• Group Session 4, Combating Negative Thoughts
• Group Session 5, Introduction to Real Life
  Exposure
• Group Session 6, Exposure to Stress or Trauma
  Memory
• Group Session 7, Exposure to Stress or Trauma
  Memory
• Group Session 8, Introduction to Social
  Problem-Solving
• Group Session 9, Practice with Social
  Problem-Solving
• Group Session 10, Relapse Prevention and
  Graduation

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Psychological ReadinessThe 3Rs of School Crisis
Intervention

• Readiness Readiness is the level at which a
  school is prepared to respond to an emergency if
  the crisis or disaster were to happen today
• Response Response is the sum total of the
  school's resources and skills to take decisive
  and effective action when a crisis situation has
  occurred
• Recovery Recovery is the process of restoring
  the social and emotional equilibrium of the
  school community

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Readiness

• Develop the necessary infrastructure and
  relationships with law enforcement, emergency
  responders, health and mental health community
  agencies, and local religious institutions
• Prepare and execute MOU

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Response

• Calm fears and anxieties
• Re-establish a sense of emotional safety
• Restore a school environment conducive to
  learning
• Triage for
• Physical proximity to the trauma
• Emotional proximity
• Principals Letter an effective screen for
  higher risk staff and children

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Recovery

• The ongoing process of restoring the social and
  emotional equilibrium of the school community by
  promoting positive coping skills and resilience
  in students and adults

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Early Recovery Services

• Psychoeducation
• Emotional Awareness
• Anxiety management and coping skills

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Intermediate Recovery Services

• Between 6-8 weeks post trauma
• Assessment
• Direct exposure or proximity
• Subjective appraisal of threat
• Previous experience with trauma or loss
• Hx of depression, anxiety, PTSD, or other
• Familiarity with victims
• Worry about safety of family or S/O
• Family response pathology
• Loss of the family home
• Parental loss of job and income
• Resist the pressure to Move On experience
  shows it is a matter of years not months

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Long-Term recovery services

• May require intensive counseling, medications,
  hospitalization
• LT intensive services are best provided by
  off-campus agencies and institutions
• Seamless referral and treatment is dependent upon
  the development of linkages with local mental
  health providers

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