# Presentation: 040746

## ERCM:  School Crisis Recovery

- Marleen Wong, Ph.D.
- Director, Crisis Counseling and Intervention Services
- Los Angeles Unified School District
- Director, Trauma Services Adaptation Center for Schools
- National Child Traumatic Stress Network/SAMHSA

## Psychological Reactions to Disaster

## How Does a School Begin to Recover?

**It begins with student and teacher perceptions of renewed security.**

## Terror in School and Community

- May 1927: Bath, MI
- Jan 1979: San Diego, CA
- Feb 1984: Los Angeles, CA
- May 1992: Yuba, CA
- Jan 1993: Grayson, KY
- Jan 1993: Los Angeles, CA
- Feb 1993: Los Angeles, CA
- Apr 1993: Sheridan, WY

- Feb 1994: Fort Meyers, FL
- May 1994: Union, KY
- Jan 1995: Redlands, CA
- Nov 1995: Lynnville, TN
- Feb 1996: Moses Lake, WA
- Feb 1997: Bethel, AK
- Oct 1997: Pearl, MS
- Dec 1997: Paducah, KY

**Notes:**
How Do You Define Terrorism? 
Threat of Violence
Systematic Use of Fear
Desire to Alter Behaviors of Others
Done for Political, Ideological or
  Religious Purposes

## Terror in School and Community

- Feb 1998: Hoboken, NJ
- Mar 1998: Jonesboro, AR
- Apr 1998: Edinboro, PA
- Apr 1998: Pomona, CA
- May 1998: Houston, TX
- May 1998: Fayetteville, TN
- May 1998: Springfield, OR
- June 1998: Richmond, VA
- Apr 1999: Taber, Canada

- May 1999: Conyers, GA
- Aug 1999: Valley Jewish
- Community Center, Granada Hills,
- CA
- Nov 1999: Deming, NM
- Dec 1999: Fort Gibson, OK
- Feb 2000: West Palm Beach, FL
- Jan 2001: Oxnard, CA
- March 2001: Santee, CA
- March 2001: El Cajon, CA
- March 2001: Gary, IN

**Notes:**
Abuse of Power
Intent to Kill or Maim
Causes Fear and Panic
Direct/Indirect Victims
Escalating Violence

## Slide 6

**Notes:**
Anatomy of a Terrorist Attack 
Surveillance
Access
Co-Conspirators
Discipline and Planning
Rehearsals
Timing and Patience

## Trauma Interferes with a Sense of Safety What is TRAUMA?

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

**Notes:**
. Powerful emotional and  physical reactions occur when terror, helplessness and horror are the primary reactions to life threat, like those experienced by over 8,000 students and staffs of the schools at Ground Zero on 9/11.  

These are difficult emotions to overcome.  Although parents can do a great deal to help their children, changes in behavior in the classroom are inescapable, whether the traumatic event is a large scale danger like a tornado or terrorist attack or a private trauma such as domestic violence or child abuse.  In either situation, children and adolescents need the help of trusted adults to get professional help, if needed, or to learn to cope constructively with their confusion, fear and distress.  
It is very likely that the ill-effects of a traumatic situation find their way to the classroom.  It is the teacher who may first recognize the symptoms of trauma when the student's behavior changes and must find new ways to re-engage the student in classroom activities and learning..   

## Rationale/Need for Recovery ServicesTrauma Creates Barriers to Learning

- Physical Changes
- Emotional Changes
- Cognitive Changes
- Behavioral Changes
- Spiritual Changes

## Understanding the Components of Recovery

**Students with Significant Post-traumatic Stress Symptoms After an Event**

**1 Year**

**3-7 Days             1-3 Months**

## Institute of Medicine 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 		Major Depression,					     	Consumption,
- 	Anxiety Disorders

## Planning For School Crisis Recovery 

**Selecting and Training Crisis Team Members**

## An Interdisciplinary Crisis Recovery Team 

**School psychologist**
**School counselor**
**School nurse****	**
**Psychiatric social worker**
**Custodian****	**

**Welfare and attendance counselor**
**School resource officer**
**Administrators**
**Secretaries**
**Other support staff**

**Who Should be on the Crisis Team?**
- 	- Principal selects the school crisis team members
- 	- Team members can be:

## Desirable Qualities for Crisis Team Members

- 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, and biases
- Ability to maintain confidentiality
- Aware of limitations
- Aware of the need for self care

## The Objective of the Recovery Phase:  Restore the Learning Environment

- Act to re-establish a sense of emotional safety
- Return the school to calm routine/schedule
- Assist with coping and understanding of reactions to danger and traumatic stress
- Support the emotional stabilization of teachers and parents

## Setting Up a Crisis Counseling Room

- Utilize school referral procedures
- Limit time with student to one class period
- Identify yourself as a member of the regional crisis team and state that you are there to listen, understand, and to support the student in school
- Ask the student to tell you his or her story
- You have a guiding role to help the student  make sense of  their experience, reduce their stress, and remain in school

## Common Action Steps to School Recovery

- Provide accurate information/ psychoeducation
- Triage and assess
- Make individual and group crisis counseling available during the first week after a crisis event
- Prepare for 3 levels of intervention
- Follow-up - be aware of secondary adversities

## Symptoms of Traumatic Stress

- Difficulty concentrating
- Difficulty sleeping or staying asleep
- Recurring traumatic images
- Hypervigilence
- Fear of recurrence
- Avoidance of and reactions to traumatic reminders

## 3 Broad Categories of Response

- Symptoms must be present for **at least 1 month** and must cause significant distress or **impairment in functioning**
**Reexperiencing: ****distressing memories of the event; traumatic dreams or nightmares, acting or feeling as if the trauma were recurring**
**Avoidance/numbing: ****diminished interest or participation in normal activities; feeling detached or estranged from others**
**Increased arousal: ****sleep difficulties, irritability; angry outbursts; difficulty concentrating; hypervigilance; exaggerated startle response**

## Fear of Reoccurrence/Separation Anxiety General Anxiety/Regressive Behaviors

- Physical complaints
- Wanting to be alone/withdrawal
- Anger/irritability/crying uncontrollably
- Lack of concentration
- Misbehavior at school
- Sleeping in the classroom
- Eating problems
- Use of drugs or alcohol
- Feelings of helplessness

## How do you determine exposure?  TRIAGE

- Physical proximity
- Emotional proximity
- Similar previous experience
- Fragile personality
- History of emotional disturbance

## Triage Questions

- Where were you when the incident occurred?
- If you did not see what happened, what were you told?
- What is the most difficult part of this experience for you?
- Do you or your friends have disturbing thoughts about the incident, can't eat or sleep, or have thoughts about harming yourself?

## Multi-Level Intervention Options

_**Tier 1 - General School-Based Interventions**_
- 	**Psychoeducation, Triage and assessment**
**	****Supportive environment**
_**Tier 2 - School-Based Interventions**_
- 	**Trauma and grief - Focused counseling **
**	****Short-term group or individual counseling**
_**Tier 3 - Specialized Community-Based Interventions**_
- 	**Referral to on or off-site mental health services **

## Example of Tier 2 School-Based Intervention: Cognitive Behavioral Intervention for Trauma in Schools - CBITS

- 	Evidence based
- 	Trauma and grief - focused
- 	Short-term group or individual counseling
- 	10 sessions
- Developed in schools for school use by
- Dr. Lisa Jaycox, RAND
- CBITS MANUAL

## For More Information About the CBITS Manual Contact: 

- Sopris West Educational Services
- 	Longmont, Colorado
- 	(303) 651-2829
- Sopriswest.com
- 	_[www.sopriswest.com](http://www.sopriswest.com/)_
- Marleen Wong, Ph.D., Director Crisis Counseling and Intervention Services
-    333 S. Beaudry, 20th Floor, LA CA 90017
**	****marleen.wong@lausd.net**

## Evaluating Your Efforts

- Desirable Outcomes of Crisis Interventions
- Monitor average daily attendance (ADA)
- Station a crisis counselor in the attendance office
- Monitor office referrals
- Maintain academic achievement
- Look at grades and standardized tests
- Monitor expulsions/suspensions/risk taking behaviors

## War in America - September 11, 2001  8 million witnesses to violence in NYC  1.2 million students in the New York City Public Schools

**War in America - September 11, 2001 **** 8 million witnesses to violence in NYC  ****1.2 million students in the New York City Public Schools**

**Notes:**
The picture on the left is the implosion of the Twin Towers.  The picture on the right shows some of the 9,000 students from 9 schools in and around Ground Zero who had to run for their lives.

The events of 9/11 "normalized" one aspect of mental health disorders because of the sheer numbers of people in the US who were traumatized, and who subsequently experienced many symptoms of posttraumatic stress.  The outpouring of support for victims also elicited protests from communities who felt that their children were traumatized everyday by violence in their neighborhoods and homes, without benefit of supportive mental health services.

The importance of the role of caretakers was underscored by the events of 9/ll when adults and children in New York and  across America witnessed the terrorist attacks.  The Pew Charitable Trust surveyed adults and found that 74% of those polled indicated that they felt depressed in the weeks following the attacks.  

RAND Research in Stress and Coping Across America After 9/11  Adults report 90% Some degree, 1 or more symptoms 44% substantial level
Parents report on children 35% 1 or more symptoms of stress
47% worried about own safety or safety of loved one

##  On the World Trade Center Attack onNYC Public School Students

**Preliminary Report to the****Board of Education**

## Gender and Ethnicity of NYC School Survey Participants Grades 4-12 (N = 8,266)

## Numbers of NYC Students in Grades 4-12 Estimated to Have a Probable Disorder with Impairment6 Months After the 9/11 Attack

| Disorder | Rate | Estimated # of Students |
| --- | --- | --- |
| PTSD | 10.5 | 75,176 |
| Major Depression |  8.4 | 60,141 |
| Generalized Anxiety | 10.3 | 73,744 |
| Separation Anxiety | 12.3 | 88,064 |
| Conduct Disorder  | 10.9 | 78,040 |
| Panic Disorder |  9.3 | 66,585 |
| Agoraphobia | 15.0 | 107.395 |
| Any of the Above Disorders | 26.5 | 189,731 |
|  |  |  |

**Notes:**
The initial report focuses on the prevalence of mental health problems and rates of exposure to trauma,most specifically addressing posttraumatic stress disorder.  These estimates reflect the proportion of children who have symptoms consistent with a given mental disorder and who also report impairment in functioning ,I.e., not being able to engage into their usual activities, having unexplained problems with school work, having parents or teacher more upset with them, etc.,

The findings were that one out of every four NYC public school children (27%) meets criteria for one or more of the probably psychiatric disorders assessed in the study and also report problems in their day to day functioning.

One out of every 10 children has PTSD
One out of every 7 has agoraphobia

Compared to prevalence rates in a 1996 NIMH study NYC pulic school students show significantly elevated rates of mental health problems.
Factors that Increased Children's Chances of having PTSD (in rank order)
1) Younger Student	               
2) Family member exposed	   
3) Female gender	
4) Any prior trauma	
5) Physical exposure	
6) Hispanic/Mixed Race

## 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)

## 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

**Notes:**
OK- these children are symptomatic and the parents are concerned- does it affect the children's academic performance (which is the primary mission of the school)

In a preliminary analysis of school records, compared with those without life threatening violence exposure
(N=49)

Questions???/

So, does the intervention work?

## Schools are Human Systems

- Is it an open or closed "Family System?"
- How did it deal with human problems and conflicts?
- How is it affected by trauma?
- What is the message of leadership?
- 	-Letters to parents
-    -Communication with students
- How quickly can it convert to emergency operations?

## Dr. Pamela Cantor, Children's Mental Health Alliance, New York

- "The shock, trauma and complexity of our societies don't permit the establishment of working alliances within 60 days.  This was the most significant limiting factor in mobilizing an effective response in New York [...] schools 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."

## Traumatic stress  affects both victims and caregivers.

## Disaster Despair

- Ultimate death
- Freedom to live as we will it
- Existential loneliness
- Loss or absence of meaning or sense to life

##     "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.

**	****"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.**

- Compassion Fatigue

## IN SUMMARY

## From the Field of Brain Research

- In order for children to learn...
- Eliminate threat from the environment
- Eliminate threat from children's hearts and minds
- Enrich the learning environment

## Sometimes a Crisis Becomes an Opportunity to Make Things Better

- What kinds of programs and services could address some of the long term issues?
- Who are the community partners, including service agencies, faith based and self-help groups who might be able to support kids?
- What kinds of in-school programs and curricula could be enhanced to teach coping and problem solving skills to students?