Exposure to violence is widespread among U.S. adolescents and may be more prevalent than initially thought, according to a recent survey of 4,023 representative adolescents (Kilpatrick et al., in press). Extrapolating from their study, the authors estimated that approximately 3.9 million adolescents have been victims of a serious physical assault and almost 9 million have witnessed an act of serious violence. In addition, an estimated 1.8 million adolescents have met DSM-IV diagnostic criteria for posttraumatic stress disorder (PTSD) during their lives, with 1.07 million having experienced PTSD symptoms within the past six months (Kilpatrick et al., as cited in Layne et al., 2001).
Fortunately, researchers have found that a comprehensive group treatment for PTSD not only reduces inner-city adolescents' symptoms, but it also improves their academic performance and school behavior (Saltzman et al., in press). The Trauma Psychiatry Service at the University of California, Los Angeles, has put this manualized adolescent trauma/grief focused group psychotherapy program in place at elementary, junior high and high schools in San Fernando, Inglewood, Lennox and northwest Pasadena, which are all disadvantaged Southern Californian communities with high rates of violent crime. Versions of the intervention were also used in Armenia after the 1988 Spitak earthquake (Goenjian et al., 1997) and in post-war Bosnia (Saltzman et al., in press).
The formal data correlating reduction in PTSD and improvement in school performance came from 17 students between the ages of 11 and 14 who participated in the second year of the program (funded through a grant from the California Governor's Office of Criminal Justice Planning) in a junior high school in northwest Pasadena. All the students had experienced catastrophic trauma and traumatic losses; many had witnessed a relative, close friend or parent of a close friend killed while they stood nearby. One student was kidnapped at knife-point. Another student was threatened by a man who had broken into her home, and a third student was in the line of fire during a drive-by shooting.
All the students showed severe PTSD symptoms when the study began. Compared to the rest of the student body, a disproportionate percentage of them were also failing classes or had been singled out for disciplinary action, such as suspensions or referral to alternate classrooms. Following the semester-long treatment, the students' PTSD symptoms were markedly reduced, and their grade point averages had gone up significantly. All the participants completed the regular academic program without further disciplinary action.
Robert Pynoos, M.D., director of the UCLA Trauma Psychiatry Program, who has studied trauma in children for the past 25 years, has found the level of exposure to catastrophic violence and loss, and the resulting posttraumatic stress, to be as severe in America's inner cities as in post-earthquake Armenia, war-torn Bosnia, post-invasion Kuwait and other trauma zones. Yet, the United States has no formal public health policy to address the problem. Pynoos told Psychiatric Times, "Most schools across the country have no formal program for assessing and treating posttraumatic stress among students, even though such programs routinely exist for firefighters, police officers and others exposed to violence and catastrophe in the course of their working lives."
Teachers and school administrators are not trained to consider that problem behaviors such as lack of concentration and attention, irritability, heightened arousal, or reactivity might be symptoms of posttraumatic stress. Where mental health treatment does exist, it is usually in the form of acute crisis intervention, courses in nonviolent conflict resolution or screening to identify the next perpetrator (Pynoos, 1999). When learning difficulties are diagnosed, they are apt to prompt funding for tutors and other cognitive enrichment, without complementary programs to also tackle the underlying mental health problem. "Raising the standard of care for [traumatized] children means systematic screening, triage and intensive treatment with appropriate follow-up when indicated," Pynoos argued.
An important component of the UCLA Trauma Psychiatry program is systematic screening of the entire student body via a self-report instrument given to groups of 20 to 40 students, rather than sole reliance on teachers, parents or students for referral.
"We are finding so many children who have had horrific experiences who never would have been identified or seen by a professional, who are suffering significant posttraumatic symptoms who never would have received any kind of help," Alan M. Steinberg, Ph.D., director of research at the UCLA Trauma Psychiatry Service told PT.
In screening the student body of one San Fernando area high school, 40 students were identified who had suffered gunshot wounds, none of whom had been referred for any psychological evaluation or counseling (Pynoos, 1999). In the Pasadena junior high school, "almost half of the students who were invited to participate in the group program had never told their parents about their trauma" (Saltzman et al., in press).
Of 1,100 junior high school students surveyed at the beginning of the second year of the program, approximately 15% had high levels of exposure to violence with severe concurrent symptoms of posttraumatic stress. About one-third of these students met criteria for inclusion in the program. Some of the students not in the program received individual counseling from the team (Saltzman et al., in press).
Built on a developmental model, the 16- to 20-week group therapy focuses not only on abating the specific symptoms of PTSD, such as intrusive reactions, emotional withdrawal, hyperarousal and so on, but also on how trauma and traumatic loss have interrupted or derailed the adolescent's development (Pynoos et al., 1995).
In treating six San Fernando high school students, clinicians found that among the most devastating effects of the trauma were the adolescents' sense of estrangement from others and their severing of previously close peer relationships, as well as loss of faith in public institutions and in the social contract itself (Layne et al., 2001). Once the clinicians have helped participants create a coherent trauma narrative and work through the traumatic events, they can help the students mobilize internal resources to address some of the secondary adversities in their lives and to plan for the future.
The program is broken down into four modules, each of which entails four to five weekly, 50-minute sessions, offered during elective classes and at different times each week to reduce the impact on any single course. The program covers the traumatic experience, trauma reminders, traumatic loss and complicated bereavement, daily adversities and ongoing stresses, and developmental progression.
Trauma reminders can "play a significant role in maintaining a child's chronic difficulties," by keeping the trauma alive in the present, according to William Saltzman, Ph.D., director of the UCLA Trauma Psychiatry Service's School-based Intervention Program, in an interview with PT.
Early in the program, participants learn how to recognize their trauma reminders and modulate their reactions. Among the six San Fernando high school students, researchers found that physical scars were ever-present, intimate reminders of the permanent, fundamental alteration the trauma had wrought (Layne et al., 2001). "When I look at myself in the mirror and see the scar," one student reported, "sometimes I can see the hand with the knife, and me putting my hand up to stop it but I can't, and then I see it go in, and then I feel really scared."
According to Layne et al. (2001), one reason for estrangement between friends who had been involved in the same traumatic event was the fact that "each was serving as a trauma reminder to the other." Trauma reminders can be as ubiquitous as the nightly news or as idiosyncratic as an SAT reading comprehension test passage on kidnapping that proved a trigger to the girl who had been kidnapped at knife-point.
Pynoos hypothesized that attention and concentration improve partly because treatment helps students to identify and manage their reactions to reminders. Traumatized adolescents "need a strategy to handle reminders not only acutely but throughout life, because there will always be reminders," Pynoos explained.
The UCLA team is now testing an instrument to assess the types of reminders children are experiencing, their frequency of exposure, the intensity of their reactivity and how long it takes them to calm down after a reminder. Very preliminary data suggest that "the longer it takes to calm down, the more severe the PTSD," according to Steinberg.
The Trauma Narrative
During the course of the program, each participant constructs a trauma narrative that includes both an objective account of events and a subjective account of what the trauma felt like and what it meant for them. Group members have several opportunities to recount their trauma and often add more detail as they become comfortable with the group and their own level of exposure, according to Saltzman. Eventually, they describe the "worst moments," a concept developed by Eth and Pynoos (1994) in their early work with children who had witnessed the homicide of a parent.
Worst moments are subjective; they may represent the peak of vulnerability, when the victim thought they were going to die or felt most helpless to intervene in events. For some of the high school students, the worst moments related to the existential dilemma that arose when they felt they had to make a split-second choice between self-preservation and trying to save another person (Layne et al., 2001).
As actual decisions about intervening inform the adolescents' trauma narratives, "reparative intervention fantasies" are a source of posttraumatic preoccupation (Layne et al., 2001; Saltzman et al., in press). These "what ifs," "if onlys" and "should haves" are motivated by equal parts shame, guilt and denial.
Among these disturbing thoughts are revenge fantasies, which are often pre-eminent among inner-city adolescents and behind many acts of what may seem to outsiders as senseless violence. In treatment, the clinicians reframe revenge fantasies as an indication of "the degree of violence the victim has actually experienced, and his or her experience of what kind of intervention would have been necessary to protect them and their loved ones in the circumstances," according to Pynoos.
Saltzman knows of at least one planned act of revenge among the junior high school students that was dismantled as a result of the group work. Reparative intervention fantasies lose their power as the victim creates a complete narrative of what really occurred and accepts the impossibility of reversing the past in the present.
The UCLA team plans to study intervention/revenge fantasies more systematically in the future. They suspect that there may be a correlation between the degree of preoccupation with reparative intervention fantasies and the severity of PTSD.
The common assumptions that inner-city children become inured to the violence around them and are immune to PTSD are undercut by the numerous case histories and trauma narratives collected by the UCLA team. What about the notion that, if left untreated, children will get better over time, as the violent events recede in memory? Longitudinal data from the Armenian earthquake suggest that if children are not treated, their PTSD symptoms will worsen and their normal development will be derailed (Goenjian et al., 1997).
The UCLA trauma treatment offers greater alternatives, according to group participant Julia, age 12, who saw her uncle stabbed to death (Saltzman et al., in press). "The group taught me that I wasn't crazy for feeling like I did. I feel calmer and more able to pay attention and work at school."
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Layne CM, Pynoos RS, Cardenas J (2001), Wounded adolescence. School-based group psychotherapy for adolescents who sustained or witnessed violent injury. In: School Violence: Assessment, Management, Prevention, Shafii M, Shafii SL, eds. Washington, D.C.: American Psychiatric Press Inc., pp163-186.
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