post traumatic stress disorder by moira mardero, elsie yip, curtis richardson & marc baureiss

POST TRAUMATIC STRESS DISORDERBy Moira Mardero, Elsie Yip, Curtis Richardson & Marc Baureiss

"Post Traumatic Stress Disorder helps us make resolution with the past. We must ride with it,

not run from it. Post Traumatic Stress Disorder is not only a mental experience, but it is a

spiritual and karmic experience, as well. Once you address the trauma clearly, own it and

recognize it, you can release the impact of what occurred and what is not serving you. The past has no business in the present. The memories

are painful, but they can't hurt you.”

Coral Anika Theill, BONSHEA: Making Light of the Dark

Myth or Fact?

It happened a long time ago, time heals all wounds, you should be over it.

The impacts of traumatic events are often delayed because people will banish the memories from their consciousness.

Medication is an option for people in healing from the impacts of trauma.

You will never really be normal again.

The single hardest-hit group of trauma victims is children.

Introduction &The History of PTSD

An emotional illness classified as an anxiety disorder

Usually the result of terribly frightening, life threatening, or otherwise highly unsafe experience

PTSD sufferers re-experience the traumatic event in some way, tend to avoid places, people that remind them of the event

Are also exquisitely sensitive to normal life experiences (hyper arousal)

History con’t

Condition has been around since people first experienced trauma

PTSD recognized as a formal diagnosis in 1980

Called “soldier heart” in the American civil war

Called “combat fatigue” in WWI

Called “gross stress reaction” in WWII

Called “post-Vietnam syndrome” during Vietnam war

Also has been called “battle fatigue & shell shock”

Some Statistics

7-8% of all people in the US will develop PTSD in their lifetime

10-30% of all combat veterans and rape victims will develop PTSD

Somewhat higher in African Americans, Hispanics and Native Americans due to:

A tendency to blame themselves, have less social support, an increased perception of racism for these ethnic groups and differences in how they may express distress

Statistics con’t

5 million people suffer from PTSD in the US

Women are twice as likely as men to develop PTSD

Half of the individuals who use outpatient mental health services have been found to suffer from PTSD

Not being present at a traumatic event does not guarantee that one cannot suffer from traumatic stress leading to PTSD. Ex. 2001 terrorist attacks

Rates of PTSD in Children

Research done at Duke University:

68% of children had direct or indirect exposure to a traumatic event by the age of 16

Witnessing a traumatic event (23%)

Learning about a traumatic event (21.4%)

Violent death of a sibling or peer (14.5%)

Being involved in a serious accident (?)

Rates of PTSD in children

Being exposed to a natural disaster (11.1%)

Being diagnosed with a physical illness (11%)

Experience of sexual abuse (10.9%)

30% of children experienced only one traumatic event while 37% had experienced multiple event

Of this study group, only 0.5% of children had a diagnosis of PTSD

Risk for PTSD Symptoms

Factors that increase the likelihood that a child develops PTSD after a traumatic event:

Age (being older)

Having another anxiety disorder

Multiple traumatic experiences

Other Negative Consequences of Childhood Trauma

These children had twice the number of other psychiatric disorders including:

Depression

Generalized anxiety disorder

Social anxiety disorder

PTSD DSM-IV Diagnosis & Criteria

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) An extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury

A threat to one’s physical integrity

Witnessing an event that involves death, injury or a threat to the physical integrity of another person

Learning about unexpected or violent death, serious harm by a family member or close associate

PTSD DSM-IV con’t

(2) The person’s response to the event must involve intense fear, helplessness, or horror

B. The traumatic event is persistently re experienced in one (or more) of the following ways:

(1) Recurrent and distressing recollections of the event (In young children, repetitive play may occur with themes or aspects of the trauma are expressed)

(2) Recurrent distressing dreams of the event

PTSD DSMV IV con’t

(3) Acting or feeling as if the traumatic event were recurring (a sense of reliving the experience, illusions, hallucinations, flashbacks.)

(4) Intense psychological distress at exposure to internal or external cues that symbolize an aspect of the event

(5) Physiological reactivity on exposure to cues from the event


C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by three or more of the following:

(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) Effort to avoid activities, places or people that arouse recollections of the event

(3) Inability to recall an important aspect of the trauma


(4) Markedly diminished interest or participation in significant activities

(5) Feeling of detachment or estrangement from others

(6) Restricted range of affect (e.g. unable to have love feelings

(7) Sense of foreshortened future (e.g., does not expect to have a career, marriage, children or normal life span)


D. Persistent symptoms of increased arousal as indicated by two (or more) of the following:

(1) Difficulty falling asleep

(2) Irritability or outbursts of anger

(3) Difficulty concentrating

(4) Hyper vigilance

(5) Exaggerated startle response


E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month

F. The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning

Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if more than 3 months

Specify if: With Delayed Onset: if at least 6 months after the stressor

PTSD in Infants & Toddlers (Birth to Age 1)

Because infants and toddlers have difficulty communicating trauma they have experienced, the following signs of distress may be exhibited:

fussing more

possible “loss” of developmental steps already acquired

possible failure to learn new and expected developmental tasks

PTSD in Preschoolers (Ages 2-5)

For preschoolers, whose language skills are weak and there is a limited ability to verbalize their feelings of distress, the following behaviours can be exhibited:

anxiousness and clinging to the parent/caregiver; separation difficulties

taking a step backward in development by thumb sucking, bed wetting, refusing to sleep or waking at night for fear of the dark

being aggressive in their play

speech difficulties

expressing magical ideas about an event (e.g. “ Daddy left because I was bad.”)

decreases or increases in appetite

PTSD in Childhood (Ages 6-12)

It would be important to watch for the following signs of distress:

sadness and crying

poor concentration

fear of personal harm

bed wetting

confusion

physical complaints (e.g. headaches)

regressive behaviours (e.g. clinging, whining)

PTSD in Childhood con’t(Ages 6-12)

aggressive behaviour at home or school

withdrawal/social isolation

attention-seeking behaviour

school avoidance

irritability

sleep disturbances (e.g. nightmares)

anxiety and fears

eating difficulty

PTSD in Teenagers(Ages 13-18)

rebelliousness

intrusive recollections

anxiety and feelings of guilt

sleep and eating disturbances

antisocial behaviour (e.g. stealing)

poor school performance

increased substance abuse

PTSD in Teenagers con’t(Ages 13-18)

poor concentration and distractibility

psychosomatic symptoms (e.g. headaches, bowel problems)

agitation or decrease in energy level (e.g. loss of interest in activities)

numbing

aggressive behaviour

depression

peer problems

Withdrawal

PTSD in Adults (Ages 19 +)

shock and disbelief

feelings of detachment

unwanted, intrusive recollections

concentration difficulty

psychosomatic complaints

eating disturbance

poor work performance

emotional and mental fatigue

irritability and low frustration tolerance

PTSD in Adults con’t(Ages 19 +)

loss of interest in activities once enjoyed

denial

depression

anxiety

hyper-vigilance

withdrawal

sleep difficulty

emotional change

marital discord

Appropriate Reactions to crisis situations Shock

Denial

Dissociative behaviour

Confusion

Disorganization

Difficulty making decisions

Suggestibility

It is crucial to give back a sense of control and to help empower the individual

(Adapted from Crisis Response in Our Schools, 2003 Lerner, Volpe, Lindell)

The Effect of Trauma

The effects of being traumatized are very individual, and survivors are impacted physically, emotionally, behaviourally, cognitively and spiritually.

Physical

Eating disturbances (more or less than usual)

Sleep disturbances (more or less than usual)

Pain in areas on the body that may have been involved in the traumatic experience

Low energy

Chronic unexplained pain

Headaches

Anxiety/panic

Emotional

Depression, spontaneous crying, despair and hopelessness

Anxiety

Extreme vulnerability

Panic attacks

Fearfulness

Compulsive and obsessive behaviours

Emotional con’t

Feeling out of control

Irritability, anger and resentment

Emotional numbness

Frightening thoughts

Difficulties in relationships

Behavioural

Self-harm such as cutting

Substance abuse

Alcohol abuse

Gambling

Self-destructive behaviours

Isolation

Choosing friends that may be unhealthy

Suicide attempts

Cognitive

Memory lapses, especially about the trauma

Loss of time

Being flooded and overwhelmed with recollections of the trauma

Difficulty making decisions

Decreased ability to concentrate

Feeling distracted

Withdrawal from normal routine

Thoughts of suicide

Spiritual

Guilt

Shame and self-blame

Self-hatred

Feeling damaged

Feeling like a “bad” person

Questioning the presence of God

Spiritual con’t

Questioning one’s purpose

Thoughts of being evil, especially when abuse is perpetuated by Clergy

Turning away from the faith or obsessively attending services and praying

Feeling that as well as the individual, the whole race or culture is bad

PTSD and its Effect on the Brain

http://www.chordsforchange.org/2010/02/04/brainonmusic/

http://www.chordsforchange.org/2010/02/04/brainonmusic/

http://www.chordsforchange.org/wp-content/uploads/2010/02/fightorflightbrain.jpg

Factors Shown to Increase the Likelihood of PTSD in

Children

The severity of the event

Parental reaction to the event

The child’s physical and /or emotional proximity to the event

Helping the Child Survive the Traumatic

eventDemaree (1995) states, “maintaining a safe

classroom environment is the cornerstone for meeting the needs of children with PTSD” ( p. 33). Teachers can individualize their programs when they know and understand the differences and special needs of children with PTSD. This can be established by:

setting clear, consistent limits


eventproviding a positive learning environment with

consistent daily routines and expectations

reassuring their safety needs by showing empathy and care

model good stress management and problem-solving skills

providing opportunities for personal control

finding positive outlets for their release of frustration and regulation of their own stress level (i.e. relaxation techniques such as yoga, singing, artwork or physical movement)


event reinforce the belief that conditions can and

will improve despite temporary setbacks

maintaining a relationship with the child

being positive and patient with the child

incorporating more physical activity in the classroom

providing ample opportunities for students to interact with one another

Associated Conditions

Along with associated symptoms, there are a number of co-occurring psychiatric disorders that are commonly found in children and adolescents who have been traumatized. They include:

major depression

substance abuse

anxiety disorders such as separation anxiety, panic disorder and generalized anxiety disorder

attention-deficit/hyperactivity disorder

oppositional defiant disorder

conduct disorder

Associated Conditions con’t

By co-occurring, we mean: one or more Mental Health Disorders as well as one or more disorders relating to substance and/or alcohol abuse

It is estimated that 4 million people in the United States have a co-occurring disorders.

Co-occurring disorders are common with trauma survivors. They should be expected rather than seen as the exception.

Associated Conditions con’t

PTSD is a risk factor for substance abuse, dependence, and addiction.

The trauma survivor is often looking for a way to numb feelings, emotions, pain and suffering in an attempt to cope.

Although not mentioned in the DSM IV, disruptive behaviour disorders often co-occur in children with PTSD.

25% ADHD15.4% Conduct Disorder25% Oppositional Defiant Disorder

(Nickerson et al, 2009)

ResilienceA set of beliefs, feelings and behaviours that

emerge at a time of crisis and adversity.

Protective Factors present in resilient children Persistence Goal-orientation Adaptability Optimism Willingness to approach novel events High Self-esteem Intelligence Good social skills

(Adapted from PTSD in Childhood, 2010, Chapman, Stefanation and Sukhan, Winnipeg)

Resiliency, What can we do?

Refer to the individual as a trauma survivor not as a victim. This reduces the sense of powerlessness.

Validate the individuals resilience and protective factors.

Build new skills and better adaptations as past coping behaviours may no longer be needed and/or acceptable.

Work from a resilience-minded perspective.

Help the trauma survivor to realizes/he has the skills from within to heal and recover.

The Support System

School Classroom Teachers

Preschool and Elementary School Age Children Adolescents Adult Students

School Guidance CounselorSchool Psychologist

Therapies provided by outside agencies

General role of the support systemProvide for safety and security

Help the child regain control over parts of his/her life.

Listen Don’t minimize the child’s perception of the crisis

and/or traumatic event.

Allow the child to share his/her feelings at his/her own pace.

Recognize that physical ailments and illness can be linked to PTSD.

Understand co-occurring disorders.

Collaborate with everyone involved.

Debriefing

Is a structure for listening and talking to the trauma survivor.

It is a way for adults to provide an environment in which children can safely express their emotions and reactions

It is not counseling

Goal of Debriefing

normalize the child’s responses

aid in the recovery process

allow a venue for venting

teach coping skills

help the child to understand what occurred

Debriefing Method

Brooks & Siegel (1996) in their book, The Scared Child, lay out a four-step method for helping children through a traumatic experience.

1. Preparing the Self2. Having the Child Tell his/her Story3. Sharing the Child’s Reactions4. Survival and Recovery

Preparing the Self

Do your research.

www.wsd1.org Departments and Services

Library Support Services Pathfinders

Prepare yourself psychologically /emotionally.

http://www.wsd1.org/

Handout, Nickerson et al, (2009) Identifying, Assessing & Treating PTSD at School

Screening & Referral

Preschool and elementary school aged childrenPlay using clay or blocks

Painting

Drawing feelings and memories

Journal writing/scribing

Writing letters/cards

Reading and discussing stories

Create a memory board about the crisis

Memory box/scrapbooking happy thoughts(Adapted from Crisis Response in Our Schools, 2003, Lerner, Volpe, Lindell)

Adolescents

Journal, poetry and story writing

Writing cards/letters

Art

Relaxation techniques

Exercise

Problem Solving Strategies

Listening to music

Small group discussions


Adult students

Temporarily altered work schedule

Writing

Relaxation/meditation strategies

Exercise

Listening to music

Social support


Programs/Resources

Kelso www.kelsoschoice.com

Five Point Scalewww.fivepointscale.com

Teen Friendly site www.kidshelpphone.ca

Resource Documents www.anxietybc.com

American Red Cross, Masters of Disasters Curriculum http://www.redcross.org/preparedness/educatorsmodule/ed-cd-main-menu-1.html

http://www.kelsoschoice.com/

http://www.fivepointscale.com/

http://www.kidshelpphone.ca/

http://www.anxietybc.com/

http://www.redcross.org/preparedness/educatorsmodule/ed-cd-main-menu-1.html

http://www.redcross.org/preparedness/educatorsmodule/ed-cd-main-menu-1.html

The School Guidance Counselor

Individual and small group counseling

Support groups

Crisis InterventionThe goal of Crisis Intervention is to help

restore the trauma survivor to previous levels of functioning. cessation of emergency reactions.understanding and expressing feelings

and emotions around the trauma.short-term goals, practical considerations

and concrete plans of action(Johnson, 1989)

The School Psychologist

Individual counseling

Assessment

Therapy provided by outside agenciesShort term treatment, focused on the acute-

stage interventions. Helping restore the trauma survivor to previous levels of functioning.

Long term treatment, focused on resolution of psychological and behavioral issues following the traumatic experience.Play TherapyArt TherapyFamily therapyPsychiatric Treatments

Trauma Recovery

Normalize the experience and the symptoms for the trauma survivor

Assist the trauma survivor in connecting with services critical to recoveryHealth and Mental Health services

Help the trauma survivor to define recovery

Facilitate connects with family, friends, the community, and culture

(Adapted from Trauma-informed, 2008)

Recovery and School Reintegration

The memories of the traumatic experience will always remain for the trauma survivor.

The individual must incorporate the event into his/her life experiences.

Creating a reintegration plan that includes goals, guidelines and contacts.

Pre-scheduled preventative sessions to address high-stress circumstances such as anniversaries could help the trauma survivor.

Monitoring

Examining the Effects of Trauma Causality

“Unlike the minor crises that are part if the normal travails of life, trauma are situations that are outside the range of expected experience” (Brooks & Siegel 3.)

Does the different causality of trauma in turn mean a particular manifestation or unique exhibition of Posttraumatic Stress Disorder?


This section will investigate the characteristics (i.e.: behavioral, cognitive, emotional, physical) of the effects of different types of trauma which could develop into Posttraumatic Stress Disorder—especially in children.

“An experience that is only moderately difficult for one person may be unbearable and traumatic to another” (Johnson 34.)


It is important to note that any significant trauma can develop into PTSD, and what is traumatic to one may not entirely be traumatic to another; because frame-of-reference, cognitive ability, abstract understanding, emotional resilience, mental fortitude,—much of which is dependent upon stages of Human Development—a similar stimuli may be received as a mild disruption to one while being an impacting nuance to shatter the psyche of another.


To better discuss the possible trauma responsible for an individual’s PTSD, the different types of trauma discussed will be both limited in numbers and categorized into traumatic experience triggers.


The manner in which the cause/trigger of the traumatic event will be categorized will be

Intimate or Direct Trigger—somehow trauma has been experienced by an individual as by his own senses or person, including imagined trauma; the trigger is the trauma.

Consequential or Reactionary Trigger—somehow trauma has been experienced by an individual which is the response of another to trauma he has experienced which can be perceived as a global/shared experience and may not have a rationality behind it; this inflicting of trauma is a perpetuating of the experience that may not be in synch with the initial trauma.

One person’s direct trigger of trauma is another’s reactionary trigger to his own trauma.

Examples of Intimate/Direct Trauma

Death of a Loved One

Divorce

Domestic Violence (or Abuse: Physical, Psychological, Sexual)

Illness & Injury

Natural Disaster

Trauma by Proxy

Warfare

Examples of General Consequential/Reactionary

Trauma Triggers

Coping with the Loss of/Unfamiliar Family Roles…………… Residential Schools

Culture Influence/Dissonance………………………………… Newcomers; Immigrants

Gang affiliations………………………………………………. Hyper-Violent Existence

Literal/Cultural Genocide……………………………………... Holocaust

Relocation—Forced, Necessary, Required……………………. Newcomers; Refugees

Socio-economic Background………………………………….. Inner-city; Single/young Parent

Examining Effects of Trauma Causality

“An argument can be made that historic generational trauma strongly influences Aboriginal people’s locus of personal and social control. It engenders a sense of fatalism and reactivity to historical and colonial forces, and this adversely influences their social relations” (Keith 22.)

It is not apt, however, to simplify the relationship of the series of traumatic experiences along a single generational thread; it is too superficial a representation, and it is too difficult to accurately discover/portray the entirety of this social phenomenon too commonly occurring amongst marginalized peoples and populations.

Intimate/Direct Trauma: Death of a Loved One

“Children believe that their world is stable, that the people who are in it today will be in it tomorrow and forever,” (Brooks & Siegel 4.)

Intimate/Direct Trauma: Death of a Loved One

Children and adolescents do not mourn as their older counterparts.

“The mourning process is not linear in children as it is in adults. For children, there is no beginning, middle, and end. Rather, the process is repeated as the child grows older and understands the death from a more mature perspective” (Brooks & Siegel 47.)

Intimate/Direct Trauma: Divorce

Though it is not uncommon, divorce is traumatic just the

same, especially for children; it is the breaking of what was believed to be unbreakable,

compounded by the fact that it is those whom were to maintain

it forever taking it apart.


Children “are the powerless victims in the divorce. They have no say in the decision, they are pushed around psychologically, and in some cases they are even used as pawns by irresponsible parents” (Brooks & Siegel 84.)

“Children of divorce were likely to be afraid to trust relationships and hesitant about making a commitment to a specific person” (Brooks & Siegel 84.)


Divorce is not a simple action; it is an on-going process which has three stages:

Crisis Stage

The Short Term

The Long Term


Age, gender, and stage of divorce affect a child’s reaction to divorce.

Ironically, it is the older children which are more likely to have a worse reaction to divorce than younger children; this reason is the concept which most would think would make it easier, but in fact it is quite the contrary; their understanding of the situation as well as their more solidified concept/identity of family makes for worse injury by divorce than the damage of divorce accompanied by ignorance and malleable sense of self & family of youth.

Intimate/Direct Trauma: Domestic Violence

Domestic violence includes physical abuse, sexual abuse, psychological abuse, and abuse of property and pets” (Lerner 55), either experienced or witnessed (as in respect to spousal abuse.)

“If a child has been abused physically, [psychologically,] or sexually, or if a child has been witness to spousal abuse, it is likely that the child will experience posttraumatic acute-stress reactions. If the abuse has been going on for a long time, the child is likely to experience the symptoms of PTSD” (Brooks & Siegel 62.)

Intimate/Direct Trauma: Domestic Violence

Children whom have experienced domestic abuse are at significant risk for delinquency, substance abuse, school drop-out, and difficulties in their own relationships, as well as exhibit symptoms of PTSD.

How children react to domestic violence is largely affected by the type of abuse being experienced/witnessed and the age/cognitive-psychological ability of the child.

Intimate/Direct Trauma: Illness & Injury

The trauma of illness & injury is not always in the actual ailment, but rather the circumstance around it:

Absent parents

Absent family

Unfamiliar or uncomfortable surroundings

Financial concerns

Intimate/Direct Trauma: Illness & Injury

“Illness and injury, [themselves,] are traumatic because they are usually unexpected” (Brooks & Siegel 6.)

“Because the terrible event happened during a normal part of life, children can become uncomfortable with ordinary life” (Brooks & Siegel 6.)

Intimate/Direct Trauma: Natural disaster

“Unlike other traumas, which mostly affect one person or one family or at most a few families, natural disasters usually traumatize whole communities” (Brooks & Siegel 73.) Long term disruptions in all aspects of life occur—few are left unscathed by the event.


The most significant feelings of bereavement to individuals whom experience natural disasters as noted from Barbara Brooks, Ph.D. & Paula M. Siegel’s book, The Scared Child: Helping Kids Overcome Traumatic Events, are:

Lost sense of security

Loss of familiar surroundings

Loss of personal possessions


Children experience and express differently than adults; trivial losses to adults may be gross detriments to children, and

granted vice versa; however, both suffer equally as well as

deeply.

Intimate/Direct Trauma: Trauma by Proxy

Not all traumas need to be experienced firsthand; some traumatic experiences are had through exposure to real events through another medium:

Media (Television, Newsprint, Music, Artistry/Digital Artistry, Internet)

Gossip amongst primary/secondary/tertiary/etc. social group

Identification to Narrator/Subject/Character/Antagonist/Etc.


Why this trauma is predominantly found in children is their perception and inability to separate/ability to identify themselves with those falling victim to circumstance.

“Trauma by proxy is filtered through a child’s perception of the world. Youngsters in varying age groups have different understandings and reactions to catastrophic events that they hear about or see in the media” (Brooks & Siegel 127.)


“Children are more vulnerable than adults to being

traumatized by distant events. Kids are particularly at risk of

developing posttraumatic symptoms after being exposed to events in which they identify with the victim” (Brook & Siegel

125.)

Intimate/Direct Trauma: Warfare

“Refugees and immigrants coming from war-torn countries or repressive regimes have often experienced considerable trauma” (Unknown 24.)

“There is a great variability in the physical and psychological effects of war and torture trauma, as well as tremendous variability in how survivors present themselves and their stories. There is also a high variability in ability to remember what happened and put into words. Many war and torture traumas are considered ‘unspeakable acts.’” (Unknown 31.)


“Children showed a significantly higher incidence of behavior problems and problems with

psychosocial competence, but significantly lower levels of depression. There were no significant differences [for

children] in anxiety. Neither age nor gender was related to any of the outcomes” (Flores 8-9).


“Features that might contribute to the development of long-lasting anxiety and trauma:

the subjection of daily life to pervasive tension and fear;

the ubiquitous use of deadly weapons including land minds; and

the targeting of violence against civilians and combatants in a hateful brutal manner” (Flores 9).

Conclusion

Though the messages from individuals suffering trauma from

different causalities maybe similar, there are nuances within their

messages and specifics within their actions which are particular; all

express anxiety, conflict, pain… but each individual burdened from a unique trauma have a distinct identifiable source of his ailing,

which can or cannot develop into posttraumatic stress disorder.

Conclusion

Overall, PTSD looks familiar amongst those whom have

been diagnosed with it; however, the trauma that offset the individual psyches express characteristics in the signs and

symptoms displayed—each case is marked by its origin and cause like a sort of identifiable

traumatic features.

References Brooks, Barbara, Ph. D. & Siegel, Paula M, (1996). The Scared Child:

Helping Kids Overcome Traumatic Events. New York: John Wiley & Sons, Inc.

Flores, Joaquin E. (1999). “Schooling, Family, and Individual Factors Mitigating Psychological Effects of War on Children.” Current Issues in Comparative Education, 2(1)—November 15. Teachers College, Columbia University.

Johnson, Kendall, Ph. D. (1989). Trauma in the Lives of Children. Alameda: Hunter House Inc.

Keith, Anita L. (2006). For Our Children Our Sacred Beings: Understanding the Impact of Generational Trauma on our Aboriginal Youth. Delta: Healing the Land Publishing.

Lerner, Mark D., Volpe, Joseph S., & Lindell, Brad. (2003). A Practical Guide for Crisis Response in Our Schools (5th Edition). Commack, NY: The American Academy of Experts in Traumatic Stress.

Nickerson, A., Reeves, M., Brock, S., & Jimerson, S. (2009). Identifying, assessing and treating ptsd at school. New York, NY: Springer