POST-TRAUMATIC STRESS DISORDER IN ISRAELI SCHOOLCHILDREN

Post-Traumatic Stress Disorder in Israeli Schoolchildren

Uri Kestenbaum
Psycho-Social Problems in the Jewish School
Azrieli Graduate School of Jewish Education and Administration
Yeshiva University

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Definition
When an individual undergoes a traumatic event, the brain is tasked with the job of
processing the experience in a way that it can store it away and carry on with life. Sometimes,
the stimuli from the traumatic event is too intense for the brain to process, and it stays in the
brains psychological system unprocessed.
Because of this, the event can remain in the individuals mind, along with the
accompanying feelings, as if the event is happening, over and over again. There are three main
symptoms that can accompany this phenomenon, and these symptoms indicate that the individual
is suffering from Post-Traumatic Stress Disorder (PTSD). The first symptom is Intrusion. When
the traumatic event is recalled in some way, a sense of danger and physical symptoms of danger
can intrude into the sufferers daily life. This sense of danger can be accompanied by memories
of the sounds, thoughts and images that were experienced during the traumatic experience. The
second symptom is avoidance. The sufferer finds it disturbing or painful to trigger the traumatic
event in his mind, so he may start avoiding situations that might set off and recall the trauma.
Lastly, the individual may experience hyper-arousal a state in which the sufferer may feel in a
constant state of danger as if there are threats and dangers all over the world he inhabits.
Problem
Israel, as a country, is faced with a unique problem regarding the treatment and
prevention of PTSD. Israeli society is one that is constantly facing terror attacks and victims of
terror are not limited to physical harm, but psychological as well. Surveys indicate that close to
45% of Israeli population have been directly exposed or had friends or relatives who were
exposed to a terrorist attack (Bleich, Gelkopf, & Solomon, 2003, 2006).

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While an individual may experience PTSD and seek treatment for it, the prevalence of
community-wide traumatic experiences makes it difficult to pinpoint who sufferers are, and to
ensure they are receiving proper treatment. In fact, studies show that most children who suffer
from posttraumatic stress symptoms fail to seek treatment and are not referred for psychosocial
services by parents or school personnel (Gurwitch, Sitterle, Young, & Pfefferbaum, 2002).
Interventions
There are two approaches to combating PTSD: targeted interventions and universal
interventions. In targeted interventions, patients are treated away from their natural environments
and grouped in treatment with other patients led by a professional. Universal approaches,
however, deal with building resiliency and strengthening resources and coping skills rather than
dealing with individual traumatic experiences (Caplan, 1974).
While the classic treatments for PTSD may include methods such as Cognitive
Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) to
process and reprocess traumatic events, methods to address larger populations have been
introduced into the Israeli school system. In fact, the school is seen as an ideal venue to deliver
mental health services, since it minimizes stigma and normalizes the process of interventions
(Pfefferbuam et al., 2003). A universal approach has been preferred in Israeli schools because it
can adequately deal with the high prevalence children with PTSD symptoms and enhances
students resiliency to an ongoing threat (Pat-Horenczyk et al., in press).
School-wide approaches are geared towards participation from students parents and
families alike by assigning homework and assignments that require help from all parties
involved. One program, ERASE -Stress (ES), is designed to deal with the following set of stress
management skills:

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a) Identifying daily stressors
b) Teaching coping skills
c) Developing body awareness (somatic reactions)
d) Developing strategies to control the body during stressful encounters
e) Clarifying and becoming aware of ones emotions
f) Stopping emotional flooding
g) Enhancing ones support system by meeting social needs and asking for help
h) Reframing negative thought patterns positively
Each of these sessions involve parents and teach them coping skills such as breathing,
mindfulness and relaxation (Gelkopf, 2008). The results of this program indicated that there were
significant reductions in all symptoms of PTSD and anxiety levels compared to the control
group.
A novel approach, borrowing from EMDR methods has been introduced by an art
therapist, Shachar Bar (2008), who has kindergarten schoolchildren practice singing a song about
running for cover from rockets. The lyrics (translated to English) are:
Color Red! Color Red!
Hurry, hurry, hurry, to a protected area
Hurry, Hurry because now its a bit dangerous
My heart is pounding, boom, ba-ba, boom, boom, boom
My body is shaking, doom, da-da doom, doom, doom
But I am overcoming
Because I am a little bit different
The impactboom now we can get up
Our body we shake, shake shake
Our legs we loosen, loosen, loosen

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Breathe deep, blow far
Breathe deep, now we can laugh
It all passed and Im glad it's over Yes!!

The song is accompanied by hand and arm movements that go in tandem with the lyricssuch as pounding ones chest and crossing the arms. The song highlights that is okay to be afraid
and give legitimization to ones fear. Breathing and laughter accompany the end of the song to
dispel the anxiety and release the tension.
Another effective school intervention is Psychological First Aid for Schools (PFA), a
program that is administered by school staff after a school-wide traumatic event (Baweja,
Kataoka, Langley, Stein & Wong, 2012). The goal of the program is to teach key skills such as:
a)
b)
c)
d)
e)

Protecting survivors from further psychological harm

Identifying those most distressed
Returning to school and familiar routines
Facilitating communication among families, students and community agencies
Educating those affected about the expectable psychological responses and basic coping
tools to stressful and traumatic events

Some helpful techniques for students include:

a) Cognitive restructuring a student might write down a couple of helpful thoughts
on a small card to carry around and pull out when intrusive thoughts might be getting in their
way.
b) Relaxation Training A student might try rating their feelings with a feeling
thermometer to use before and after relaxation exercises.
c) Trauma Narrative Pictures or stories are utilized by reading and recounting the
traumatic memory. The story is reviewed several times to decrease the amount of anxiety it
provokes.

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d) In Vivo Exposure Students can make a list of things they are avoiding and they
are assigned one or two things that can be practiced each week to do again and cease
avoiding.

Discussion
Research has shown that prolonged exposure to traumatic events cause a break-down of
ones natural resilience even on a national level (Bleich, Gelkopf, Melamed & Solomon, 2006).
Despite the negative effects of ongoing trauma and the potential for PTSD symptoms, there
exists a positive outcome to the experience. Researchers have identified five areas in which
sufferers of PTSD have experienced growth in a way that was unattainable before the traumatic
event. This is referred to as Posttraumatic Growth. The five areas are: 1) People discover that
opportunities become available that were unavailable before. 2) People discover individuals that
they share a strong bond with particularly toward those who have also experienced traumatic
events. 3) Some experience a strong sense of resilience toward any challenging situation. 4)
Some find a greater and fuller appreciation of life, in general. 5) Some feel a deeper spiritual
connection in their lives often accompanied by a change in their set of beliefs and values.

References:
Baweja, S., Langley, A., Kataoka, S., Stein, B., & Wong, M. (2012). Responding to students with PTSD
in schools. Child Adolesc Psychiatr Clin N Am. ; 21(1): 119-x.

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Bleich, A., Gelkopf, M., & Solomon Z. (2003). Exposure to terrorism, stress-related mental health
symptoms, and coping behaviors among a nationally representative sample in Israel. Journal of
the American Medical Association, 290, 612620.
Ehntholt, K. A., Smith, P. A., & Yule, W. (2005). School-based cognitivebehavioral therapy group
intervention for refugee children who have experienced war-related trauma. Clinical Child
Psychology and Psychiatry, 10, 235250.
Pat-Horenczyk, R., Dopplet, O., Miron, T., Villa, Y., Brom, D., & Chemtob, C. M. (2007). Risk-taking
behaviors among Israeli adolescents exposed to recurrent terrorism. American Journal of
Psychiatry, 164, 6672.
Pfefferbaum, B., Sconzo, G. M., Flynn, B. W., Kearns, L. J., Doughty, D. E., Gurwitch, R. H., Nixon, S.
J., & Nawaz, S. (2003). Case finding and mental health services for children in the aftermath of
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NATAL Israel. (n.d.). Retrieved from:
http://natal.org.il/English/?CategoryID=229