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I Elite Table of Contents Bullying in Children and Youth Chapter 1 (4 CE Hours ~ $24.00)...... Page 1 Final Examination Questions...... Page 14

Early Attachment Theory: Research and Clinical Applications Chapter 2 (3 CE Hours ~ $18.00)...... Page 15 Final Examination Questions...... Page 26

The Returning U.S. Veteran of Modern War: Background Issues, Chapter 3 Assessment and Treatment (3 CE Hours ~ $18 .00)...... Page 27 Final Examination Questions...... Page 37

Complete all 10 hours allowed through home-study for only $50.00!

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II CHAPTER 1  Bullying occurs in all geographic regions and is also important for practitioners to facilitate BULLYING IN CHILDREN AND YOUTH all types of schools. It involves large numbers healing in bullies, the perpetrators, as well as in (4 CE HOURS) of children and youth from the United environments where bullying begins and thrives. States in all socioeconomic backgrounds, in This course will define bullying and its effects Course objectives racial groups that have been studied and in on children, youth and families, as well as In this course, learners will be able to: areas of different population density (urban, populations most vulnerable to being bullied, ! ! Define bullying as it applies to children and suburban and rural settings). Whereas social and settings in which it most often occurs. In youth. stereotypes may convey the impression that addition, it will discuss interventions that mental ! ! Identify the characteristics of child and youth certain ethnic or socioeconomic groups are health professionals can use to prevent and heal bullies. more likely to bully and perpetrate violence, bullying. ! ! Understand the various forms of and settings research reveals no significant racial Bullying where bullying occurs. differences in the rates of bullying (Nasel, ! Bullying is a behavior linked to child ! Identify the characteristic symptoms of a 2001). development, relationship formation and child or youth who is being bullied.  Most students report that when they are ! psychological well-being. Bullying is a ! Understand how to guide parents to protect bullied, adults do not notice. learned behavior. According to the American their children from bullies.  In a 2001 study by Kaiser Foundation in ! Psychological Association (APA), bullying is ! Understand that bullying is a worldwide conjunction with Nickelodeon TV network commonly characterized as aggressive behavior problem. and Children Now, 86 percent of children ! that: ! Learn statistics that relate to bullying in ages 12-15 interviewed said they get teased  Is intended to cause distress or harm. children and youth within the United States. or bullied at school – making bullying more !  Involves an imbalance of power or strength ! Provide prevention and intervention prevalent than smoking, alcohol, drugs or sex between the aggressor and the victim. information to assist children, youth and among this age group.  Commonly occurs repeatedly over time families when they’ve experienced bullying.  According to the National Youth Violence (APA, 2004). Introduction Prevention Resource Center, 30 percent of I shall remember and will never forget teens in the U.S. are estimated to be involved In its 2004 Resolution on Bullying Among Monday: my money was taken. in bullying in one way or another. Children and Youth, the APA described bullying  Tuesday: names called.  Victims are always vulnerable in some way. as taking many forms, including physical Wednesday: my uniform torn, They are more anxious and insecure than bullying; teasing or name-calling; social Thursday: my body pouring with blood. other students (Olweus, 1993). exclusion; peer sexual harassment; bullying  Friday: it’s ended.  Bullying is a worldwide problem that ranges about race, ethnicity, religion, disability, sexual Saturday: freedom… from England to Japan to New Zealand to orientation and gender identity; and cyber British Columbia to South America. Bullying bullying. These words are from the final pages of a diary can affect victims far away because it now Bullying could also be defined as “actualized written by a 13-year-old boy, a victim of bullying occurs through cyberspace, including through arrogance.” It is abusive behavior by one or more who was found dead hanging from the banister e-mail, cell phone texting, instant messaging, person(s) against a victim or victims. While railing at his home on the Sunday after he made blogging and social networking sites. his final entry (Taken from the book “Bullycide, bullying can be a direct attack such as teasing, Death at Playtime: An expose of Child Suicide Until recently, and even now, the common thread taunting, threatening, stalking, name-calling, Caused by Bullying,” Harper/Collins 2003). in all countries is that children are relentlessly hitting, making threats, coercion and stealing, it and repeatedly bullied without significant can also be subtler through malicious gossiping, Bullying in children and youth has become objections or outrage from responsible adults. spreading rumors and intentional exclusion. All excessively widespread and aggressive in the forms of bullying result in victims becoming 21st century. Bullying behavior causes a harmful The mental health professional’s socially rejected and isolated because of physical social, physical, psychological and academic responsibility or psychological intimidation that occurs impact on personal well-being in very young The most horrifying and damaging effect of repeatedly over time to create an ongoing pattern children to older teenagers. And through their bullying is child or adolescent suicide. Because of harassment and abuse. own actions and inaction of others who hold suicidal ideation and suicide occurs among young responsible roles, bullies learn that antisocial bullying victims, it is essential for mental health As noted above, bullying is an imbalance in behavior and exerting control over others is providers to help caregivers to identify and real or perceived power that exists between acceptable and that it works. Bullying creates intervene on behalf of their bullied children. It the bully and the victim (U.S. Department of an atmosphere that is unhealthy for everyone. It is also essential that mental health professionals Education, 2010). When defining bullying, other interferes with child and youth development and help caregivers to identify the key gatekeepers, sources often include the words “repeated,” can lead to suicide and school violence. those people who regularly encounter individuals “ongoing” and “exposed over time” in addition or families in distress, and who can identify to intentionally inflicting or attempting to The pioneering work of Dan Olweus in Norway and refer children and youth at risk for suicide. inflict injury or discomfort on another (Olweus, and Sweden as well as other researchers has Key gatekeepers include teachers and school 2001). Bullying intensity can range from mild found that: staff, school health personnel, clergy, natural to moderate to severe. In addition, harm to the  Children and youth in the United States are community helpers, extended family and victim is not intentionally provoked by the victim teased, threatened or tormented by bullies to emergency health care personnel. himself. The various forms of bullying include: the extent that 160,000 students skip school  Physical – hitting, kicking, shoving, spitting, each day. While suicide is an outcome at the end of the hair pulling, strangling and so on.   The most common forms of bullying in bullying spectrum, bullying can also have a  Verbal – taunting, teasing, name calling, hate middle and high school are related to life-long effect on the emotional well-being of speech, threatening. physical appearance, disabilities, perceived victims, affecting them on many levels, including  Emotional/relational – rejection or sexual orientation or gender expression, and long-term psychological and physical wellbeing. exclusion of others, rumors, gossip, forcing exhibiting perceived or true lesbian, gay, In addition, while mental health providers must others to do things.  bisexual or transgender-related characteristics pay attention to supporting children, youth  Sexual – unwanted hugs, punches, slaps or (Survey, 2008). and families when they experience bullying, it sexual jokes.

Elite Page 1  Cyber bullying – using Internet, e-mails, away and feel helpless and afraid themselves.  Feelings of loneliness. instant messaging, text messages and social Feeling emboldened, the bully escalates  Suicidal ideation. networking sites to taunt, tease, harass and his actions toward the victim. Two types of  Higher rates of school absenteeism. spread rumors or gossip. bystanders may surface; those that move away A child may show few or many signs of bullying. from the victim and clear of the bully, and those The bullying relationship affirms the power For example, warning signs that a child is bullied that join forces with the bully. needs of the abuser and takes advantage of the at school include: vulnerability of the victim in a situation where Victims  An abrupt lack of interest in school or refusal lack of external support leaves the victim feeling Victims of bullying are likely to be anxious, to go to school. isolated and exposed, and in which there are insecure, cautious, and suffer from low self-  Takes an unusual route to school. lasting consequences for the victim as a damaged esteem, rarely defending themselves or retaliating  Suffers a drop in grades. self-concept. when confronted by bullies. They may lack  Few or no friends.  Withdraws from family and school activities. Bullies may work alone or in a group, and social skills and, for many reasons, tend to be  Is sad, sullen or angry after receiving a phone the victim is usually isolated. Witnesses or isolated. They may appear physically, mentally, call or e-mail. bystanders are frequently present and may feel emotionally or sexually oriented differently than  Uses derogatory or demeaning language paralyzed by their own sense of vulnerability to their peers. Depending on their family dynamics, when talking about peers. the bully (Ressenger, 2010). Bullying can occur they may or may not have overly protective  Stops talking about peers and everyday among peer groups, sibling groups or work parents. They may have been victims of parental activities. groups. Or bullying can be random with bullies or sibling bullying and simply have not learned  Disheveled, torn or missing clothing. not knowing their victims. how to self-nurture, assert themselves or regulate their emotions when stressed. A child may never  Physical injuries. Power and bullying suffer from bullying until the family moves to a  Unable to sleep, sleeps too much, or is Webster’s New World College Dictionary new school where the values and environment are exhausted. (Macmillan, fourth edition, 1999) provides dramatically different from what they’ve known. The victim feels helpless and can develop severe various definitions of power. The definition most Because of new stressor, a child’s self-confidence depression and rage. He is angry at himself, at closely associated with bullying states, “The can plummet. Jackson is an example of such a observers, and at adults who didn’t intervene as ability to control others, sway, influence. Power child. well as at the bully. He may suffer academically, denotes the inherent ability or the admitted develop psychosomatic complaints, withdraw right to rule, govern and determine. Authority Jackson’s story from family and friends, and fantasize about refers to the power, because of rank or office to Jackson was raised by his single mom in a revenge. give commands, enforce obedience and make small, rural community in Upper Michigan. His decisions.” classmates knew Jackson all his life and were A tragic story happy to play with this little boy who had a slight South Hadley, Mass., is a place where severe Authors, Suellen and Paul Fried, in their book, speech impediment. When Jackson was in the bullying ended in death for one young student in “Bullies and Victims: Helping Your Child sixth grade, his mother met a man on a business 2010. Nine students were charged in connection Through the Schoolyard Battlefield,” (New York: trip and subsequently moved Jackson to Detroit with the death of Phoebe Prince, a 15-year-old M. Evans and Company, Inc, 1996), include six when she and the man were married. teenager formerly from Ireland, who killed factors that further identify bullying: herself after having been harassed by girls at her 1. Intent to harm – The perpetrator finds Jackson was suddenly thrust into an environment high school. Six of the bullies were charged with pleasure in the taunting and continues even where there were more children in his middle felonies and three more were also charged, but as when the victim’s distress is obvious. school class than there were in his entire school juveniles. 2. Intensity and duration – The teasing up north. The kids dressed differently and there continues over a long period, and the degree was much confusion every time they changed Massachusetts district attorney Elizabeth of taunting is damaging to the self-esteem of classes during the school day. Sensing his wide- Scheibel charged the group with “relationship the victim. eyed, frightened insecurity, a girl his age decided aggression,” which included three months of 3. Power of the abuser – The abuser maintains to help him. Unfortunately, she’d been the target verbal insults and physical threats. Phoebe, power because of age, strength, size or for teasing because she had physically developed with a history of depression, was also targeted gender. earlier than other girls. Noticing the girl paying electronically on Facebook where she received 4. Vulnerability of the victim – The victim is attention to Jackson prompted taunting from messages urging her to kill herself. In addition, more sensitive to teasing, cannot adequately her bullies, and Jackson was drawn into her the young victim was also targeted in the library, defend him- or herself and has physical or victimized world. In addition, they noticed hallways, shoved into lockers and taunted psychological qualities that make him or her Jackson’s speech and began to taunt him as well. walking home from school. According to some more prone to vulnerability. As time passed, Jackson became their target. students, teachers observed a few of the incidents. 5. Lack of support – The victim feels isolated Jackson was miserable and begged his mother to And on the day she died, the bullying was and exposed. Often, the victim is afraid to move back “home.” His mother, caught up in her extremely intense when South Hadley students report the abuse for fear of retaliation. new world and relationship, told her son to avoid followed her home, calling her offensive names 6. Consequences – The damage to self- these kids, and his stepfather told him to stand his while throwing a large drink in her direction. concept is long lasting, and the impact on the ground and learn to fight “like a man.” Jackson Surprisingly, students interviewed following victim leads to behavior marked by either felt psychologically abandoned by his caregivers, her death didn’t see her bullying as a serious withdrawal or aggression. and the school officials were too busy with their problem, calling it “normal girl drama.” As the According to author Barbara Coloroso, children “more urgent issues” to address the bullying at case drew nationwide attention and outrage, the and youth who bully look for potential targets Jackson’s school. question became, “Where were the adults?” The and often search for potential bystanders. Once When children and youth are bullied South Hadley High School principal said: “There targeted, the victim is depersonalized in some Bullying causes negative psychosocial were instances of name-calling with Phoebe the way by the bully through taunts, ridicule and/ functioning in victims. Problems that occur week before she died. These were brought to or harassing physical behavior. The bullied child because of bullying (APA, 2004) include: our attention, and we dealt with those kids right or youth moves away in fear and blames him- or  Lowered self-esteem. away. We also talked to her, we had her working herself for the attack. Often bystanders move  Higher rates of depression. with a school counselor, we talked to her mom.”  Anxiety. Page 2 Elite (Pytel, 2010). This begs the question: Could Post-traumatic stress disorder and depression 1. Passive victims – Representing the largest the school have done anything else to prevent contribute to intense anxiety that prompts group, passive victims do not directly Phoebe’s suicide? high-risk behaviors in children and youth. Both provoke bullies; they may appear to be are often present in young victims of bullying. physically or emotionally weaker and do not Experts remain divided on whether legal action Suicide is an action taken at the end of the defend themselves. They may have few or no was the right choice. They wonder whether depression spectrum and has been attempted friends and can be overly protected by their children should be judged solely on group by too many victims. When young traumatized parents. Heather is an example: behavior, or did taking legal action finally bring victims suffer from depression and bullying, the issue to light? Heather they can become intensely distraught and Heather was adopted at birth and cherished hyper-reactive and become more vulnerable to Bullying, trauma and post-traumatic by her adoptive parents. She was dressed experiencing suicide ideation and attempting stress disorder in beautiful clothes and exposed to many suicide. Hyper-reactivity is one PTSD and acute Bullying has been linked to creating trauma in privileges, such as exotic vacations and stress symptom. children and youth. And trauma can create acute learning opportunities. As Heather grew stress disorder and in more severe cases post- Anthony is someone who at an early age older, she spent more time in her parents’ traumatic stress disorder. The latter, known as developed post-traumatic stress disorder and was company than she did playing with other PTSD, is marked by clear physiological changes also bullied. children. They were overly cautious of that occur because of exposure to life-threatening Heather’s safety and often worried when events and impairs physical, cognitive, social, Anthony she was out of their purview. When Heather emotional, self-regulation and relational daily Anthony suffered from emotional developmental became older, she asked her parents to take functioning. Children and youth who may be disruptions when he was removed from his home her out of private school and place her in more vulnerable to acquire acute stress or post- and placed in foster care because of sexual abuse public school. When she entered public traumatic stress disorders are likely to: by his mother’s boyfriend at age 5. Anthony school for the first time, at age 11, she asked   Have had prior vulnerability factors that also suffered from learning disabilities and was some of the students where she could find included early trauma, no functional social frequently teased by his young schoolmates. the bottled water machine and told some of support, concurrent stress and genetic As he grew older, he also grew more and more her new “friends” about her family and the makeup. oppositional and was moved to other out-of- fun time they all had in France the previous   Report greater perceived threat or danger, home placements. At age 12, he was obese, summer. Her classmates soon erroneously suffering, terror and horror, or fear. temperamental and sad. His mother’s parental labeled Heather “a spoiled rich girl” and   Have exposure to social environments rights had been terminated, and there was little began to taunt her at school. Heather was that promote self-hatred, shame, guilt and hope of locating his biological father. Different surprised and hurt by their comments and stigmatization. case managers came in and out of his life, but he didn’t understand why she’d been targeted.   Have experienced greater stressors with was moved to a therapeutic foster home where She didn’t know how to defend herself and regard to unpredictability, uncontrollability, he met new loving foster parents with grown simply remained silent during her abuse. The sexual victimization, betrayal, and real or children. At the same time, he was introduced taunts grew, and eventually Heather’s parents perceived responsibility. to a young therapist who quickly diagnosed him and school officials intervened when other with PTSD, and once again, Anthony became Indicators that bullied kids may have acquired students began to throw food at her in the acquainted with yet another mental health acute stress or PTSD include: cafeteria.  professional.  Persistently re-experiencing the trauma 2. Provocative victims – These youths through images, thoughts, or perceptions His new foster parents knew he was vulnerable represent a smaller group than passive as recurrent and intrusive distressing at his new school because of his prior academic victims and are actually aggressive recollections of the traumatic event; recurring struggles and were prepared for handling themselves, especially toward others who distressing dreams of the event; acting Anthony’s explosive temper. It didn’t take appear weaker than they. They may lack or feeling as if the traumatic event were long, because bullies at school picked up on his anger management skills and are not liked by recurring; intense psychological distress at vulnerability. They even devised a plan to pose as peers. They may react negatively to conflict exposure to internal or external cues that his friend and later verbally and physically harm or losing. Jim is an example. symbolize or resemble an aspect of the him. For a brief week, they included him in their traumatic event; and physiological reactivity group and made him an “honorary member.” The Jim on exposure to internal or external cues youth beamed. The group was about to attack him Jim, age 14, loves sports. He was always that symbolize or resemble aspects of the on a Friday afternoon when a teacher happened eager to join a neighborhood game of traumatic event. to see their suspicious activity in a secluded touch football, but became very upset  Persistent avoidance of stimuli associated part of the gym. He was able to intercede before when he lost a game or made a bad play. with the trauma and numbing of general the boys could do real harm, but Anthony was The neighborhood kids would avoid Jim responsiveness not present before the trauma devastated by their behavior. He spent the sometimes when they set up a game simply including efforts to avoid thoughts or feelings weekend sleeping and eating. His foster parents because Jim often lost his temper when they of conversations associated with the trauma; were caught off guard by his depression and were just trying to have fun. When Jim began avoiding activities, places or people that lethargy, and especially when Anthony began to his freshman year in high school, he joined arouse recollections of the trauma; inability talk about dying. They asked him if he intended the junior varsity basketball team and was to recall an important aspect of the trauma; to hurt himself, and the boy replied that it had thrilled to practice, but got easily angered markedly diminished interest or participation been on his mind for a while. “He just didn’t when he wasn’t thrown the ball or when he in significant activities; feeling detachment see the point.” If it had not been for his foster fouled out of the game. The other players or estrangement from others; and restricted parents’ quick and insightful actions as well as soon excluded Jim from their social activities range of affect. his therapist’s intensive intervention, Anthony and began to call him derogatory names  Persistent symptoms of increased arousal might have attempted to take his life. while “accidentally” elbowing him during practices. that include difficulty falling or staying Different types of victims asleep; irritability or outbursts of anger; According to researcher Olweus, there are three 3. Bully-victims – These people represent difficulty concentrating; hyper-vigilance; and types of bullying victims: a small percentage of bullies and have exaggerated startle response (Brohl, 2008). experienced bullying themselves. They are

Elite Page 3 typically physically weaker than their bullies,  Narrow, isolated or unmonitored areas. A cyber bully can use the following forums to but are stronger than those they bully. Mary is  Lack of policies that pertain to student bully victims. They include: an example. transitions to and from class and before or  Blogs (web logs). Blogs provide users with after school. the tools to publish personal content online Mary  Lack of support for students with special about a range of subjects. These topic areas Mary was the oldest of seven children and a needs. connect children and youth with similar surrogate mother to many of them, especially  Public humiliation from adult supervisors. interests. when her parents drank. She was also on  Overlooking signs of bullying and  Chat rooms. Chat rooms are virtual the front line when it came to her father’s discouraging disclosure (Stephenson and meeting places where users find people to temper, because she was the one he struck Smith, 1994). communicate with online. Chat rooms can when he lost his temper. His size and strength accommodate many users simultaneously. overwhelmed Mary, while her mother stood But victimization isn’t limited to schools.  Instant messaging (IM). Two or more kids silently by when her husband went on a Siblings bully one another, and the effects can can communicate online, and IM users create rampage. Mary grew up being bullied by be devastating as well, except that psychological contact lists. her father – the person who should have harm can occur on an even deeper level because  Message boards. Kids with like interests protected her. As they prepared to walk to the home is where children first learn to feel safe. discuss them online. the corner bar on Friday evenings, Mary’s In addition, children are bullied in their  Short message service (SMS). Text parents always directed her to watch her own neighborhoods where there is a lack of messages can be sent with cell phones. younger brothers and sisters. At age 12, she responsible adult supervision and unsafe playing  E-mail (electronic mail). A service provider towered over the little ones and was much areas. Says Todd: “I hated my neighborhood. can send messages from one person to stronger than her closest sibling. But instead There were a bunch of kids that had been there another. of being sensitive to their needs, Mary simply long before I moved in and they all hung together  Discussion groups (newsgroups). Group used her strength and power to bully them. cause their daddies had all hung together when forums are devoted to one topic, and When they needed help getting ready for bed, they were young, too. It was like a fraternity for messages are posted in bulletin form and Mary slapped and shouted at them. She called 10-year-olds, for god’s sake, and I was the new remain on a server instead of being e-mailed. them names and frightened them by saying kid that never fit in. I remember one time they she’d call the police to take them away if they In a survey of randomly selected middle called me to their fort, and when I climbed up in didn’t behave. schoolers in one of the U.S.’s largest school the tree, they all raced down the ladder and left districts, researchers Patchin and Hinduja found Settings where bullying occurs me there all alone, calling me a loser.” that cyber bullying victims were 1.9 times more High-risk areas for bullying are places where Malls, theaters and other public places are likely and cyber bullying offenders were 1.5 there is no adult supervision, inadequate adult settings where bullying also occurs. One latency times more likely to have attempted suicide than supervision or lack of structure – areas where age young woman reported: “I was waiting for those who were not cyber bullying victims or children have nothing to do or are free to do as my sister to meet me at the food court at the offenders. The authors concluded that suicide they wish. mall, and all of a sudden a group of about five prevention and intervention should be included Bullying occurs while children travel to and boys around my age sat down near my table. in schools’ bullying and cyber bullying response from school, but it is most likely to happen They began to laugh, and when I turned around, program. on school property (Beane, 2008). Almost 10 they were making nasty gestures at me. I felt The most common forms of offending were percent of students are bullied at school (Pawlik- humiliated and walked quickly to toward the posting online information about another Kienlen, 2007). Some of the school-related places mall bathroom. I could hear them laughing and person to make others laugh, and getting an include bus stops, bathrooms, buses, hallways, shouting comments such as, ‘Look at that fat b. upsetting e-mail from someone victims know cafeterias, playgrounds, locker rooms, gyms, She’s asking for it.’” parking lots, stairwells, between buildings and (NetFamilyNews.org. 2010). Adolescents are also bullied at the workplace, even classrooms. Sports activities can set the and the effects include loss of productivity and Megan’s story stage for bullying to occur as well. While not high absenteeism rates. Sara said this: “I don’t A middle-aged Missouri woman was charged discussed very openly, sports bullying occurs know why the guys at work give me such a hard with cyber bullying 13-year-old Megan Meier, when violence, taunting and humiliation is often time. I really need this job, and they goof off. a youth suffering from depression and attention viewed as normal behavior and assigned as just When I’m serious, they just make fun of me and deficit hyperactivity disorder. Megan took her a place where it’s okay to have a “competitive call me all kinds of names behind my boss’s own life after receiving harassing e-mails from edge.” The adults in charge of school sports back. I get so nervous before going to work that the woman, who was posing as a young boy programs most often set the tone for bullying sometimes I’ve had to call in sick. The problem interested in Megan. to occur. Sometimes these adults can contribute is, I know they’d take it out on me if I reported The woman was convicted of three minor to bullying through their excessive aggressive them.” offenses after federal prosecutors were able to behavior and unreasonable expectations of their charge her with conspiring to violate the fine players. Coaches have been known to publicly Cyber bullying print in MySpace’s agreement that addresses humiliate and verbally abuse their students, in Cyber bullying is becoming a serious problem creating fictitious identity and harassment. addition to encouraging bullying behavior in their among children and youth, and yet fewer than 30 team members toward rival team members. At the percent of the victims know their bullies. Cyber Cyber bullying creates the same effects as other same time, parents overlook these behaviors and bullying is any harassment that occurs via the types of bullying. Victims feel overwhelmed encourage their kids to “suck it up.” Internet. Name calling in chat rooms, posting and helpless. Bullies can remain somewhat anonymous and may be more apt to bully because Factors that contribute to school bullying fake profiles on websites, vicious forum posts and cruel e-mail messages are different forms of of their anonymity. It can prompt behavior include: cyber bullying. In addition, school bulletin boards that normally would not occur because it is  No anti-bullying policy. can be spammed with hateful rumors directed convenient and detached.  Crowded locker rooms. toward a specific student, and fictitious profiles  Inconsistent discipline. Warning signs when a child is being cyberbullied on a social networking site can prompt a victim  Inconsistent behavior standards. include: to falsely engage with someone who appears to   High teacher turnover.  There are large cell phone charges from the be someone else.  Low staff morale. same number.

Page 4 Elite  The child appears secretive about using the and physical bullying often occur at the same Psychological, social and relational computer. time, and many times begin with just one act and bullying   The child sends and receives coded messages. escalate to the point of multiple acts by multiple Bullying isn’t limited to pushes and verbal   A child visits websites that promote negative bullies. For example, teasing can lead to taunting, attacks. Psychological bullying is behavior that messages. but teasing is not the same as taunting. Teasing is intentionally harms another person by using   A child becomes upset, irritable and supposedly a “fun” thing to do with friends, but social manipulation that includes: emotional after spending time texting or on taunting is a choice to bully someone for whom  Ostracizing or ignoring peers. the computer. you have contempt. Author Barbara Coloroso  Not inviting peers to join groups or activities.   A child has personal photos posted without defines teasing and taunting differently:  Spreading lies or rumors. his/her permission.  Teasing:  Name-calling.  A child spends excessive time using chat  1. Allows the teaser and person teased to swap  Teasing hurtfully. rooms. roles with ease. Psychological bullying has effects for victims Author Allan L. Beane, Ph.D., outlines several 2. Isn’t intended to hurt the other person. that include feeling helpless, out of control, “Cyber Rules.” They include: 3. Maintains the basic dignity of everyone low self-esteem, and at the end of the spectrum,   Never provide personal information of an involved. experiencing acute stress and long-term intimate nature that should be discussed 4. Pokes fun in a lighthearted, clever and benign symptoms of post-traumatic stress disorder only with parents, family, close friends or way. (Brohl, 2008). professionals. 5. Is meant to get both parties to laugh.  Never give out any passwords to anyone 6. Is only a small part of the activities shared by Victims may experience insomnia, anxiety and other than parents. kids who have something in common. depression.   Never give out personal contact information. 7. Is innocent in motive. Tied closely to psychological bullying is   Never use inappropriate language and never 8. Is discontinued when the person teased social and relational bullying. This type of write anything that you wouldn’t mind the becomes upset or objects to the teasing. bullying causes negative feelings in victims and world reading. Taunting: encourages social isolation and exclusion. Social  Do not participate in gossip or spreading 1. Is based on an imbalance of power and is and relational bullying often interfaces with rumors. Simply stop communicating. one-sided: the bully taunts while the bullied psychological bullying and can include:  Never upload or download photos, music or child is taunted. 1. Passing hurtful notes on to other children videos without parent’s permission. 2. Is intended to harm. and youth, or using graffiti to send pejorative  Treat others online the way you want to be 3. Involves humiliating, cruel, demeaning, or messages about a particular person. treated. bigoted comments thinly disguised as jokes. 2. Embarrassment and humiliation, such as  Immediately report any hurtful comments and 4. Includes laughter directed at the target, not making lewd noises when someone begins to threats against yourself or anyone else and with the target. speak in class. immediately stop communication. 5. Is meant to diminish the sense of self-worth 3. Threatening gestures and behaviors toward  Internet time should be limited and agreed of the target. victims. upon with parents (Beane, 2008). 6. Induces fear of further taunting or can be a 4. Social rejection and isolation through group Reporting cyber bullying prelude to physical bullying. exclusion. When children and youth are threatened, make 7. Is sinister in motive. 5. Spreading nasty and malicious rumors and racist remarks, or spread malicious gossip to 8. Continues especially when the targeted child lies. attempt slander online or otherwise, they should becomes distressed or objects to the taunt. 6. Destroying and manipulating relationships. be reported to the police. It is important to 9. There is no playfulness associated with Sexual bullying maintain a record of threats. However, printouts, taunting. Physical, verbal and psychological bullying according to Beane, are generally not considered 10. It is intended to isolate the victim. frequently targets a child or youth’s sexuality. admissible evidence. The author suggests using Sibling taunting Questionnaire responses from a study conducted a monitoring software program that collects and by the American Association of University For example, an older sibling begins to tease his preserves electronic evidence. The author also Women Educational Foundation (“Hostile younger sister about wearing glasses, “Hey four cautions victims or their caregivers not to install Hallways” study, 1993) from over 1,600 students eyes, can you finally read?” At first, his sister or remove any programs or take other remedial from eighth through 11th grade provided some laughs at his remark. She looks up to him and action on the computer or communication device unsettling information: appreciates his attention. during this process, because it will adversely  86 percent of girls reported being sexually affect the investigation. Her brother continues, “Mom told me you were harassed by their peers.  A sample list of cyber bullying and Internet the only one in the family who ever needed  25 percent of girls reported being sexually websites created to prevent, support victims and glasses. That’s what they call a defect. You’re harassed by school staff.  halt bullying is included here: defective.” The little girl begins to look confused,  85 percent of girls and 76 percent of  www.cybertiplin.com “Did her mother think she was defective? What boys reported having experienced sexual  www.safekids.com did defective mean?” It didn’t sound good. harassment.   www.isafe.org Her brother, sensing his sister’s concern begins  65 percent of girls reported being touched,  www.stopbullying.org to enjoy her reaction. He’s feeling as though he grabbed or pinched in a sexual way.   www.cyberbullyinghelp.com has some control over her emotions when he  13 percent of girls and 9 percent of boys  www.stoptextbullyhelp.com sees her face redden. His remarks continue to reported being forced to do something sexual  www.wiredsafety.org escalate until his sister begins to cry. Noticing other than kissing.   www.netfamilynews.org her distress, his mother asks what happened, and  24 percent of girls stayed home from school he behaves as though he hasn’t a clue. He knew or cut classes to avoid sexual harassment. Bullying behavior has many layers his sister could or would not strike back. There  One third reported experiencing sexual There are several layers to bullying. Complex was no well-intentioned give and take during bullying in sixth grade or earlier. bullying combines different levels and types of the siblings’ interaction. Instead, the young  The youth reported that they’d experienced aggression as bullies grow to intimate and harm bully became excited and felt powerful over the sexual harassment in the school hallways their victims over time. Psychological, verbal success of the attack. Elite Page 5 (73 percent), classroom (63 percent), school and shunning someone because of their sexual there are sub-group child and youth populations grounds (48 percent) and in the cafeteria (34 orientation. In addition, it includes displaying that been historically targeted for bullying. percent). sexually explicit material intended to humiliate or Teenage bullying degrade another person, sexually explicit graffiti Girls who mature early and boys who mature Teenage bullying is a serious issue that can and displaying sexually explicit material that late are at high risk for being sexually bullied. lead to mental health problems and devastating targets victims, such as graffiti in bathrooms. The study also pointed to a serious educational consequences in victims. The Columbine High consequence as well as significant threats to the Physical sexual bullying can include pinching, School shooters, for example, had been long- physical and emotional well-being of targeted bra snapping, pulling down pants or pulling up time victims of bullying. Eric Harris and Dylan kids. a skirt, brushing against the body in a sexual Klebold killed 12 classmates and one teacher, and manner, sexual touching or grabbing or sexual While author Coloroso defines teasing and injured 18 other students before they took their assault (Criminal activity can include sexual taunting differently, she also defines flirting and own lives. These two youth had been relentlessly bullying). verbal sexual bullying differently as well. When taunted at school over a period of time. At one she defines “flirting,” she states: Miranda’s story point, they were surrounded and squirted with ketchup packets while teachers observed. Eric’s  Flirting … Miranda killed herself when she was just 14 suicide note mentioned that in their minds, it was ŠŠ Allows and invites both persons to swap years old. When she was 12, she had reported “payback time.” roles with ease. being raped by a prominent 16-year-old athlete ŠŠ Isn’t intended to hurt the other person; is in her rural community. The young man pleaded According to Teens Health, “Bullying occurs an expression of desire. guilty and was placed on probation. The school when a person is picked on over and over again ŠŠ Maintains the basic dignity of both backlash included calling her terrible names by an individual or a group with more power, persons. and blaming her for the rape. In one lawsuit, her either in terms of physical strength or social ŠŠ Is meant to be flattering and parents stated that a teacher forced her to stand standing.” Some victims experience a decline in complimentary. next to the rapist, even though there had been a school performance and become isolated. Phoebe ŠŠ Is an invitation to have fun together and restraining order against him (Coloroso, 2008). Prince’s suicide is an example of what can occur enjoy each other’s company. at the end of the spectrum as a result of teen Physical bullying ŠŠ Invites sexual attention. bullying. ŠŠ Is intended to make the other person feel Common bullying behaviors involve physical Teen bystanders or other witnesses to teen wanted, attractive and in control. contact, including:  bullying are often at a loss when they report their ŠŠ Is discontinued when the person who is  Pinching.  feelings watching bullying occur. The National being flirted with becomes upset, objects  Pushing, shoving and tripping.  Youth Violence Prevention Resource Center to the flirting or is not interested.  Kicking.  (NYVPRC) shares these statistics: ŠŠ Is playful.  Hitting, slapping, elbowing and shouldering  88 percent of junior high and senior high  Whereas, verbal sexual bullying … (slamming).  school students said that they battled feelings ŠŠ Is based on an imbalance of power and is  Restraining.  of guilt and helplessness after witnessing one-sided: the bully sexually taunts, and  Flushing someone’s head in the toilet bullying. the victim is demeaned and degraded. (swirling).   The reactions ranged from blaming the victim ŠŠ Is intended to harm and exploit.  Forcing someone into small spaces such as to avoiding the bully. ŠŠ Is invasive and intended to assert the lockers or closets.   Fear of being targeted themselves. status of the bully.  Spitting, throwing objects – even food.  ŠŠ Is intended to be degrading or  Threatening body language. Gay, lesbian bisexual and transgender demeaning. Many physical forms of bullying are completed teens (GLBT) ŠŠ Is intended to express control and without adult notice. It can be humiliating and Bullying can begin at an early age for children domination. embarrassing to be pushed and shoved in front of who are, erroneously or not, identified or self- ŠŠ Is intended to violate the boundaries of friends, especially when bullied victims fall down identified as gay, lesbian, bisexual or transgender. the target. or are some way physically put in the position of One victim reported that taunts were targeted ŠŠ Is intended to make the other person feel appearing even more vulnerable. at him when he entered kindergarten. The boys rejected, ugly, degraded, powerless, or in his class called him a “stupid girl” because uncomfortable. Restraining someone against their will can also be extremely harmful to victims. As author he preferred dolls and tried on dress-up clothes ŠŠ Continues, especially when victim during free play. becomes distressed or objects to the Allen Beane reports in his book, “Protect Your sexually charged comment. Child From Bullying,” it creates multilevels of According to one study, 31 percent of gay youth bullying. He states, “One 16-year-old girl was had been threatened or injured at school in the In sexual bullying, there is no invitation – just an held down on the floor by a group of girls who past year (Bart, 1998). Other statistics include: attack. The victim is embarrassed, humiliated and then marked all over her face with a permanent  Gay, lesbian and bisexual youth are two to shamed and tends to feel powerless. If the victim marker. You can imagine how hurt she was three times more likely to attempt suicide protests, she or he is assigned a pejorative name emotionally.” than their heterosexual counterparts (HHS such as “bitch,” “queer” or “loser.” Populations of children and youth most 1989). “Can you espouse the values of fairness and  Gay teens in the U.S. schools are often often targeted respect, and at the same time discriminate subjected to such intense bullying that they’re Both males and females are victims of bullying and injure? Sexist and sexually harassing unable to receive an adequate education and range in age as young as toddlers and as behaviors are dissatisfying and therefore (Chase, 2001). old as young adults in college. An 8-year-old, undesirable actions that hurt people and  GLBT students are more apt to skip school thought to be the youngest child to die from are unworthy of people of intelligence and because of the fear, threats and property bullying in England, hung herself with her jump integrity.” vandalism directed at them. Twenty-two rope because of the intolerable bullying she Peter Minor percent of gay respondents had skipped experienced at school (Coloroso, 2008). Females Sexual respect curriculum school in the past month because they felt represent a larger percentage of victims who unsafe there (Ibid). Sexual bullying can include staring at genital suffer from sexual bullying, in particular. Yet, areas, leering or making obscene gestures,

Page 6 Elite  28 percent of gay students will drop out of are more likely to be victimized by peers.  The feeling of entitlement and privilege school, more than three times the national Frequently, these children report being called to control, dominate and subjugate, and average for heterosexual students (Chase, names related to their disability (Dawkins, otherwise abuse another human being. 2001). 1996).  Intolerance toward differences – believes  GLBT youth feel they have nowhere to turn.  Children with hemiplegia or paralysis of one “different” means inferior and thus not Four out of five gay and lesbian students side of their body are more likely than other worthy of respect. say they don’t know one supportive adult at children their age to be victimized by peers In his book, author Allan Beane states that some school (Washington Post, 2001). and to have fewer friends than other children experts believe that aggression is a basic, inherent (Yude, Goodman & McConachie, 1998). Schools and other community environments human trait, and that certain factors could  Children with diabetes and who are where children and youth gather should be increase levels of aggression beyond acceptable dependent on insulin may be especially safe for all kids. For every GLBT youth who norms. High levels of testosterone in men, for vulnerable to peer bullying (Storch, et al, reported being targeted for anti-gay harassment, example, can encourage aggressive behavior that 2004). four heterosexual youths reported harassment or inflicts harm and leads to antisocial behaviors.  Children who stutter may be more likely violence for being perceived as gay or lesbian. Higher levels of testosterone have been found than their peers to be bullied. In one study, Kids who reported there was a supportive faculty even in some preschool bullies. 83 percent of adults who had problems with with an openly gay staff were more likely to feel stammering as children said that they had In addition, a University of Michigan study by as if they belonged in their school. been teased or bullied; 71 percent of those Michelle Wirth and Olvier Schultheiss appears Obese children and youth who had been bullied said it happened at least to have found that the human brain may have Being obese by itself appears to increase once a week (Hugh-Jones & Smith, 1999). a built-in mechanism that detects and responds the likelihood of being a victim of bullying. to emotions perceived in the faces of others. Usually children are able to identify when their Researchers report that 17 percent of children Participants in the study with high levels of peers are bullying them. Sometimes, however, ages 6-11 were estimated to be obese between testosterone seemed to enjoy or be rewarded by children with disabilities do not realize they are 2003 and 2006, and parents of these children an annoyed look or angry face that was prompted being targeted. They may believe, for example, report that they rate bullying as their top health by mistreatment. It was surmised that bullies that they have a new friend, when in fact this concern for their kids. feel rewarded for mistreating others (Wirth and “friend” is making fun of them. Schultheiss, 2007). In a study conducted by the Eunice Kennedy Can bullying a child or youth with Shriver National Institute of Child Health and According to the U.S. Department of Health and Development, obese children in the early grades disabilities be illegal? Human Services, there is no one single cause of school are more likely to be bullied than Yes! Bullying behavior may cross the line of bullying among children and youth. Rather, thinner kids, contributing to depression, anxiety to become “disability harassment,” which is individual, family, peer, school and community and loneliness. The study found that children illegal under Section 504 of the Rehabilitation factors can place a child or youth at risk for ages 8-11 were more likely to be bullied than Act of 1973 and Title II of the Americans with bullying his or her peers. Beane describes some children who weren’t overweight, regardless of Disabilities Act of 1990. According to the U.S. of these factors, and they include: sex, race or other factors. It found that children Department of Education, disability harassment  Temperament – Child and youth were bullied whether they were rich or poor, is “intimidation or abusive behavior toward a temperament is significant factor in made better or worse grades and that race didn’t student based on disability that creates a hostile bullying (Begsag, 1989). Temperament is seem to be a factor (Pediatrics, 2010). environment by interfering with or denying a a combination of qualities that make up student’s participation in or receipt of benefits personality. An impulsive child with a more In addition, in a study of children ages 11 to 16, services, or opportunities in the institution’s volatile temper may be more likely to become researchers found that overweight and obese girls program” (U.S. Department of Education). When a bully. were more likely than normal weight peers to a school discovers that harassment may have  Jealousy – When children are motivated be teased or to be made fun of and to experience occurred, staff must investigate the incident(s) to bully out of jealousy, they have been relational bullying (socially excluded). promptly and respond appropriately. This threatened in some way by another child’s Overweight and obese girls were also more likely behavior can take different forms, including perceived success with grades, wealth, to be physically bullied (Janssen, Craig, Boyce verbal harassment, physical threats and popularity, attractiveness and so on. and Pickett, 2004). threatening written statements.  Fear – When children bully out of fear, they Children and youth with disabilities and The bully have projected their insecurities and fears special needs Bullying is related to feeling contempt for onto another person. Some children fear There is a small but growing amount of research someone considered to be worthless, inferior or rejection from other kids or losing status in literature on bullying among children with undeserving of respect. Bullying does not appear the eyes of someone they want to impress, disabilities and special needs. This research to be about anger or conflict. Contempt relates such as a boyfriend or girlfriend. They may indicates that these children may be at particular most closely to how the bully views his target. fear loss of social status or being laughed risk of being bullied by their peers. For example, at. Many times bullies fear losing what they Further, contempt is a strong feeling of dislike research tells us that: have already, such as intermittent praise toward someone considered to be worthless,  Children with learning disabilities (LD) are from a popular peer or mentor. They want inferior or undeserving of respect. Contempt at greater risk of being teased and physically to protect their self-image and restrict their can range from disregard to scorn to hate. Bias bullied (Thompson, Whitney and Smith, range of contacts with the kids who appear or prejudice related to race, gender, sexual 1994). most vulnerable. Kids will bully someone orientation, physical attributes, mental capacities  Children with attention deficit hyperactivity else when they fear being exposed for real or and religion can be fertile ground bullies use to disorder (ADHD) are more likely than perceived weaknesses as well. prey on their victims. Psychological advantages  other children to be bullied. They are also  Self-perception that incorporates a sense occur for children or youth that express contempt somewhat more likely than others to bully of “superiority” toward others – This through bullying. They include: their peers (Unnever & Cornell, 2003). perception folds into the earlier discussion  Power to exclude, isolate, segregate or bar the  Children with medical conditions that regarding contempt that bullies feel for their victim who is viewed as unworthy. affect their appearance, such as cerebral victims, when someone is thought to be palsy, muscular dystrophy and spina bifida, undeserving of one’s respect. Most cultures,

Elite Page 7 including faith-based and ethnic, over role in how others are perceived as socially bullying themselves. They are typically centuries promoted their own specialness acceptable in faith communities, schools or physically weaker than their bullies, but are and even superiority of other cultures. If other social and cultural settings. stronger than those they bully. one was not of a particular caste, religion or Bullies can be impulsive and mistreat others Dieter Wolke from the University of color, he or she could easily become a victim without thinking of the consequences to their Hertfordshire in England identified a fourth of bullying. Parents are very powerful role actions. Some bullies have experienced or group of bullies called “pure bullies” According models. One former bully remarked that his observed abuse at home or have been overly to Wolke, this group appear to be healthy father often told his children how special and disciplined. In addition, their caregivers may individuals who enjoy school and use bullying to superior they were because of their birth- have been lax in their attention to providing obtain dominance. Pure bullies just seem to enjoy given societal roles. guidelines and character development in their bullying others.  Desire for attention – Some children children. Yet two major peer risk factors for through parental abuse and neglect or Girls and bullying bullying have been identified and are: parent overindulgence desire attention and “Them – the junior caps who run the social 1. Bullies are more likely to have friends that have difficulty understanding that their underground in these rustic gulags. They bully. actions will impact others. Some children are the bully-princesses who have always 2. Bullies share positive attitudes toward and youth simply lack sensitivity and abounded in Grade 6 female society. Their violence. have been raised to believe that they are hair is perfect, their clothes ditto, and They extraordinarily special. Parents go a long way Bullies are typically aggressive toward adults decide who is in and who is condemned to in demonstrating tolerance or intolerance as well as peers. Bullies are often impulsive the outer darkness, the subject of ridicule, as well as compassion. If caregivers are and they demonstrate a need to dominate, are whispers, and ostracism. I knew instinctively lacking in sensitivity, they provide strong typically lacking in empathy and are often more on which side of the great divide I would fall. role modeling for repeated behavior in their willing to resolve conflict through violence. … I had a gut instinct that books were not children. They are more likely than other children to be highly regarded as a suitable pastime and that  Response to tension environments – convicted of a crime in adulthood (Olweus, bookish kids came just after rabies-riddled Multiple tension environments that include 1993). raccoons in the pecking order. Oh yes … I peer pressure, cultural oppression, academic Warning signs that children or youth are engaging was an odd child indeed.” (Taken from “What stress, volatile teachers or parents, and in bullying behavior include: I Didn’t Do at Summer Camp” by Alexandra economic worry contribute to unregulated  Lacking in empathy. Shea; Glove and Mail, May 28, 2001.) bullying behavior as well.  Viewing violence more favorable than most The tactics used by girls who bully are distorted  Prejudice – One well-known family therapist kids. versions of some normal mechanisms of said, “There is tyranny in prescribing only  Being aggressive toward adults, parents and social development. According to research one right way.” Bullies develop within teachers. by Lagerspetz, Bjorqvist and Peltonen at the environments where children are brought  Demonstrating a hot temper, being impulsive University of Miami, when girls bully, they use up to believe that it is “bad” to be different. and intolerant of obstacles or delays. things like alienation, ostracism, deliberate and Prejudice can begin early and become the  Finding it difficult to fit in with rules. calculated random exclusions, and spreading of reason why children or youth who behave,  Needing to dominate and suppress others, rumors to harass their peers. Specific behaviors look or speak differently are persecuted. asserting him- or herself by means of force can include:  Mimicking a culture of media violence – and threats, and getting his or her own way  Encouraging other kids to ignore or pick on a TV, online games and other media violence (Commonwealth of Massachusetts, 2010). specific child. can contribute to an increase in a child’s  Playing jokes or tricks designed to embarrass aggression. A study conducted in 2003 by the A common myth about children and youth who and humiliate. Kaiser Family Foundation found that nearly bully is that they are “loners.” In fact, research  Anonymous prank phone calls or harassing half of parents with children between the indicates that most bullies are not socially e-mails from dummy accounts. ages of 4 and 6 reported that their children isolated. Bullies report having an easier time  Inciting others to act out violently or imitated aggressive behaviors on television. making friends than children and youth who do aggressively. (The foundation also found that 87 percent not bully. Children and youth who bully usually  Deliberate exclusion of other kids with the of kids mimic positive behaviors observed have at least a small group of friends who support intent to make them feel left out. on TV.) or encourage their bullying.  Name calling, rumor spreading and other  Revenge – Bullies who were mistreated An additional myth is that children and youth malicious verbal interactions. at some time in their lives may grow into who bully have low self-esteem. In fact, they  Being friends one week and then turning victim bullies (discussed earlier in this have average or above-average self-esteem. against a peer the next week with no incident course). Because of those earlier experiences, Interventions that focus on building the self- or reason for the alienation. they may feel inadequate and helpless. To esteem of children and youth who bully probably  Whispering in front of other kids with the compensate, they attempt to gain some will be ineffective in stopping bullying behavior intent to make them feel left out. “control” through overwhelming and over- (www.stopbullyingnow.hrsa.gov, 2010). powering their victims. They may seek The typical girl bully is popular, well liked by revenge on those who bullied them or, in the According to Olweus, there are three different adults, does well in school, and can even be case of the Columbine High School shooters, types of bullies: friends with the girls she bullies. Girl bullies they may attempt to make a larger statement 1. Aggressive bully – One who tends to be do not normally get into fistfights, but use to “the world” by retaliating with innocent physically strong, impulsive, hot tempered, more rumors or gossip to exclude others, or bystanders. belligerent, fearless, coercive, confident and shares secrets and tease other girls about their  Social influences – They are very powerful, lacking in empathy. appearance or athletic ability. More often than especially in the adolescent population. 2. Passive bully – One who tends to be insecure not, she will use her peers to join her in bullying Wanting to accommodate or “fit in” is a and is much less popular than aggressive and or will pressure her peer group to instigate natural part of this life cycle, and occurs even bullies, with low-self esteem and few likable bullying (National Crime Prevention Council, in younger children. Peer pressure prompted qualities, and is often unhappy at home. 2010). Girl bullies may travel in “packs,” and by cultural and societal norms plays a huge 3. Bully-victim –This type includes a small good kids often get drawn into the behaviors percentage of bullies who have experienced because they, too, don’t want to be targeted.

Page 8 Elite Girls will bully boys as well as girls. Victims can  Peers were active participants in 48 percent  “He deserved it and knew it was coming.” experience low self-esteem, a drop in grades, of the episodes.  “He’s not my friend.” anxiety, depression, drug use and even eating  Peers were involved in some capacity in 85  “I’m friends with the person who spit on her.” problems. Many times adults are less likely to percent of the bullying episodes.  “It’s just part of school drama.” recognize bullying in girls than in boys. Often,  Peers reinforced the bullying in 81 percent of  “Why would I say something? I don’t tell on the bullying tactics by girls are viewed as normal the episodes. other people.” social interaction or “girl drama.”  Peers were more respectful and friendly  “Why would I want to invite trouble?” toward the bullies than the victims.  “She’s a total loser.” Family risk factors for bullying  “He doesn’t know what he’s talking about. Children and youth who bully are more likely Only 15 percent of girls who see bullying or who Maybe this will shut him up.” than their non-bullying peers to live in homes are stuck in the middle of bullying episodes speak  “It’s not my problem!” where there is: up and say that it is not okay (National Crime  A lack of warmth and involvement on the Council, 2010). Standing by and observing bullying is a form of betrayal and abandonment to those bullied. In part of parents. Reasons why children and youth do not intervene  addition, there are times when bystanders become  Overly permissive parenting (including a lack when bullying occurs include: active participants, described by researcher of limits for children’s behavior).  The bystander does not know what to do  Olweus as “henchmen/followers who take an  A lack of supervision by parents. and hasn’t been taught ways to intervene, to  active part but do not start the bullying.” Olweus  Harsh, physical discipline. report the bullying or to help the target. Just  also describes some bystanders as “passive  A model for bullying behavior. as bullying is a learned behavior, so children bullies” who support the bullying but do not take must be taught ways to stop it. Bullying and other violent or antisocial an active part; and “passive supporters,” who  The bystander is afraid of becoming a new behaviors like the bullying but do not display open support. target of the bully. Research shows that bullying can be a sign of In the middle are “disengaged onlookers,” who  The bystander is afraid of getting hurt other serious or violent behavior. Children and watch what happens and don’t take a stand. And himself. The bully is bigger and stronger youth who frequently bully their peers are more like the young woman who shared her story, and has a reputation that justifies the fear; so likely than others to: there are “possible defenders” who don’t like the  jumping into the melee doesn’t appear to be a  Get into frequent fights. bullying but do nothing to stop it.  smart thing to do.  Be injured in a fight.   Vandalize property.  The bystander is afraid of doing something The one sub-group Olweus describes as non-  Steal property. that will only make the situation worse. bystanders include “defenders of the target” who don’t like the bullying and try to help the victim.  Drink alcohol. A bystander’s story   Smoke. Looking back at her years in high school, one The aftereffects of witnessing bullying lead   Be truant from school. young woman retells how she witnessed several to school, home or institutional environments   Drop out of school. instances where bullying occurred in the girls’ clouded by fear and uncertainty during an already   Carry a weapon. bathroom at her school. She vividly remembers difficult time when children and adolescents are Young bullies are more likely to report that one incident when she and a friend were combing struggling to understand and define themselves. they own guns for risky reasons, such as to gain their hair in the bathroom and she witnessed her But bystanders can act, and should be encouraged respect or frighten others. And boys who were friend being bullied by older students. to be part of prevention and the solution to identified as bullies in middle school were four “Louise and I were standing in front of the sink bullying. Bystanders are a powerful majority times as likely as their non-bullying peers to have talking and laughing as we brushed our hair. of children and youth, and they can use their more than one criminal conviction by age 24 Louise was very attractive, and the boys at school influence to: (www.stopbullyingnow.hrsa.gov, 2010). really liked her. As we were standing there, two  Speak up and offer support to bullying Both boys and girls can develop into bullies. senior girls came into the bathroom, and seeing victims, even it means standing up to the Louise, roughly elbowed her into a corner. When bully in front of other bystanders. Victims are both male and female as well, and  methods of bullying may vary by gender. Experts she protested, one girl in particular slapped  Walk away from bullies who enjoy attention are not sure now whether boys bully more than Louise and told her not to even look at the senior when they brag about past experiences with girls. While boys are more overt in their bullying, girl’s boyfriend. Louise cried out while I just victims. stood there frozen, wanting to help Louise but  Refuse to join in if someone is being bullied. girls are more subtle and used bullying more  frequently to gain social control. literally unable to move. The senior girl calmly  Report all bullying immediately to adults. walked out of the bathroom with her friend, Bully prevention and intervention There are gender differences in the types of knowing she’d put the fear of God in both of us. bullying that children experience, such that There are many signs, listed earlier in this boys are more likely than girls to report being “I felt ashamed, useless, and a terrible friend. I course, that a child or youth is being bullied. physically bullied by their peers, and girls are helped Louise gather herself together and when Many of these signs relate to school attendance more likely than boys to report being targets of I asked if we should report the incident to the or academic performance, in addition to other rumor-spreading and sexual comments (Harris, principal, she said she didn’t want to get into mood or behavior changes that a child or youth Petrie and Willoughby, 2002, Nasel, 2001). Girls more trouble. Can you believe that? She thought experiences in the home or elsewhere. In review, report being bullied by boys and girls, while she would be in trouble with the school. But they include:  boys report being bullied primarily by other boys things like that happened all the time, and no one  Abrupt lack of interest in school or refusal to (Melton, 1998, Olweus, 1993). reported it. People were afraid they’d get into go to school. trouble with the school or get picked on even  Takes an unusual route to school. Bystanders more by the bullies.”  Suffers a drop in grades. Researchers Pepler and Craig (1995) examined  Has few or no friends. Witness rationale the roles of peers in bullying episodes observed  Withdraws from family and school activities. Some of the excuses shared by child and youth in urban school playgrounds in Toronto, Ontario.  Is sad, sullen, or angry after receiving a bystanders who have witnessed bullying include: Their work revealed that: phone call or e-mail.   “I don’t want to think about it. It’s too much  Peers intervened in only 13 percent of the  Uses derogatory or demeaning language to have to deal with.” episodes at which they were present. when talking about peers.

Elite Page 9  Stops talking about peers and everyday professionals encourage family caregivers to also need to know that any threats or physical activities. convey these basic messages: assaults on their part will be reported to people in  Has disheveled, torn or missing clothing.  I believe in you. authority.  Has physical injuries.  I love you. Physical assaults and serious harassment should  Has stomachaches, headaches, panic attacks.  I will create a safe place for you to live. be reported to the school when applicable, and  Is unable to sleep, sleeps too much, or is  I will role-model respect, resiliency and to the police when it poses serious harm. Police exhausted. optimism. response will vary according to the state law.  Makes unusual comments about feeling  I will set reasonable and developmentally In some instances, parents will need to file a hopeless or disengaged from life. appropriate limits and guidelines for you. complaint with a court-designated professional  Alludes to death as a form of feeling better.  I will help you learn how to handle life or speak to a juvenile court representative. An  Exhibits changes in mood and/or often cries situations. officer will more likely interview the victim or becomes angry or withdrawn.  I will listen to you. and alleged perpetrator in the presence of other  I will care for you. If bullying includes violence or physical acting adults that could possibly include parents. One  You are important to me. out of any kind, adults are more likely to respond principal dealt with the bullying at his school  I will not allow you to bully others. and intervene, and when necessary, disrupt and by negotiating an agreement with local law discipline the child or youth bullies. However, Mental health practitioners can help caregivers enforcement to have officers respond as soon as when bullying takes on a less obvious form, even identify and intercede when they see bullying possible to his bullying reports. He said it had adults don’t seem to know what to do. Therefore, occur. For example, parents more easily see a large effect on students when a police officer when preventing and addressing all forms of bullying in their children through sibling explained the possible legal consequences to bullying, it is imperative to address an antiquated interaction. Allowing their own children to alleged bullies and their caregivers. mindset that bullying among children and youth intimidate, terrify, shun, ridicule or physically Engaging families in bullying prevention is part of the healthy formation of a young harm one another in the home sets the stage for person’s character. them to practice the same behavior out in the activities world. Mental health professionals can also promote Bullying and role of mental health respectful family engagement by assigning their practitioners And yet, shaming or physically punishing families “homework” that includes: Mental health professionals can begin to address young bullies for their behavior isn’t the answer.  Practicing democratic engagement. bullying by being role models themselves by how Studies of bullies’ backgrounds report that For example, when children are given they comport themselves in the therapy setting. physical punishment played a big role in their choices about planning their activities and By demonstrating appropriate boundary and limit lives. Isolation (including neglect), humiliation, arranging chores and schedules, they practice setting, remaining respectful and reliable, and shaming and emotional abandonment are also problem solving while, at the same time, facilitating psychological growth and resilience not useful coping tools in responding to sibling feeling respected. As children grow into in clients, mental health practitioners demonstrate bullying. Instead, the mental health professional responsibility and as their decision-making healthy interaction and provide a safe emotional should discuss with adult parents “common capacities grow, their ability to forecast environment for their clients. sense” behaviors that must be consistently problems and outcomes and make good repeated. These include: choices increases. As homework, mental Mental health professionals are in a unique   Immediate intervention and zero tolerance for health professionals can ask families to create position to help individuals, families and bullying behavior. a chore board together and come up with communities understand what causes bullying in   Examining with children the root of their chore assignments and timelines. order to address the problem. Because families behavior. What happened?  Identifying and creating safe physical are the first line of defense when it pertains to   Teaching and demonstrating that arms are spaces within the home environment. children developing into bullies, mental health “for hugging.” Mental health professionals can prompt professionals can help parents reexamine   Demonstrating and practicing with children families to discuss what helps children conventional erroneous thinking or behavior that self-regulation. within the family to feel safe and what promotes bullying. Through a parallel process   Nurturing empathy. parents can do to help their children feel between mental health practitioners and parents,   Creating opportunities to “do well.” safe. This practice can extend to providing parents can then guide their own children toward   Asking children to identify and use language safe handling of pets as well. Mental health identifying, negotiating and practicing new to express themselves. professionals can ask parents to create a thinking and behaviors.   Teaching children how to dislodge and cope checklist of safety questions for their children When addressing family dynamics in families with physical and emotional stress. and ask these questions during routine  where bullying exists or has occurred, the  Role-modeling friendship skills. moments during the day or evening. For  therapist can also work on individual self-  Redirecting activities. example, as parents drive their kids to and exploration, expression, problem solving and Reporting bullying from school, they can have a conversation positive family engagement. However, adults Mental health professionals can support parents about what or who helps their children feel and children also need to be instructed that self- in reporting bullying to the police and other safe or what do their children keep with them expression does not exist through hurting another public oversight authorities such as school that help them feel safe. person. Clear, loving and consistent limits are  administrators. Encourage parents to take photos  Safe play. When it pertains to bullying, safe highly recommended by practitioners with of all injuries to their children. (Let them know play ensures that children do not harm others families where children bully other children. to hold a ruler next to the injuries to identify their while they’re engaged in play activities. For At times, therapist-client psychotherapy timelines sizes.) In addition, mental health practitioners instance, while it is normal to enact certain are short term, and facilitating “good enough can ask parents to keep a record of all medical aspects of villain versus hero themes, it is not parenting” is a very realistic goal. Promoting treatment, medical expenses and all related normal to hurt others during the process of “good enough” parenting is solution-focused with travel expenses and let them know to include the game. In addition, safe play ensures that a timeline, but it does teach and promote enough counseling expenses as well to their expense children are not exposed to potential bullying skills in parents to help their children begin to list. Encourage parents to date the photos and if their play is left unsupervised or they are feel emotionally and physically safe within their code them in a way that will link them back to otherwise exposed to older or more dominant home. In working toward that goal, mental health their written record. Children and youth bullies potential bullies. Even playing board games

Page 10 Elite can be an exercise where families engage appointments or make an error in parental  Self-awareness. Supporting the development with one another without name-calling and judgment. A homework assignment could of language skills in parents and children that taunting. Practicing safe play while tickling include asking parents to strategize with prompt them to identify and express personal children and wrestling is an important part of their children about how to handle mistakes, feelings is another important task for mental teaching safe play. In addition, mental health missteps and ill-timed behavior within the health professionals. When people have the professionals can ask their clients to chose family. In addition, further discussion can ability to assess their personal feelings and and organize a special time during the day to occur around mistakes that occur outside of consider their likes and dislikes, they’re engage in play with their children. the home through sports, theater or shopping building their aptitude for self-awareness.  Philanthropy, good works and helpfulness. activities. Practitioners can ask their families as part of Teaching empathy and compassion is an  Cooperation and negotiation. Children and a homework assignment to take two to five important parenting role. As a homework youth take their cooperation and negotiating minutes alone each day for one week to think assignment, mental health professionals can skills into the larger community as they enter about and write down what helps them feel ask families to chose a volunteer activity or school and begin to participate in the larger safe. Other questions professionals may want decide where they would like to donate and community. Learning self-regulation is a to pose are what qualities do family members share their resources, such as canned goods major social/emotional milestone for children most value within themselves and with each or clothing. In addition, professionals can and youth, particularly during times of stress other? consistently pose the question: “Who helps or frustration. Mental health practitioners can Working with parents when their children whom in this family?” suggest homework that includes simple and  Clear and consistent discipline and flexible tasks or time to complete those tasks. bully others guidance. Clear, consistent, loving guidance Family participation in board games and It is not uncommon for parents to be in denial takes time and poses a challenge to parents outdoor physical activities such as volleyball or somewhat defensive when their own children when both work and timelines are tight. or badminton also provide cooperation and have been caught bullying other kids. Mental Consistent and loving discipline guidance negotiation opportunities for parents to teach health professionals must walk a fine line also takes thoughtful self-regulation at times their children about these very important between being clear about the inappropriateness for parents when they’re also coping with social and emotional skills. How do parents of the behavior itself and implying the character multi-leveled stress and their own particular role-model planning for extended family or of their kids is less than sterling. In fact, parents upbringing. Mental health professionals faith and social engagement with friends or may tend to take a clinician’s message further can ask parents to practice a specific type business associates? Finally, how do parents and misinterpret it to mean that they are less than of behavior in response to their children’s negotiate time with their own children? sterling as parents themselves. As noted earlier, misbehavior and consistently check in with  Resiliency building. Resilience is the act studies of the background of bullies conclude that parents for a) consistency and b) outcome. At of rebounding or springing back after being physical punishment played a big role in their all times, professionals should express a zero stretched or pressed, or recovering strength, lives. So mental health practitioners must also tolerance for bullying among siblings or with spirit and good humor. It is associated be mindful not to encourage excessive parental other children. with being able to adapt to negative life response in the form of verbal or physical  Character discussion. According to James experiences not merely by surviving but by behavior with their children either. Hillman, author of the “The Force of thriving and benefiting from handling or Professionals should remind parents that while Character,” an individual who demonstrates experiencing difficult times. When children they are responsible for their children’s actions, little character is someone “with little and youth have been bullied, their resiliency they are not necessarily to blame for them either. insight … is simply one who does not skills or lack of skills are tested. Remind parents that bullying that is stopped early imagine who he is – in short, an innocent. ŠŠ Researchers have identified two major is positive and that to stop bullying in children Innocence has no guiding governance but resiliency factors present in resilient as early as possible prevents them from being ignorance and denial.” (Hillman, 1999). children. They include individual as well labeled or stereotyped as bullies. It is also helpful Hillman’s description could very easily be as environmental factors and emphasize to remind parents that because their children were describing a bully. When addressing the topic the power of a consistently supportive capable of being bullies, they are probably also of resiliency, mental health professionals person in the life of a child. Research has capable of being sensitive to the needs of others. can begin by asking parents and children focused on people who seem naturally what they believe good character to be, and resilient, but plenty of other young people Strongly reinforce with parents that they must what qualities constitute good character? grow to be resilient because they are intervene immediately with discipline, not Practitioners can assign homework to supported by their caregivers to rebound punishment, when their children bully others. families that includes developing a list of from challenges and enjoy their lives and Let them know that discipline, rather than people they know who they believe have continue to thrive. punishment, takes time but is more constructive good character. For example, would the list  Mental health professionals can help and responsive to the needs of their children. include people that demonstrate empathy, parents effectively communicate with Time taken, though, is well worth it as children honesty, trust and self-control? Do people their children about ways they can begin to recognize that actions have intended and with character stand up to bullies or do they learn from negative life experiences. unintended outcomes. Using discipline instead of tell an adult in a position to help? Does In the last century, during the punishment includes four steps. someone with good character know when Civil Rights Movement, families Discipline steps to act and or retreat? And do people with communicated to their children 1. Be clear with the bully about what he or she good character know when to retreat from that racism was more about the has done. dysfunctional behavior? Even small children people who were bullying and being 2. Place the responsibility of the bullying on the can engage in this type of discussion. oppressive with others than about shoulders of the young bully.   Second opportunities. Giving parents the child victims themselves. “It’s 3. Require that the child or youth fix the permission to give their children second not about you, honey,” one woman problem. The child must solve the problem he chances when they make mistakes is reports her mother said at the time. or she created through some type of apology, an important message for mental health “It’s about them. They’re just foolish, restitution, reconciliation or resolution. professionals to send to their clients. Mental and their parents haven’t taught them 4. Leave the child’s or youth’s dignity intact. health practitioners have opportunities to how to behave yet.” role model this behavior when parents forget Elite Page 11 Helping to heal victims Mental health practitioners can contrive or to increase awareness of and attention to the issue Ensuring ongoing victim safety, helping child borrow stories that indirectly address the victim’s of bullying in schools and in society at large. In and youth victims work through their grief, worries, problems, self-perceptions or anxieties 2007, David Shepherd and Travis Price in Nova addressing trauma when it has occurred, that grew from their bullying experiences. Scotia took a stand against bullies in their school. reframing or reprocessing the bullying experience Professionals can also use personal references After hearing a student was called a homosexual with victims to facilitate their resolution and their when they approach a story or chose to use and threatened for wearing pink, the two youths empowerment, and supporting family members symbols more relevant and topical to the victim. went to a nearby discount store and bought 50 through the recovery process are essential tasks In either case, mental health professionals pink shirts, including tank tops, to wear to school for mental health professionals. must know their victims’ likes, dislikes, story the next day. “I just figured enough was enough,” of victimization and understand the victims’ Shepherd was quoted as saying. The next day, The immediate and ongoing safety of the child symptoms in order to formulate and share a through word spread online, hundreds of students is the primary focus when working with bullying story. Embedded within a story should be some showed up in pink clothing and little was heard victims. Mental health practitioners must key words or prompts that help victims to from the bullies again. continue to inquire about the child or youth’s come up with a solution or resolution to what further protection as well. Asking questions to Mental health professionals and the has happened to them. In general, practitioners parents and even children such as “What steps share a parallel story to the victim’s personal larger community have been taken to further ensure your child’s experience and mask the protagonist (the victim) Most professional mental health association safety?” or “Has there been a plan put in place to as the central character, through using a positive code of ethics discuss good citizenship as part ensure that this child will not be further abused?” symbol. of their mental health professional values. is very important. Mental health professionals As a professional community, mental health should inquire about what family, school or social Working with schools practitioners need to stand together with other support systems are in place to protect this child. Mental health professionals are called in at organizations to reinforce the message that A protection/safety plan should be discussed times to help school administrators sort through bullying will not be tolerated in any society. Part with family, and when appropriate, with school the issue of school bullying and help them of this mission should include: officials and even law enforcement. Steps should build a bullying prevention program. Mental  Discussion about what bullying means at its be taken to ensure that further exposure to the health professionals can begin by asking school most subtle levels. bully, without a restitution plan generated from officials, teachers and students what bullying  A zero tolerance for bullying by a the bully and his/her family, should be prevented. means and to talk about signs that it could have professional organization, network, club or Depending on their circumstances, some victims occurred at their own school. Role-play can office.  may feel guilty or blame themselves for being be used, and is often a fun way to demonstrate  Support of local bullying prevention bullied, excusing their perpetrator’s behavior for and teach assertive behavior. This can be programs.  any number of reasons. They may be fearful of accomplished with young children through  Using one’s time and talents to volunteer retaliation, and their fears often are well founded. puppetry or dolls within the classroom setting as where there is need to increase awareness of In addition, young victims may experience well. It can also help to suggest ways for children bullying in the community and in schools, grief because of their loss of innocence, social to compromise or to express their feelings in a such as classroom visits with students or standing or hope. Their worldview or perspective positive way. Consultants can demonstrate how donating time at a church to talk about the may have been changed, and they may repeat children can resolve problems firmly and fairly. effects of bullying.  to themselves negative messages that pertain to And it can be helpful to teach children about  Urging and reinforcing non-bullying trusting others. It is important that practitioners how to ignore routine teasing and that not all behaviors and a zero tolerance in youth repeatedly let their young clients know that they provocative behavior must be acknowledged. organizations or child and youth sports are not bad because of bad things that happen to leagues. Teaching children the value, too, of making and  them. keeping new friends is another instructional  Demonstrating and teaching tolerance and tool and helps them to understand courtesy empathy for difference. Parents and the mental health practitioner  Exploring diversity by attending different must ensure that if the victim internalizes his/ skills. Students also look for ways to respond to bullies; mental health professionals can help ethnic professional affiliations. her experience in a self-diminished way, they  Being a mentor to children and youth through need to help the child to reprocess or reframe them identify acts of aggression, bossiness or discrimination while encouraging them to trust a volunteer organization such as the Big the experience to ensure that the child or youth Brother or Big Sister programs. understands that he or she is not responsible for and value their own feelings. Mental health being bullied and to speak out and recognize consultants can also help teachers recognize Summary when there may be danger present for further bullying and its many forms and learn how to This course has defined bullying and its effects bullying. In addition, it is another role of the intercede immediately and to call upon other on children and youth as well as populations most mental health professional to support young teachers for help when needed. Consultants vulnerable to being bullied, and settings where victims in giving meaning to their experiences can also help them understand that ignoring it most often occurs. Bullying is commonly and recovering their resiliency and enjoyment of or overlooking the problem does not make it characterized by aggressive behavior that is life. go away; instead it increases the chances that intended to cause distress or harm, and involves bullying will escalate. an imbalance of power or strength between the Use of metaphor to heal victims Many schools have used existing anti-bullying aggressor and the victim. Victims typically are Mental health professionals can help heal the school curriculums or adapted them to meet vulnerable, and when there is a lack of support wounds caused by bullying in children and youth their particular school need. And many of them for them, feel isolated and exposed, which can through the use of metaphorical storytelling. incorporate student peer support groups and zero- lead to damage to their self-concept and behavior Metaphorical or symbolic stories are extremely tolerance policies. Parent-teacher associations marked by either withdrawal or aggression. helpful because they speak to an individual’s have become a part of the policy-setting groups Bullying commonly occurs where there is unconscious world while bypassing normal as well. little or no adult supervision, inadequate adult conscious resistance, as well as draw upon supervision or a lack of structure – areas where associations presented in a story related to Canada is the largest national community to children have nothing to do or are free to do problem solving and recovery. Stories address incorporate an anti-bullying campaign, called as they wish. Bullying can be physical, verbal, the victim’s experience without direct discussion Pink Shirt Day. Normally held in February, Pink emotional and relational or sexual, and can occur of it. Shirt Day is an innovative, widespread campaign Page 12 Elite over the Internet. The bullying relationship  Romain, Trevor (1998) “Cliques, Phonies and  National Runaway Switchboard. 800-621- affirms the power needs of the abuser and takes other Baloney,” Free Spirit. 4000. advantage of the vulnerability of the victim.  Shriver, Maria (2001). “What’s Wrong with  National Victim Center. 800-621-4000. Timmy?” New York, Warner Books.  Trevor Helpline for Gay, Lesbian and Victims can acquire acute stress or post-  Walker, Alice (1991). “Finding the Green Bisexual Youth. Thetrevorproject.org 800- traumatic stress disorder as a result of being Stone.” San Diego, Harcourt Brace 850-8078. bullied. Children and youth who may be more Jovanovich. vulnerable to acquiring these conditions are Online Support  Webster-Doyle, Terrence (1991). “Why is likely to have had prior vulnerability factors,  www.bullybeware.com Everybody Always Picking on Me? A Guide report greater perceived threat or danger, have  www.bullying.org to Understanding Bullies for Young People.” exposure to social environments that promote  www.cfchildren.org Middlebury, Vt. Atrium Society Publications. self-hatred, shame, guilt and stigmatization, and  www.familyfun.com have experienced greater stressors with regard Books for parents and school personnel  www.GLSEN.org National organization to to unpredictability, uncontrollability, sexual  Beane, Allan L. (1999). “The Bully-Free fight anti-gay bias in K-12 schools. victimization, betrayal, and real or perceived Classroom.” Free Spirit.  www.healthyplace.com responsibility. Researchers have discovered that  Bonds, M. & Stoker, S. (2000) “Bully-  www.home-school.com there are three different victim types: provocative Proofing Your School. A Comprehensive  www.kidshelp.org. victims, bully-victims and passive victims. Dieter Approach for Middle Schools.” Free Spirit. Wolke says another type of bully is the pure  Garritty, Carla, Porter, William, Sager, Nancy bully. and Short-Camillie, Cam. (2000) “Bully- Proofing Your School, A Comprehensive Bullying does not appear to be about anger Approach for Elementary Schools (Second or conflict. Instead, it appears to relate to Edition).” Sopris West. feeling contempt for someone considered to be  Greenbaum, S., Turner, B. & Stephens, R. worthless, inferior or undeserving of respect. (1989). “Set Straight on Bullies,” Malibu, Olweus categorizes bullying bystanders as CA, Pepperdine University, National School (Final examination questions on next page) “henchmen or followers” who take an active Safety Foundation. part but do not start the bullying, or “passive  Hoover, John H., and Ronald Oliver. (1996). bullies,” who support the bullying but do not “The Bullying Prevention Handbook: take an active part and passive supporters who A Guide for Prinicpals, teachers and like the bullying but do not display open support. Counselors.” Bloomington, Ind., National He also discusses “disengaged onlookers” who Educational Service. 800-733-6786. watch what happens and don’t take a stand. He  Kaufman, G. & Raphael, L. (1990). includes another group of bystanders that are “Stick Up for Yourself: Teacher’s Guide,” “possible defenders” who don’t like the bullying Minneapolis, MN, Free Spirit. but do nothing to stop it, and a sub-group called  McCoy, Elin. (1997) “What To Do When “defenders of the target” that don’t like the Kids Are Mean To Your Child.” Readers bullying and try to help the victim. Digest Parenting Guide Services.  Mental health professionals become guardians  Olweus, Dan (1993) :”Bullying at School: for the safety of bullied children and youth by What We Know And What We Can Do.” facilitating bullying prevention and intervention Oxford, England. Backwell Publishers. 800- 216-2522. strategies with families and victims, schools  and communities. Working with parents in a  Ross, Dorothea M. (1996) “Childhood parallel process to guide their children to identify Bullying and Teasing, What School bullying behaviors or to defend themselves Personnel, Other Professionals and Parents against bullying, advocating for bullied victims Can Do.” Alexandria, VA, American Counseling Association. and reporting bullying are other functions of  mental health professionals. Working with child  Sheras, Peter (2002), “Your Child, Bully or or youth victims to help them grieve, reframe Victim? Understanding and Ending School and reprocess their abuse and work toward full Yard Tyranny.” New York, Skylight Press. recovery to becoming resilient against further Support organizations and hotlines abuse are other essential tasks for the mental  American Foundation for Suicide Prevention. health professional. www.afsp.org. 888-333-2377.  Victim support – References  Covenant House Youth Crisis Hotline. 800- 999-9999. Books for children and adolescents   Berenstain, Stand, and Jan Berenstain.  Focus Adolescent Services. www.focusas.com 877-362-8727. (1993). “The Berenstain Bears and the  Bully.” New York: Random House.  National Center for Victims of Crime. www.  ncvc.org. 703-276-2880.  Bosch, Carl. (1988) “Bully on the Bus.”  Parenting Press.  National Clearinghouse on Child Abuse and  Brown, Marc (1983). “Arthur’s April Fool.” Neglect Information. Http://nccanch.acf.hhs. gov/pubs/reslist/tollfree.cfm. Boston: Little, Brown & Company.   Cohen-Posey, Kate. (1995). “How to Handle  National Domestic Violence Hotline. 800- 799-7233, 800-787-3224 (TTY). Bullies, Teasers and Other Meanies.”  Rainbow Books.  National Mental Health Association. www.  nmha.org. 800-969-6642.  Romain, Trevor. (1997) “Bullies are a Pain in  the Brain.” Free Spirit.  National Referral Network for Kids in Crisis. www.kidspeace.org. 800-543-7283.

Elite Page 13 NOTES BULLYING IN CHILDREN AND YOUTH Final Examination Questions Choose the best answer for questions 1 through 5 and then proceed to www.elitecme.com to complete your final examination.

1. Bullying is an imbalance a. depending on one’s perspective. b. that does not exist. c. in real or perceived power. d. caused by a mental disorder.

2. Victims of bullying are frequently a. secure. b. insecure. c. happy. d. the smallest child in the class.

3. According to researcher Olweus, there a. is just one type of victim. b. are three types of victims. c. are no victims, just bystanders. d. would be no victims if adults got involved.

4. Psychological bullying is behavior that intentionally harms another person by using a. mind control. b. social manipulation. c. several bullies. d. verbal threats with no intent to act upon the threats.

5. Mental health professionals should a. encourage parents to take photos of any physical injuries of their bullied children. b. refrain from working with parents when there are physical injuries to their bullied children. c. never encourage parents to take photos of any physical injuries of their bullied children. d. recommend self defense classes for the child and encourage fighting back.

PYGA04BY12 Page 14 Elite CHAPTER 2 the infant during the first hours and days of its explore their environment and learn to survive EARLY ATTACHMENT THEORY: life. Historically, bonding has been described independently (Ainsworth, 1982; Bowlby, 1988). RESEARCH AND CLINICAL in almost mystical terms and is often linked In effect, the caregiver functions as a safe haven. with the notion of maternal or paternal instinct. When the child feels threatened or afraid, he or APPLICATIONS Berger (1980) demystified the bonding process, she can return to the caregiver for comfort and (3 CE HOURS) proposing instead that it is the parental reaction to soothing. It is equally important that the caregiver Learning objectives: four factors that promote bonding attachment: can be trusted to provide this care whenever !! Describe the difference between attachment 1. Appearance, meaning the child’s immature needed, because “the formation of social bonds, and bonding. physical characteristics and helplessness. of social and emotional communication, the !! Understand how working models of 2. Sense of ownership resulting from development of a sense of confidence and trust attachment influence a child’s perceptions identification of the infant as the parent’s in others, the perception of the parent as the and behaviors. progeny. source of security and protection, and feelings of !! List and describe the six attachment 3. The degree of physical and behavioral self-esteem are dependent on such care and its classification types or styles. similarity with the parent. reliability” (Mukaddes, et.al., 2000). ! ! Identify factors including caregiver behaviors 4. Hormonal influences. Attachment isn’t just an instinctual biological that influence a child’s attachment style. Early studies by Klaus and Kennell (1976) drive for safety and security. The opportunity !! Describe symptoms and behaviors associated described a process that takes place immediately to psychologically attach to a caregiver is also with reactive attachment disorder. after birth. It is during this sensitive period, an essential developmental task that determines !! Distinguish recommended assessment described by others as the “golden hour,” that both the child’s immediate well-being and and treatment interventions for reactive the mother is felt to be “unusually open to taking the course of his or her future growth and attachment disorder from those that may be in her baby and learning more about the talents development. The type of attachment relationship harmful. of her newborn” (Klaus and Kennell, 2001). a child has can actually alter the structures, !! Understand ethical obligations in the They concluded that this period of heightened neurochemicals and connectivity of the infant’s provision of attachment-based services. sensitivity in the mother was the ideal time to brain that affect language, thinking, motor control Introduction develop a strong bonding relationship between and emotions. For example, it appears that Fourteen-month-old Gina accompanies her mother and child. However, the outcomes of pathogenic care giving, the absence of caregivers, mother, Raquel, and Raquel’s friend Maria their early study have yet to be replicated and and the disruption of the early care-giving to a medical check-up. In the waiting room, do not account for healthy bonds established environment significantly affect the ability of the Gina contentedly plays with some blocks near in adoptive families (Landy, 2009). While this hypothalamic-pituitary-adrenal (HPA) axis to her mother. Another patient comes into the initial “bonding experience” can help parents regulate the body and brain’s response to stress room and sits next to where Gina is playing. develop an emotional connection leading to the (Corbin, 2007). Gina looks at her but does not attempt to development of a more permanent bond, children As research continues, there is also increasing interact and inches closer to her mother. need ongoing sensitive care from the parent to evidence of the relationship between the Raquel gets up to go to the front desk to form strong attachments. development of secure attachment and the answer a question and Gina crawls after her. development of a child’s capacity to regulate both Raquel picks her up and she smiles. Shortly What is attachment? arousal and emotion (van der Kolk and Fisler, after this, Raquel is called into the office and Attachment refers to the relationship developed 1994; Schore, 2001a). briefly leaves the room, leaving Gina in the between an infant and a parent or primary care of her friend. Gina cries and attempts to caregiver during the first two to three years of Several factors can affect the quality of a child’s crawl after Raquel; Maria is unable to soothe life. Unlike bonding, which predominantly refers attachment. These can include the child’s her or engage her in play while her mother is to the mother’s initial emotional response to the temperament (more active and outgoing, or gone. When Raquel returns to the room, Gina infant, attachment refers to the child’s behaviors the opposite, for example), the context of the immediately reaches out to her. When Raquel and feelings in the relationship and occurs later situation (stranger present, familiar room, and picks her up, Gina stops crying. in the infant’s development (Berger, 1980). How so on) early history (a traumatic experience, for this relationship forms depends on the degree One of the most important factors in the growth example) and other things. But the way in which the caregiver meets the child’s needs for care, a parent responds to and interacts with a young and development of children is the quality of comfort and security. the relationship between the child and parent child is the key factor in how an attachment or primary caregiver. Healthy development Attachment functions to ensure the survival of develops. depends on the child’s capacity to relate to the child by keeping the child in close proximity Development of healthy attachment and care for others. Children depend on their to the caregiver, thus improving the child’s Children are not born attached to their caregiver primary caregiver to provide the close, supportive chances of survival. Both the child and caregiver but instead learn through the repeated experience relationship necessary for learning and achieving learn to reference and respond to each other’s of significant social interaction whom they prefer independence, and this relationship can affect the cues in a reciprocal and bi-directional affectional (Bowlby, 1982; Ainsworth, 1967; Stafford & quality of the child’s future relationships. process. (Landy, 2009). The attachment system Zeanah, 2009). Healthy development relies on the also “motivates young children to seek comfort, In the preceding example, Gina displays age- presence of a stable caregiver who can provide support, nurturance and protection from a appropriate behaviors and appears to be on appropriate emotional and verbal stimulation. discriminated attachment figure.” (Stafford & track developmentally. She currently prefers Early studies in attachment focused on children Zeanah, 2006). Gina, in the example above, her mother to strangers and is able to be easily in institutions. Later research on the effects of demonstrated proximity maintenance, a basic comforted by her. Gina clearly appears to enjoy a abuse and neglect revealed that the quality of care characteristic of attachment, by staying close to close relationship with her mother. “Attachment” played a more important role than the separation her mother and resisting separation from her. is a term most often used to describe this alone and that a small group of consistent, powerful relationship. While “bonding” is often A central theme of attachment theory lies in the reliable, affectionate and attentive caregivers used interchangeably with the term “attachment,” important role the caregiver plays in establishing could promote healthy development in children the meanings of these two terms differ a sense of security. Dependable caregiving (Smyke, et.al. 2002). considerably. that is readily available and responsive to the Infant, toddler and caregiver behaviors that child’s needs creates a secure base from which What is bonding? promote attachment by either maintaining children can leave and return to as they gradually The term “bonding” relates to the parental tie to Page 15 proximity to the attachment figure or providing explore, using parents as a secure base for the world and assists the child’s goal-directed the opportunity for meaningful interaction exploration. Caregivers need to encourage this, behavior, emotional regulation and ability to include: welcome the child back and celebrate his or assess the safety of relationships (Allen, 2011).  Smiling. her accomplishments. The child seeks comfort For example, internal working models help them  Sucking. from the caregiver during times of uncertainty to “predict and interpret others’ behaviors and to  Looking at each other; gazing into each and the caregiver will help interpret new or plan their own response” (Riggs, 2000). other’s eyes. unfamiliar situations. Children need a stimulating In the 1970s, psychologist Mary Ainsworth,  Vocalizing to each other. environment that encourages exploration – but a student of John Bowlby, expanded upon  Following and locomotion. overstimulation and the inability of the caregiver Bowlby’s work. After conducting numerous  Clinging and grasping. to act as a buffer from stress can have negative hours of observation of children and their parents  Physical touch and hugging. side effects on children. in homes, she developed an observational  Exploring the surroundings. As children continue to develop as individuals procedure that could be conducted under a more  Feeding interactions. (19-36 months), it is important that caregivers controlled setting, the strange situation procedure  Crying. provide opportunities for the child to make (SSP). This consisted of observation of the child  Playing. choices. Children will begin to balance their during periods of high and low stress to evaluate  Relaxing and allowing themselves to be wants and needs with their caregiver’s desires, the balance between the child’s motivation comforted. and the caregiver will establish appropriate to explore the environment and his or her The development of the attachment relationship limits. Other critical tasks for caregivers during motivation to seek comfort from a discriminated is a gradual process involving numerous this period are helping children cope with the attachment figure. (Stafford & Zeanah, 2006). interactions between the child and primary range of emotions they experience, and as they Ainsworth’s research focused on 23 children caregiver over time. In the first few months expand their social circle, supporting these new between the ages of 12 and 18 months and how of life, the infant’s response signals (crying, friendships and experiences. Children are also they responded when briefly left alone and then stretching, finger holding) are indiscriminate. For very sensitive to tone of voice during this time reunited with their mothers (Ainsworth, et.al., example, they initially cry in response to things; and want to know their caregivers are interested 1978). Since then, it has become one of the most crying is not used to communicate. Concurrently in them and proud of their accomplishments. widely used standardized techniques to assess the parent or primary caregiver is recognizing and the quality of attachment between the child and Attachment theory responding to the child’s signals, nurturing him or caregiver. The first clinical description of behaviors her and maintaining a protective closeness. Over associated with what is now known as attachment In the strange situation procedure, the mother, time, as responses are reinforced, infants learn to disorders was made by Spitz (1945) in his work child and cohorts are observed through a one-way communicate through crying that they are hungry, in hospitals and institutions with foundlings. mirror as they complete various activities and tired or experiencing discomfort. Though infants These children lacked a specific primary steps. The procedure starts with the mother and continue to respond to other people, at about 2-3 caregiver, but despite adequate care, his research child entering a toy-filled room. A few minutes months they begin to discriminate between their indicated significant impairment in motor and later, a stranger joins them. Then the mother primary caretaker and others. behavioral development as compared to the norm. leaves the room and the child is left with the During the first six months of life, children stranger for three minutes. The mother returns, Later, Bowlby, also influenced by his early respond best to immediate and consistent the stranger leaves and then a few minutes later work with delinquent children and Harlow’s attention and comfort and cannot be “spoiled” the mother leaves then returns. research with rhesus monkeys, was the first by it. From 3 to 7 months, the child begins to to describe mother-infant attachment. His During the procedure, observers are focused on smile and vocalize, and the caregiver reciprocates theory, largely intact and supported by research the child’s behavior, specifically how the child with appropriate emotional responses. The child to this day, identified that healthy social and responds 1) to a stranger; 2) when the caregiver also can be comforted by the caregiver. As the emotional development was dependent on the leaves the room; and then 3) when the caregiver child achieves milestones in physical and motor presence of a strong relationship between the returns. In a healthy attachment, there is a development, skills such as crawling and walking infant and a primary caregiver. He postulated balance between the child’s attachment to the enable the child to maintain close proximity. that the mother’s face, hair, voice, touch and so caregiver and a need to explore. But it is how the Infants gradually learn to discriminate between on elicited infant behaviors such as grasping, child responds when reunited with the mother people, and by the latter part of their first year clinging, smiling and babbling, and that over that demonstrates the child’s level of attachment have developed the capacity to form preferred time, this established an attachment bond. security. As it turned out, the length of time attachments. The onset and establishment of (Kagan, 2011). Bowlby described this attachment the child cried while mother was gone or even focused attachment occurs from 7 to 18 months. as “a lasting psychological connectedness whether they cried at all was not what defined At 12-18 months, a child may protest loudly between human beings” (Bowlby, 1969, p. 194). their level of security, but rather, the child’s when his or her caregiver leaves. It is also during behavior when the mother returned. (Stroufe & Bowlby also theorized that during the first this time the infant acquires the ability for person Siegel, 2011). 9-12 months of their lives, children develop permanence, that is, keeping the caregiver cognitive schema, or internal working models Based upon the organization of behaviors in mind even when he or she is not present (IWMs) to represent emotions and expectations displayed by the child during the separations (Rosenblum, et.al. 2009). At this stage, infants resulting from interactions with their parents and reunions, Ainsworth and colleagues respond more discriminately, with a striking or caregivers. The internal working models are (1978) identified three major patterns of decline in friendliness to others; do not want to based on the child’s perceptions of whether the attachment: secure attachment, ambivalent- go to strangers; and have distinct preferences caregiver was responsive and whether the child insecure attachment, and avoidant-insecure for the attachment figures in their lives (Stafford is worthy of such a response (Bowlby, 1973). attachment. Later, researchers Main and Solomon & Zeanah, 2006). They experience stranger and In other words, individuals form relationship (1986) added a fourth attachment style called separation anxiety, and caregivers will need to expectations about their role (such as loveable disorganized-insecure attachment based upon respect their baby’s fears and need for closeness. versus unlovable) and that of others (such as their own research. Between 12-14 months, children begin to nurturing versus cold) based on early experiences demonstrate the ability to develop other Historically, across cultures, maternal with their attachment figure. The consolidation of attachments and a hierarchy of preference. attachments are often primary. Consequently, these internal working models forms the child’s About 13-18 months of age, they start to much of the 50-60 years of research has conceptual representation of self, others and primarily focused on mothers, while fathers Page 16 have been viewed as secondary caregivers. of cognitive, physical and social-emotional the child may or may not exhibit distress, will But this is changing, particularly in Western development. Imagine the additional burden for seek proximity after separation, and calm down cultures. Research appears to support that infants children who experience physical or emotional quickly when the caregiver returns. The child will become attached to both mothers and fathers, abuse by their primary caregiver(s). Not only freely explore the environment around him or her and attachment relationships with either helps do they suffer the immediate effects of the and will seek contact with the caregiver when establish the regulation of the child’s affect and maltreatment, they also experience the loss distressed. Once comforted, the child moves on arousal. (Rosenblum, et.al. 2009). Fathers, like of the parent or caregiver as a “secure base” and continues play. Essentially, these children mothers, also make significant contributions to (Ainsworth, 1982; Bowlby, 1988). As a result, trust their caregivers to provide protection and the child’s development. (Lamb, 1997, 2002). the child’s internal working models view adults care and are comfortable seeking them out when Research does suggest some differences. as either harmful or unable to protect them they are frightened or hurt. (Ainsworth, et.al., For example, fathers are more likely to be from harm. And without their secure base, 1978; Rosenblum, et.al., 2009). emotionally supportive and challenging during they will become less curious and limit their Parental behaviors that support this style include play, which further supports infant exploration; exploration of the environment. The results of sensitivity or the ability to be attuned to the the emphasis of maternal behaviors is in these early experiences, however, can be changed child’s needs, flexibility and the ability to respond supporting the infants’ ability to seek comfort and through appropriate systematic and therapeutic consistently to the child’s signals, particularly other support (Grossman et.al. 2002). interventions. when distressed. (NICHD Early Child Care Hazen et.al (2010) conducted a longitudinal Attachment styles Research Network, 1997). Insecurely attached study of parental behaviors that demonstrated A child’s attachment style generally develops children tend to have unresponsive, insensitive qualitatively different caregiver roles and patterns based on the child’s perception or understanding or controlling caretakers. Landy (2009) identified of attachment between mothers and fathers; these of the caregiver’s reliability in providing comfort, other critical caregiver behaviors that researchers patterns resulted in different child outcomes. support and security. The attachment style associate with the development of secure The study focused on sensitive and frightened describes the quality of the relationship a child attachment. These include: or frightening caregiver behaviors and the later feels toward an adult caregiver, not the parent or  Comforting a child, particularly when it is development of externalized (e.g., attention, caregiver’s feelings about the child. hurt, upset or frustrated. regulation) and internalized (e.g., anxiety,  Accepting the child’s negative feelings, such Scientific research on parent-child relationships depression) problems. Frightening behaviors as anger, jealousy, sadness and fear. suggests that two primary types of attachments include physical, facial and verbal threatening  Being sensitive and responding to the child’s form, secure attachments and insecure behaviors (e.g., sudden invasions of vulnerable cues. attachments. Currently there are four main areas of the body, baring one’s teeth, suddenly  Frequently directing actions toward the infant styles of attachment described in the literature roaring); frightened behaviors (e.g., backing and providing emotional support during (Ainsworth, et.al., 1978, Main & Solomon, away from the infant when infant approaches); activities. 1990): dissociative behaviors (e.g., freezing, handling  Being careful not to overwhelm the child by  Attachment Style A: Insecure-avoidant. baby like an inanimate object); and role-reversed being too intrusive or directive.  Attachment Style B: Secure/balanced. behaviors (e.g., deferential or sexualized  Showing positive feelings toward the child  Attachment Style C: Insecure-ambivalent/ behaviors). and expressing genuine love and interest. resistant (also called anxious/resistant).  Allowing the child to be as separate and Results indicated that children whose fathers  Attachment Style D: Disorganized/ autonomous in exploring the environment as were both insensitive and frightening showed disoriented. possible while keeping him or her safe. higher levels of emotional under-regulation Children who are secure in their attachments  Behaviors synchronized with interactions that and attention problems, but that sensitive more freely explore their environment and are are smooth and reciprocal with the child’s. caregiving by fathers mitigated the negative able to learn with confidence, tend to be more impact of frightening behaviors for fathers – but, Insecure-ambivalent/resistant (also popular with peers and exhibit more positive curiously not for mothers. This led researchers social interaction with other kids, tend to be known as anxious/ambivalent) – Style C to hypothesize that “fathers who stay sensitive more emotionally stable and able to express and Children who are preoccupied with their while keeping babies highly stimulated, on the manage their feelings well, and demonstrate caregiver, yet ambivalent, characterize this fence between fear and fun, may actually be greater ability to handle stress and help others pattern. They exhibit extreme distress when a scaffolding their children’s later development of handle stress. parent or primary caregiver leaves. However, the ability to regulate intense emotions, cope with while they will seek them out, they do not appear overstimulation and stay focused” (Hazen, et. Children with insecure attachment are more comforted by their return and may struggle to get al., 2010). Why doesn’t this occur with mothers? likely to struggle in being confident and learning away from them. They are reluctant to explore They suggest that the maternal role as a secure about their surroundings, seem more at risk for the environment and exhibit frustration with their base is incompatible with frightening behavior, hostile, antisocial or difficult relationships with parents’ responses to them. (Ainsworth, et.al., and this confusion can lead to later internalized other children, are more likely to be emotionally 1978). The caregivers of ambivalently attached problems. unstable and have difficulty in expressing and children are likely to be very anxious about the managing feelings and are more likely to struggle The effects of trauma on attachment child and at times overprotective and interfering when stressed, act out in unhealthy ways and There are still many people who assume that (Landy, 2009). Research suggests that ambivalent be insensitive to others who are stressed. The exposure to trauma at a much younger age has attachment results from the caregivers’ following characteristics highlight each of the no effect because children are too young to inconsistent pattern of availability. Simply put, four main attachment types: understand or too young to remember. However, children with an ambivalent pattern of attachment trauma affects children at any age and can Secure/balanced – Style B have learned that they cannot depend on their severely disrupt the attachment process. For Infants with secure attachments to their caregivers to be there when needed. example, studies on exposure to community caregivers have a balanced and organized and domestic violence clearly demonstrate that regulatory strategy. They are able to express Insecure-avoidant/defended – Style A trauma threatens a child’s attachment and sense their emotions and look to their parents for help The insecure avoidant/defended style of of trust (Osofsky, 2004). in regulating emotional and physical distress. attachment is characterized by children who A securely attached child will generally appear tend to avoid or ignore a parent or caregiver’s This disruption in the attachment process can happy and content when interacting with a presence, show little response when the caregiver also lead to disruption in other critical areas caretaker. When separated from the caretaker, is close by, display few strong emotional Page 17 outbursts, and avoid or ignore the caregiver classified into one of these three main styles. ŠŠ Low frustration tolerance and self- or parent’s responses toward them. In fact, Of those, in general, approximately 60 percent control. these children, when given a choice, will show of children can be categorized as B, securely ŠŠ Very disorganized and disoriented in no preference between their caregiver and attached, and approximately 18 to 25 percent can approach to problems. a complete stranger. In the strange situation be categorized as A, avoidant. The attachment ŠŠ May miss parents and appear frightened procedure, children will explore the room and style categorized as C, ambivalent in their when with them as well as away from toys but with no reference back to the caregiver. attachment, is considered relatively uncommon, them. They tend to snub or ignore the caregiver affecting an estimated 7-15 percent of U.S. Long-term effects of attachment style at reunion and do not need to be calmed children (Cassidy and Berlin,1994; Ainsworth Attachment styles displayed in adulthood are not (Ainsworth, et.al., 1978). et al., 1978). Furthermore, the shape of this necessarily the same as those seen in infancy, distribution is similar across cultures, although A child is likely to develop insecurely avoidant though research suggests that early attachments specific percentages of A’s and C’s may vary attachment when the caregiver consistently can have a serious impact on later psychological (van Ijzendoorn and Sagi 1999). In addition, in fails to respond or ignores the child’s negative and social development. While the predictive the United States, approximately 15 percent of emotions. In extreme cases, they may neglect all value of various attachment assessments (e.g., children are difficult to classify into one of these of the child’s emotional needs. These caregivers strange situation procedure, Attachment Q-sort) three styles and have a “disorganized/disoriented” may actually be very good at teaching tasks and requires further study, there is strong evidence attachment style (National Center for Education setting limits but may be hostile, ignoring or that early attachment disorganization, for Statistics, 2007). rejecting. (Landy, 2009). Research suggests that example, is a powerful predictor of children’s avoidant attachment might also be the result of Patterns of early attachment and later socio-emotional development and of stress abusive caregivers who punish children when development management problems and psychopathology they reach out to them for help. Outwardly What benefit is there in understanding and (Smeekens, et.al., 2009). rejecting caregivers who respond to children with studying attachment styles? They are important Much that we do know is the result of research hostility and indifference teach those children because children often show different outcomes by attachment researcher Alan Sroufe and to deny their own needs. Such children may in their well-being and development based on others with the Institute of Child Development look independent, but in actuality, they appear attachment style. Lundy (2009) outlined some of at the University of Minnesota. The Minnesota independent because they have not learned to the important aspects of a child’s growth affected Longitudinal Study of Parents and Children depend on others (Lamb 2000; Main 2000). by attachment quality including the following:  began in 1975 with 267 low-income, first-time Insecure attachment – disorganized/  Secure: mothers and has focused on social relationships, Š disorientated – Style D Š Cooperative with parents. including how people view them and risk and ŠŠ Affectively positive. Children with this attachment style do not protective factors. The main goal of the study is ŠŠ Socially competent and seeks out friends. demonstrate clear attachment behavior. Rather, to follow the course of human development and ŠŠ Has good self-control. they seem to possess characteristics of both the identify those factors contributing to good and ŠŠ Can problem-solve with confidence. ambivalent and avoidant style. Characterized poor outcomes. (Sroufe, et. al., 2005 & 2010). ŠŠ Easily comforted if upset/seeks help if by a lack of a coherent attachment strategy overwhelmed. The sample of 180 children in Sroufe’s study of for interacting with the parent, children with ŠŠ Manages well away from parents. infant-child attachment lead relatively unstable this style are not predictable in their actions  Insecure/avoidant: lives compared to other studies that tend to focus and responses to caregivers. Children with ŠŠ Tends to be non-compliant and to disobey on middle class children. Considering styles of disorganized attachment seem unable to cope rules. attachment, the study revealed that if children easily or be comforted when stressed and are ŠŠ Often very angry and hostile. had a secure mother-infant attachment, they hypersensitive to perceived abuse. During ŠŠ Isolated from group, does not seek were likely to be self-reliant into adolescence, reunion, such children often appear dazed and interaction. have a better sense of self-esteem, have lower either confused or fearful or demonstrate freezing ŠŠ Can be excessively angry but has control rates of psychopathology, enjoy successful peer in the caregiver’s presence. One moment they in nonsocial situations. relationships through age 16 and do well in seem anxious to please, and the next moment ŠŠ May be quite competent. school – especially in math – at all ages. They angry or openly rejecting of the parent or ŠŠ When in pain or upset, withdraws and also found that anxious, poorly attached infants caregiver. They may control or comfort the does not seek help. could become more secure if their mothers caregiver instead of being comforted. Repetitive, ŠŠ Manages well away from parents. enter stable love relationships or alleviate their stereotyped gestures and motions are also  Insecure-ambivalent/resistant: symptoms of depression. behaviors exhibited. (Main & Solomon, 1999). ŠŠ May have behavioral difficulties and Adult attachments According to Main and Solomon (1986), fluctuate between being tense and While the focus of this course is on early inconsistent behavior on the part of parents helpless. attachment, familiarity with adult attachment might be a contributing factor in this style of Š Š Tends to be fearful and tense. behaviors can be helpful in recognizing patterns attachment. At times, the caregiver may seem Š Š Has poor social skills, tends to be that may support or compromise a parent or frightened and unable to manage the child and dependent on others. caregiver’s relationships with others and their the situation; at other times, the caregiver is the Š Š Impulsive, low frustration tolerance. ability to effectively nurture and discipline a source of fear, exhibiting hostility and anger. In Š Š Lacks confidence and assertiveness with child. Think about the last time you said or did later research, Main and Hesse (1990) argued little ability to problem-solve. something that reminded you of one of your that parents who act as figures of both fear and Š Š Needs sensitive care-giving, often parents or primary caregivers. Simplification? reassurance to a child contribute to a disorganized difficult to calm down. Yes, but this illustrates the impact of early attachment style. Because the child feels Š Š Often misses parents and seems helpless relationships on future functioning. An adult both comforted and frightened by the parent, and tense without them. classification of attachment can be assessed using confusion results.   Disorganized/disoriented: the Adult Attachment Interview (AAI), developed Š Prevalence of attachment styles Š Usually has behavioral difficulties and is by Main and Goldwyn (1998). This complex unpredictable. Researchers working with separate data sets assessment process is extensively used in ŠŠ Is often both a bully and a victim. and in different cultures have generally found research and identifies four major classifications ŠŠ Has poor social skills. that most children (about 85 percent) can be of adult attachment with additional subcategories. Page 18 The main attachment types are described as: knows what to expect. For example, when an developmental disability. She reported that  The secure-autonomous/free classification infant is hungry or soiled, he or she may not 4-year-old Nathan usually played alone and describes adults who seem to be at peace be attended to for hours or even days. in fact appeared to prefer it. He squirmed with their experiences with their parents.  The infant or young child is hospitalized or when she or her husband attempted to hug They recognize the influence of those early separated from his or her parents. him. And recently, after tumbling off the experiences on their personality. They value  An infant or young child is moved from one swing set, he did not cry or seek her out for relationships and seek them out. caregiver to another (can be the result of comfort despite a nasty brush burn. After an  Insecure-dismissing people do not value adoption, foster care or the loss of a parent). extensive assessment process, Nathan was relationships. They dismiss the idea that their  The parent is emotionally unavailable diagnosed with a disorder of attachment, early experiences affected them and may because of depression, an illness or a reactive attachment disorder of early either idealize their early caregivers or not substance-abuse problem. childhood. have any memory of them.  The infant or child is routinely exposed to Reactive attachment disorder, or RAD, is  Insecure-preoccupied people want community or domestic violence. believed to be an extremely rare but serious relationships but see them as unpredictable It is important to remember, though, that most condition resulting from the inability of infants and strive for greater closeness. They are children are naturally resilient, and even those and young children to develop healthy bonds with preoccupied with their past and current who’ve been neglected, lived in orphanages or at least one primary caregiver. Because the child’s relationships with their parents and frequently had multiple caregivers can develop healthy basic needs for comfort, affection and nurturing continue trying to get the kind of consistent relationships and strong bonds. It’s not clear why aren’t consistently met, his or her ability to nurturing they still crave. some babies and children develop problems with establish loving and caring attachments with  Adults classified as unresolved often exhibit attachment and others don’t. On the impact on others is compromised. This may permanently distorted, disorganized thought patterns adult relationships, for example, Riggs (2010) alter the child’s growing brain and hinder social- as well as the emotions of anger and fear. says, “Although emotional abuse in childhood emotional and physical development. The interview will reveal that they have not can jeopardize the functioning of the attachment resolved the loss of a loved one by death, Reactive attachment disorder begins before system, it does not necessarily condemn someone absence or by the trauma or abuse they age 5, usually starting in infancy, and affects permanently to unhappy romantic relationships. experienced growing up. both boys and girls. Standardized criteria for With appropriate support and intervention, it is this disorder was first described in version possible to overcome this unfortunate historical Problems with attachment three of the Diagnostic and Statistical Manual disadvantage and find happiness and contentment What happens to children who have not formed of Mental Disorders (APA, 1980), with the with a loving partner” (37). secure attachments or manifest clinically diagnostic criteria undergoing further refinement significant symptoms of insecure attachment? As Early signs and symptoms of disrupted in subsequent editions. The current diagnostic we have seen, research suggests that failure to attachment in babies (Mayo Clinic, 2011) may nomenclature, described in the Diagnostic and form secure attachments early in life can have a include: Statistical Manual of Mental Disorders, Fourth negative impact on behavior in later childhood  Withdrawn, sad and listless appearance. edition – Text revision (DSM-IV-TR), describes and throughout life. To feel safe and develop  Doesn’t make sounds, like cooing. the essential criteria for a diagnosis of reactive trust, infants and young children need a stable,  Fails to smile. attachment disorder of infancy or early childhood caring environment. Their basic emotional  Avoids eye contact. as “markedly disturbed and developmentally and physical needs must be consistently met.  Does not follow others in the room with his inappropriate social relatedness in most contexts What happens when the caregiver response or her eyes. that begins before age 5 years and is associated is pathologically inappropriate or there is no  Fails to reach out when picked up. with grossly pathological care.” (pg. 127). response to the child’s signals at all? We know  Has no interest in playing peek-a-boo or other Other features that may be associated with the that when a baby cries, his or her need for a meal interactive games. disorder include evidence of physical abuse, or a diaper must be met with a shared emotional  Has no interest in playing with toys. delays in growth or malnutrition. Notably, the exchange that may include eye contact, smiling  Engages in self-soothing behavior, such as etiology of approximately one-half of pediatric and caressing. rocking or self-stroking. cases with the general medical diagnosis of  Cries inconsolably. A child whose needs are ignored or met with failure to thrive (FTT) is reactive attachment  Is calm when left alone; doesn’t seem to emotionally or physically abusive responses disorder of infancy. Such infants have significant notice or care when left alone. from caregivers comes to expect rejection or developmental deficiencies, including height and  Rejects caregiver’s efforts to calm, soothe hostility. The child then becomes distrustful weight below the third percentile and deficiencies and connect. and learns to avoid social contact. Emotional in social responsiveness (Tibbetts-Kleber & interactions between babies and caregivers Signs and symptoms in toddlers, older children Howell, 1985). may affect development in the brain, leading to and adolescents (Mayo Clinic, 2011) may Problems with social relatedness, according attachment problems and affecting personality include: to DSM-IV-TR, are either of the “inhibited” and relationships throughout life.  Withdraws from others. or “disinhibited” type. The inhibited type is  Avoids or dismisses comforting comments or Problems with attachment occur when children characterized by “persistent failure to initiate gestures. have been unable to consistently connect with a or respond in a developmentally appropriate  Acts aggressively toward peers. parent or primary caregiver. This can happen for fashion to most social interactions, as manifest  Watches others closely but does not engage in many reasons: by excessively inhibited, hypervigilant, or highly  social interaction.  The caregiver rarely responds to an infant’s ambivalent and contradictory responses, e.g., the  Fails to ask for support or assistance. cries or offers comfort. child may respond to caregivers with a mixture   Exhibits obvious and consistent awkwardness  No one looks at, talks to, or smiles at the of approach, avoidance and resistance to comfort, or discomfort. infant. or may exhibit frozen watchfulness.” (American   Masks feelings of anger or distress.  A young child gets attention only by acting Psychiatric Association, 2000). out or displaying other extreme behaviors. Reactive attachment disorder  A young child or baby is mistreated or A child exhibiting this subtype presents as Nathan was referred to the clinic by his abused. extremely withdrawn and emotionally detached. pediatrician after his adoptive mother  Sometimes the child’s needs are met and He or she is aware of what’s going on around, expressed concerns that he might have a sometimes they aren’t. The child never appears to be on the alert, yet may not react or Page 19 respond to people or other stimuli. He or she may beyond RAD, intended to capture relationship- the signs and symptoms of reactive attachment push others away, ignore them or even act out in specific psychopathology. ... The basic premise disorder beyond early childhood. Even long-term aggression when others try to get close. Children underlying these forms of attachment disorders is longitudinal studies, and these are uncommon, with inhibited behavior shun relationships and that the child has an attachment relationship with do not support a strong predictive value from attachments to virtually everyone. a discriminated caregiver, but that the attachment measurements obtained with the highly regarded relationship is seriously disturbed” (2009). strange situation procedure (Rutter, M., Kreppner, The disinhibited type is evidenced by “diffuse J, and Sonuga-Barke, E., 2009). There is some attachments as manifest by indiscriminate Before diagnosing RAD, practitioners are evidence that when placed in a better care-giving sociability with marked inability to exhibit advised to follow the American Academy of environment, children who are seen as the appropriate selective attachments, e.g., Child and Adolescent Psychiatry (2005) Practice emotionally withdrawn/inhibited type experience excessive familiarity with relative strangers Parameters for RAD: resolution, while problems for those seen as the or lack of selectivity in choice of attachment  Observe the child serially with all caregivers indiscriminately social/disinhibited type continue figures.” (American Psychiatric Association, and an unfamiliar adult. to persist for some (O’Connor, et.al.; Zeanah, 2000). Children with disinhibited behavior  Obtain a thorough history of caregiving et.al., 2008; Zeanah & Smyke, 2009). indiscriminately seek attention and comfort from environments from various sources. virtually everyone and don’t seem to prefer their  Use a relatively structured observational The course of reactive attachment disorder parents or primary caregiver to others. They paradigm to ensure consistent observations varies according to the individual factors of frequently ask for help, exhibit developmentally across multiple relationships. the parents and child (such as, their resilience) inappropriate behavior (younger than his or her and the severity and duration of psychosocial Although the strange situation procedure is not age) and may appear chronically anxious. deprivation. But with appropriate treatment and intended as nor is it a valid diagnostic tool, it appropriately supportive environment, children Children with reactive attachment disorder may may have added value to the assessment process. can develop more stable and healthy relationships develop either behavior pattern. While some For example, the procedure would be useful with caregivers and others. (American Psychiatric children have signs and symptoms of just one in understanding more about how the child’s Association, 2000). type of behavior, many exhibit both. Regardless attachments are organized toward his or her of the type, clinicians must differentiate between caregivers (Zeanah & Smyke, 2009). Differential diagnosis behaviors characteristic of RAD and other Risk factors Symptoms of insecure attachment are similar to psychiatric disturbances before a diagnosis can the early symptoms of other issues and may or There are no accurate statistics on how many be made. If a child meets criteria for mental not mean that someone actually has a clinical infants and children have the condition, but retardation, a diagnosis of reactive attachment disorder. Things become more complicated studies have found it to be more common in disorder can be given only if problems in the when assessment indicates the possibility of an maltreated children, young children coming into formation of selective attachments are not a issue requiring clinical diagnosis and treatment. foster care and children living in orphanages and function of the retardation. Issues related to the Reactive attachment disorder, one of the most institutions (cited in Zeanah and Smyke, 2009). differential diagnosis of RAD will be reviewed misunderstood and poorly researched disorders, Other factors that may increase the chance of further in the course. can be difficult to diagnose without a full history developing reactive attachment disorder include: or when other conditions co-occur. In addition to problems with social relatedness,  Frequent changes in foster care or caregivers. there must also be evidence of pathogenic care  Inexperienced parents. Currently, there is not a valid standardized either currently or in the past. DSM-IV-TR  Prolonged hospitalization. assessment tool for the diagnosis of reactive requires one of the following:  Extreme poverty. attachment disorder, although many symptom  “Persistent disregard of the child’s basic  Forced removal from a neglectful or abusive checklists – which have not been validated emotional needs for comfort, stimulation and home. and include behaviors inconsistent with any affection.”  Significant family trauma, such as death or accepted classification system – can be found on  “Persistent disregard of the child’s basic divorce. the Internet. RAD is often confused with other physical needs.”  Postpartum depression in the baby’s mother. neuropsychiatric and behavioral disorders that  “Repeated changes of primary caregiver that  Parents who have a mental illness, anger share symptoms or are co-morbid with RAD, prevent formation of stable attachments (e.g., management problems or drug or alcohol leading to over- and under-diagnosis. These frequent changes in foster care)” (American abuse. include: Psychiatric Association, 2000).  Autism spectrum disorders. Course  Pervasive developmental disorders. Again, while the risk for pathological care is Many problems in later childhood and adulthood,  Childhood schizophrenia. higher in certain situations (such as chronic such as delayed learning, poor self-esteem,  Attention deficit/hyperactivity disorder medical conditions, extreme poverty or parental anger problems, depression, delinquency and (ADHD). substance abuse) that doesn’t mean children will poor romantic and peer relationships, have been  Post-traumatic stress disorder (PTSD). develop RAD. It is more likely that they won’t. attributed to complications of reactive attachment  Oppositional defiant disorder. disorder. Some advocates of controversial Current diagnostic criteria do not adequately  Conduct disorder. therapies for RAD even cite historical figures, describe the presumed etiology or adequately  Social phobia. such as Adolf Hitler, Saddam Hussein and Edgar capture the range of behavioral symptoms for the  Genetic syndromes. two subtypes (inhibited or disinhibited), creating Allen Poe as examples of individuals with RAD further challenges in diagnosis. who did not get help in time (despite the obvious One of the symptoms of reactive attachment barriers to assessment and diagnosis) (Thomas, disorder making diagnosis difficult is impaired One other limitation of the RAD diagnosis is n.d.). Consequently, there is much fear and hype social interaction – a clinical problem found that it focuses exclusively on child-focused around the diagnosis. in several other disorders of childhood, such intrapersonal problems. This does not address as pervasive developmental disorder (PDD), However, the long-term consequences of other types of disturbances that may exist though the characteristics of problems with aberrant attachment patterns on social-emotional between the child and caregiver. For example, social interaction are unique to each of these functioning are unclear. Although the behaviors Zeanah and Smyke argue the need to describe and disorders (Scheeringa, 2001). Although reactive have long been recognized in severely neglected, validate disorders that exist between, rather than attachment disorder – disinhibited type looks maltreated or institutionalized children, the within, individuals: “In fact, we and others have similar to attention deficit hyperactivity disorder, disorder has only been researched well in the suggested additional forms of attachment disorder it differs in that the social behavior is specifically last decade, and there has been little research on Page 20 associated with attempts to form social This does not imply that all children who are is a dearth of misinformation about attachment attachments after a very brief acquaintance. neglected or abused will exhibit this disorder. It and problems attributed to disrupted or unhealthy may occur: attachment in early childhood. What we do know Delays in language development and  If the child has limited opportunity to form for sure is that all children do not develop the stereotypical behaviors, often found with RAD, selective attachments because of frequent same or have the same outcomes, even though also resemble pervasive developmental disorder. changes in primary caregiver(s) or marked their early experiences may be similar. For One of the most significant differences is that unavailability of an attachment figure. example, exposure to life events considered in contrast to the other disorders, children  When child is seriously neglected (such as risk factors does not mean that the child who with reactive attachment disorder can achieve with parents who are severely depressed or experiences these events is destined to develop significant improvement when placed with stable, substance abusers). clinically significant problems. Likewise, there nurturing caregivers. (Mukaddes, et.al. 2000). are degrees of insecure attachment most of which Also according to the ICD-10, children with RAD Deprivation maltreatment disorder is doesn’t lead to social emotional or developmental have normal social capacity, despite inadequate characterized by markedly disturbed, problems warranting treatment. language development, if symptoms of autism developmentally inappropriate attachment are not present; there are no severe cognitive behaviors, in which a child rarely or minimally APSAC recommendations: assessment and deficits present that are resistant to changes in turns preferentially to a discriminated attachment diagnosis the environment (like autism); and there are no figure for comfort, support, protection or Despite widespread misinformation and restricted areas of interest or resistant, persistent nurturance. There are three patterns: insufficient scientific research concerning the or repetitive stereotypical behavioral patterns. 1. Emotionally withdrawn or inhibited – benefits and risks of interventions, attachment (World Health Organization, 1992). Child rarely or minimally seeks comfort in therapies have became increasing popular, distress; responds minimally to comfort; has Other diagnostic classifications particularly with maltreated children in foster limited positive affect and excessive levels One of the problems with the RAD diagnosis is care and adoptive homes. Concerned about or irritability, sadness or fear; reduced or that it doesn’t adequately align with the primary potentially harmful techniques used by certain absent social and emotional reciprocity (e.g., feature of attachment behavior, a child’s act of therapists, the Professional Society on the reduced affect sharing, social referencing, seeking proximity to a caregiver during distress. Abuse of Children (APSAC) convened the turn-taking and eye contact). (Allen, 2011). That is not to say that all variances Task Force on Attachment Therapy, Reactive 2. Indiscriminate or disinhibited – Child is in attachment behavior are pathological. Another Attachment Disorder, and Attachment Problems overly familiar around unfamiliar adults; difficulty is that currently the DSM-IV-TR or (Chaffin, et.al, 2006). The task force report fails, even in unfamiliar settings, to check ICD-10 classification systems do not include any established APSAC’s position, including practice back with adult caregivers after venturing other disorders of attachment beyond reactive recommendations, and was endorsed by the away; and exhibits a willingness to go off attachment disorder. American Psychological Association (2006). with an unfamiliar adult with minimal or no Recommendations specific to the diagnosis and Some researchers have proposed alternative hesitation. assessment of attachment problems include: diagnostic criteria for a broader range of 3. Mixed pattern – Requires evidence of two 1. Assessment should include information about attachment disturbances, including disorders or more behaviors from the first two pattern patterns of behavior over time, and assessors of nonattachment, secure base distortions and types. This type persists and is much harder should be cognizant that current behaviors disorders of disrupted attachment. (Zeanah & to treat. may simply reflect adjustment to new or Boris, 2000; Boris, et.al., 1998; Zeanah, et.al, Like the DSM, the DC:0-3 is a multi-axial system stressful circumstances. 1993). Until this is resolved and there are of five axes. Clinicians diagnosing children with 2. Cultural issues should always be considered acceptable alternatives, practicing clinicians may deprivation maltreatment disorder should also list when assessing the adjustment of any child, diagnose children with RAD who do not fully current caregiving relationships on Axis II and especially in cross-cultural or international meet diagnostic criteria for the disorder (Chaffin, psychosocial and environmental stressors under placements or adoptions. Behavior appearing et.al, 2006). axis IV. Two tools that can be used to evaluate deviant in one cultural setting may be Recognizing the need for a systematic, relationships on Axis II are: (1) The Parent-Infant normative for children from different cultural developmentally based approach to developmental Relationship Global Assessment Scale (PIR- settings, and children placed cross-culturally and mental health difficulties in children under GAS) and the Relationship Problems Checklist. may experience unique adaptive challenges. 4 years old, Zero To Three, the National Center 3. Assessment should include samples of The Parent-Infant Relationship Global Assessment for Infants, Toddlers, and Families, established a behavior across situations and context. Scale (PIR-GAS) is used to assess and describe diagnostic classification task force in 1987. The It should not be limited to problems in the quality of caregiving-child relationships on Diagnostic Classification of Mental Health and relationships with parents or primary Axis II and offers a wide range of scores that are Developmental Disorders of Infancy and Early caretakers and instead should include categorized as either adapted (81-100), features Childhood (DC:0-3).(Zero To Three, 2005) was information regarding the child’s interactions of a disordered relationship (41-80) or disordered designed to complement, not replace existing with multiple caregivers, such as teachers and relationship (0-40). These include: day care providers, and peers. Diagnosis of diagnostic systems such as the Diagnostic and   91-100 Well adapted. RAD or other attachment problems should Statistical Manual of Mental Disorders of the   81-90 Adapted. not be made solely based on a power struggle American Psychiatric Association (DSM-III-R,   71-80 Perturbed. between the parent and child. 1987) and the International Classification of   61-70 Significantly perturbed. 4. Assessment of attachment problems should Diseases of the World Health Organization (ICD   51-60 Distressed. not rely on overly broad, non-specific or 9). The goal was to fill gaps in current systems   41-50 Disturbed. unproven checklists. Screening checklists and to advance professional communication and   31-40 Disorder. are valuable only if they have acceptable clinical research into adaptive and maladaptive   21-30 Severely disordered. measurement properties when applied to the behaviors of infancy and early childhood.   11-20 Grossly impaired. target populations where they will be used.  Deprivation maltreatment disorder  0-10 Documented maltreatment. 5. Assessment of attachment problems requires According to the DC:0-3R Revised Edition Implications for practice: assessment considerable diagnostic knowledge and skill (2005), deprivation maltreatment disorder occurs Despite years of clinical scientific study, there is to accurately recognize attachment problems in the context of deprivation or maltreatment still much that we need to learn about attachment and to rule out competing diagnoses. including persistent or severe parental neglect and its implications for clinical practice. There Consequently, attachment problems should or documented physical or psychological abuse. be diagnosed only by a trained, licensed Page 21 mental health professional with considerable than 70 studies, interventions designed to increase a core modality. (Lieberman & Van Horn, 2004). expertise in child development and parental sensitivity were the most effective. Because the focus is to help parents interpret the differential diagnosis. These interventions focused on the parent-child child’s responses to them from a developmental 6. Assessment should first consider more relationship and teaching positive parenting skills. perspective, a thorough understanding of child common disorders, conditions and Other characteristics resulting in outcomes that development is essential to this approach. explanations for behavior before considering are more successful were those interventions that Child-parent psychotherapy is one of the rarer ones. Assessors and caseworkers should were shorter term, more focused and goal-directed. few empirically validated interventions for be vigilant about the allure of rare disorders Based on research to date, Zeanah and Smyke traumatized children under age 6. According to in the child maltreatment field and should be (2009) identify the following practice implications: the National Child Traumatic Stress Network alert to the possibility of misdiagnosis.  The first priority of treatment is to establish a (n.d.), there have been three randomized control 7. Assessment should include family and safe and stable caregiving environment with a trials of child-parent psychotherapy with trauma- caregiver factors and should not focus solely warm and consistent caregiver. exposed children. In addition, four published on the child.  Carefully assess the relationship between the studies provide support for the efficacy of 8. Care should be taken to rule out conditions primary caregiver and child. Does the child relationship-based models with at-risk samples, such as autism spectrum disorders, have an attachment relationship? including anxiously attached dyads and children pervasive developmental disorder, childhood  If not, treatment begins by helping the of depressed mothers, with improvement in schizophrenia, genetic syndromes or other child establish one with a caregiver who attachment security, maternal empathy and conditions before making a diagnosis of can be emotionally available, sensitive and goal-corrected partnerships. NCTSN also reports attachment disorder. responsive; values the child as a unique that the treatment is flexible and allows for the 9. Diagnosis of attachment disorder should individual; and can place the needs of the incorporation of a discussion of cultural values never be made simply based on a child’s child above his or her own. and culture-related experiences. And it appears to status as maltreated, as having experienced  If the child has an established attachment be well accepted by clinicians. trauma, as growing up in an institution, as relationship, what is the quality of that being a foster or adoptive child, or simply connection? The goal in this case is to Interaction guidance because the child experienced pathogenic enhance and reduce maladaptive qualities in Interaction guidance (McDonough, 2004) is also care. Assessment should respect the fact that the relationship. another dyadic therapy designed for families resiliency is common, even in the face of  Treatment can be conducted with the overburdened by barriers and problems – such great adversity. caregiver or with the caregiver and child, but as poverty, lack of education, large family size, it is essential that the relationship between substance abuse, inadequate housing and lack Intervention and treatment them is the focus. of social support – and who have not been Interventions to address attachment problems,  The chief goal of treatment is helping the successfully engaged in treatment previously. including reactive attachment disorder, fall child learn, through repeated interactions Interaction guidance therapy helps families enjoy into two categories: attachment research-based with the adult caregiver, that the caregiver and understand their child’s behavior through interventions and attachment therapies. can be relied upon to provide comfort, interactive play. Parents view their videotaped Attachment research-based interventions use support, nurturance and protection. play interactions, reflect and discuss what is recognized, standardized and validated diagnostic  Additional problems such as cognitive and observed. The parent’s interactive strengths criteria to guide diagnosis. However, actions language delays, post-traumatic symptoms are emphasized and praised. Discussion about that are considered attachment therapies often or aggression should be addressed with other interaction challenges may also become a focus describe behaviors characteristic of other appropriate interventions. of treatment. (Stafford & Zeanah, 2006). disorders or in some cases not a part of any Child-parent psychotherapy (CPP) Circle of Security recognized diagnostic system. For example, one Child-parent dyadic psychotherapy was The Circle of Security project is an educational attachment disorder symptoms checklist includes developed by Alice Lieberman and associates and group parent psychotherapy protocol behaviors that are either not characteristic of from “infant-child psychotherapy,” a developed by Glen Cooper, Kent Hoffman and RAD or are more descriptive of the caregiver’s psychoanalytic approach to treating disturbed Bert Powell (2002), designed to shift problematic behavior instead of the child’s. Items on this list infant-parent relationships. Both approaches or at-risk patterns of attachment-care-giving include “not affectionate on parent’s terms (not identify the “patient” as the child-parent interactions to a more appropriate developmental cuddly)”; “cruelty to animals”; “parents appear relationship. Child-parent psychotherapy pathway. A major goal of the Circle of Security hostile and angry”; and “persistent nonsense integrates insight-oriented psychotherapy, project is to develop a theory- and evidence- questions and chatter” (Thomas, n.d.). psychodynamic, developmental, trauma, social based intervention protocol that can be used Attachment therapies conceptualize a child’s learning and cognitive behavioral theories into in a partnership between professionals trained behavior in terms of the child’s internal its attachment-focused approach. In addition to in scientifically based attachment procedures pathology and past caregivers instead of the the focus on the parents’ early relationships, the and appropriately trained community-based current environment and relationships. These intervention also addresses current life stresses practitioners. controversial attachment therapies emphasize the and cultural values. The Circle of Security (COS) protocol is based child’s resistance to attachment and the need to Therapy focuses on safety, affect regulation, on contemporary attachment and developmental work through the deeply rooted rage that resulted improving the child-caregiver relationship, theories and affective neuroscience. from adverse experiences (maltreatment, loss, normalization of trauma related response, and Interventions, according to Cooper, et.al, (2000) adoptions, changes in child care and so on) in joint construction of a trauma narrative. The are based on the following core constructs: early childhood (Chaffin, et.al., 2006). goal of child-parent psychotherapy is twofold:  Learning (including therapeutic change) In contrast, evidenced-based interventions are 1) improve the parent-child relationship, and 2) occurs from within a secure base relationship. designed to affect the child’s attachment pattern return the child to the appropriate level of social-  The quality of the parent-child attachment, by focusing on caregiver patterns of behavior emotional functioning and developmental course. which is amenable to change, plays a and thinking. This is in line with the research Child-parent psychotherapy incorporates a variety significant role in the life trajectory of the by Ainsworth and others because it indicates it of treatment modalities, including assistance child. is the quality of caregiver sensitivity that most with problems of daily living and modeling  Interventions need to be based on a influences attachment security. In a review by appropriate protective behavior; interpretation and differential diagnosis that is informed by Bakermans-Kranenburg et.al, (2003) of more unstructured developmental guidance; and play as research-based theory. Page 22  Lasting change comes from parents About attachment therapy RAD have control issues and trust issues and developing specific relationship capacities “Attachment therapy” is a term informally used to problems developing a conscience. Parents are instead of learning techniques to manage describe treatment for reactive attachment disorder. encouraged to establish control so they can achieve behaviors. The capacities needed for a secure Attachment therapy practitioners and advocates relief from the anger, manipulations and other relationship include: frequently report that it is more effective than disturbing behaviors and thus be able to provide ŠŠ Observational skills informed by traditional therapies despite the lack of a coherent the safe, compassionate care essential to bonding. a coherent model of children’s rationale and any meaningful empirical evidence. However, attachment therapy practitioners report developmental needs. (Stafford and Zeanah). Because there is no that attachment between the child and caregiver ŠŠ Reflective functioning and the ability to officially recognized and quantified entity called versus anger control is the primary goal of therapy. enter into reflective dialogue. “attachment therapy,” definitions differ based on Practitioners also believe that once the child is ŠŠ The ability to engage with children in the the practitioner or group doing the defining. bonded, other changes in behavior will occur regulation of their emotions. simultaneously (Buenning, n.d.). The Association for Treatment and Training ŠŠ Empathy. in the Attachment of Children (ATTACh) is Although the term “holding therapy” was used Before treatment, there is an initial assessment an international coalition of practitioners and more in the past in reference to specific type using the strange situation procedure, (Ainsworth, families hoping to raise public awareness about of intervention, it is currently recognized by et.al., 1978), observations, a videotaped interview the role of attachment in humans and the benefits ATTACh and others in the attachment therapy using two validated assessment tools and of attachment therapies. ATTACh believes that community as “a technique which can be one caregiver questionnaires about the child. The addressing the internal beliefs that drive these part of a more comprehensive treatment for child’s attachment pattern is classified as well behaviors is the proper stance for attachment- attachment issues during which other supportive as the caregiver’s attachment strategy (secure/ focused treatment, contrary to research findings therapeutic techniques may be utilized. Essential secure, dismissing/avoidant, preoccupied/ supporting a focus on the relationship between components include eye contact, appropriate ambivalent and unresolved/disorganized). child and caregiver. touch, empathy and genuine expression of emotion, nurturance, reciprocity, safety and COS is a collaborative, visually based approach In recent years, this group has sought to clearly acceptance. While a variety of holding positions (with extensive use of both graphics and edited redefine “attachment therapy” and defend it from can be used, the physical safety of the client is videotapes of their interactions with their charges that it is harmful to children after the the primary consideration”. children) to helping parents better understand, highly publicized death of 10-year-old Candace both cognitively and emotionally, the needs Newmaker, who was being treated for reactive Rage-reduction therapy of their children. The group circle serves as a attachment disorder with a type of holding Like holding therapy, the description for rage graphic representation of the child’s needs and therapy referred to as “rebirthing.” (Crowder & reduction therapy has also undergone a public attachment system, with the caregiver serving as Lowe, 2000; Janofsky, 2001). relations face-lift in recent years. Currently the the safe haven. In a common-sense fashion, it can While ATTACh continues to strongly support and term “rage reduction” refers to a therapeutic goal, be used in a variety of settings, including group, not a specific technique. Reducing the client’s family therapy or home visitation. The group endorse non-traditional attachment therapy, it has taken steps to distance itself from more coercive rage in order to facilitate more adaptive emotional protocol involves a 20-week parent education and regulation, cognitive processing and relational psychotherapy intervention. All learning centers forms of treatment, including posting a “White Paper on Coercion in Treatment” on its website capacity may be a goal of attachment therapy. In on the following themes: the early years of attachment work, the phrase  (ATTACh Board of Directors, 2007).  Teaching the basics of attachment theory via referred to a confrontational and physically the Circle of Security.™ Currently, ATTACh promotes a definition of intrusive technique developed by Robert Zaslow   Increasing parent skills in observing parent- attachment therapy as one that “denotes the focus used to elicit rage in order to reduce resistance child interactions. of the therapeutic process rather than a specific and thereby facilitate the healing of the child   Increasing capacity of the caregiver to intervention technique” and identifies the goal of (ATTACh, 2007; Zaslow, 1975). recognize and sensitively respond to attachment therapy as enabling “the person to form children’s need to move away to explore and secure, reciprocal relationships that the person Rebirthing to move back for comfort and security. can heal from the trauma and other psychological Rebirthing is the name of an intervention that is   Supporting a process of reflective dialogue disorders such as anxiety and depression caused often associated with holding therapies (and one between clinician and parent to explore both by, or made worse by, the disruption of early that many in the attachment therapy community strengths and areas of parent difficulties (i.e., attachment.” The focus of attachment therapy is now are hoping to distance and distinguish their being “bigger, stronger, wiser and kind”; twofold, according to ATTACh: therapies from). It is based on the theory that supporting exploration; and supporting “The first is to build a secure emotional one of the major issues children need to resolve attachment). attachment between the child and caregiver is trauma from around the time of birth. The   Introducing parent to a user-friendly way to (or in the case of an adult in therapy, building state of Colorado made this procedure illegal explore the caregiver’s miscued defensive the attachment between the client and the after the death of several children, most notably strategies. therapist). Once the person is able to make 10-year-old adopted girl Candace Newmaker, who suffocated after she was wrapped in a flannel Therapy is individualized based on each use of a trusting relationship to learn new information and skills, the focus then shifts sheet for more than an hour to simulate birth – or dyad’s attachment-caregiver pattern. Common ‘‘rebirthing.’’ misattunements are explored, and alternative to healing the psychological, emotional and strategies provided. For example, a caregiver with behavioral issues that develop as a result The law was enacted midway through the trial an insecure/dismissing adult attachment pattern of the parent-child disruption and/or early of two therapists who treated Candace and were whose child has an avoidant pattern will often trauma.” For those issues, ATTACh advocates charged with child abuse resulting in death. The “overfocus” on the child’s exploration to avoid the use of a variety of treatment interventions unlicensed therapist and practice owner, whom activation of the child’s attachment behavior (such including those based on behavioral, the therapists assisted, was also charged with as distress about an impending separation or at the cognitive and psychodynamic theory. unlicensed practice of psychotherapy, criminal impersonation and falsifying documents in time of reunion). For a preoccupied parent with a Holding therapy resistant/ambivalent child, the moment to focus on addition to child abuse resulting in death. The Proponents of this treatment and other adopted mother was also charged in the death might be just the opposite, (that is, a moment on controversial therapies believe that most children the videotape when the child engages in competent, of her daughter. (Lash, 2001; Crowder & Lowe, with RAD usually experience extreme feelings 2000). independent exploration when not distressed.). of anger. They also believe that all children with Page 23 Candace, the adopted daughter of Jeane 5. State-of-the-art, goal-directed, evidenced-  Do not engage in solicitation of testimonial Newmaker, was being treated for reactive based approaches that fit the main presenting endorsements (including solicitation of attachment disorder and the inability to form problem should be considered when selecting consent to use a client’s prior statement as a a loving bond with her adoptive mother. Her a first-line treatment. Where no evidence- testimonial endorsement) from current clients biological mother lost custody of her to North based option exists or where evidence-based or from other people who, because of their Carolina state officials over issues of neglect. treatment options have been exhausted, particular circumstances, are vulnerable to The expectation of the two therapists was that by alternative treatments with sound theory undue influence. pushing against Candace with sofa pillows from foundations and broad clinical acceptance Several concerns expressed about practitioners the outside to simulate contractions, she would are appropriate. Before attempting novel or who use and promote controversial attachment fight her way out of the sheet, as if emerging highly conventional treatments with untested therapies (or other flavors of the month) is that from a womb, and form a close attachment with benefits, the potential for psychological or these therapies have been developed outside of Ms. Newmaker. (Crowder & Lowe, 2000). physical harm should be carefully weighed. the scientific community, and literature promoting APSAC recommendations: intervention 6. First-line services for children described the efficacy of these therapies hasn’t undergone as having attachment problems should be independent peer review. The information is and treatment founded on the core principles suggested The Professional Society on the Abuse of widely distributed to parent groups, the public by attachment theory, including caregiver and other clinicians as self-published website Children’s (APSAC) Task Force on Attachment and environmental stability, child safety, Therapy, Reactive Attachment Disorder and material. Because of ethical concerns about how patience, sensitivity, consistency and some of these services are advertised, the ASPAC Attachment Problems (2006) recommends the nurturance. Shorter term, goal-directed, following on treatment and interventions: Task Force on Attachment Therapy, Reactive focused, behavioral interventions targeted Attachment Disorder and Attachment Problems 1. Treatment techniques or attachment at increasing parent sensitivity should be parenting techniques involving physical (2006) included the following recommendations considered as a first-line treatment. in its report: coercion, psychologically or physically 7. Treatment should involve parents and enforced holding, physical restraint, physical 1. Claims of exclusive benefit (i.e., that no other caregivers, including biological parents if treatments will work) should never be made. domination, provoked catharsis, ventilation of reunification is an option. Fathers and mothers rage, age regression, humiliation, withholding Claims of relative benefits (e.g., that one should both be included if possible. Parents treatment works better than others) should or forcing food or water intake, prolonged of children described as having attachment social isolation, or assuming exaggerated only be made if there is adequate controlled problems may benefit from ongoing support trial scientific research to support the claim. levels of control and domination over a child and education. Parents should not be are contraindicated because of risk of harm 2. Use of patient testimonials in marketing instructed to engage in psychologically or treatment services constitutes a dual and absence of proven benefit and should physically coercive techniques for therapeutic not be used. (This recommendation should relationship. Because of the potential for purposes, including those associated with any exploitation, the task force believes that not be interpreted as pertaining to common known child deaths. and widely accepted behavior management patient testimonials should not be used to approaches used within reason, such as time- Additional ethical considerations: market treatment services. out, reward and punishment contingencies, advertisement of treatment services 3. Unproven checklists or screening tools occasional seclusion or physical restraint as Clinicians in private practice and practice should not be posted on websites or necessary for physical safety, restriction of groups educate the public about their services disseminated to lay audiences. Screening privileges, “grounding,” offering physical and the issues affecting their clients through a checklists known to have adequate comfort to a child and so on). variety of methods: public seminars, written and measurement properties and presented with 2. Prognostications that certain children are Internet advertising, blogs, and more. Most are qualifications may be appropriate. destined to become psychopaths or predators also guided by their profession’s ethical code 4. Information disseminated to the lay public should never be made based on early of conduct for competent practice and truthful should be carefully qualified. Advertising childhood behavior. These beliefs create an representation of credentials and services. For should not make claims of likely benefits that atmosphere conducive to overcorrection and example, the National Association of Social cannot be supported by scientific evidence harsh or abusive treatment. Professionals Workers Code of Ethics (2008) requires that and should fully disclose all known or should speak out against these and similar social workers: reasonably foreseeable risks.  unfounded conceptualizations of children  Base practice on recognized knowledge, Attachment theory and social services who are maltreated. including empirically based knowledge, practice 3. Intervention models that portray young relevant to social work and social work ethics.  In addition to clinical interventions, attachment children in negative ways, including  Should exercise careful judgment and take theory has also influenced other aspects of describing certain groups of young children responsible steps (including appropriate social services, medicine and law. For example, as pervasively manipulative, cunning or education, research, training, consultation the assessment of attachment is increasingly a deceitful, are not conducive to good treatment and supervision) to ensure the competence of crucial component in termination of parental and may promote abusive practices. In their work and to protect clients from harm rights (TPR) cases. The purpose of “bonding general, child maltreatment professionals when generally recognized standards do not evaluations” is to assess the nature and degree of should be skeptical of treatments that exist in an emerging area of practice.  attachment between a child and his or her birth describe children in pejorative terms or that  Ensure that their representations to clients, parents and foster parents (or other caregivers): advocate aggressive techniques for breaking agencies and the public about professional (Barone, et.al. 2005). down children’s defenses. qualifications, credentials, education, 4. Children’s expressions of distress during competence, affiliations, services provided or Additional ways attachment theory has changed therapy should always be taken seriously. results to be achieved are accurate. how social service practitioners and programs Some valid psychological treatments may  Give thorough, accurate information about work include (Landy, 2009):  involve transitory and controlled emotional the service so clients may weigh the benefits  Using family-friendly practices during distress. However, deliberately seeking and risks of treatment. and immediately after childbirth, such as to provoke intense emotional distress or  Protect research participants from providing birthing centers, allowing fathers dismissing children’s protests of distress is unwarranted physical or mental distress, to be with their partners throughout labor and contraindicated and should not be done. harm, danger or deprivation. delivery, and having newborn infants room-in with their mothers. Page 24  Psychiatry and Human Development. 30 (4), 273-287.  Providing extended visiting hours for parents evidence-based interventions and programs to ŠŠNational Association of Social Workers (2008). Code of ethics of the national visiting children in the hospital. help children form strong, secure attachments if association of social workers. Washington, DC: NASW Press. ŠŠNational Center for Education Statistics (2007). Overview of attachment theory.  Preferring the use of foster families instead this has been lacking in their early development. Retrieved July 27, 2011 from http://nces.ed.gov/pubs2007/2007084_C8.pdf ŠŠNICHD Early Child Care Research Network. (1997). The effects of infant childcare on of institutions for children who are without infant-mother attachment security: Results of the NICHD Study of Early Child Care. Bibliography Child Development, 68 (5), 860-879. ŠŠAinsworth, M. D. S. (1967), Infancy in Uganda: Infant care and the growth of love, parents or in protective care. ŠŠNCTSN National Child Traumatic Stress Network (n.d.). Fact Sheet: Child- Parent Baltimore: Johns Hopkins University Press. Psychotherapy. Retrieved May 11, 2011 http://www.nctsnet.org/sites/default/files/  ŠŠAinsworth, M.D.S. (1973). The development of infant-mother attachment. In B.  Making efforts to keep children with natural assets/pdfs/cpp_general.pdf Caldwell and H. Ricciuti (Eds.), Review of Child Development Research (Vol. 3). ŠŠO’Connor, T.G., Marvin, R.S., Rutter, M., Olrick, J.T., & Britner, P.A. (2003). parents or extended family whenever possible, Chicago, Ill.: University of Chicago Press. Child-parent attachment following early institutional deprivation. Development and ŠŠAinsworth, M.D.S.; Blehar, M.; Waters, E.; and Wall, S. (1978). Patterns of Attachment. Psychopathology, 15, 19-38. and if not, trying to ensure continuity of care Hillsdale, NJ: Erlbaum. ŠŠRiggs, S.A. (2010). Childhood emotional abuse and the attachment system across the ŠŠAllen,B.(2011). The use & abuse of attachment theory in clinical practice with and to avoid repeated moves and foster care life cycle: what theory and research tell us. Journal of Aggression, Maltreatment and maltreated children, Part 1: Diagnosis & assessment. Trauma, Violence & Abuse, 12 Trauma, 19(1), 5-51. pp. 80-103). (1), 3-12. placements for the child. ŠŠRosenblum, K.L., Dayton, C.J., & Muzik, M. (2009). Infant social and emotional ŠŠAmerican Psychiatric Association (1980). Diagnostic and statistical manual of mental development. In C.H. Zeanah (Ed.), Handbook of Infant Mental Health, 3rd ed. (pp.  disorders (3rd ed.). Washington, D.C.: American Psychiatric Press.  Promoting increased understanding of the 80-103) . New York: Guilford. ŠŠAmerican Psychiatric Association (2000). Diagnostic and statistical manual of mental ŠŠRutter, M., Kreppner, J, & Sonuga-Barke, E.(2009). Emanuel Miller Lecture: effects of loss and the stages of grieving in disorders (4th ed., text rev.) Washington, D.C.: American Psychiatric Press. Attachment insecurity, disinhibited attachment, and attachment disorders: where do ŠŠAssociation for Treatment and Training in the Attachment of Children (n.d.). ATTACh research findings leave the concepts? Child Psychology and Psychiatry 50:5, 529-543. young children. accepted definitions. Retrieved July 1, 2011 from http://www.attach.org/. ŠŠScheeringa, M.S. (2001). The differential diagnosis of impaired reciprocal social  ŠŠAssociation for Treatment & Training in the Attachment of Children (2007.). ATTACh  Considering the contribution of parent-child interaction in children: A review of disorders. Child Psychiatry and Human white paper on coercion in treatment. Retrieved 7/1/2011 from http://www.attach.org/. Development, 32(1), 71-89. ŠŠBarone, N. M., Weitz, E. I., & Witt, P. H. (2005). 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APSAC recommendations: child welfare ŠŠBowlby, J. (1988). A Secure Base. New York: Basic Books. ŠŠSroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study ŠŠBuenning, W.D. (n.d.). 1. Understanding the symptoms and 2. Practical therapy. from birth to adulthood. Attachment & Human Development, 7(4). 349-367. Recognizing the particular vulnerability of children Retrieved 7/19/11 from http://www.reactiveattachmentdisordertreatment.com/ssi/ ŠŠSroufe, L. A., Coffino, B., & Carlson, E. A. (2010). Conceptualizing the role of early articles.html experience: Lessons from the Minnesota Longitudinal Study. Developmental Review, in the child welfare system to misinformation ŠŠBuenning, W.D. (n.d.). Infant & Child Attachment Checklists. Retrieved July 19, 2011, 30(1), 36-51. from http://www.reactiveattachmentdisordertreatment.com/ssi/checklist.html. about attachment issues and questionable ŠŠSroufe, L. A., Egeland, B., Carlson, E.A., & Collins, W. A.(2005). The Development ŠŠCassidy, J. & Berlin, L.J. (1994). The Insecure/Ambivalent Pattern of Attachment: of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. Theory and Research. Child Development, 65 (4), 971-991. interventions and practices, The Professional NY: The Guilford Press. ŠŠChaffin, M., Hanson, R., Saunders, B.E., Nichols, T., Barnett, D., Zeanah, C., Berliner, ŠŠStroufe, A. & Siegel, D. (2011). The case for attachment theory: the verdict is in. Society on the Abuse of Children’s (APSAC) L., Egeland, B., Newman, E., Lyon, T., Letourneau, E. & Miller-Perrin, C. (2006). Family Therapy Networker, 35(2), 34-51. Report of the APSAC task force on attachment therapy, reactive attachment disorder, ŠŠStafford, B. S. & Zeanah, C.H. (2006/2009). Attachment Disorders (pp.231-251). In J. Task Force on Attachment Therapy, Reactive and attachment problems. Child Maltreatment, 11(26), 76-89. L. Luby (Ed.), Handbook of Preschool Mental Health. New York: Guilford. ŠŠCircle of Security Project (n.d.) Retrieved June 16, 2011 from http://www. ŠŠThomas, N. (n.d.). What is attachment disorder/reactive attachment disorder (RAD). Attachment Disorder, and Attachment Problems circleofsecurity.org/ Retrieved July 19, 2011 from http://www.attachment.org/pages_what_is_rad.php ŠŠCorbin, J.R. (2007). Reactive attachment disorder: A biopsychosocial disturbance of (2006) recommends the following: ŠŠThompson, R.A., Goodvin, R. & Meyer, S. (2006). Social development: psychological attachment. Child and Adolescent Social Work Journal, 24, 539-552. understanding, self-understanding, and relationships (pp.3-19). In J. L. Luby (Ed.), ŠŠCrowder C. & Lowe, P. (2000, October 29). Her name was Candace. Rocky Mountain 1. Treatment provided to children in the child Handbook of Preschool Mental Health. New York: Guilford. News. Retrieved July 20, 2011 from http://www.rockymountainnews.com/news/2000/ ŠŠTibbetts-Kleber A. L. & Howell, R.J. (1985). Reactive attachment disorder of infancy. welfare and foster care systems should be oct/29/her-name-was-candace/ Journal of Clinical Child Psychology, 14 (4), 304-310. ŠŠGrossmann, K., Grossmann, K.E., Fremmer-Bombik, E., Kindler, H., Scheuerer- ŠŠVan der Kolk, B.A. and Fisler, R.F. (1994). Childhood abuse and neglect and the loss of based on a careful assessment conducted Englisch, H. & Zimmerman, P. (2002). The uniqueness of the child-father attachment self-regulation. Bulletin of the Menninger Clinic, 58 (2), 145 – 168. relationship: Fathers’ sensitive and challenging play as a pivotal variable in a 16-year ŠŠvan Ijzendoorn, M.H., & Sagi, A. (1999). Cross-cultural patterns of attachment: by a qualified mental health professional longitudinal study. Social Development, 11(3), 307-331. Universal and contextual dimensions. In J. Cassidy & P. Shaver (Eds.), Handbook of ŠŠHazen, N.L., McFarland, L., Jacobvitz, D., & Boyd-Soisson (2010). Father’s with expertise in differential diagnosis and attachment theory and research. pp. 713-734. New York: Guilford Press frightening behaviors and sensitivity with infants: relations with fathers’ attachment ŠŠWorld Health Organization. (1992). International statistical classification of diseases representations, father-infant attachment, and children’s later outcomes. Early child development. Child welfare systems and related health problems, 10th revision. Geneva, Switzerland: Author. Childhood and Care, 180, 51-69. ŠŠZaslow, R.W. & Menta, M. (1975). The psychology of the Z process: Attachment and should guard against accepting treatment ŠŠInstitute for Attachment and Child Development (n.d.) What is attachment? Retrieved activity. San Jose, CA: San Jose State University Press. July 20, 2011from http://instituteforattachment.org/what_is_attachment_disorder.htm ŠŠZeanah, C.H., Jr. & Boris, N.W. (2000). Disturbances and disorders of attachment in prescriptions based on word-of-mouth ŠŠInstitute for Attachment and Child Development (n.d.). Randolph attachment disorder early childhood. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed.) questionnaire. Retrieved July 20, 2011 from http://instituteforattachment.org/articles_ New York: Guilford. recruitment among foster caregivers or other Randolph_Attachment_Disorder.htm ŠŠZeanah, C.H., Jr., Mammen, O.K., Lieberman, A.F. (1993). Disorders of attachment.. ŠŠJanofsky, M. (2001, April 18). Girl’s death brings ban on a kind of therapy. New York lay individuals. In C.H. Zeanah, Jr. (Ed.), Handbook of Infant Mental Health (pp. 332- 349). New Times. Retrieved July 1, 2011 from http://www.nytimes.com/2001/04/18/us/girl-s- York: Guilford. death-brings-ban-on-a-kind-of-therapy.html 2. Child welfare systems should not tolerate any ŠŠZeanah, C.H. & Smyke, A.T. (2009). Attachment disorders. In C.H. Zeanah, Jr. (Ed.), ŠŠKelly, V. J. (2003). Theoretical rationale for the treatment of disorders of attachment. Handbook of Infant Mental Health, 3rd ed. (pp. 421-434). New York: Guilford. parenting behaviors that normally would be Retrieved July 20, 2011 from http://www.attach.org/theorational.htm ŠŠZERO TO THREE. (2005). Diagnostic Classification of Mental Health and ŠŠKlaus, M.H. & Kennel, J.H. (1976). Maternal-infant bonding: The impact of early Developmental Disorders of Infancy and Early Childhood: Revised Edition (DC:0-3R). considered emotionally abusive, physically separation or loss on family development. St. Louis: Mosby. Washington, DC: ZERO TO THREE Press. ŠŠKlaus, M.H. & Kennel, J.H. (2001). Commentary: Routines in maternity units: are they abusive or neglectful simply because they are still appropriate for 2002? Birth, 28(4), 274-275. alleged to be part of attachment treatment. For ŠŠLamb, M.E. (1997). Fathers and child development: An introductory overview and guide. In M.E. Lamb (Ed.), The role of the father in child development (3rd ed., pp. example, withholding food, water or toilet 1-18). New York: Wiley. ŠŠLamb, M.E. (2002). Infant-father attachments and their impact on child development. access as punishment; exerting exaggerated In C. Tamis-LeMonda & N. Cabrera (Eds.), Handbook of father-involvement (pp. 93- 117). Mahwah, New Jersey: Lawrence Erlbaum Associates. levels of control over a child; restraining ŠŠLandy, S. (2009). Pathways to competence: encouraging healthy social and emotional development in young children. Baltimore: Paul H. Brookes Publishing Co. children as a treatment; or intentionally ŠŠLash, C. (2001, January 28). The death of a new beginning. Pittsburgh Post-Gazette. provoking out-of-control emotional distress Retrieved 7/20/11 from http://post-gazette.com/headlines/20010128rebirthnat3.asp ŠŠLieberman, A. F. & Van Horn, P. (2005). Don’t hit my mommy!”: A manual for Child- (Final examination questions on next page) should be evaluated as suspected abuse and Parent Psychotherapy with young witnesses of family violence. Washington, D.C.: Zero to Three Press. handled accordingly. ŠŠMain, M. & Cassidy, J. (1988) Categories of response to reunion with the parent at age 6: predictable from infant attachment classifications and stable over a 1-month period. Developmental Psychology, 24, 15-426. Summary ŠŠMain, M. & Goldwyn, (1998). Adult attachment scoring and classification system. Attachment is a developmental achievement that Unpublished manuscript, University of California at Berkeley. Referenced by Landy, S. (2009) in Pathways to Competence: Encouraging healthy social and emotional lays the foundation for future social-emotional development in children, 150-151. Baltimore: Paul H. Brookes Publishing Co. ŠŠMain, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related development. From research, we know that young to infant disorganized attachment status: Is frightened/frightening parental behavior the linking mechanism? In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), children normally form strong attachments Attachment in the Preschool Years: Theory, Research, and Intervention, 161-182. Chicago, IL: University of Chicago Press. with one or two primary caregivers and that the ŠŠMain, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disorientated ability of the caregiver to consistently provide attachment pattern. In T.B. Brazelton & M.W. Yogman (Eds.), Affective Development in Infancy (pp.95-124). Norwood, NJ: Ablex. sensitive and responsive care determines the ŠŠMain, M. & Solomon, J. (1990). Procedures for identifying infants as disorganized/ disoriented during the Ainsworth Strange Situation. In M.T. Greenburg, D. Cicchetti, quality of attachment. Internal working models & E.M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention, 121-160. IL: University of Chicago Press. represent emotions and expectations resulting ŠŠMarvin, R., Cooper, G., Hoffman, K. and Powell, B.(2002). The Circle of Security project: Attachment-based intervention with caregiver – pre-school child dyads. from a child’s interactions with his or her parent Attachment & Human Development, 4(1), 107–124. or caregiver and determine whether the child ŠŠMayo Clinic (n.d.) Reactive attachment disorder. Retrieved May 2, 2011 from http://www.mayoclinic.com/health/reactive-attachmentdisorder/DS00988/ develops secure or insecure and organized or DSECTION=symptoms ŠŠMcDonough, S. (2004). Interaction guidance. In A. Sameroff, S. McDonough, & K. disorganized attachments. However, the quality Rosenblum (Eds.), Treatment of infant-parent relationship disturbances (pp. 79-96). New York: Guilford Press. of attachment can vary over time depending ŠŠMukkaddes, N.M., Bilge, S., Alyanak, B. & Kora, M.E. (2000). Clinical characteristics on circumstances, and there are researched and and treatment responses in cases diagnosed as reactive attachment disorder. Child

Page 25 NOTES EARLY ATTACHMENT THEORY: 5. DSM-IV-TR criteria for a diagnosis of RESEARCH AND CLINICAL reactive attachment disorder includes all of the following except APPLICATIONS a. Markedly disturbed and Final Examination Questions developmentally inappropriate social Choose the best answer for questions relatedness in most contexts. 1 through 5 and then proceed to b. A child’s failure to seek proximity to a www.elitecme.com to complete your caregiver. final examination. c. Behavior begins before age 5. d. The child is associated with grossly 1. Which of the following statements about pathological care. bonding is not true? a. Bonding relates to the parental tie to the infant during the first hours and days of its life. b. Factors that promote bonding include the sense of ownership from identification of the infant as the parent’s progeny. c. The appearance of an infant has no impact on the bonding process. d. Factors that promote bonding include hormonal influences.

2. Which of the following statements about attachment is true? a. Attachment functions to ensure the survival of the child by keeping the child in close proximity. b. Attachment refers to the parental feelings of the parent. c. A central theme of attachment theory lies in the role the caregiver plays in guiding a child to act with self-reliance as soon as possible. d. Attachment is a biological drive that a caregiver cannot influence.

3. Which of the following statements about attachment styles is not true? a. The attachment style describes the quality of the relationship a child feels toward an adult caregiver. b. The attachment style describes the quality of the feelings a parent or caregiver has for the child. c. Scientific research on parent-child relationships suggests that two primary types of attachments form secure attachments and insecure attachments. d. Children who are secure in their attachments more freely explore their environments.

4. Outcomes in the well-being and development of a child who has a secure attachment style are all of the following except a. Is cooperative with parents. b. Is socially competent and seeks out friends. c. Is easily comforted if upset and seeks help if overwhelmed. d. Can be excessively angry but has control in nonsocial situations. PYGA03EA12

Page 26 CHAPTER 3 problems. At the end of the day, the most that this will enhance morale and cohesion and THE RETURNING U.S. VETERAN OF important initial needs of returning veterans are reduce “battle fatigue.” Even if soldiers manifest MODERN WAR: BACKGROUND ISSUES, to be heard, understood, validated, and comforted clear and unequivocal signs of severe war zone in a way that matches their personal style. Every stress reactions that affect their capacity to carry ASSESSMENT AND TREATMENT war is unique in ways that cannot be anticipated. out their responsibilities, attempts are made to (3 CE HOURS) There is much to be learned by listening carefully restore the soldier to duty as quickly as possible Learning objectives and intently. by providing rest, nourishment, and opportunities !! Identify the form and course of adaptation to to share their experiences as close to their units The form and course of adaptation to as possible. The guiding principal is known as war zone stressors. war zone stressors !! Describe the kinds of war zone stressors Proximity - Immediacy - Expectancy - Simplicity The psychological, social, and psychiatric toll of soldiers are confronted with in modern war. (PIES). Early intervention is provided close to a war can be immediate, acute or chronic. These !! Identify how veterans of modern war initially soldier’s unit, as soon as possible. Soldiers are time intervals reflect periods of adaptation to present post-involvement symptoms. told that their experience is normal and they can severe war zone stressors that are framed by !! Describe how to assess the presenting expect to return to their unit shortly. They are different individual, contextual, and cultural symptoms of the modern war veterans. also provided simple interventions to counteract features, and unique additional demands, which !! Compare and contrast conventional mental “fatigue” (e.g., “three hots and a cot”). All that are important to appreciate whenever a veteran of health treatment vs. treatment for modern war said, some combat environments do not allow for war presents clinically. soldiers. “debriefing” and “three hots and a cot,” due to !! State the course of treatment for active duty The immediate interval refers to psychological conditions such as sniper fire and harsh combat soldiers vs. veterans seeking health care. reactions and functional impairment that occur terrain. The point here is that soldiers who !! List the important areas of functioning to in the war zone during battle or while exposed experience severe war zone stress reactions will evaluate returning veterans. to other severe stressors during the war. The hopefully have received some sort of special care. ! ! Describe the characteristics of combat fatigue immediate response to severe stressors in the On the other hand, it is without question casualties and combat stress reactions. war zone has had many different labels over stigmatizing for soldiers to share fear and doubt ! ! List the combat stress reactions of acute many centuries (e.g., combat fatigue); the label and to reveal signs of reduced capacity. This is stress disorder and post-traumatic stress combat stress reaction is currently used most especially true in the United States modern, all- disorder. often. However, this is somewhat a misnomer. volunteer military with many soldiers looking to ! ! Describe the basic considerations for care for As discussed in this course, direct combat advance their careers. Thus, it is entirely possible returning veterans. exposure is not the only source of severe stress that some veterans who present at VA medical ! ! List the practitioner issues that may surface in a war zone. The term war zone stress reaction centers will have suffered silently and may as a result of working with modern war carries more meaning and is less stigmatizing to still feel a great need not to show vulnerability veterans. soldiers who have difficulties as a result of their because of shame. experiences other than direct life-threat from Introduction combat. It should be underscored that being fired Combat fatigue casualties It is safe to assume that all soldiers are impacted upon is only one of the many different severe war It should be noted that a very small percentage by their experiences in war. For many, surviving zone stressors. of soldiers actually become what are known the challenges of war can be rewarding, maturing, as combat fatigue casualties. (However, this and growth-promoting (e.g., greater self-efficacy, In the war zone, soldiers are taxed physically and may be due to under-reporting.) Research on enhanced identity and sense of purposefulness, emotionally in ways that are unprecedented for Israeli soldiers has revealed that severe war zone pride, camaraderie, etc.). Conversely, the them. Although soldiers are trained and prepared stress reactions are characterized by variability demands, stressors, and conflicts of participation through physical conditioning, practice, and between soldiers and liability of presentation in war can also be traumatizing, spiritually various methods of building crucial unit cohesion within soldiers. The formal features of severe and morally devastating, and transformative in and buddy-based support, inevitably, war zone incapacitating war zone stress reactions are: potentially damaging ways, the impact of which experiences create demands and tax soldiers and  Restlessness. can be manifest across the veteran’s lifespan. unit morale in shocking ways. In addition, the  Psychomotor deficiencies. pure physical demands of war zone activities  This course will share useful information for  Withdrawal. should not be underestimated, especially the  Increased sympathetic nervous system addressing the following questions: behavioral and emotional effects of circulating 1. What are the features of modern war that activity. norepinephrine, epinephrine and cortisol (stress  may significantly impact the quality of life,  Stuttering. hormones), which sustain the body’s alarm  well-being, and mental health of returning  Confusion. reaction (jitteriness, hypervigilance, sleep  veterans?  Nausea. disruption, appetite suppression, etc.). In battle,  2. What are important areas of functioning to  Vomiting. soldiers are purposely taxed so that they can  Severe suspiciousness and distrust. evaluate in returning veterans? retain their fighting edge. In addition, alertness, 3. What might be beneficial for veterans of hypervigilance, narrowed attention span and However, because soldiers will vary considerably modern war who request clinical services? so forth are features that have obvious survival in the form and course of their decompensation The material below provides an initial schematic value. as a result of exposure to extreme stress, military so that mental health professionals including personnel are prone to use a functional definition Enlisted soldiers, non-commissioned officers and of combat fatigue casualty. For commanders, clinicians in the Department of Veterans Affairs officers are trained to identify the signs of normal (VA) can begin to appreciate the experience the defining feature is that the soldier ceases to “battle fatigue” as well as the signs of severe function militarily as a combatant, and acts in of soldiers returning from war. Rather than a war zone stress reactions that may incapacitate definitive road map, it is a starting place. a manner that endangers himself or herself and military personnel. However, the boundary line his or her fellow soldiers. If this kind of severe Needless to say, each veteran will have a between “normal” and “pathological” response to response occurs, soldiers may be evacuated from highly individualized and personal account the extreme demands of battle is fuzzy at best. the battle area. Finally, clinicians should keep of what happened to him/her and what he or When they are able, officers routinely use post- in mind that most combatants are young and she experienced or witnessed in war. Each battle “debriefing” to allow soldiers to vent and that during the late teens and early 20s is a time veteran will also reveal a unique set of social, share their emotional reactions. The theory is when vulnerable individuals with family histories psychological, and psychiatric issues and Page 27 of psychopathology (or other diatheses) are at with the majority of these reactions remitting in stressors and burdens), have few secure and greatest risk for psychological decompensation the following months. Generalizing from this reliable outlets for unburdening their experiences, prompted by the stress of war. As a result, a very literature, it is safe to assume that although acute and receive little or no validation in the weeks, small number of veterans of the modern war may stress reactions are very common after exposure months, and years following exposure to war present with stress-induced severe mental illness. to severe trauma in war, the majority of soldiers trauma. who initially display distress will naturally adapt For soldiers who may be in a war zone for Most VA clinicians will interact with veterans and recover normal functioning in the following protracted periods of time, with ongoing risks of the modern wars during the chronic phase of months. Thus, it is particularly important not and hazards, the acute adaptation interval spans adjustment. Nevertheless, early assessment of be unduly pathologizing about initial distress or the period from the point at which the soldier is PTSD and other co-morbid conditions implicated even the presence of ASD. objectively safe and free from exposure to severe from exposure to the war is crucial in providing stressors to approximately one month after return The chronic phase of adjustment to war is effective treatment as soon as possible. Although to the U.S., which corresponds to the one-month well known to VA mental health practitioners; technically chronic with respect to time since interval during which acute stress disorder (ASD) it is the burden of war manifested across the hostilities ceased, soldiers’ mental health status may be diagnosed, according to DSM-IV. This lifespan. It is important to note that psychosocial will be relatively new with respect to their distinction is made so that a period of adaptation adaptation to war, over time, is not linear and extra-war roles and social context. For example, can be identified that allows clinicians to discern continuous. For example, most soldiers are not a soldier might be newly reunited with family how a soldier is doing psychologically following debilitated in the immediate impact phase, but and friends, which may tax coping resources the opportunity to recover naturally and receive they are nevertheless at risk for chronic mental and produce shame and lead to withdrawal. In rest and respite from severe stressors. Otherwise, health problems implicated by experiences this context, interventions provided as early as diagnostic labels used to identify transient during battle. Also, although ASD is an excellent possible will still provide secondary prevention distress or impairment may be unnecessarily predictor of chronic PTSD, it is not a necessary of very chronic maladaptive behavior and pathologizing, stigmatizing and inappropriate precondition for chronic impairment because adaptation. because they are confounded by ongoing there is sufficient evidence to support the notion On the other hand, it is important to appreciate exposure to war zone demands and ongoing of delayed PTSD. Furthermore, the majority of that many things may have happened to a veteran immediate stress reactions. Typically, in the acute people who develop PTSD did not meet the full with steady difficulties through the immediate phase, soldiers are in their garrison (in the U.S. or diagnostic criteria for ASD beforehand. It is also and acute phases that color the person’s clinical overseas) or serving a security or infrastructure- important to appreciate that psychosocial and presentation. For example, a soldier may have building role after hostilities have ceased. psychiatric disturbance implicated by war zone been provided multiple interventions in the war exposure waxes and wanes across the lifespan Acute stress disorder (ASD) symptoms zone and in the acute phase, such as critical (e.g., relative to life demands, exposure to critical The symptoms of ASD include three dissociative incident stress debriefing (CISD), or pastoral reminders of war experiences, etc.). symptoms (Cluster B), one re-experiencing counseling or formal psychiatric care. It is symptom (Cluster C), marked avoidance (Cluster Post-traumatic stress disorder (PTSD) is one important to assess and appreciate the course of D), marked anxiety or increased arousal (Cluster of many different ways a veteran can manifest care provided and not to assume that the veteran E), and evidence of significant distress or chronic postwar adjustment difficulties. Veterans is first now presenting with problems. It could impairment (Cluster F). The diagnosis of ASD are also at risk for depression, substance abuse, be that some veterans experienced their attempts requires that the individual has experienced at aggressive behavior problems, and the spectrum to get help and guidance or respite as personal least three of the following: of severe mental illnesses precipitated by the failure and they may have been stigmatized,  A subjective sense of numbing or stress of war. Generally, the psychological risks ostracized, or subtly punished for doing so. from exposure to trauma are proportional to detachment. What kinds of war zone stressors do  Reduced awareness of one’s surroundings. the magnitude or severity of exposure and the modern day soldiers confront?  De-realization. degree of life-threat and perceived life-threat. The It is important to appreciate the various  Depersonalization. latter is particularly pertinent to the war in Iraq, types of demands, stressors, and potentially  Dissociative amnesia. where the possibility of exposure to chemical or biological threats was a genuine concern. traumatizing events that veterans of the war The disturbance must last for a minimum of two Exposure to chemical or biological toxins can be may have experienced. This will help facilitate days and a maximum of four weeks (Cluster G), obscure, yet severely alarming before, during and communication between clinician and patient and after which time a diagnosis of post-traumatic after battle. enhance understanding and empathy. Although stress disorder (PTSD) should be considered. there may be one or two specific traumatic A number of individual vulnerabilities have been Research has shown that there is little empirical events burned into the consciousness of returning shown to moderate risk for PTSD. For example: justification for the requirement of three soldiers that plague them psychologically,  History of psychiatric problems (in particular, dissociation symptoms. Accordingly, experts in traumatic events need to be seen in the context depression). the field advocate for consistency between the of the totality of roles and experiences in the war  Poor coping resources or capacities. diagnostic criteria for ASD and PTSD because zone.  Past history of trauma and mistreatment many individuals fail to meet diagnostic criteria increases risk for post-traumatic pathology. In addition, research has shown convincingly that for ASD but ultimately meet criteria for PTSD while exposure to trauma is a prerequisite for the despite the fact that their symptoms remain Individuals who show particularly intense and development of significantly impairing PTSD, unchanged. frequent symptoms of ASD (particularly, severe it is necessary but not sufficient. For veterans, hyperarousal) in the weeks following trauma are Unfortunately, there have been insufficient there are a host of causes of chronic PTSD. In particularly at risk for chronic PTSD. In addition, longitudinal studies of adaptation to severe terms of war zone experiences, perceived threat, the quality and breadth of supports in both the war zone stressors. On the other hand, there is low-magnitude stressors, exposure to suffering military and civilian recovery contexts (in the a wealth of research on the temporal course of civilians, and exposure to death and destruction, military and outside the military) and beyond post-traumatic reactions in a variety of other have each been found to contribute to risk for (e.g., in the home) can impact risk for PTSD. traumatic contexts (e.g., sexual assault, motor chronic PTSD. It should also be emphasized People who need intervention most are the ones vehicle accidents). These studies have revealed that the trauma of war is colored by a variety of that are isolated and cannot get the respite from that the normative response to trauma is to emotional experiences, not just horror, terror, work, family, and social demands that they may experience a range of ASD symptoms initially, and fear. Candidate emotions are sadness about need (or who have additional family or financial

Page 28 losses, or frustration about bearing witness of dying men and women. These experiences gossip and rumors directed toward individuals. to suffering, guilt about personal actions or may be intensely demoralizing for some. It also In peacetime, these types of experiences are inactions, and anger or rage about any facets of is likely that memories of the aftermath of war devastating for victims and create helplessness, the war (e.g., command decisions, the behavior of (e.g., civilians dead or suffering) are particularly powerlessness, rage, and great stress. In the war the enemy). disturbing and salient. zone, they are of no less impact. Described below are the types of stressful war Perceived threat Ethno-cultural stressors zone experiences that veterans of the first Persian Veterans may report acute terror and panic and Minority soldiers may in some cases be subject Gulf War reported as well as the psychological sustained anticipatory anxiety about potential to various stressors related to their ethnicity issues and problems that may arise as a result. We exposure to circumstances of combat, including (e.g., racist remarks). Some service members assume that many of these categories or themes nuclear (e.g., via the use of depleted uranium in who may appear to be of Arab background may will apply to returnees from the wars in Iraq and certain bombs); biological; or chemical agents; experience added racial prejudice/stigmatization, Afghanistan. missiles (e.g., SCUD attacks); and friendly fire such as threatening comments or accusations Preparedness incidents. Research has shown that perceptions directed to their similarity in appearance to the of life-threat are powerful predictors of post-war enemy. Also, Arab-Americans may experience Some veterans may report anger about perceiving mental health outcomes. conflict between American identity and identity that they were not sufficiently prepared or trained related to their heritage. Such individuals may for what they experienced in the war. They Difficult living and working environment have encountered pejorative statements about may believe that they did not have equipment These low-magnitude stressors are events or Arabs and Islam as well as devaluation of the and supplies they needed or that they were circumstances representing repeated or day-to- significance of loss of life among the enemy. insufficiently trained to perform necessary day irritations and pressures related to life in procedures and tasks using equipment and the war zone. These personal discomforts or Perceived radiological biological and supplies. Some soldiers may feel that they were deprivations may include the lack of desirable chemical weapons exposure ill prepared for what to expect in terms of their food, lack of privacy, poor living arrangements, Some veterans of the war will report personal role in the deployment and what it would be like uncomfortable climate, cultural difficulties, exposures to an array of radiological, nuclear, in the region (e.g., the desert). Some veterans boredom, inadequate equipment, and long biological, and chemical agents that the veteran may have felt that they did not sufficiently workdays. These conditions are obviously believes he/she encountered while serving in the know what to do in case of a nuclear, biological, non-traumatizing but they tax available coping war zone. Given the extensive general knowledge or chemical attack. From a mental health resources, which may contribute to post- of Persian Gulf War illnesses among soldiers professional’s perspective, veterans who report traumatic outcomes. (and the public), there is no doubt that veterans feeling angry about these issues may have felt Concerns about life and family of the new wars will experience concerns about relatively more helplessness and unpredictability potential unknown low-level exposure that may disruptions in the war zone, factors that have been shown to chronically affect their health. For some, these Soldiers may worry or ruminate about how increase risk for PTSD. perceptions may produce a hypervigilant internal their deployment might negatively affect other focus of attention on subtle bodily reactions Combat exposure important life-domains. For National Guard and and sensations, which may lead to a variety of It appears that the new wars entail more Reserve troops, this might include career-related somatic complaints. stereotypical exposure to warfare experiences concerns (e.g., losing a job or missing out on a such as firing a weapon, being fired on (by enemy promotion). For all soldiers, there may be family- Assessment or potential friendly fire), witnessing injury related concerns (e.g., damaging relationships New veterans of the wars will present initially and death, and going on special missions and with spouse or children or missing significant in a myriad of ways. Some may be very frail, patrols that involve such experiences, than the events such as birthdays, weddings, and deaths). labile, emotional, and needing to share their story. ground war offensive of the Persian Gulf War, The replacement of the draft with an all-volunteer The modal presentation is likely to be defended, which lasted three days. Clinicians who have military force and the broadening inclusion of formal, respectful, laconic, and cautious (as if extensive experience treating veterans of other women in a wide variety of positions (increasing they were talking to an officer). Generally, it is wars, particularly Vietnam, Korea, and WW II their potential exposure to combat) significantly safe to assume that it will be difficult for new should be aware of the bias this may bring to change the face of this new generation of veterans of the wars to share their thoughts and bear when evaluating the significance or impact veterans. Single parent and dual-career couples feelings about what happened during the war and of experiences in modern warfare. Namely, are increasingly common in the military, which the toll those experiences have taken on their clinicians need to be careful not to minimize highlights the importance of developing a strong mental health. It is important not to press any reports of light or minimal exposure to combat. working relationship between the clinician, the trauma survivor too soon or too intensely and They should bear in mind that in civilian life, veteran and his or her family. As is the case with respect the person’s need not to feel vulnerable for example, a person could suffer from chronic difficult living and working conditions, concerns and exposed. PTSD as a result of a single, isolated life-threat about life and family disruptions can tax coping Clinical contacts should proceed from triage experience (such as a physical assault or motor resources and affect performance in the war zone. vehicle accident). (e.g., suicidality/homicidality, acute medical Sexual or gender harassment problems, and severe family problems may Aftermath of battle Some soldiers may experience unwanted sexual require immediate attention), screening, formal Veterans of the new wars will no doubt report touching or verbal conduct of a sexual nature assessment, to case formulation/treatment exposure to the consequences of combat, from other unit members, commanding officers, planning, with an emphasis on prioritizing targets including observing or handling the remains or civilians in the war zone that creates a hostile for intervention. In all contacts, the clinician of civilians, enemy soldiers, U.S. and allied working environment. Alternatively, exposure should meet the veteran where he or she is with personnel, or animals; dealing with prisoners of to harassment that is non-sexual may occur on respect to immediate needs, communication war; and observing other consequences of combat the basis of gender, minority, or other social style, and emotional state. Also, the clinician such as devastated communities and homeless status. This kind of harassment may be used to should provide the veteran a plan for how the refugees. Veterans may have been involved in enforce traditional roles, or in response to the interactions may proceed over time and how they removing dead bodies after battle. They may have violation of these roles. Categories of harassment might be useful. The goal in each interaction is seen homes or villages destroyed or they may include indirect resistance to authority, deliberate to make sure the veteran feels heard, understood, have been exposed to the sight, sound, or smell sabotage, indirect threats, constant scrutiny, and respected, and cared for.

Page 29 Comprehensive assessment will inform case or discharging from the military in a sluggish origin, may have a particularly difficult time formulation and treatment planning. There are economy reduces the potential for the veteran’s returning to their role as adult children. The many potentially important variables to assess ability to be considered for many jobs, since they process of serving active duty in a war zone is when working with a veteran of war: have been unable to keep up with technical and a maturing one, and younger veterans may feel 7 Work functioning 7 Psychological other career training. as if they have made a significant transition to adulthood that may conflict with parental symptoms Clinicians will also encounter veterans who have expectations and demands over time. 7 Interpersonal 7 Past distress and voluntarily or involuntarily ended their military functioning coping service following their deployment. Issues related Veterans who are parents may feel somewhat to this separation may include the full-range displaced by the caretaker who played a primary 7 Recreation and 7 Previous traumatic of emotional responses including relief, anger, role in their child’s life during deployment. self-care events sadness, confusion and despair. Veterans in Depending on their age, the children of veterans 7 Physical functioning 7 Deployment-related this position might benefit from employment- may exhibit a wide range of regressive or experiences related assessment and rehabilitation services, challenging behaviors that may surprise and tax Often, when working with individuals who including an exploration of career interests and their returning parent. This normal, expected have been exposed to potentially traumatic aptitudes, counseling in resume building and adjustment can become problematic and experiences, there is pressure to begin with job interviewing, vocational retraining, and prolonged if the veteran is struggling with his or an assessment of traumatic exposure and to emotional processing of psychological difficulties her own psychological distress post-deployment. encourage the veteran to immediately talk impeding work success and satisfaction. Thus, early (and repeated) assessment and early family oriented intervention may be indicated. about his or her experiences. However, it is Interpersonal functioning recommended that it is most useful to begin Another important area of assessment involves Finally, homecoming and subsequent the assessment process by focusing on current interpersonal functioning. Veterans of war hold interpersonal functioning can be compounded psychosocial functioning and the immediate a number of interpersonal roles including son/ if the veteran was physically wounded needs of the veteran and to assess trauma daughter, husband/wife/partner, parent, and during deployment. Younger families may be exposure, as necessary, later in the assessment friend and all of these roles may be affected particularly less prepared to deal with the added process. While we discuss assessment of trauma by the psychological consequences of their stress of recovery, rehabilitation or adjustment to history more fully below, it is important to note military service. A number of factors can affect a chronic physical disability. here that the best rule of thumb is to follow interpersonal functioning including the quality Recreation and self-care the trauma survivor’s lead in approaching a of the relationship pre-deployment, the level of Participation in recreational activities and discussion of trauma exposure. Clinicians should contact between the veteran and his or her social engaging in good self-care are foundational verbally and non-verbally convey to their patients network during deployment, and the expectations aspects of positive psychological functioning. a sense of safety, security and openness to and reality of the homecoming experience. hearing about painful experiences. However, it is However, they are often overlooked in the also equally important that clinicians do not urge The military offers some support mechanisms assessment process. Some veterans who appear their patients to talk about traumatic experiences for the families of soldiers, which are aimed at to be functioning well in other domains may before they are ready to do so. shoring up these supportive relationships and be attending less to these areas of their lives, smoothing the soldier’s readjustment upon return particularly if they are attempting to appear Work functioning from the war. It can be useful to assess the extent “stoic” and to keep busy in order to control any Work-related difficulties can have a significant to which a veteran and his or her family have painful thoughts, feelings or images they may impact on self-efficacy, self-worth and financial used these services and how much they did or be struggling with. Thus, a brief assessment of stability and thus deserve immediate attention, did not benefit from such services. It is important engagement in and enjoyment of recreational and assessment, and referral. They are likely to be to note that these services do not always extend self-care activities may provide some important a major focus among veterans of war. Part-time to non-married partners (of the same or different information about how well the veteran is coping military employees and Afghan reservists (who gender), sometimes leading to a more difficult post-deployment. make up a significant proportion of the military and challenging homecoming experience. And Physical functioning presence in the Mideast) face unique employment they are also much more difficult to access for Early assessment of the physical well-being challenges post-deployment. Employers vary families that do not live in close proximity to of veterans is critical. Sleep, appetite, energy significantly in the amount of emotional and military installations where these supports are level, and concentration can be impaired in the financial support they offer their reservist plentiful. employees. Some veterans will inevitably have post-deployment phase as a result of exposure to confront the advancement of their co-workers As with all areas of post-deployment adjustment, to potentially traumatizing experiences, the while their own civilian career has stalled during veterans may experience changes in their development of any of a number of physical their military service. While some supportive interpersonal functioning over time. It is not disease processes or the sheer fatigue associated employers supplement reservist’s reduced uncommon for families to first experience a with military duty. Clinicians are again military salaries for longer than required, the “honeymoon” phase of reconnection marked charged with the complex task of balancing majority do not, leaving many returning soldiers by euphoria, excitement, and relief. However, the normalization of transient symptoms with in dire financial situations. a period of discomfort, role confusion, and the careful assessment of symptoms that could renegotiating of relationship and roles can follow indicate more significant psychological or Employment issues can be a factor even among this initial phase. Thus, repeated assessment of physical impairment. Consistent with good reservists who work for supportive employers. interpersonal functioning over time can ensure clinical practices, it is important to ensure that a Often, the challenges inherent in military duty that any relational difficulties that threaten veteran complaining of these and other somatic/ can impact a soldier’s satisfaction with his or the well-being of the veteran are detected and psychological symptoms be referred for a her civilian position. Thus, some returning addressed. complete physical examination to investigate veterans may benefit from a re-assessment any potential underlying physical pathology and Depending on specific personal characteristics of vocational interest and aptitude. This is to provide adequate interdisciplinary treatment of the veteran, certain interpersonal challenges particularly important for veterans that were planning. placed in military occupational specialties (MOS) may be more or less relevant to assessment where very little of their training translates to the and treatment. For instance, younger veterans, Psychological symptoms civilian job market. And returning from the war particularly those who live with their family of Once the clinician gains an overall sense of the

Page 30 veteran’s level of psychosocial functioning, a Past distress and coping experiences such as shame, guilt, confusion, broader assessment of psychological symptoms, In determining the extent of treatment needed and the need by some soldiers to appear and responses to those symptoms that may be for a particular presenting problem, an resilient and unaffected by their experiences. impairing can be useful. However, this process assessment of the history of the problem and the However, unique deployment stressors can also be difficult and confusing since a wide veteran’s previous responses to similar stressful accompany involvement in each contemporary range of emotional and cognitive responses experiences is useful. A general sense of pre- military action that may be important to assess. to deployment and post-deployment stressors deployment work and interpersonal functioning Thus, clinicians need to balance their use of including increased fear and anxiety, sadness and along with any significant psychological history current exposure assessment methods with grief, anger or rage, guilt, shame and disgust, can place current distress in context. A diathesis- openness to hearing and learning from each new ruminations and intrusive thoughts about past stress model suggests that veterans with a history veteran’s personal experience. experiences, and worries and fears about future of mental health difficulties can be at increased functioning may be expected. Often a good risk for psychological problems following a Section 1 of the Deployment Risk and Resiliency clinical interview can elicit some information stressful event such as deployment to a war zone, Inventory, developed by Daniel and Lynda King about the most salient symptoms for a particular although this relationship is not absolute. and colleagues at the National Center for PTSD, veteran, which can be supplemented with more can provide an excellent starting point for the Another area worth assessing that can provide a structured assessment using diagnostic interviews assessment of deployment-related stressors and wealth of pertinent information is the veteran’s and questionnaires. buffers. Items on this measure were derived from general orientation toward coping with difficult focus groups with Persian Gulf veterans, and Again, clinicians must use their judgment in life events and its potential relationship to current they provide useful information about some of responding to transient normal responses to painful thoughts, emotions and bodily sensations. the newer stressors associated with contemporary potentially traumatizing events versus symptoms Many veterans will enter into their military deployments. that may reflect the development or exacerbation experience with a flexible and adaptive array of of a psychological disorder. Sometimes assessing coping skills that they can easily bring to bear on The inventory describes nine domains of war both psychological responses and even responses their current symptoms. In other cases, veterans zone stressors that modern war veterans may to those responses can help determine whether may have successfully used coping strategies in have experienced. A careful assessment of each some form of treatment is indicated. For the past that are no longer useful in the face of of these domains can be useful both as a starting instance, veterans may appropriately respond the current magnitude of their symptoms. Coping point for assessing any potential ASD and/or to the presence of painful thoughts and feelings styles can be assessed with one of a number PTSD and more generally to establish a sense by crying, talking with others about their of self-report measures. However, through a of the potential risk and resiliency factors that experiences, and engaging in other potentially sensitive clinical interview, one can also get a may bear on the veteran’s current and future valued activities such as spending time with general sense of how often the veteran generally functioning. friends and family. However, others may attempt uses common coping styles such as stoicism, The treatment of the returning modern to suppress, diminish or avoid their internal social support, suppression and avoidance, and war veterans experiences of pain by using alcohol or drugs, active problem solving. (This section was written by: Josef I. Ruzek, Ph.D., Erika Curran, M.S.W., disordered eating, self-injurious behaviors Matthew J. Friedman, M.D., Ph.D., Fred D. Gusman, M.S.W., Steven (such as cutting), dissociation and behavioral Previous traumatic events M. Southwick, M.D., Pamela Swales, Ph.D., Robyn D. Walser, Ph.D., While there is evidence in the literature for a Patrician J. Watson, Ph.D., and Julia Whealin, Ph.D. Edited by: Kathryn avoidance of external reminders or triggers of Brohl, M.A., L.M.F.T.) trauma-related stimuli. Given that a full range relationship between repeated lifetime exposure to traumatic events and compromised post-event It is important that VA, vet center and other of psychological responses may be seen, and mental health practitioners recognize that the given that multiple symptoms (and co-morbid functioning, this relationship may be less evident among veterans who are seen in the months skills and experience they’ve developed in disorders) may be present, one challenge to the working with veterans with chronic PTSD will clinician during the assessment process is to following their return from war. However, there may still be important clinical information to serve them well with those returning from the prioritize targets of potential treatment. A few war. Their experience in talking about trauma, general rules of thumb can be helpful: be gained from assessing a veteran’s lifetime  experience with such traumatic events such as educating clients and families about traumatic  First, one must immediately attend to stress reactions, teaching skills of anxiety and symptoms that may require emergency childhood and adult sexual and physical abuse, domestic violence, involvement in motor vehicle anger management, facilitating mutual support intervention such as significant suicidal or among groups of veterans, and working with homicidal ideation, hopelessness, self- or industrial accidents, and experience with natural disasters, as well as their immediate trauma-related guilt, will all be useful and injurious behavior or acute psychotic applicable. The challenges, described below, symptoms. and long-term adjustment following those  experiences. discuss ways in which treatment of these veterans  Second, it is useful to address symptoms that may differ from the usual contexts of care, and are most disruptive to the veteran (which Deployment-related experiences pay specific attention to particular methods and should be evidenced by a careful assessment Obviously, the assessment of potentially materials that may be relevant to the care of the of psychosocial functioning). traumatizing events that occurred during  veteran recently traumatized in war.  Finally, the best way to develop a treatment deployment will be an important precursor plan for a veteran with diverse complaints is to treatment for many veterans of modern The helping context: active duty vs. to develop a case formulation to functionally war, particularly for those who struggle with veterans seeking health care explain the potential relationship between symptoms of re-experiencing, avoidance/ There are a variety of differences between the symptoms in order to develop a numbing, dissociation, or increased arousal. VA the contexts of care for active duty military comprehensive treatment plan. Substance and other mental health clinicians can be highly personnel and veterans normally being served abuse, disordered eating, and avoidance skilled in many of the clinical subtleties involved in the VA. These differences may affect the of trauma-related cues may all represent in this assessment such as: way practitioners go about their business. First, attempts to avoid thoughts, feelings and 1. The importance of providing a safe and many veterans will not be seeking mental health images of trauma-related experiences. Thus, nonjudgmental environment. treatment. Some will have been evacuated for developing an intervention that focuses on 2. Allowing the veteran to set the pace and tone mental health or medical reasons and brought avoidance behavior per se, rather than on of the assessment. to VA, perhaps reluctant to acknowledge their specific and diverse symptoms of avoidance, 3. Understanding the myriad of issues emotional distress and almost certainly reluctant may be a more effective treatment strategy. that involve the disclosure of traumatic to consider themselves as having a mental health

Page 31 disorder (e.g., PTSD). Second, emphasis on (Dunning, 1996). Many in this population with quality of life. We also have the opportunity diagnosis as an organizing principle of mental never planned to go to war and so may be to intervene directly in key areas of life health care is common in VA. Patients are faced with obstacles to picking up the life they functioning, to reduce the harm associated with given DSM-IV diagnoses, and diagnoses drive “left.” Whether active duty, National Guard, or continuing post-traumatic stress symptoms and treatment. This approach may be contrasted Reservist, listening to and acknowledging their depression if those prove resistant to treatment. with that of frontline psychiatry, in which concerns will help empower them and inform The latter may possibly be accomplished via pathologization of combat stress reactions is treatment planning. interventions focused on actively supporting strenuously avoided. The strong assumption is family functioning in order to minimize family War veterans entering residential mental health that most soldiers will recover, and that their problems, reducing social alienation and care will have come to the VA through a process responses represent a severe reaction to the isolation, supporting workplace functioning, and different from that experienced by “traditional” traumatic stress of war rather than a mental preventing use of alcohol and drugs as self- patients/clients. If they have been evacuated illness or disorder. According to this thinking, medication (a different focus than addressing from the war zone, they will have been rapidly the “labeling” process may be counterproductive chronic alcohol or drug problems). moved through several levels of medical triage in the context of early care for war veterans. As and treatment, and treated by a variety of health Prevent family breakdown Koshes (1996) noted, “labeling a person with an care providers (Scurfield & Tice, 1991). Many At time of return to civilian life, soldiers can illness can reinforce the “sick” role and delay will have received some mental health care in the face a variety of challenges in re-entering or prevent the soldier’s return to the unit or to a war zone (e.g., stress debriefing) that will have their families, and the contrast between the useful role in military or civilian life” (p. 401). been judged unsuccessful. Some veterans will fantasies and realities of homecoming (Yerkes Veterans may have a number of incentives to perceive their need for continuing care as a sign & Holloway, 1996) can be distressing. Families minimize their distress: of personal failure. Understanding their path to themselves have been stressed and experienced  To hasten discharge. the VA will help the building of a relationship and problems as a result of the deployment  To accelerate a return to the family. the design of care. (Norwood, Fullerton, & Hagen, 1996; Jensen  To avoid compromising their military career More generally, the returning soldier is in a & Shaw, 1996). Partners have made role or retirement. state of transition from war zone to home, adjustments while the soldier was away, and Fears about possible impact on career prospects and clinicians must seek to understand the these need to be renegotiated, especially given are based in reality; indeed, some will be judged expectations and consequences of returning the possible irritability and tension of the medically unfit to return to duty. Veterans may home for the veteran. For example, is the veteran veteran (Kirkland, 1995). The possibility exists be concerned that a diagnosis of PTSD, or even returning: that mental health providers can reduce long- acute stress disorder, in their medical record  To an established place in society? term family problems by helping veterans and may harm their chances of future promotion,  To an economically deprived community.? their families anticipate and prepare for family lead to a decision to not be retained, or affect  To a supportive spouse or cohesive military challenges, involving families in treatment, type of discharge received. Some may think that unit? providing skills training for patients (and where the information obtained if they receive mental  To a large impersonal city? possible, their families) in family-relevant health treatment will be shared with their unit  To unemployment? skills (e.g., communication, anger management, commanders, as is sometimes the case in the  To financial stress? conflict resolution, parenting), providing short- military.  To an American public thankful for his or her term support for family members, and linking sacrifice? families together for mutual support. To avoid legitimate concerns about possible pathologization of common traumatic stress Whatever the circumstances, things are unlikely Prevent social withdrawal and isolation reactions, clinicians may wish to consider to be as they were. PTSD also interferes with social functioning. avoiding, where possible, the assignment of The challenge here is to help the veteran avoid The deployment of a family member creates diagnostic labels such as ASD or PTSD, and withdrawal from others by supporting re-entry a painful void within the family system that is instead focus on assessing and documenting into existing relationships with friends, work eventually filled (or denied) so that life can go symptoms and behaviors. Diagnoses of acute colleagues, and relatives, or where appropriate, on. The family assumes that their experiences or adjustment disorders may apply if symptoms assisting in the development of new social at home and the soldier’s activities on the warrant labeling. Concerns about confidentiality relationships. The latter may be especially battlefield will be easily assimilated by each must be acknowledged and steps taken to create relevant with individuals who leave military other at the time of reunion and that the pre-war the conditions in which veterans will feel able to service and transition back into civilian roles will be resumed. The fact that new roles talk openly about their experiences, which may life. Social functioning should be routinely and responsibilities may not be given up quickly include difficulties with commanders, misgivings discussed with patients and made a target for upon homecoming is not anticipated (Yerkes & about military operations or policies, or possible intervention. Skills training focusing on the Holloway, 1996, p. 31). moral concerns about having participated in the concrete management of specific difficult social war. It will be helpful for clinicians to know Learning from Vietnam veterans with situations may be very helpful. Also, as indicated who will be privy to information obtained in an chronic PTSD below, clinicians should try to connect veterans assessment. The role of the assessment and who From the perspective of work with Vietnam with other veterans in order to facilitate the will have access to what information should be veterans whose lives have been greatly disrupted development of social networks. discussed with concerned patients. by their disorder, the chance to work with Prevent problems with employment Active duty service members may have the combat veterans soon after their war experiences Associated with chronic combat-related PTSD option to remain on active duty or to return represents a real opportunity to prevent the have been high rates of job turnover and general to the war zone. Some evidence suggests that development of a disastrous life course. Today, difficulty in maintaining employment, often returning to work with one’s cohort group there is more of an opportunity to directly focus attributed by veterans themselves to anger during wartime can facilitate improvement of on traumatic stress reactions and PTSD symptom and irritability, difficulties with authority, symptoms. Although their wishes may or may not reduction (e.g., by helping veterans process PTSD symptoms, and substance abuse. Steady be granted, service members often have strong their traumatic experiences, by prescribing employment, however, is likely to be one feelings about wanting or not wanting to return medications) and thereby reduce the degree to predictor of better long-term functioning, as it to war. For recently activated National Guard and which PTSD, depression, alcohol/substance can reduce financial stresses, provide a source Reservists, issues may be somewhat different misuse, or other psychological problems interfere of meaningful activity and self-esteem, and give

Page 32 opportunities for companionship and friendship. to the war zone, concerns about having been veteran returning from war experience and In some cases, clinicians can provide valuable evacuated and what this means, worries about is intended to improve understanding and help by supporting the military or civilian work reactions of unit, fear of career ramifications, recognition of symptoms, reduce fear and shame functioning of veterans, by teaching skills of concern about reactions of family, concerns about symptoms, and, generally, “normalize” maintaining or, in the case of those leaving the about returning to active duty). One advantage of his or her experience. It should also provide military, finding of employment, or facilitating such an orientation is that it will assist with the the veteran with a clear understanding of how job-related support groups. development of a helping relationship. recovery is thought to take place, what will happen in treatment, and, as appropriate, the role Prevent alcohol and drug abuse Connect veterans with each other of medication. With such understanding, stress The co-morbidity of PTSD with alcohol and In treatment of chronic PTSD, veterans often reactions may seem more predictable and fears drug problems in veterans is well established report that perhaps their most valued experience about long-term effects can be reduced. (Ruzek, 2003). Substance abuse adds to the was the opportunity to connect in friendship problems caused by PTSD and interferes with and support with other vets. This is unlikely Education in the context of relatively recent key roles and relationships, impairs coping, and to be different for returning war veterans, who traumatization (weeks or months) should include impairs entry into and ongoing participation in may benefit greatly from connection both with the conception that many symptoms are the result treatment. PTSD providers are aware of the need each other and with veterans of other conflicts. of psychobiological reactions to extreme stress to routinely screen and assess for alcohol and Fortunately, this is the strength of VA and vet and that, with time, these reactions, in most cases, drug use, and are knowledgeable about alcohol center clinicians, who routinely and skillfully will diminish. Reactions should be interpreted and drug {especially 12-Step) treatment. Many bring veterans together. as responses to overwhelming stress rather than are learning as well about the potential usefulness as personal weakness or inadequacy. In fact, Offer practical help with specific of integrated PTSD-substance abuse treatment, some recent research (e.g., Steil & Ehlers, 2000) and the availability of manualized treatments for problems suggests that survivors’ own responses to their this dual disorder. “Seeking Safety,” a structured Returning veterans are likely to feel overwhelmed stress symptoms will in part determine the degree group protocol for trauma-relevant coping skills with problems related to workplace, family and of distress associated with those symptoms and training (Najavits, 2002), is seeing increased use friends, finances, physical health, and so on. whether they will remit. Whether, for example, in VA and should be considered as a treatment These problems will be drawing much of their post-trauma intrusions cause distress may depend option for war veterans who have substance use attention away from the tasks of therapy, and in part on their meaning for the person (e.g., “I’m disorders along with problematic traumatic stress may create a climate of continuing stress that going crazy”). interferes with resolution of symptoms. The responses. In addition, for many newly returning Training in coping skills war veterans, it will be important to supplement presence of continuing negative consequences Returning veterans experiencing recurrent traditional abstinence-oriented treatments with of war deployment may help maintain post- intrusive thoughts and images, anxiety and panic attention to milder alcohol problems, and in traumatic stress reactions. Rather than treating in response to trauma cues, and feelings of guilt particular to initiate preventive interventions to these issues as distractions from the task at hand, or intense anger are likely to feel relatively reduce drinking or prevent acceleration of alcohol mental health practitioners can provide a valuable powerless to control their emotions and thoughts. consumption as a response to PTSD symptoms service by helping veterans identify, prioritize, This helpless feeling is in itself a trauma (Bien, Miller, & Tonigan, 1993). For all returning and execute action steps to address their specific reminder. Because loss of control is so central to veterans, it will be useful to provide education problems. trauma and its attendant emotions, interventions about safe drinking practices and the relationship Attend to broad needs of the person that restore self-efficacy are especially useful. between traumatic stress reactions and substance Wolfe, Keane, and Young (1996) put forward abuse. several suggestions for clinicians serving Coping skills training is a core element in the Persian Gulf War veterans that are also repertoire of many VA and vet center mental General considerations of care health providers. Some skills that may be Connect with the returning veteran important in the context of present-day war. They recommended attention to the broad effective include: As with all mental health counseling, the  range of traumatic experience. They similarly  Anxiety management (breathing retraining relationship between veteran and helper will be recommended broad clinical attention to the and relaxation). the starting point for care. Forming a working  impact of both pre-military and post-military  Emotional “grounding.” alliance with some returnees may be challenging,  stressors on adjustment. For example, history  Anger management, and communication. however, because most newly-returned veterans of trauma places those exposed to trauma in the may be, as Litz notes, “defended, formal, However, the days, weeks, and months following war zone at risk for development of PTSD, and respectful, laconic, and cautious” and reluctant a return home may pose specific situational in some cases, war experiences will activate to work with the mental health professional. challenges; therefore, a careful assessment of the emotions experienced during earlier events. Especially in the context of recent exposure to veteran’s current experience must guide selection Finally, recognition and referral for assessment war, validation (Kirkland, 1995) of the veteran’s of skills. For example, training in communication of the broad range of physical health concerns experiences and concerns will be crucial. skills might focus on the problem experienced by and complaints that may be reported by Discussion of “war zone,” not “combat,” stress a veteran in expressing positive feelings towards returning veterans is important. Mental health may be warranted because some traumatic a partner (often associated with emotional providers must remember that increased health stressors (e.g., body handling, sexual assault) numbing); anger management could help the symptom reporting is unlikely to be exclusively may not involve war fighting as such. Thought veteran better respond to others in the immediate psychogenic in origin (Proctor et al., 1998). needs to be given to making the male-centric environment who do not support the war. hospital system hospitable for women, especially Methods of care: Overview Whereas education helps survivors understand their experience and know what to do about it, for women who have experienced sexual assault Management of acute stress reactions and coping skills training should focus on helping in the war zone, for whom simply walking problems faced by recently returned veterans them know how to do the things that will support onto the grounds of a VA hospital with the are highlighted below. Methods of care for the recovery. It relies on a cycle of instruction that ubiquitous presence of men may create feelings war veteran with PTSD will be similar to those includes education, demonstration, rehearsal of vulnerability and anxiety. provided to veterans with chronic PTSD. with feedback and coaching, and repeated Practitioners should work from a patient/client- Education about post-traumatic stress practice. It includes regular between-session task centered perspective, and take care to find out reactions assignments with diary self-monitoring and real- their current concerns (e.g., fear of returning Education is a key component of care for the world practice of skills. It is this repeated practice Page 33 and real world experience that begins to empower trauma-related guilt may be helpful in addressing in the Gulf War. Seventeen percent of Gulf War the veteran to better manage his or her challenges veterans’ concerns about harming or causing veterans believe they have “Gulf War syndrome” (see Najavits, 2002, for a useful manual of death to civilians. (Chalder et al., 2001). trauma-related coping skills). Family counseling Besides PTSD, modern veterans may experience Exposure therapy Mental health professionals within VA and vet a range of “amorphous stress outcomes” (Engel, Exposure therapy is among the best-supported centers have a long tradition of working with 2001). Factors contributing to these more treatments for PTSD (Foa et al., 2000). It is family members of veterans with PTSD. This amorphous syndromes include suspected toxic designed to help veterans effectively confront same work, including family education, weekend exposures, and ongoing chronic exhaustion their trauma-related emotions and painful family workshops, couples counseling, family and uncertainty. Belief in exposure to toxic memories, and can be distinguished from simple therapy, parenting classes, or training in conflict contaminants has a strong effect on symptoms. discussion of traumatic experience in that it resolution, will be very important with returning Added to this, mistrust of military and industry, emphasizes repeated verbalization of traumatic veterans. Some issues in family work are intense and contradictory media focus, confusing memories (see Foa & Rothbaum, 1998, for a discussed in more detail below. scientific debates, and stigma and medicalization detailed exposition of the treatment). Patients can contribute to increased anxiety and Early interventions for ASD or PTSD are exposed to their own individualized fear symptoms. If modern war veterans arrive at VA medical stimuli repetitively, until fear responses are centers very soon (i.e., within several days or When working with a recent veteran, the consistently diminished. Often, in-session several weeks) following their trauma exposure, clinician needs to address a full range of exposure is supplemented by therapist-assigned it is possible to use an early intervention to try potentially disabling factors: harmful illness and monitored self-exposure to the memories or to prevent development of PTSD. Although beliefs, weight and conditioning, diagnostic situations associated with traumatization. In most cognitive-behavioral early interventions have labeling, unnecessary testing, misinformation, treatment settings, exposure is delivered as part only been developed recently and have not yet over-medication, all or nothing rehabilitation of a more comprehensive “package” treatment; been tried with war-related ASD, they should approaches, medical system rejection, social it is usually combined with traumatic stress be considered as a treatment option for some support, and workplace competition. The education, coping skills training, and, especially, returning veterans, given their impact with provider needs to be familiar with side effects cognitive restructuring (see below). Exposure other traumas and consistency with what is of suspected toxins so that he or she can therapy can help correct faulty perceptions known about treatment of more chronic PTSD. educate the veteran, as well as the potential of danger, improve perceived self-control of In civilian populations, several randomized somatic symptoms that are related to prolonged memories and accompanying negative emotions, controlled trials have demonstrated that brief (i.e., exposure to combat stressors, and the side and strengthen adaptive coping responses under 4-5 sessions) individually administered cognitive effects of common medications. The provider conditions of distress. behavioral treatment, delivered about two weeks should take a collaborative approach with the Cognitive restructuring after a trauma, can prevent PTSD in some patient, identifying the full range of contributing Cognitive therapy or restructuring, one of the survivors of motor vehicle accidents, industrial problems, patient goals and motivation, social best-validated PTSD treatments (Foa et al., accidents, and assault (Bryant et al., 1998, 1999) support, and self-management strategies. A 2000), is designed to help the patient review who meet criteria for ASD. sustained follow-up is recommended. and challenge distressing trauma-related beliefs. This treatment is comprised of education, For those with inexplicable health problems, It focuses on educating participants about the breathing training/relaxation, imaginal and in Fischoff and Wessely (2003) outlined some relationships between thoughts and emotions, vivo exposure, and cognitive restructuring. The simple principles of patient/client management exploring common negative thoughts held by exposure and cognitive restructuring elements that may be useful in the context of veteran care: trauma survivors, identifying personal negative  of the treatment are thought to be most helpful.  Focus communication around patients’ beliefs, developing alternative interpretations or A recent unpublished trial conducted by the concerns. judgments, and practicing new thinking. This  same team compared cognitive therapy and  Organize information coherently. is a systematic approach that goes well beyond  exposure in early treatment of those with ASD,  Give risks as numbers. simple discussion of beliefs to include individual  with results indicating that both treatments were  Acknowledge scientific uncertainty. assessment, self-monitoring of thoughts,  effective, with fewer clients dropping out of  Use universally understood language. homework assignments, and real-world practice.  cognitive therapy. Bryant and Harvey (2000)  Focus on relieving symptoms. In particular, it may be a most helpful approach to noted that prolonged exposure is not appropriate a range of emotions other than fear, guilt, shame, There is evidence that both cognitive behavioral for everyone (e.g., those experiencing acute anger, and depression that may trouble veterans. group therapy (CBGT) and exercise are effective bereavement, extreme anxiety, severe depression, For example, anger may be fueled by negative for treating Gulf War illness. In a recent clinical those experiencing marked ongoing stressors beliefs (e.g., about perceived lack of preparation trial, Donata et al. (2003) reported that CBGT or at-risk for suicide). Cognitive restructuring or training for war experiences, about harm done improved physical function, whereas exercise may have wider applicability in that it may be to their civilian career, about perceived lack of led to improvement in many of the symptoms expected to produce less distress than exposure. support from civilians). Cognitive therapy may of Gulf War veterans’ illnesses. Both treatments also be helpful in assisting veterans to cope with Toxic exposure, physical health concerns, improved cognitive symptoms and mental health distressing changed perceptions of personal and mental health functioning, but neither improved pain. In this study, CBGT was specifically targeted at physical identity that may be associated with participation War syndromes have involved fundamental, functioning, and included time-contingent in war or loss of wartime identity upon return unanswered questions about chronic somatic activity pacing, pleasant activity scheduling, (Yerkes & Holloway, 1996). symptoms in armed conflicts since the U.S. sleep hygiene, assertiveness skills, confrontation Civil War (Hyams et al., 1996). In recent history, A useful resource is the Cognitive Processing of negative thinking and affect, and structured unexplained symptoms have been reported by Therapy manual developed by Resick and problem solving skills. The low-intensity aerobic Dutch peacekeepers in Lebanon, Bosnia, and Schnicke (1993), which incorporates extensive exercise intervention was designed to increase Cambodia; Russian soldiers in Afghanistan and cognitive restructuring and limited exposure. activity level by having veterans exercise once Chechnya; Canadian peacekeepers in Croatia; Although designed for application to rape-related per week for one hour in the presence of an soldiers in the Balkan war; individuals exposed PTSD, the methods can be easily adapted for exercise therapist, and independently 2-3 times to the El Al airliner crash; individuals given use with veterans. Kubany’s (1998) work on per week. These findings are important because the anthrax vaccine; individuals exposed to the they demonstrate that such treatments can be World Trade Center following 9/11; and soldiers Page 34 feasibly and successfully implemented in the VA Pharmacotherapy hypotensive effects, and these agents should also health care system, and thus should be considered Pharmacologic treatment of acute stress be tapered, rather than discontinued abruptly, in for the treatment of modern war veterans who reactions order to avoid rebound hypertension. Further, present with unexplained physical symptoms. Pharmacological treatment for acute stress because anti-adrenergic agents might interfere with counter regulatory hormone responses to Family involvement in care reactions (within one month of the trauma) is hypoglycemia, they should not be prescribed to The primary source of support for the returning generally reserved for individuals who remain survivors with diabetes. soldier is likely to be his or her family. We know symptomatic after having already received brief from veterans of the Vietnam War that there can crisis-oriented psychotherapy. This approach is Finally, the use of antidepressants may make be a risk of disengagement from family at the in line with the deliberate attempt by military sense within four weeks of war, particularly time of return from a war zone. We also know professionals to avoid medicalizing stress- when trauma-related depressive symptoms that emerging problems with ASD and PTSD can related symptoms and to adhere to a strategy of are prominent and debilitating. To date, there wreak havoc with the competency and comfort immediacy, proximity, and positive expectancy. has been one published report on the use of the returning soldier experiences as a partner and Prior to receiving medication for stress-related antidepressants for the treatment of acute stress parent. While the returning soldier clearly needs symptoms, the war zone survivor should have a disorder. Recently traumatized children meeting the clinician’s attention and concern, help can thorough psychiatric and medical examination, criteria for acute stress disorder who were treated be extended to include his or her family as well. with special emphasis on medical disorders that with imipramine for two weeks experienced Support for the veteran and family can increase can manifest with psychiatric symptoms (e.g., significantly greater symptom reduction than the potential for the veteran’s smooth immediate subdural hematoma, hyperthyroidism), potential children who were prescribed chloral hydrate. or eventual reintegration back into family psychiatric disorders (e.g., acute stress disorder, Pharmacologic treatment of post- life, and reduce the likelihood of future more depression, psychotic disorders, panic disorder), traumatic stress disorder damaging problems. use of alcohol and substances of abuse, use of Pharmacotherapy is rarely used as a stand-alone Outpatient treatment prescribed and over-the-counter medication, and treatment for PTSD and is usually combined If the veteran is living at home, the clinician possible drug allergies. It is important to assess with psychological treatment. Findings from can meet with the family and assess with them the full range of potential psychiatric disorders, subsequent large-scale trials with paroxetine their strengths and challenges and identify and not just PTSD, since many symptomatic have demonstrated that SSRI treatment is clearly any potential risks. Family and mental health soldiers will be at an age when first episodes effective both for men in general and for combat practitioners can work together to identify goals of schizophrenia, mania, depression, and panic veterans suffering with PTSD. and develop a treatment plan to support the disorder are often seen. We recommend SSRIs as first-line medications family’s reorganization and return to stability in In some cases, a physician may need to prescribe for PTSD pharmacotherapy in men and women coordination with the veteran’s work on his or her psychotropic medications even before completing with military-related PTSD. SSRIs appear to be own personal treatment goals. the medical or psychiatric examination. The effective for all three PTSD symptom clusters in If one or both partners are identifying high acute use of medications may be necessary when both men and women who have experienced a tension or levels of disagreement, or the clinician the patient is dangerous, extremely agitated, or variety of severe traumas. They are also effective is observing that their goals are markedly psychotic. In such circumstances, the patient in treating a variety of co-morbid psychiatric incompatible, then issues related to safety need should be taken to an emergency room; short- disorders, such as major depression and panic to be assessed and plans might need to be made acting benzodiazepines (e.g., lorazepam) or high- disorder, which are commonly seen in individuals that support safety for all family members. potency neuroleptics (e.g., Haldol) with minimal suffering with PTSD. Additionally, the side effect Couples who have experienced domestic violence sedative, anticholinergic, and orthostatic side profile with SSRIs is relatively benign (compared or infidelity are at particularly high risk and in effects may prove effective. Atypical neuroleptics to most psychotropic medications) although need of more immediate support. When couples (e.g., risperidone) may also be useful for treating arousal and insomnia may be experienced early can be offered a safe forum for discussing, aggression. on for some patients with PTSD. negotiating, and possibly resolving conflicts, When a decision has been made to use Second-line medications include nefazadone, that kind of clinical support can potentially help medication for acute stress reactions, rational TCAs, and MAOIs. Evidence favoring the to reduce the intensity of the feelings that can choices may include benzodiazepines, anti- use of these agents is not as compelling as for become dangerous for a family. Even support adrenergics, or antidepressants. Shortly after SSRIs because many fewer subjects have been for issues to be addressed by separating couples traumatic exposure, the brief prescription of tested at this point. The best evidence from open can be critically valuable, especially if children benzodiazepines (4 days or less) has been shown trials supports the use of nefazadone, which are involved and the parents anticipate future to reduce extreme arousal and anxiety and to like SSRIs, promotes serotonergic actions and co-parenting. improve sleep. However, early and prolonged is less likely than SSRIs to cause insomnia or use of benzodiazepines is contraindicated, since Residential rehabilitation treatment sexual dysfunction. Trazadone, which has limited benzodiazepine use for two weeks or longer has Inpatient hospitalization could lengthen the time efficacy as a stand-alone treatment, has proven actually been associated with a higher rate of returning personnel are away from their families, very useful as augmentation therapy with SSRIs; subsequent PTSD. or it could be an additional absence from the its sedating properties make it a useful bedtime family for the veteran who has recently returned Although anti-adrenergic agents including medication that can antagonize SSRI-induced home. It is important to the ongoing support clonidine, guanfacine, prazosin, and propranolol insomnia. Despite some favorable evidence of of the reuniting family that clinicians remain have been recommended (primarily through the efficacy of MAOIs, these compounds have aware that their patient is a partner and parent. open non-placebo controlled treatment trials) received little experimental attention since Family therapy sessions, in person or by phone for the treatment of hyperarousal, irritable 1990. Venlafaxine and buproprion cannot be if geographical distance is too great, can offer aggression, intrusive memories, nightmares, recommended because they have not been tested the family a forum for working toward meeting and insomnia in survivors with chronic PTSD, systematically in clinical trials. their goals. The potential for involving the there is only suggestive preliminary evidence There is a strong rationale from laboratory patient’s family in treatment will depend on their of their efficacy as an acute treatment. Of research to consider anti-adrenergic agents. It is geographic proximity to the treatment facility. importance, anti-adrenergic agents should be hoped that more extensive testing will establish Distance can be a barrier, but the family can still prescribed judiciously for trauma survivors their usefulness for PTSD patients. The best be engaged through conference phone calls, or with cardiovascular disease due to potential visits as can be arranged. Page 35 research on this class of agents has focused on may need to be integrated into existing VA PTSD gain an appreciation of the veteran’s prior schema prazosin, which has produced marked reduction residential rehabilitation programs or other VA about their role in the military (and society) and in traumatic nightmares, improved sleep, and mental health programs. Approaches to this the trouble the person is having assimilating global improvement in veterans with PTSD. integration of psychiatric evacuees will vary, (incorporating) war zone experiences into that Hypotension and sedation need to be monitored. and each receiving site will need to determine existing belief system. Patients should not be abruptly discontinued from its own “best fit” model for provision of services Typically, in traumatized veterans, assimilation anti-adrenergics. and integration of veterans. At the National is impossible because of the contradictory nature Center’s PTSD Residential Rehabilitation Despite suggestive theoretical considerations and of painful war zone events. The resulting conflict Program in the VA Palo Alto Health Care System, clinical findings, there is only a small amount is unsettling and disturbing. Any form of early it is anticipated that modern war patients/ of evidence to support the use of carbamazepine intervention or treatment for chronic PTSD clients will generally be integrated with the rest or valproate with PTSD patients. Further, the entails providing experiences and new knowledge of the milieu (e.g., for community meetings, complexities of clinical management with these so that accommodation of a new set of ideas affect management classes, conflict resolution, effective anti-convulsants have shifted current about the self and the future can occur. communication skills training), with the attention to newer agents (e.g., gabapentin, exception of identified treatment components. A variety of factors including personal and lamotrigine, and topirimate), which have yet to The latter elements of treatment, in which cultural characteristics, orientation toward be tested systematically with PTSD patients. war veterans will work together, will include coping with stressors and painful emotions, pre- Benzodiazepines cannot be recommended for process, case management, and acute stress/ deployment training, military-related experiences, patients with PTSD. They do not appear to have PTSD education groups (and, if delivered in and post-deployment environment will shape efficacy against core PTSD patients. No studies groups, exposure therapy, cognitive restructuring, responses to modern wars. Further, psychological have demonstrated efficacy for PTSD-specific and family/couples counseling). The thoughtful responses to deployment experiences can be symptoms. mixing of returning veterans with veterans expected to change over time. While mental health professionals within the VA are among the Conventional anti-psychotics cannot be from other wars/conflicts is likely, in general, to most experienced and accomplished in assessing recommended for PTSD patients. Preliminary enhance the treatment experience of both groups. and treating chronic combat-related PTSD, results suggest, however, that atypical anti- Practitioner issues veterans of the newer wars can be expected to psychotics may be useful, especially to Working with modern war veterans affected present unique clinical challenges. augment treatment with first- or second-line by war zone trauma is likely to be emotionally medications, especially for patients with difficult for therapists. It is likely to bring up The absence of immediate symptoms following intense hypervigilance or paranoia, agitation, many feelings and concerns such as: exposure to a traumatic event is not necessarily dissociation, or brief psychotic reactions  Reactions to stories of death and great predictive of a long-term positive adjustment. associated with their PTSD. As for side effects, suffering. Depending on a variety of factors, veterans may all atypicals may produce weight gain, and  Judgments about the morality of the war. appear to be functioning at a reasonable level olanzapine treatment has been linked to the onset  Reactions to patients who have killed. immediately upon their return home, particularly of Type II diabetes mellitus.  Feelings of personal vulnerability. given their relief at having survived the war zone  and returned to family and friends. However, General guidelines  Feelings of therapeutic inadequacy.  as life circumstances change, symptoms of Pharmacotherapy should be initiated with SSRI  Perceptions of a lack of preparation for distress may increase to a level worthy of clinical agents. Patients who cannot tolerate SSRIs or acute care that may affect ability to listen intervention. who show no improvement might benefit from empathically to the patient and maintain the nefazadone, MAOIs, or TCAs. therapeutic relationship (Sonnenberg, 1996). Even among those veterans who will need psychological services post-deployment, ASD For patients who exhibit a partial response to Koshes (1996) suggested that those at greatest and PTSD represent only two of a myriad of SSRIs, one should consider continuation or risk for strong personal reactions might be psychological presentations that are likely. augmentation. A recent trial with sertraline young, inexperienced staff who are close in age Veterans of the newer wars are likely to showed that approximately half of all patients to patients/clients and more likely to identify have been exposed to a wide variety of war who failed to exhibit a successful clinical with them, and technicians or paraprofessional zone stressors that can impact psychological response after 12 weeks of sertraline treatment, workers who may have less formal education functioning in a number of ways. did respond when SSRI treatment was extended about the challenges associated with treating for another 24 weeks. Practically speaking, these patients but who actually spend the most The psychological assessment and treatment clinicians and patients/clients will usually be time with patients. Regardless of degree of of veterans returning from war is likely to be reluctant to stick with an ineffective medication experience, all mental health workers must complicated and clinically challenging. We must for 36 weeks, as in this experiment. Therefore, monitor themselves and practice active self-care. enter into the assessment process informed about augmentation strategies seem to make sense. Managers must ensure that training, support, and the possible stressors and difficulties that may be Here are a few suggestions based on clinical supervision are part of the environment in which associated with service in war zones and open to experience and pharmacological “guesstimates,” care is offered. suspending any preconceived notions about how rather than on hard evidence: Summary and final remarks any given individual might react to their personal   Excessively aroused, hyperreactive, or Individuals join the military for a variety of experience during war. It will be important for dissociating patients might be helped by reasons, from noble to mundane. Regardless, over us to broadly assess functioning over a variety of augmentation with an anti-adrenergic agent. time, soldiers develop a belief system (schema) domains, to provide referrals for acute needs, and   Labile, impulsive, or aggressive patients about themselves, their role in the military, the to provide some normalizing, psycho-educational might benefit from augmentation with an military culture, etc. War can be traumatizing not information to veterans and their families in an anti-convulsant. only because of specific terrorizing or grotesque attempt to facilitate existing support networks   Fearful, hypervigilant, paranoid, and war zone experiences but also due to dashed or and naturally occurring healing processes. psychotic patients might benefit from an painfully shattered expectations and beliefs about Repeated assessment over time will best serve atypical anti-psychotic. perceived coping capacities, military identity, and our veterans, who may experience changing so forth. As a result, soldiers who present for care needs over the months and years following their Integrating modern war soldiers into wartime exposure. existing specialized PTSD services in VA medical centers or through private practice environments may be disillusioned in one way or Service members with stress-related problems another. The mental health practitioner’s job is to Page 36 References and Additional Resources NOTES ŠŠBien, T.H., Miller, W.R., & Tonigan, J.S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315-335. THE RETURNING U.S. VETERAN ŠŠBryant, R.A., & Harvey, A.G. (2000). Acute stress disorder: A handbook of theory, assessment, and treatment. Washington, DC: American Psychological Association. OF MODERN WAR: BACKGROUND ŠŠBryant, R.A., Harvey, A.G., Basten, C., Dang, S.T., & Sackville, T. (1998). Treatment of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive ISSUES, ASSESSMENT AND counseling. Journal of Consulting and Clinical Psychology, 66, 862-866. ŠŠBryant, R.A., Sackville, T., Dang, S.T., Moulds, M., & Guthrie, R. (1999). Treating TREATMENT acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. American journal of Psychiatry, 156, 1780-1786. Final Examination Questions ŠŠCatherall, D. R. (1992). Back from the brink: A family guide to overcoming traumatic stress. New York: Bantam Books. Choose the best answer for questions ŠŠChalder, T., Hotopf, M., Unwin, C, Hull, L, Ismail, K., David, A., etal. (2001). Prevalence of Gulf war veterans who believe they have Gulf war syndrome: 1 through 5 and then proceed to questionnaire study. British Medical Journal, 323, 473-476. www.elitecme.com to complete your ŠŠCurran, E. (1996). Parenting group manual. Menlo Park, CA: National Center for PTSD. final examination. ŠŠCurran, E. (1997). Fathers with war-related PTSD. National Center for PTSD Clinical Quarterly, 7(2), 30-33. Donta, S.T., Clauw, D.J., Engel, C.C., Guarino, P., Peduzzi, P., Williams, D.A., et al. (2003). Cognitive behavioral therapy and aerobic exercise for 1. The immediate response to severe stressors Gulf War veterans’ illnesses: A randomized controlled trial. Journal of the American Medical Association, 289, 1396-1404. in the war zone is most often currently ŠŠDunning, CM. (1996). From citizen to soldier: Mobilization of reservists. In R.J. Ursano & A.E. Norwood (Eds.), Emotional aftermath of the Persian Gulf War: labeled Veterans, families, communities, and nations (pp. 197-225). Washington, DC: American Psychiatric Press. a. Combat fatigue. ŠŠEngel, C. (2001). Outbreaks of medically unexplained physical symptoms after military action, terrorist threat, or technological disaster. Military Medicine, 166(12) b. Post war syndrome. Supplement 2, 47-48. c. Combat stress reaction. ŠŠFigley, C. (1989). Helping traumatized families. San Francisco: Jossey-Bass. ŠŠFischoff, B., & Wessely, S. (2003). Managing patients with inexplicable health d. War zone stress. problems. British Medical journal, 326, 595-597. ŠŠFoa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford. 2. The guiding principal to restore a soldier to duty as quickly as possible is known as “PIES,” an acronym that stands for all of the following except a. Proximity. b. Insight. c. Expectancy. d. Simplicity.

3. Acute stress disorder (ASD) a. Is a precondition for chronic impairment. b. Is linear and continuous. c. Is an excellent predictor of chronic PTSD. d. Is not common after exposure to severe trauma in war.

4. A number of factors can affect interpersonal functioning, including a. The quality of the relationship pre- deployment. b. The level of contact between the veteran and his or her social network during deployment. c. The expectations and reality of the homecoming experience. d. All of the above.

5. One of the best-supported treatments for post-traumatic stress disorder (PTSD), designed to help veterans effectively confront their trauma-related emotions and painful memories, is a. Cognitive therapy. b. Intervention therapy. c. Collaborative therapy. d. Exposure therapy.

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