Communique Article for School Psychologists

Crisis Management
in the Schools
A Cognitive Model of PTSD

Summarized by Karen Lake, Predoctoral
Intern, Psychological & Social
Services, APPIC Internship Site, Dallas
Independent School District, TX
In an invited essay for Behaviour
Research and Therapy, Anke Ehlers and
David Clark (2000) discuss posttraumatic
stress disorder as described in a cognitive
model. Their article, “A Cognitive
Model of Posttraumatic Stress Disorder,”
explores theoretical reasons that some
individuals overcome traumatic events
within months while others’ symptomology
persists for years.
This theoretical paper proposes that
persistent PTSD occurs when individuals
process traumatic events in a way that
reproduces a sense of threat in current situations.
The authors address reasons for
persistent symptomology including an
inability to see the trauma event as timelimited,
overgeneralization of the danger
from the event to a normal range of activities,
interpretation of one’s own reaction
as well as others’ reactions in the aftermath
of the event as negative, and maladaptive
behavioral strategies and cognitive
processing styles.
Ehlers and Clark also provide treatment
implications based on the proposed cognitive
model. Specifically, treatment should
address the trauma memory by elaborating
and integrating the experience in order to
reduce intrusive reexperiencing, and problematic
appraisals that maintain the current
threat should be explored and modified.
Finally, dysfunctional behavioral and
cognitive strategies preventing memory
elaboration, exacerbating symptoms,
and/or hindering reassessment of problematic
appraisals should be abandoned.
Although the model in its entirety has
not been evaluated empirically, several of
its central features have been tested with
promising results. Specifically, Ehlers and
Clark cite multiple supportive sources for
negative appraisals of the trauma, negative
interpretations of initial PTSD symptoms,
negative appraisals of others’ posttrauma
responses, and improvement of
symptoms with the development of a cohesive
and organized narrative of the event.
Many of the supportive studies, however,
were conducted by the authors themselves.
The cognitive model proposed by Ehlers
and Clark may have important implications
for school psychologists when faced with
crises in the schools. First, this model confirms
traditional knowledge of PTSD as
Editor’s Note: In this edition of the Research Reviews column, Crisis Management in the Schools
Interest Group members summarize recent crisis management publications. In this issue we will be
focusing on research related to posttraumatic stress disorder (PTSD) and below we bring to your
attention to three articles we believe have relevance to school psychologists. The first article summarized
provides a cognitive model of PTSD that may help to inform the school crisis intervention
response (especially as it relates to the identification of more serious psychological trauma victims).
The second paper reviews the literature regarding the treatment of PTSD among children and provides
guidance regarding best therapeutic practices. The final article summarized offers a metaanalytic
review of the predictors of PTSD.
developing due to a real or perceived serious
threat to one’s well-being. The authors
sought to explore preexisting characteristics
that perhaps make individuals more
susceptible to the development of PTSD.
The implications may be useful for crisis
response in the schools as a means of identifying
those individuals who may need secondary
and tertiary levels of treatment. The
authors also provided research-based treatment
protocols that may be used with
school personnel and students experiencing
distress following a school or community
crisis event. Furthermore, the central
features of PTSD presented in this model
may be modified through psychoeducational
groups in the schools. Specifically, school
personnel may be able to normalize the
emotional and psychological turmoil that
may result from school-based trauma.
Ehlers and Clark’s cognitive model of
posttraumatic stress disorder provides
theoretical foundations for the symptoms
of persistent PTSD as well as potentially
helpful treatment implications. This model
may prove useful for school personnel in
the identification of secondary and tertiary
treatment groups and in the treatment
planning for these groups. The model has
promising implications and warrants further
Ehlers, A., & Clark, D. (2000). A cognitive model of
posttraumatic stress disorder. Behaviour Research
& Therapy, 38, 319–345.
Posttraumatic Stress
Disorder in Youth
Summarized by Elizabeth J. Zhe,
PsyD, Culver Academies, Culver, IN
Professional Psychology: Research and
Practice published a review article
by Feeny, Foa, Treadwell, and March
(2004) critiquing research on PTSD treatments
for youth. Despite the substantial
amount of research on the treatment of
PTSD in adult populations, PTSD treatment
outcome studies in youth populations
are sparse. Feeny et al.’s review
strives to bring light to the clinical implications
of existing research and to detect
gaps where future research is needed.
The authors review the prevalence of
trauma exposure in school-age populations
and youth with emotional disturbances, as
well as common psychological reactions to
exposure. PTSD is pinpointed as the most
common type of psychological reaction to
trauma exposure, and yet few youth with
PTSD receive empirically supported treatments
for their diagnosis. Common selfreport
measures used to evaluate traumatized
youth are also briefly reviewed. Feeny
et al. identify numerous self-reports as adequate
initial screening instruments; however,
none provides a Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV;
American Psychiatric Association, 1994)
diagnosis of PTSD. Foa, Johnson, Feeny, &
Treadwell (2001) describe the Child PTSD
Symptom Scale as a solid measure that evaluates
both DSM-IV symptoms and functional
An empirical review of cognitive and
behavioral treatments (CBT) for youth
with PTSD is then provided. Due to the
lack of research on other types of treatments
for traumatized youth (i.e., one published
randomized controlled study of a
non-CBT psychosocial intervention and
no published pharmacological interventions
with controlled trials), only CBTs
are reviewed. Reviewed treatments were
individually delivered exposure treatment,
eye-movement desensitization and reprocessing
(EMDR), anxiety-management
training (AMT), group-delivered treatments,
and child–parent treatments for
sexual abuse-related trauma.
On the whole, the authors assert that
there is mounting empirical support for the
use of numerous CBT programs in the treatment
of youth with PTSD. Key findings are
(a) there is preliminary evidence found in
numerous single-case designs for the effectiveness
of exposure, group CBT with exposure,
and anxiety-management training; (b)
evidence is found in well-designed research
studies with randomized trials that brief
treatments for disaster- and violence-related
PTSD are efficacious; (c) sequential studies
of child and parent CBT programs
(including exposure and parent-training
for PTSD and symptoms of sexual abuse)
are suggestive of short- and long-term efficacy
when provided in either individual,
group, or parallel child and parent treatments;
and (d) effective CBT treatments
for sexually abused youth, with or without
a focus on treating PTSD, entail parent or
family involvement. While the review suggests
CBT is the most empirically supported
treatment of PTSD for youth, psychologists
should base their choice of CBT
methodology on consideration of whether
sexual trauma is involved, if there are cooccurring
mental health diagnoses, and the
youth’s developmental level.
Feeny et al. (2004) conclude with a discussion
of areas for future research and
the necessity for psychologists to obtain
additional supervision or education in CBT
as it relates to PTSD. By and large, additional
research is needed to conduct largescale
randomized control trials comparing
CBT and other common PTSD
Stephen Brock, PhD, NCSP, is on the school psychology faculty of California State University, Sacramento.
He is a member of NASP’s National Emergency Assistance Team (NEAT), a past-coordinator of
the Crisis Management Interest Group, and author of the recently developed NASP school crisis intervention
training curriculum (Crisis Intervention & Recovery: The Roles of School-Based Mental Health Professionals).
This column will appear several times during the year. If you would like to write a research summary
and/or know of a study that should be summarized please contact Dr. Brock at
treatments (e.g., pharmacological, nondirective
play therapy, psychodynamic therapies),
as well as the effectiveness of medication
alone versus medication plus
psychosocial treatment interventions. The
authors also cite the need for treatment
outcome research studies to include measures
beyond those of symptom reduction,
such as academic and family functioning.
There is also a need for large-scale dissemination
studies in natural settings and
investigation of how treatment outcome
is impacted by comorbidity, family functioning,
and early termination.
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th
ed.). Washington, DC: Author.
Feeny, N. C., Foa, E. B., Treadwell, K. R. H., & March,
J. (2004). Posttraumatic stress disorder in youth:
A critical review of the cognitive and behavioral
treatment outcome literature. Professional Psychology:
Research and Practice, 35, 466–476.
Foa, E. B., Johnson, K., Feeny, N. C., & Treadwell, K.
R. T. (2001). The Child PTSD Symptom Scale
(CPSS): Preliminary psychometrics of a measure
for children with PTSD. Journal of Clinical Child
Psychology, 30, 376–384.
Predictors of PTSD
Among Adults
Summarized by Calissia Thomas
Tasby, Predoctoral Intern, Psychological
& Social Services, APPIC Internship
Site, Dallas Independent School
District, Dallas, TX
In the past decade, studies have been
conducted to specifically examine the
role certain variables play in contributing
to PTSD in adults. Since more than half
of the United States population is exposed
to a traumatic event, but only approximately
7% actually develop PTSD, the importance
placed on determining why the
remaining 43% do not develop PTSD is warranted
(Kessler, Sonnega, Bromet, Hughes,
& Nelson, 1995). In examining these phenomena,
most reviews, with the exception
of Brewin, Andrews, and Valentine (2000),
failed to conduct a comprehensive review
of the PTSD literature or use quantitative
measures (effect size [ES]; Emery, Emery,
Shama, Quiana, & Jassani, 1991; Fontana &
Rosenheck, 1994; Green, 1994). This lack of
comprehensive and quantitative research
prompted the study by Ozer, Best, Lipsey,
and Weiss (2003) summarized below.
In a meta-analysis conducted through
a literature review examining symptoms
predictive of PTSD, Ozer et al. (2003) identified
2,647 articles that related to PTSD,
of which 476 met the inclusion criteria.
Studies that did not assess all of the clusters
of PTSD symptoms as defined in the
4th edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV;
American Psychiatric Association, 1994)
© 2008, National Association of School Psychologists September 2008, Volume 37, Number 1 | Communiqué | 35
were eliminated leaving 68 studies to be
included in the present study. Of the 68
studies, all met criteria under seven predictors
of PTSD in adults (ages 18 and
over) that included:
(a) a history of at least one other
trauma prior to the index traumatic
event, (b) psychological adjustment
prior to the traumatic event, (c)
family history of psychopathology,
(d) perceived life threat during the
traumatic event, (e) perceived
social support following the traumatic
event, (f) peritraumatic emotionality—
high levels of emotion
during or in the immediate aftermath
of the traumatic event, and (g)
peritraumatic dissociation—dissociative
experiences during or in the
immediate aftermath of the traumatic
event. (Ozer et al., 2003, p. 55)
Results of the analysis using the seven
criteria above yielded significant effect
sizes. Family history, prior trauma, and
prior adjustment produced the smallest
effect size (weighted r = .17). The largest
effect size was produced by peritraumatic
dissociation (weighted r = .35). From the
results, prior characteristics do not appear
to play a significant role in the development
of PTSD. Instead the psychological
response (or peritraumatic psychological
processes) following exposure to a traumatic
event is the best predictor of PTSD.
These findings are important for school
psychologists to understand when working
with children and their families, especially
during crisis. Understanding the factors
that contribute to PTSD in adults may
also help in providing psychological services
that counteract the development of
PTSD in children. Specifically, these results
suggest that it is important to mitigate the
psychological arousal level after a crisis.
The present study was not designed to
account for all mechanisms that contribute
to PTSD. For example, future investigators
may want to examine the statistical role
that distal predictors such as family history
of psychopathology and prior trauma
play in the development of PTSD. ■
American Psychiatric Association. (1994).
Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Brewin, C. R., Andrews, B., & Valentine, J. D.
(2000). Meta-analysis of risk factors for posttraumatic
stress disorder in trauma-exposed
adults. Journal of Consulting and Clinical
Psychology, 68, 748–766.
Emery, V. O., Emery, P. E., Shama, D. K., Quiana,
N. A., & Jassani, A. K. (1991). Predisposing
variables in PTSD patients. Journal of Traumatic
Stress, 4, 325–343.
Fontana, A., & Rosenheck, R. (1994). Posttraumatic
stress disorder among Vietnam theater
veterans: A causal model of etiology in a community
sample. Journal of Nervous and Mental
Disease, 182, 677–684.
Green, B. L. (1994). Psychosocial research in
traumatic stress: An update. Journal of Traumatic
Stress, 7, 341–362.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M.,
& Nelson, C. B. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey.
Archives of General Psychiatry, 52, 1048–1060.
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S.
(2003). Predictors of posttraumatic stress
disorder and symptoms in adults: A metaanalysis.
Psychological Bulletin, 129, 52–73.
Culturally Responsive Practice
Resources and Initiatives
NASP is pleased to announce the release of the latest
career brochure, School Psychology: The Role of a
Native American School Psychologist. The brochure
outlines the important contributions indigenous
school psychologists make toward strengthening
Native communities and helping children succeed
in school and life. Additionally, information about
what services school psychologists provide and
how NASP supports culturally responsive practice
are noted. The brochure was developed by
the Native American Group of the Multicultural
Affairs Committee.
■ Read more about the recruitment initiatives
of the Multicultural Affairs Committee
on the Culturally Competent
Practice webpage at www.nasponline
■ Download the Native American
career brochure or order copies
from the NASP website
Directory of Bilingual School Psychologists. NASP is building an online directory
of bilingual schools psychologists. NASP members who are fluent in languages other
Mary Beth Klotz, NCSP, is NASP Director, IDEA Projects and Technical Assistance. Some of the


  1. Cyndi and Laura say....Lots of great and relevant references and articles to refer back to.

  2. Agree with Laura...and I like how the first article relates back to schools, specifically.