(Jonathan Sandoval) Crisis Counseling, Interventio (B-Ok - Xyz)

Crisis Counseling, Intervention,
and Prevention in the Schools
Since the first edition was published in 1988, the role of crisis intervention and prevention
has become central to mental health professionals working in the schools. Disasters such
as Hurricane Katrina, terrorist attacks both in this country and around the world, and
various school shootings have greatly increased school crisis research and policy devel-
opment. This book is designed for an introductory graduate course taken by students in
school psychology, school counseling, and school social work. The first three chapters
provide a crisis response overview. The next 10 chapters deal with crises for children and
adolescents, and the last six chapters cover crises that manifest themselves primarily in
adolescence. Discussions of the 16 most prevalent types of crises are covered, including
their characteristics, causes, interventions, and preventive programs. All chapters have
been updated, six heavily revised or totally rewritten by new authors, and two new chap-
ters (Ch. 8 & 19) have been added.
Jonathan Sandoval is a Professor of Education at the University of the Pacific and Professor
Emeritus at the University of California, Davis, United States.
Consultation and Intervention in School Psychology Series
Series Editor: Sylvia Rosenfield
Under the advisory editorship of Sylvia Rosenfield, The Routledge Consultation and Inter-
vention in School Psychology Series will provide a full array of both handbooks and
textbooks in the area of school consultation and intervention. Handbooks will be edited
volumes that provide in-depth, up-to-date coverage of the latest theories, research, meth-
odologies, issues, applications, and policies in targeted areas of study. Each handbook will
profile the boundaries and various sectors within its field of study and will vary in length
from 400 to 600 printed pages. Textbooks may be either edited or authored volumes
that include some theory but focus mainly on the skills that are central to evidence-based
practice. They will generally range from 200–400 pages. Following is a list of volumes
published or in development in each of these categories.
Handbooks
• Erchul & Sheridan: Handbook of Research in School Consultation (2007)
(New edition scheduled for 2013)
• Esquivel & Lopez: Handbook of Multicultural School Psychology (2007)
Textbooks
• Lambert et al.: Consultee-Centered Consultation (2004)
• Rosenfield: Becoming a School Consultant: Lessons Learned (2012)
• Sandoval: Crisis Counseling, Intervention and Prevention in the Schools, 3e (2013)
• Rosenfield: Instructional Consultation and Collaboration (2013)
• Sandoval: An Introduction to Consultee-Centered Consultation in the Schools (2013)
• Ingraham & Myers: Multicultural Consultation (2014)
• Truscott: Supporting Teachers: A Guide for School Professionals
Persons interested in developing handbooks or textbooks in school consultation should

contact either Sylvia Rosenfield or Rebecca Novack at the following addresses.
Dr. Sylvia Rosenfield Rebecca Novack

502 Moorings Circle Associate Editor, Education
Arnold, MD 21012 Routledge Publishers
Phone: 410-975-0088 711 Madison Ave.
srosenf@umd.edu New York, NY 10017
212-216-7848
Rebecca.Novack@taylorandfrancis.com
Crisis Counseling, Intervention,
and Prevention in the Schools
Third Edition
Edited by
Jonathan Sandoval
University of the Pacific
Third edition first published 2013
by Routledge
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© 2013 Taylor & Francis
The right of the editor to be identified as the author of the editorial
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All rights reserved. No part of this book may be reprinted or
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or registered trademarks, and are used only for identification and
explanation without intent to infringe.
First edition published by Lawrence Erlbaum Associates 1988
Second edition published by Lawrence Erlbaum Associates 2001
Library of Congress Cataloging in Publication Data
Crisis counseling, intervention and prevention in the schools / edited
by Jonathan Sandoval, University of the Pacific. — Third edition.
pages cm
Includes bibliographical references and index.
1. School psychology—United States. 2. Crisis intervention
(Mental health services)—United States. 3. Mental health
counseling—United States. I. Sandoval, Jonathan, editor of
compilation.
LB1027.55.C74 2012
371.7′130973—dc23
2012034356
ISBN: 978-0-415-80770-8 (hbk)
ISBN: 978-0-415-80771-5 (pbk)
ISBN: 978-0-203-14585-2 (ebk)
Typeset in Sabon
by Apex CoVantage, LLC
We dedicate this book to the memory of Alexis Sophie Pham (1986–2012).
Her brief life was an inspiration to many. We will remember her with
fondness and admiration.
Contents
Preface ix
List of Contributors xi
1 Conceptualizations and Principles of Crisis Counseling,

Intervention, and Prevention 1
JONATHAN SANDOVAL
2 Preparing for the School Crisis Response 19

STEPHEN E. BROCK
3 Considering Culture in Crisis Work 31

JONATHAN SANDOVAL
4 School Entry, School Failure, and the Discovery

of Learning Disabilities 46
COLETTE L. INGRAHAM
5 Divorce: Crisis Intervention and Prevention with Children

of Divorce and Remarriage 66
ANDREW M. LAMDEN & JONATHAN SANDOVAL
6 Bullying: Students Hurting Students 85

JULIANA RASKAUSKAS
7 Child Maltreatment 106

LINDA WEBSTER
8 Helping Children Cope With Grief 128

AUBREY URESTI
9 Illness: A Crisis for Children 153

DIANNE CASTILLANO & AMY N. SCOTT
10 Children of the Disabled, Incarcerated, or Deployed 173

MARI GRIFFITHS IRVIN, MELISSA KEANE, & JONATHAN SANDOVAL
viii Contents
11 The Stress of Moving 198
JONATHAN SANDOVAL
12 Acts of Violence 212

JONATHAN SANDOVAL, STEPHEN E. BROCK, & KATIE KNIFTON
13 Preparing for and Responding to Disasters 229

STEPHEN E. BROCK, QUINN BALLARD, & CHRISTINA SAAD
14 Suicide 242
OANH K. TRAN, ALEXIS S. PHAM, & JOHN M. DAVIS
15 Lesbian, Gay, Bisexual, Transgender, and Questioning

(LGBTQ) Youth 264
SUZY R. THOMAS
16 Adolescent Pregnancy and Parenthood 291

KATHERINE HADLEY CORNELL
17 Conflict and Crisis Within the Family System 314

SUZY R. THOMAS & JEFF COOK
18 Rape and Sexual Assault 334

VIRGINIA L. SCHIEFELBEIN & JONATHAN SANDOVAL
19 Nonsuicidal Self-Injury 362

DAVID N. MILLER
Index 383
Preface to the Third Edition
The first and second editions of this book were designed to fill a gap in the preparation
and education of many mental health professionals working in schools. The two editions
have served as texts in graduate courses for school psychologists, school counselors, school
social workers, school nurses, and school administrators, and been used as a handy refer-
ence source for school-based practitioners. Since the publication of the second edition in
2002, the number of sources of information about crisis intervention have grown steadily,
stimulated by an increase in terrorist attacks and natural disasters at home and abroad.
There is now a larger research base for practice and a new awareness of the importance of
being prepared to respond to the effects of a number of traumas in children’s lives.
This new edition presents updated information on topics from the second edition using
a number of new authors. The chapters on bullying, child maltreatment, helping children
cope with grief, illness, suicide, adolescent pregnancy and parenthood, and “Conflict and
Crisis Within the Family System” have been completely rewritten. In addition, the previ-
ous chapter on children of parents with disabilities has been expanded to “Children of
the Disabled, Incarcerated, or Deployed,” covering two additional populations at risk.
The remaining chapters have been extensively revised to highlight new research and
new resources for prevention and intervention. Topics covered in this volume (but rarely
addressed as crises in other resources for school practitioners) include moving, rape and
sexual assault, school failure, and adolescent pregnancy and parenthood. The third edition
contains a new chapter on “Nonsuicidal Self-Injury,” a topic of increasing concern in the
schools. One excellent chapter from the second edition, “Helping Children with Eating
Disorders,” is not included, since this topic is often covered in courses on child psycho-
pathology. The reader may wish to consult the second edition for this valuable resource.
One feature of this volume is an emphasis on evidence-based practice. The authors have
been scrupulous in documenting research and best practice to support their recommenda-
tions for counseling, intervention, and prevention. While covering new ground, the central
message of these chapters is the same as before: School mental health professionals can do
much to reduce children’s stress and to facilitate their coping and healthy development.
Hazardous situations faced by children need not lead to lasting crisis responses. Along
with the chapter contributors, I feel confident that this book provides the kind of informa-
tion and inspiration that is needed to reach these goals.
Jonathan Sandoval
Contributors
Quinn Ballard, MA
Student in School Psychology
California State University, Sacramento
Stephen E. Brock, PhD, NCSP

Director and Professor, School Psychology Program
Dianne Castillano, MA
Doctoral Student in School Psychology
University of the Pacific, Stockton
Jeff Cook, PhD

Assistant Professor
University of Wisconsin, Whitewater
Katherine Hadley Cornell, PsyD

Private Practice
Lutherville, Maryland
John M. Davis, PhD

Department Chair, Educational Psychology
California State University, East Bay
Colette L. Ingraham, PhD, NCSP

Director and Professor, School Psychology Program
San Diego State University
Mari Griffiths Irvin, PhD

Professor Emeritus
Melissa Keane, MA
Katie Knifton, MA
xii Contributors
Andrew M. Lamden, LCSW
Private Practice
Kentfield, California
David N. Miller, PhD

Associate Professor of Education
University at Albany, State University of New York
Alexis S. Pham, MA
Juliana Raskauskas, PhD

Associate Professor
Christina Saad, MA
Jonathan Sandoval, PhD, ABPP

Professor of Education
Rev. Virginia L. Schiefelbein, PhD, BCC

Staff Chaplain
Sparrow Hospital, Lansing, Michigan
Amy N. Scott, PhD

Assistant Professor of Education
Suzy R. Thomas, PhD

Associate Professor
St. Mary’s College of California, Moraga
Oanh K. Tran, PhD

Assistant Professor
California State University, East Bay
Aubrey Uresti, MA
Berkeley Unified School District
Berkeley, California
Linda Webster
Associate Professor of Education
1 Conceptualizations and Principles
of Crisis Counseling, Intervention,
and Prevention
Jonathan Sandoval
Perhaps the feature of a traumatic event that is most dramatic to witness is the effect on the
individual. Children in crisis suddenly function with greatly diminished capacity when meet-
ing everyday demands. Students whom others have seen behaving only competently and
efficiently suddenly become disorganized, depressed, hyperactive, confused, or hysterical
(Pynoos, 1994). Customary problem-solving activities and resources seem to evaporate.
Individuals who are in what Caplan (1964) refers to as a state of psychological disequi-
librium often behave irrationally and withdraw from normal contact. They cannot be
helped using usual counseling or teaching techniques. Nevertheless, children in crisis are
usually also in school. Their crisis reaction to stress makes learning almost impossible and
many are unable to comply with classroom rules and expectations for behavior. School
psychologists, counselors, and other guidance personnel must be able to support teachers,
parents, and the children themselves during periods of crisis. In addition, school person-
nel must be forward-thinking and anticipate that crises will often occur in children’s lives.
They must be prepared to act and find ways to help children master the challenges of
crises when they occur.
A History of Crisis Intervention Theory

The earliest work on crisis intervention is usually attributed to Erich Lindemann (1944)
and his studies of the aftermath of the Coconut Grove nightclub fire. This disaster, which
occurred in Boston in the late 1930s, took a large toll of human life. For the first time,
a social scientist conducted systematic observations of the reactions of victims and their
families to a natural disaster, although others, including Anna Freud, noted the traumatic
impacts of war on combatants (Fletcher, 2003). The Coconut Grove study, plus Linde-
mann’s experiences after opening a community mental health agency in Wellesley, Mas-
sachusetts, formed the basis for his ideas about crisis and crisis intervention that linked
observations of social transitions and reactions to traumatic events.
Erik Erikson (1962) contributed the next major milestone in crisis intervention theory
with the 1950 publication of Childhood and Society. Erikson’s theory revolves around the
notion of specific crises characterizing each developmental stage of an individual’s life. His
contribution was the notion of crisis as a normal developmental phenomenon, and that
intervention that led to a balanced resolution at the time of a crisis would prevent later
problems in emotional development and maturation.
The third early pioneer was Gerald Caplan, whose formulations about the primary
prevention of emotional disorders and mental health consultation led to the notion of
an entirely new field of preventive psychiatry (Caplan, 1961, 1964). Caplan’s data came
from early work with Peace Corps volunteers, with parents reacting to premature birth
and with families coping with the affliction of tuberculosis. His (and others’ associated
2 Jonathan Sandoval
with the Harvard School of Public Health) adoption of ideas from public health and the
application of them to mental health settings had an enormous influence that led to the
blossoming of crisis intervention centers throughout the country.
Caplan’s work came at a time when there was a great push on the part of the federal
government for community mental health agencies and at a time of great social unrest in
our country. The 1960s brought unprecedented illegal use of psychoactive drugs on the
part of adolescents and young adults. These forces, particularly drug abuse, led to the
creation in the community and on college campuses of crisis counseling agencies, often
nontraditional in nature, which could deal with the problems of alienated youth, espe-
cially drug overdose (Beers & Foreman, 1976). During this time, telephone crisis lines
also came into widespread use, spurred on by a growing interest in suicide prevention
services (Golan, 1978).
The late 1970s and early 1980s saw the burgeoning of a great deal of interest in brief
psychotherapy (e.g., Bellak & Small, 1978; Davanloo, 1978). This trend emerged as a
result of cuts in mental health funding and of new techniques and procedures for dealing
rapidly with mental health problems. Mental health workers began to appreciate that as
much could be accomplished in six to eight sessions as had earlier taken years.
Another trend from this period was an interest in stress and its impact on physical and
mental health. Theorists such as Hans Selye (1974) and Adolph Meyer (cited in Moos
& Schaefer, 1986) have noted how a variety of environmental events may have broader
effects than previously believed. Physical events may have emotional sequelae and vice
versa. Normal life events such as graduation from school, birth of a child, or marriage,
not to mention unpleasant events such as job failure, a death in the family, or divorce,
may foreshadow the development of symptoms and disease. Moreover, stressful events
are additive or perhaps multiplicative in their action, in that the more events with which
the individual must cope, the more likely an illness response will develop (Moos &
Schaefer, 1986).
During the 1980s and 1990s focus has shifted to more extreme forms of crisis inter-
vention. In succeeding revisions of the American Psychiatric Association’s Diagnostic
and Statistical Manual, the concept of posttraumatic stress disorder (PTSD) came to be
refined and identified in children and youth (Fletcher, 2003). The definitions of PTSD have
focused more attention on this phenomenon and more study of therapeutic techniques to
ameliorate the effects. Also this period saw a number of school-based acts of terrorism
and violence that were widely publicized and discussed in the popular media. Perhaps the
most dramatic example was the murderous attack on Columbine High School in Little-
ton, Colorado. These events led to legislation outlawing the possession of certain types of
weapons, increased attention to the causes and prevention of violence in youth, and an
awareness of the impact of bullying.
Two events defined the first decade of the 21st century: the 9/11 destruction of the
World Trade Center and Pentagon, and the aftermath of Hurricane Katrina. Because of
the extreme nature of the events and the widespread media coverage, more effort has gone
into preparing psychologists and others to respond to disaster, and more attention has
been given to the effects on children of witnessing traumatic events (Eisenberg & Silver,
2011). National professional organizations such as the National Association of School
Psychologists and the American Psychological Association have sponsored the training
and certification of crisis workers.
Although crisis theory has had a relatively brief history, sufficient research findings and
clinical observations exist for school psychologists and other school mental health workers
to apply the ideas and techniques to the school setting, and crisis response teams exist in
many school districts (Brock et al., 2009; Brock, Sandoval, & Lewis, 2001).
Conceptualizations and Principles of Crisis Counseling, Intervention, and Prevention 3
Definitions and Distinctions
The term crisis is used generically to stand for both the event and the reaction. It is useful
to make a distinction, however. Donald C. Klein and Erich Lindemann (1961) offer the
following definition:
An emotionally hazardous situation (or emotional hazard) refers to any sudden altera-
tion in the field of social forces within which the individual exists, such that the
individual’s expectations of himself and his relationships with others undergo change.
Major categories of hazards include: (1) a loss or threatened loss of significant rela-
tionship; (2) the introduction of one or more new individuals into social orbit; (3) tran-
sitions in social status and role relationships as a consequence of such factors as (a)
maturation (e.g., entry into adolescence), (b) achievement of a new social role (e.g.,
marriage), or (c) horizontal or vertical social mobility (e.g., job promotion). (p. 284)
Klein and Lindemann use the term hazard to capture the notion that many individuals
are able to pass through such alterations with little difficulty or with a minimum amount
of stress. They are resilient in the face of the hazard. Others, however, find themselves
immobilized or damaged by the hazard. Natural disasters and acts of terrorism would be
included in their definition of hazard, but other events, such as witnessing domestic vio-
lence or being victimized by a bully, can also impact children.
Klein and Lindemann (1961) reserve the term crisis “for the acute and often prolonged
disturbance that may occur in an individual or social orbit as a result of an emotional
hazard” (p. 284). Emotional hazards faced by school children include: losses in significant
relationships associated with the death of a parent, parental divorce and remarriage, death
of a sibling or the loss of a parent to illness, maturational challenges such as the begin-
ning of puberty, and transitions such as those accompanying movement into new schools
or new educational programs. Nonpromotion is a hazard, but so is promotion to a new
grade, with its separation from a known, possibly favored teacher and the adjustment to
change and an unknown, new teacher. Disasters typically bring about these same disrup-
tions since they often result in loss of life or of status, such as becoming homeless. Many
children will navigate these hazards with little or no ill effect. Others will develop crisis
reactions and come to the attention of school psychologists and other school personnel.
Caplan (1964) offers a general view of an emotional crisis as a “psychological disequi-
librium in a person who confronts a hazardous circumstance that for him constitutes an
important problem which he can, for the time being, neither escape nor solve with his
customary problem solving resources” (p. 53). Caplan views a crisis as being a period
when the individual is temporarily out of balance. This state of disequilibrium provides
an opportunity for psychological growth as well as a danger of psychological deteriora-
tion. Although there are great risks that may occur to the future mental well-being of an
individual who passes through a crisis, there is also an opportunity for an individual to
change. It is an old but traditional cliché to point out that the Chinese character for crisis
includes ideographs related to the concept of danger as well as the concept of opportunity.
An aspirational goal in helping an individual who is undergoing a crisis is to intervene
in such a way as to use the situation to enhance personal growth, or at least to restore
the individual to a previous level of functioning. The goal is not to reorganize completely
the individual’s major dimensions of personality, but to restore the individual with creative
problem solving. Of course by successfully resolving a crisis an individual will most likely
acquire new coping skills that will lead to improved functioning in new situations, but that
is only a desired, possible outcome, not the sole objective of the process.
4 Jonathan Sandoval
Because failure to cope is at the heart of a crisis, and the promotion of coping is an
overall objective of crisis intervention, it is useful to consider what normal coping entails.
Moos and Billings (1984) have identified a taxonomy of coping skills organized into three
domains, each with three skills. The first is appraisal-focused coping. The three skills in
this domain enable the individual to find meaning and to understand the crisis—that is, to
apprehend it in a productive manner. They are (a) logical analysis and mental preparation,
(b) cognitive redefinition, and (c) cognitive avoidance or denial. Thus, in first becoming
aware of a hazardous event, a child may think it through rationally, step by step, and
prepare for what will probably happen next, may reframe the hazard in a variety of ways,
or may keep all or part of it at a distance, mentally, until he or she is ready to deal with it.
The second domain is problem-focused coping. The three skills in this domain enable
the individual to confront the reality brought about by the crisis. These are (a) seeking
information and support, (b) taking problem-solving action, and (c) identifying alterna-
tive rewards. This last skill involves changing activities and relationships so there may be
substitutions for the sources of satisfaction lost by the hazardous event.
The third domain is emotion-focused coping. Here, the three skills enable the child to
manage the feelings generated by the crisis and to maintain affective equilibrium. The
three skills are (a) affective regulation, (b) emotional discharge, and (c) resigned accep-
tance. These skills allow one to maintain control of emotions, or to vent them in a way
that brings relief. However, many situations cannot be controlled, and resigned acceptance
may lead to avoidance and withdrawal as a way to protect the self. As we see later in the
chapter, and in others in this book, much of crisis intervention is directed at stimulating
one or more of these coping skills, or even teaching them depending on the individual and
the type of hazard he or she is attempting to negotiate.
There has been a great deal of interest in the concept of resilience, or the personal and
situational factors that enable some children to overcome difficult situations or events
(Werner, 1989). Children who are able to negotiate hazardous situations without a crisis
response may be characterized as having good social competence, good problem-solving
skills, a degree of autonomy, and a strong sense of purpose and the future (Bernard, 1992).
They also come from supportive family and school environments with high expectations
and encouragement of participation in meaningful activities. Some children will be vulner-
able to hazardous events and transitions, and others will not.
Types of Crises
Although there are a number of ways that crises may be defined and outlined (cf. Aguilera,
1998; Smith, 1990), most authorities distinguish between developmental crises and situ-
ational crises. Developmental crises occur when an individual moves from one develop-
mental stage to another. Situational crises, however, are incidents that are unexpected and
accidental. They are often labeled traumatic. Baldwin (1978; Burgess & Baldwin, 1981)
has developed perhaps the most useful taxonomy. He emphasizes in his taxonomy the
impact on the individual rather than the nature of the hazard.
Dispositional Crises
Baldwin (1978) calls his first class of crises dispositional crises. These crises are “distress
resulting from a problematic situation in which the therapist responds to the client in
ways peripheral to a therapeutic role; the intervention is not primarily directed at the
emotional level” (p. 540). In a dispositional crisis an individual typically lacks both infor-
mation and encouragement to go about solving a problem in an unusual way. The school
psychologist who helps a pupil learn about a local program for overweight teenagers might
be dealing with such a crisis. In general, the major counseling strategy with these pupils is to
provide information, particularly information that would be difficult for the child or ado-
lescent to obtain on his or her own. If the client is capable of doing most of the “research,”
the counselor merely points the way. The act of obtaining the information on one’s own
builds self-confidence and increases the chance of the information being believed. Another
specific strategy is to rule out possible hidden, serious emotional implications of the seem-
ingly innocent request for information. The counselor must be sure the current problem is
not an offshoot of another, more serious situation. The school mental health worker should
also consider referring the client on. Another expert may provide information that is either
more comprehensive or more authoritative than is available at the school. If the real reason
for the request is to discuss a more serious problem outside of the scope of solution in the
school, a referral for long-term therapeutic intervention may be required.
Anticipated Life Transitions

Baldwin’s (1978) second category subsumes crises of anticipated life transitions. These are
crises “that reflect anticipated but usually normative life transitions over which the client
may or may not have substantial control” (p. 542). Common transitions for children are
entering school, moving from grade to grade, moving to another school, or moving from
a self-contained special education classroom to a mainstream one. The birth of a sibling
or pregnancy in a teenager also fits this category in as much as they are transitions from
one status (only child or adolescent) to another (sibling or mother).
One approach to dealing with crises related to life transitions is to provide informa-
tion about what is about to occur in the person’s life. As a preventive technique, I discuss
anticipatory guidance and emotional inoculation later in the chapter, but a child in the
middle of a transition also needs to know what is likely to occur next and what the normal
experiences and emotions are for those going through such a transition. School personnel
can provide this kind of normative information.
An alternative is to let peers supply the information. Another strategy is to establish
support groups consisting of a number of children facing the same transition. If the group
functions well, it may facilitate the expression of feeling and the acquisition of produc-
tive coping mechanisms as members share experiences and join in mutual problem solv-
ing. Even young children can do productive group problem solving through devices such
as a classroom meeting (Edwards & Mullis, 2003), or other structured approaches to
classroom discussions of children’s self-identified conflicts and problems (Doll, Zucker, &
Brehm, 2004; Fuller, 2007).
Traumatic Stress
A third class of crises results from traumatic events. These are “emotional crises precipi-
tated by externally-imposed stressors or situations that are unexpected and uncontrolled,
and that are emotionally overwhelming” (Baldwin, 1978, p. 543). Young (1998) notes six
types of traumatic hazards: severe illness or injury, violent or unexpected death, threat-
ened death or injury, acts of war, natural disasters, and man-made industrial disasters.
Traumatic events for children in school include the sudden death of a family member, cata-
strophic illness, hospitalization, parental disablement, parental divorce, physical abuse,
pregnancy, sexual assault, and academic failure. Often, the pupil facing one or more of
these events is emotionally overwhelmed and unable to bring previously learned coping
strategies into play.
6 Jonathan Sandoval
The counselor’s first goal is to help the child understand the impact of what has occurred.
Because of the suddenness of occurrence, the counselee probably has not had time to think
through all of the impacts of what has happened. Exploration of the event and the atten-
dant feelings will get the child to gain needed perspective and overcome defensive reac-
tions. Traditional nondirective helping interviews (Benjamin, 1981) can accomplish this
task and can stimulate appraisal-focused coping (Moos & Billings, 1984). Another goal
for helping in this kind of crisis is to mobilize any existing coping mechanisms the child
may have (Ruzek et al., 2007). If the individual has characteristic ways of dealing with
stress in other situations, the counselor can remind the child of these, be they appraisal-,
problem-, or emotion-focused. Then the counselor can facilitate the transfer of the old
skills to the new crisis (Brenner, 1984).
If the counselee is not coping at all, it may be possible to provide the pupil with new
coping mechanisms. Brenner (1984) refers to the process as teaching new coping strate-
gies, and believes the new technique will be more easily learned if it is close to the child’s
initial reaction.
For example, Joshua’s teacher helped him substitute sublimination for impulsive act-
ing out as a coping technique after his mother deserted him. Josh’s first impulse was
to express his anger by running around the classroom, pushing furniture and people
out of his way. His teacher helped him to think of several vigorous physical activi-
ties which would not be destructive but which would still serve to release his pent-up
emotions. (p. 173)
Another way of helping victims of traumatic crisis is to relieve them of other, unrelated
stressors (Brenner, 1984). A child who has been traumatized by his parent’s announced
divorce may be temporarily relieved of certain expectations at school if those expectations
are adding to the child’s sense of being overwhelmed. If, however, the child is using school
achievement in a sublimation strategy, it might be wiser to search for other potential
sources of stress to be modified or eliminated.
Maturational/Developmental Crises
Crises in this fourth category result “from attempts to deal with an interpersonal situa-
tion reflecting a struggle with a deeper (but usually circumscribed) issue that has not been
resolved adaptively in the past and that represents an attempt to gain emotional maturity”
(Baldwin, 1978, p. 544). Focal issues for this class of crises include dependency, value con-
flicts, sexual identity, capacity for emotional intimacy, responses to authority, and attain-
ing reasonable self-discipline. All of these issues may erupt in school children but are more
visible during adolescence.
These crises are different from others in that they usually occur as another episode in
a pattern of relationship problems that have similar dynamics. In secondary schools, the
attainment of sexual maturity by young people precipitates a number of these crises, as
does adolescence in general. Struggles with parents and teachers often develop to the point
of crisis in this class. A special case of such a crisis is the adolescent discovery of a homo-
sexual orientation (Ross-Reynolds & Hardy, 1985; Chapter 15, this volume).
Once again, the counselor can be of help with clients in this kind of crisis by facilitating
the exploration of thoughts and feelings. In this instance, however, the hope is to identify
issues underlying the crisis. This strategy will be particularly attractive to dynamically ori-
ented counselors. What thoughts and feelings does the client have about significant others
and the self? What value conflicts are being experienced and what are their origins? What
themes and conflicts appear to be unresolved? Are these issues related to trust, acceptance
and control of aggression, attitudes toward learning, separation, accepting limits from
others, and so on?
Next, the counselor works to support the individual in crisis to redefine relationships
and develop adaptive interpersonal skills. Because most of these crises involve creating
new ways of interacting with other people in the student’s social environment, helping
him or her learn new prosocial strategies is effective. Strategies for making friends may be
taught directly (Stocking, Arezzo, & Leavitt, 1980) but providing models to observe (or
even read about, e.g., Fassler, 1978) is also beneficial.
Crises Reflecting Psychopathology

Baldwin (1978) describes the fifth category: “These are emotional crises in which a pre-
existing psychopathology has been instrumental in precipitating the crisis or in which
psychopathology significantly impairs or complicates adaptive resolution” (p. 546). The
problems of a child hallucinating in school or a severely depressed adolescent might well
achieve crisis proportions. Eating disorders may come to the attention of teachers. These
kinds of crises, although present in the school, are rarely the kind that special services
practitioners are trained for and thus usually result in a referral to outside community
resources. School personnel do have a role in preventing a worsening of the child’s adjust-
ment by keeping him or her functioning academically as well as possible.
In addition, special services personnel may assist teachers and administrators to appreci-
ate that the child has problems that cannot be resolved in school yet can be managed in a
reasonable way in the classroom. Generally, with children experiencing this kind of crisis,
it is wise not to respond to the underlying problem. This in-depth treatment is a task for
professionals.
What can be done is to support the child’s attempts to respond to the stressful situation
as adaptively as possible. Whatever the child is doing in school that is appropriate and pro-
ductive can be acknowledged and encouraged. At the same time, the counselor can search
for ways to reduce stress, especially by eliminating any stressors that may be pushing the
child beyond his or her capacity to cope.
In addition, the counselor must look for ways to support other school staff and even
parents who will also undergo trauma when dealing with a psychopathological child. Con-
sultation skills and techniques are particularly valuable in this respect.
Psychiatric Emergencies
This sixth class consists of “crisis situations in which general functioning has been severely
impaired and the individual rendered incompetent or unable to assume personal respon-
sibility” (Baldwin, 1978, p. 547). Examples include children coming to school bent on
suicide, intoxicated with alcohol or drugs, reacting to hallucinogenic drugs, undergoing
acute psychoses, and expressing uncontrollable anger. These are all “classic” crises of the
type in which the individual is often dangerous to him- or herself or others.
The counselor’s efforts in this type of crisis are directed at assessing the danger by
attempting to learn the physical or psychiatric condition of the pupil. Counselors must
gather facts to clarify the situation so that they may take action quickly and appropriately.
Much of this information may need to be collected from persons other than the child.
The first principle in psychiatric crises is to intervene quickly so as to reduce danger and
ensure safety. The school professional must be willing to mobilize all medical or psychi-
atric resources necessary and thus must be familiar with state law and local community
8 Jonathan Sandoval
agencies. Prior to the need for such information, school practitioners should familiarize
themselves with community resources. Not only must they know about existing agencies,
but also they must learn the details of what services are offered and they must know the
key personnel to contact (Sandoval, 1985a).
Learning which pupils to refer to outside experts takes a novice a long time because
of the difficulty in evaluating one’s own competence and the problem of determining if a
referral has worked out. School practitioners must routinely review their cases with super-
visors and peers to develop their expertise.
Crisis Counseling and Intervention
Crisis Counseling Goals

One approach to considering the goals for work with children in crisis is to consider tasks
the children must accomplish if they are to manage the crisis situation successfully and
emerge intact. Moos and Schaefer (1986) identify five major adaptive tasks as follows.
1. Establish the meaning and understand the personal significance of the situation. The
child must come to view the event personally. He or she must realize all of the short-
and long-term ramifications of what has occurred and assign it a meaning. This mean-
ing will undoubtedly be limited by the child’s cognitive and emotional development.
2. Confront reality and respond to the requirements of the external situation. The child
must marshal resources in order to maintain his or her remaining social roles. The
victim still must go to school, play in the neighborhood, and be part of a family in
spite of the crisis.
3. Sustain relationships with family members and friends as well as with other individuals
who may be helpful in resolving the crisis and its aftermath. The child, particularly, must
depend on others for assistance in dealing with the crisis situation. The child must keep
lines of communication open to parents and friends and look to them for support. Where
adult authorities are involved, such as other school personnel, or medical or social agency
helpers, the child must be able to cooperate and use the assistance rendered.
4. Preserve a reasonable emotional balance by managing upsetting feelings aroused
by the situation. The powerful emotions stemming from a crisis must be mastered.
Through a combination of appropriate expression and the use of strategies to manage
or block the full impact of the event, children can achieve a sense of hope that will
enable them to continue functioning.
5. Preserve a satisfactory self-image and master a sense of competence. The child must
search for new roles in which to be competent or return to old arenas where he or
she has been successful in the past in order to achieve a sense of competence. Because
many crises threaten a sense of self, the individual must work particularly hard to find
compensating ways to feel good about the self.
Generic Counseling Principles

Given that crisis counseling is different from usual school counseling and has the aforemen-
tioned goals, it is useful to indicate a general strategy for helping people in a crisis situation.
What follows will be a generic model taken from the work of Lindemann (1944), Caplan
(1964), Rusk (1971), and others (see Brymer et al., 2006; Golan, 1978; Miller, 2012; Rob-
erts, 2000; or Slaikeu, 1990, for more exhaustive models). An individual counselor will
change and adapt these techniques depending on the type of crisis, the student’s age, and
the specifics of the type of crisis. Although I have outlined the principles in the general order
that they are applied in a crisis, they are not necessarily sequential in practice.
In working with a pupil in crisis:
1. Begin counseling immediately. By definition, a crisis is a time when a child is in danger

of becoming extremely impaired emotionally. The longer the pupil remains in a haz-
ardous situation and is unable to take action, the more difficult it will be to facilitate
coping and a return to equilibrium (Nadler & Pynoos, 1993). When a person remains
in a state of confusion without any kind of human support, anxiety and pain are sure
to result.
However, following a disaster, psychological counseling may not be appropriate
in the first month (Watson, Brymer, & Bonanno, 2011). Instead attending to safety
and comfort issues, and other practical life issues, should take precedence until the
child is settled.
2. Be concerned and competent. The pupil will need a certain amount of reassurance dur-
ing a crisis situation. The more the counselor can present him- or herself as a model
of competent problem solving and demonstrate the process of taking in information,
choosing between alternatives, and taking action, the more the child will be able to
begin to function appropriately. This higher functioning will come about both from a
sense of safety and security and from observing a clear model. The counselor does not
call attention to his or her competence but keeps it in the background as the counsel-
ing goes on. Competence is also enhanced by the counselor being sensitive to cultural
issues both in the child’s family and in the school as a whole.
3. Listen to the facts of the situation. Before proceeding, the counselor must carefully
gather information about the events leading up to the crisis, eliciting as many details as
possible. Not only will solutions come from these facts, but also concrete knowledge
of the situation will put the pupil’s behavior into perspective—is this child behaving
rationally or irrationally? Such a determination allows the counselor to judge the
severity of the crisis and to proceed accordingly.
4. Reflect the individual’s feelings. The counselor should explicitly focus the discussion
on the pupil’s affective experience and encourage its appropriate expression. The
objective here is not only to create empathetic understanding, but also to legitimize
affect. The child must learn that feelings can be discussed and are an important part
of problem solving. By reflecting feelings the counselor also “primes the pump” in that
it gives the counselee a way to begin and continue exploring what occurred. Reflect-
ing feelings is an important strategy to make psychological contact (Slaikeu, 1990).
Koocher and Pollin (1994) identify eight fears associated with a medical crisis that
must be expressed and dealt with: fear of loss of control, loss of self-image, depen-
dency, stigma, abandonment, isolation, death, and expressing anger.
5. Help the child realize that the crisis event has occurred. Do not accept the child’s
defensiveness or let the mechanisms of denial or other defensives operate and prolong
the crisis situation unnecessarily. Some denial may actually be coping, in that it gives
the child a chance to be desensitized to what has occurred. Prolonged or complete
denial may not lead to coping. Encourage the pupil to explore the crisis events without
becoming overwhelmed. By asking appropriate, well-timed questions, the counselor
can control the pace of exploration. Roberts (2000) suggests questioning to determine
previous coping methods and dangerousness or lethality.
6. Do not encourage or support blaming. This strategy also is a way of avoiding the
pupil’s defensiveness and of encouraging coping. If one can put blame aside, and
focus on what has occurred, the child may more quickly move on. Dwelling on being
10 Jonathan Sandoval
a victim leaves one in a passive position rather than moving on to an active role. The
focus should be shifted to self-esteem issues and internal strengths rather than remain-
ing oriented toward external causation and guilt.
7. Do not give false reassurance. The counselor should always remain truthful and realis-
tic, even though it is tempting to offer unrealistic comfort. The individual in crisis will
always suffer anxiety, depression, or tension, and the counselor must acknowledge
that the discomfort will probably continue for some time. At the same time, it is pos-
sible to provide some sense of hope and expectation that the person will ultimately
overcome the crisis. The counselor should be clear that there will always be scars and
tenderness resulting from a crisis. Nevertheless, the child or adolescent will be able to
get on with his or her life eventually, and may even develop new strengths.
8. Recognize the primacy of taking action. The individual will need real assistance in
accomplishing everyday tasks during the time of crisis. Every crisis counseling inter-
view should have as an ultimate outcome some action that the client is able to take.
Restoring the client to the position of actor rather than victim is critical to success,
because taking effective action helps to restore a sense of self.
Generic Crisis Intervention Principles

In addition to interviewing the child or counseling, the counselor also must take action
or intervene, with or without the participation of the person in crisis. These interventions
may be within or outside of the counseling setting. With younger children, particularly, it
will be expeditious to make changes in the environment, in the classroom or at home, to
reduce stress.
1. Facilitate the re-establishment of a social support network. If possible, get the child
to accept some help from others. It is usually possible to find either a group of peers
or family members who can provide emotional support and temporary physical assis-
tance during the crisis. In this way the pupil’s energies may be devoted to coping with
the crisis. If family is not available, there are often community resources available and
the counselor should be knowledgeable about them (Sandoval, 1985a).
2. Engage in focused problem solving. Once the counselor has been able to formulate an
accurate, comprehensive statement about the counselee’s perception of the situation
and identifying all of the sources of concern, it will be possible to begin the process of
exploring potential strategies to improve or resolve the emotionally hazardous situ-
ation. Jointly, the counselor and pupil review the strategies explored and select one
for trial. The outcome should be an action plan (Roberts, 2000). This is much like
the problem solving that occurs in other kinds of counseling but must be preceded by
the steps previously mentioned. Moving too quickly to problem solving is a common
mistake of novices (Egan, 1994). However effective the problem solution is, the very
process of turning attention to the future and away from the past, is beneficial in and of
itself. Some solutions may involve actions by others such as teachers or school admin-
istrators. To the extent necessary, the counselor may act as an intermediary communi-
cating with authorities on the child’s behalf.
3. Focus on self-concept. Any action strategies must be implemented in the context of
what the client thinks it is possible for him- or herself to accomplish. The crisis situ-
ation often leads to a diminution in self-esteem and the acceptance of blame for the
crisis. With an emphasis on how the person did cope well given the situation so far and
how the person has arrived at a strategy for moving forward, there can be a restora-
tion of the damaged view of the self. Counselors can emphasize what positive there is
in the situation, even if it seems relatively minor. Even the victim of a sexual assault
can be congratulated for at least surviving physically.
4. Encourage self-reliance. During the process of crisis counseling, the counselee will
have temporarily become dependent on the counselor for direct advice, for stimulat-
ing action, and for supplying hope. This is a temporary situation and before the crisis
intervention interviews are over, the counselor must spend some time planning ways to
restore the individual to self-reliance and self-confidence. Typically in counseling this
is done by the counselor consciously moving into a position equal with the counselee,
sharing the responsibility and authority. Although earlier the counselor has taken
charge, eventually he or she must return to a more democratic stance. Techniques
such as onedownsmanship, in which the counselor acknowledges the pupil’s contribu-
tion to problem solving while minimizing the counselor’s own contribution (Caplan,
1970), permit the counselee to leave the crisis intervention with a sense of accomplish-
ment. Helping individuals to find alternative rewards and sources of satisfaction (i.e.,
using problem-focused coping) is most helpful.
Although these principles may generally apply to all crisis counseling and intervention,
it is important to realize that there are specific techniques that are appropriate to a given
kind of crisis. Table 1.1 lists goals and general intervention techniques that seem most
appropriate for each of Baldwin’s crisis types.
Table 1.1 General Principles: Counseling Goal Interventions Particularly Relevant to Baldwin’s Six
Classes of Emotional Crisis
Crisis Type Goals General Intervention
1. Dispositional crises Confront reality • Provide information—educate

• Rule out hidden, serious emotional
implications
• Refer to expert
2. Anticipated life transitions Confront reality • Anticipatory guidance
• Provide support groups
3. Traumatic stress Establish meaning • Help client understand the impact
of what has occurred
Preserve emotional • Mobilize existing coping
balance mechanisms
Preserve self-image • Provide new coping mechanisms
4. Maturational/ Sustain relationships • Identify underlying issues
developmental crises • Support client in redefining relationships
and developing adaptive interpersonal
responses
5. Crisis reflecting Preserve self-image • Support attempts to respond to stressful
psychopathology situation as adaptively as possible
Confront reality • Find ways to reduce stress
• Refer to experts
• Do not respond to underlying problems
6. Psychiatric emergencies Preserve self-image • Intervene quickly to reduce danger
Establish meaning • Assess medical or psychiatric condition
• Clarify situation
• Mobilize all medical or psychiatric
resources necessary
Other chapters in this volume contain a number of specific ways to respond to a particular
hazardous event, such as the death of a parent. Because of the suddenness of circumstance
and limits of working in schools, often school counselors, school psychologists, and other
school-based mental health professionals will not be in a position to offer long-term care.
Instead, they are able to offer psychological first aid (PFA) until other community-based
professionals can take over. PFA is particularly applicable in cases of school violence or
disaster or other traumatic stresses. The foregoing counseling and intervention principles
are consistent with PFA as described by Slaikeu (1990) and Ruzek and colleagues’ (Ruzek
et al., 2007). An excellent field operations guide may be retrieved from the National Center
for PTSD (Brymer et al., 2006) [http://www.ncptsd.va.gov/pfa/PFA.html]. The concept of
PFA will be explored in Chapter 13, and Table 1.2 provides an overview of this approach.
The Counselor in Crisis

Not much has been written explicitly about the counselor’s feelings and adaptive behav-
ior at a time of crisis. However, it is clear that disaster workers such as firefighters are
Table 1.2 Overview of Psychological First Aid (Brymer et al., 2006; Ruzek et al., 2007)
Actions Goals Examples of Skill
Preparing to deliver To have both intellectual Entering the setting

psychological first aid skills to implement PFA and appropriately,
the emotional readiness to acknowledging culture
proceed Maintaining a professional
presence
Contact and engagement To make contact with Introducing self
survivors in a compassionate Discussing confidentiality
and helpful manner
Safety and comfort To provide physical and Ensuring physical safety
emotional comfort and safety Protecting from additional
trauma
Stabilization To calm and focus emotionally Listening empathetically
overwhelmed victims and Modeling calmness
survivors
Information gathering: To identify and address Eliciting concerns about
needs and current immediate needs and the future
concerns plan interventions Exploring loss and grief
Practical assistance To help survivors address Creating an action plan
identified needs and concerns Helping establish priorities
Connection to social To establish connections to Encouraging the use of
supports family, friends, and community immediately available
resources who can provide support persons
emotional and physical support Engaging in play, sports,
or other pleasurable activities
Information on coping To provide information about Explaining normal emotional
stress and coping that will help reactions to stress
survivors deal with the Teaching relaxation techniques
hazardous event
Linkage with To make appropriate referrals Exploring community
collaborative services to available services survivors resources
may need in the future Following up on referrals
adversely affected by responding to a crisis (Everly, Lating, & Mitchell, 2000). Those
responding to airline disasters seem to have a particularly difficult time, but all emer-
gency workers are subject to the same reactions as the victims of the crisis. They too
will exhibit symptoms of stress. Responses are individual and may not be apparent to
an observer or supervisor. Often witnessing the aftermath of a traumatic event can recall
a crisis worker’s own past experience of trauma and loss (e.g., Carroll, 1998). Training
and supervision permit the avoidance or diminution of countertransference while serv-
ing as a helper during a crisis.
In a sense, then, a crisis in a child is also a time of crisis for the counselor. Because
the event may have come up suddenly and unexpectedly and because the child’s prob-
lem may be quite serious, the counselor is likely to experience heightened anxiety and
momentary disorganization. A number of principles for the counselor’s behavior may
also be identified.
l. Remove distracters and other stressors acting on you. Set aside your other duties and
roles. Order your priorities and realize your limits. Give as much time as you can to
the crisis and put off what is not urgent.
2. Avoid impulsive action. You must act quickly but you should also take time to plan
in a time of crisis. Gather your thoughts and think through the possibilities prior to
seeing the affective parties in a crisis situation.
3. Delegate authority. The medical response to a crisis is the triage process. Not only
are the most important risks to the patient assessed and identified but also roles are
assigned to various medical personnel. In the schools, there is the ideal of the multi-
disciplinary team, and with effort it can be a reality. In times of crisis, by delegat-
ing authority among school psychologists, counselors, social workers, school nurses,
administrators, and teachers, there will be minimal duplication of effort and a greater
likelihood that professionals will be tackling those tasks they can do best.
4. Model calmness in a way consonant with your personality. Although Carl Rogers
(1957), for example, argues that the counselor should always be genuine and honest
with the client, there are times when such openness may not be in the best interest of
the client. If the counselor is overly upset and angry about the child’s predicament and
acts it out in front of the client, it may have the effect of getting in the way of emotion-
focused coping.
5. Be prepared. The Scout Motto is still valuable. The more one is informed about the
particular crisis the child is experiencing, the easier the process of working with him or
her will be. One aim of this book is to provide school psychologists and other school
personnel with the knowledge base to begin to work with the common crises they
will encounter. “Be prepared” has another meaning, however, and that is to anticipate
that various crises will occur and to expend some energy in planning and executing
prevention programs that will keep hazardous situations from developing into crises
for large numbers of children.
6. Seek supervision and debriefing. Poland and McCormick (1999) suggest that the crisis
caregivers may help themselves and others cope in the aftermath of a crisis: by knowing
oneself and respecting one’s limitations; by asking for special support from family; by
taking care of oneself physically, by supporting other members of that team; by using
humor; by recognizing that the crisis will impact oneself; and by talking to others.
The goal of a debriefing is to detect burnout among crisis workers and move toward
an individualized stress management intervention when it is detected. The debriefing
itself can provide emotion-focused coping, in that it permits the expression of ideas
and emotions in a psychologically safe environment.
Prevention Programs
Many of the early pioneers in crisis intervention (e.g., Caplan, 1961; Klein & Lindemann,
1961) came from a background in public health and stressed the prevention of crises.
The public health model conceptualizes three levels of prevention (Bower, 1965): primary
prevention or universal prevention, which is directed at the population at large; second-
ary prevention or selective level, which is directed at identifiable vulnerable groups; and
tertiary prevention, which aims to reduce the impact of a condition for individuals through
treatment and rehabilitation. These levels have been adapted, with a change in terminol-
ogy (Tier 1, 2, and 3), in the RTI movement (Shinn & Walker, 2010).
At least five general strategies have been used in the schools to prevent various kinds of
crises from occurring. They are educational workshops, anticipatory guidance, screening,
consultation, and research (Sandoval, 1985b).
Educational Workshops and Programs

An educational workshop is a short, intensive course of study on a topic that generates
feelings and emotions. As a result, workshops emphasize student participation and discus-
sion. It is preventive to the extent that the topic of the workshop is intended to forestall
future mental health problems. A number of programs exist for children under the general
heading of psychological education. Programs, such as classroom meetings (Edwards &
Mullis, 2003) and others (Miller, 1976), help children express their feelings about what
is occurring in the social environment of the classroom, and attempts to free them from
the anxiety that may occur from crises that may develop in the classroom. Others have
pointed out the value of a psychologist’s role in all curriculum designs (e.g., Jones, 1968)
because so many school subjects can bring up unpleasant emotions. Specific curriculum
materials have been developed on topics such as death, dying, suicide, and illness, as
pointed out in later chapters in this book. An example is Family and Schools Together, a
program designed to bolster family functioning and reduce risk of school failure, violence,
delinquency, and substance abuse (Crozier, Rokutani, Russett, Godwin, & Banks, 2010).
Anticipatory Guidance and Emotional Inoculation

The second technique, anticipatory guidance, also has a variant called emotional inocula-
tion. Offering anticipatory guidance consists of orienting a student intellectually to events
that are likely to occur in the future and helping him or her prepare effective coping strate-
gies. Emotional inoculation puts the emphasis on future feelings and emotions rather than
on the cognitive. Events in question are ones that experience has shown are difficult for
individuals to cope with and may influence educational performance, such as reminders
of loss. Examples of anticipatory guidance are programs that are designed to help children
adjust to new institutional settings, or programs that inform students as to what can be
expected, both intellectually and emotionally, when a new sibling is born. An example of
emotional inoculation is helping an adolescent anticipate the grieving process after the
death of a significant person.
Screening Programs
A third preventive technique involves setting up procedures to identify children who are vul-
nerable to particular hazardous situations so that they might receive special assistance at the
appropriate time. Screening programs consist of designing means (usually questionnaires,
rating scales, or group tests) to determine who is at a high risk of not coping. The follow-up
intervention might be anticipatory guidance, a workshop, a special remediation program,
or preventive counseling.
Screening has been particularly effective in identifying children who are at risk of edu-
cational failure, but it is conceivable that screening could be designed to identify children
who are also at risk for other kinds of crises. An example would be an effort to learn which
families, in the near future, plan to enlarge their numbers so that children might be identi-
fied for workshops designed to facilitate the adjustment to a new sibling.
Consultation
Serving as a consultant is another important way that school psychologists and other spe-
cial services personnel can act preventively in crises. Consultation is defined as one profes-
sional helping a second professional be more effective in his or her job (Caplan, 1970). In
this context, a consultant is defined as a special services worker collaborating with teach-
ers, administrators, or parents to help them deal more effectively with the child or teacher
in crisis. By working with teachers, and possibly with parents, a mental health professional
can help these key adults support children when they become involved in a crisis situation
and be sensitive to the various emotional needs a child may have during times of crisis.
Research
Doing research is not usually conceived of as a preventive activity. Nevertheless, the more
that is known about a phenomenon through research, the better able we are to predict and
control that phenomenon. The more we understand about crises, the more effective we
will be in creating workshops, educational curriculum, anticipatory guidance programs,
screening programs, and consultation interventions. Evaluative and case study research on
crises and crises intervention programs is within the capability of the school psychologist
and school counselor and should be thought of as important preventive activities.
Developmental Issues in Crisis Counseling

A number of texts on counseling, even texts focusing solely on counseling children, ignore
an important point. A child of 5 and an adolescent of 16 have radically different faculties
for dealing with information and reacting to events. Differences in cognitive, social, and
emotional development mean that they will respond differently to hazards and will need
to be counseled differently should they develop a crisis reaction. The same event, the death
of a parent, for example, may be a crisis for a preschooler as well as a high school senior,
but each will react and cope with the event differently. Counseling with younger children
often involves the use of nonverbal materials, many more directive leads in order to elicit
and reflect feelings, and a focus on concrete concerns as well as fantasy.
Traditional talk therapies, such as nondirective counseling, capitalize on a client’s capac-
ity for rational thought and high level of moral development and are more likely to be
effective with adolescents. With adolescents, the crisis worker can also acknowledge and
use the age-appropriate crisis of establishing an identity.
In reviewing the generic crisis counseling principles just outlined, it seems reasonable to
expect that younger children would have a greater difficulty acknowledging a crisis, and
would be more prone to use immature defenses such as denial and projection to avoid
coping with a crisis. In contrast, an adolescent might use more advanced defenses such as
rationalization and intellectualization. In counseling children, more time might be spent
on exploring reactions and feelings to the crisis situation and establishing support systems
that engage in lengthy problem solving. With older adolescents, then, it may be possible to
focus much more on establishing reasonable expectations and avoiding false reassurance,
as well as spending more time on focused problem-solving activities. These developmental
issues will be explored in more depth in the following chapters.
Conclusion
School-based mental health workers have a powerful role to play in helping children
cope with and regain equilibrium after a crisis response to a hazardous situation. Adding
together exemplars of Baldwin’s six classes of crisis yields a large number of events that
occur in the school-age population and that undoubtedly interfere with the effective learn-
ing of children in schools. The techniques and theories of crisis counseling have a relatively
short history of being applied and evaluated. Much of what is done with a child in crisis
depends on what kind of crisis it is, the age of the child, the time available to the coun-
selor, and the counselor’s skills. To be efficient, group interventions that are preventive in
nature may be necessary to cope with the strong need for crisis counseling in the schools.
The remainder of this book, following a discussion of the preparation for crises and the
role of culture, deals with crisis counseling and intervention in particular kinds of situa-
tions. School psychologists and others in the schools can have an enormous impact on the
mental health of children if they are aware of the many hazards in children’s lives and are
able to act immediately in helping students develop positive coping responses to avoid or
mitigate a crisis response. Children may regain equilibrium, not lose precious time away
from learning to emotional disorganization, and possibly even develop successful new
coping strategies as a result of successfully passing through a crisis. They will be able to
face emotional hazards throughout their lifetimes with a greater degree of confidence and
success. If we are successful in developing our crisis counseling and intervention skills, and
in implementing prevention programs, future children surely must benefit.
REFERENCES
Aguilera, D. C. (1998). Crisis intervention: Theory and methodology (8th ed.). St. Louis, MO: Mosby.
Baldwin, B. A. (1978). A paradigm for the classification of emotional crises: Implications for crisis
intervention. American Journal of Orthopsychiatry, 48, 538–551.
Beers, T. M. Jr., & Foreman, M. E. (1976). Intervention patterns in crisis intervention. Journal of
Counseling Psychology, 23, 87–91.
Bellak, L., & Small, L. (1978). Emergency psychotherapy and brief psychotherapy (2nd ed.). New
York: Grune & Stratton.
Benjamin, A. (1981). The helping interview (3rd ed.). Boston: Houghton Mifflin.
Bernard, B. (1992). Fostering resiliency in kids: Protective factors in the family, school, and commu-
nity. Prevention Forum, 12(3), 1–16.
Bower, E. M. (1965). Primary prevention of mental and emotional disorders: A frame of reference.
Mental Health Monograph, 5 (The Protection and Promotion of Mental Health in Schools).
Bethesda, MD: U.S. Department of Health, Education, and Welfare.
Brenner, A. (1984). Helping children cope with stress. Lexington, MA: D.C. Heath.
Brock, S. E., Nickerson, A. B., Reeves, M. A., Jimerson, S. R., Feinberg, T., & Lieberman, R. (2009).
School crisis prevention and intervention: The PREPaRE model. Bethesda, MD: National Asso-
ciation of School Psychologists.
Brock, S. E., Sandoval, J., & Lewis, S. (2001). Preparing for crises in the schools (2nd ed.). New
York: John Wiley.
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., . . . Watson, P. (2006). Psy-
chological first aid: Field operations guide (2nd ed.). National Center for PTSD. Retrieved from
http://www.ncptsd.va.gov/pfa/PFA.html
Burgess, A. W., & Baldwin, B. A. (1981). Crisis intervention theory and practice. Englewood Cliffs,
NJ: Prentice Hall.
Caplan, G. (1961). An approach to community mental health. New York: Grune & Stratton.
——— (1964). Principles of preventative psychiatry. New York: Basic Books.
——— (1970). Theory and practice of mental health consultation. New York: Basic Books.
Carroll, S. (1998). Crisis and counter-transference: Caretaking the caretaker. National Association
of School Psychologists Communique, 27(3), 28–29.
Crozier, M., Rokutani, L., Russett, J. L., Godwin, E., & Banks, G. E. (2010). A multisite program
evaluation of families and schools together (FAST): Continued evidence of a successful multifam-
ily community-based prevention program. The School Community Journal, 20(1), 187–207.
Davanloo, H. (1978). Basic principles and techniques in short-term dynamic psychotherapy. New
York: Spectrum.
Doll, B., Zucker, S., & Brehm, K. (2004). Resilient classrooms: Creating healthy environments for
learning. New York: Guilford.
Edwards, D., & Mullis, F. (2003). Classroom meetings: Encouraging a climate of cooperation. Pro-
fessional School Counseling, 7, 20–28.
Egan, G. (1994). The skilled helper (5th ed.). Pacific Grove, CA: Brooks/Cole.
Eisenberg, N., & Silver, R. C. (2011). Growing up in the shadow of terrorism: Youth in America
after 9/11. American Psychologist, 66, 468–481. doi: 10.1037/a0024619
Erikson, E. (1962). Childhood and society (2nd ed.). New York: W. W. Norton.
Everly, G. S., Lating, J. M., & Mitchell, J. T. (2000). Innovations in group crisis intervention. In A.
R. Roberts (Ed.), Crisis intervention handbook: Assessment, treatment and research (pp. 77–94).
New York: Oxford University Press.
Fassler, J. (1978). Helping children cope. New York: Free Press.
Fletcher, K. E. (2003). Childhood posttraumatic stress disorder. In E. J. Mash & R. A. Barkley
(Eds.), Child psychopathology (2nd ed., pp. 330–371). New York: Guildford Press.
Fuller, G. B. (2007). Reality therapy approaches. In H. T. Prout & D. T. Brown (Eds.), Counseling
and psychotherapy with children and adolescents: Theory and practice for school and clinical set-
tings (4th ed., pp. 332–387). Hoboken, NJ: Wiley.
Golan, N. (1978). Treatment in crisis situations. New York: Free Press.
Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., . . . Ursano, R.
J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical
evidence. Psychiatry, 70, 283–315. doi:10.1521/psyc.2007.70.4.283
Jones, R. M. (1968). Fantasy and feeling in education. New York: New York University Press.
Klein, D. C., & Lindemann, E. (1961). Preventive intervention in individual and family crisis situ-
ations. In G. Caplan (Ed.), Prevention of mental disorders in children (pp. 283–306). New York:
Basic Books.
Koocher, G. P., & Pollin, I. (1994). Medical crisis counseling: A new service delivery model. Journal
of Clinical Psychology in Medical Setting, 1, 291–299.
Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psy-
chiatry, 101, 141–148.
Miller, G. (2012). Fundamentals of crisis counseling. Hoboken, NJ: Wiley.
Miller, J. P. (1976). Humanizing the classroom. New York: Praeger.
Moos, R., & Billings, A. (1984). Conceptualizing and measuring coping resources and processes.
In L. Goldberger & S. Breznitz (Eds.), Handbook of stress: Theoretical and clinical aspects (pp.
109–145). New York: Macmillan.
Moos, R. H., & Schaefer, J. A. (1986). Life transitions and crises: A conceptual overview. In R. H.
Moos & J. A. Schaefer (Eds.), Coping with life crises: An integrated approach (pp. 3–28). New
York: Plenum.
Nader, K., & Pynoos, R. (1993). School disaster: Planning and initial interventions. Handbook of
post-disaster interventions. Journal of Social Behavior and Personality, 8, 299–320.
Poland, S., & McCormick, J. S. (1999). Coping with crisis: Lessons learned. Longmont, CO: Sopris
West.
Pynoos, R. S. (1994). Traumatic stress and developmental psychopathology in children and adoles-
cents. Lutherville, MD: Sidran Press.
Roberts, A. R. (2000). An overview of crisis theory and crisis intervention. In A. R. Roberts (Ed.),
Crisis intervention handbook: Assessment, treatment and research (pp. 3–30). New York: Oxford
University Press.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change.
Journal of Consulting Psychology, 21, 95–103.
Ross-Reynolds, G., & Hardy, B. S. (1985). Crisis counseling for disparate adolescent sexual dilem-
mas: Pregnancy and homosexuality. School Psychology Review, 14, 300–312.
Rusk, T. N. (1971). Opportunity and technique in crisis psychiatry. Comprehensive Psychiatry, 12,
249–263.
Ruzek, J. I., Brymer, M. J., Jacobs, A. K., Layne, C. M., Vernberg, E. M., & Watson, P. J. (2007).
Psychological first aid. Journal of Mental Health Counseling, 29, 17–49.
Sandoval, J. (1985a). Notes on teaching school psychologists about community resources and agen-
cies. Trainers’ Forum, 5(2), 1–4.
Sandoval, J. (Ed.). (1985b). Mini-series on crisis counseling in the schools. School Psychology
Review, 14, 255–324.
Selye, H. (1974). Stress without distress. New York: New American Library.
Shinn, M. R., & Walker, H. M. (Eds.). (2010). Interventions for achievement and behavior problems
in a three-tier model including RTI. Bethesda, MD: National Association of School Psychologists.
Slaikeu, K. A. (1990). Crisis intervention: A handbook for practice and research (2nd ed.). Needham
Heights, MA: Allyn & Bacon.
Smith, L. L. (1990). Crisis intervention: Theory and practice. In J. E. Mezzich & B. Zimmer (Eds.),
Emergency psychiatry (pp. 305–331). Madison, CT: International University Press.
Stocking, S. H., Arezzo, D., & Leavitt, S. (1980). Helping kids make friends. Niles, IL: Argus Com-
munications.
Watson, P. J., Brymer, M. J., & Bonanno, G. A. (2011). Postdisaster psychological intervention since
9/11. American Psychologist, 66, 482–494. doi:10.1037/a0024806
Werner, E. (1989). High-risk children in young adulthood: A longitudinal study from birth to 32
years. American Journal of Orthopsychiatry, 59, 72–81.
Young, M. A. (1998). The community crisis response team training manual (2nd ed.). Washington,
DC: National Organization for Victim Assistance.
2 Preparing for the School Crisis Response
Stephen E. Brock
It is not a question of if, but rather of when a school will be required to respond to a crisis.
For example, it is impossible to prevent natural disasters such as hurricanes, tornadoes,
earthquakes, and floods. In addition, while much can be done to prevent other types of
crises, such as school violence, it seems unlikely that we can prevent all such events. Conse-
quently, school crisis response preparedness is required (Brock, Sandoval, & Lewis, 2001).
While it is next to impossible to prepare for all contingencies, school crisis response
preparedness places schools in the best possible position to respond to crisis events. The
importance of this preparedness is reinforced by the fact that school crisis response is mul-
tidisciplinary. As illustrated in Figure 2.1, which employs the U.S. Department of Home-
land Security’s (2008) Incident Command System (ICS), school crisis response includes a
number of different individuals filling a number of different roles. Response planning helps
to ensure that each of these individuals knows what to do in times of crisis and that there
is little delay in the provision of crisis services.
In the pages that follow, this chapter will review activities that my experiences have
found to be important to school crisis response preparedness. They include (a) obtaining
Incident Commander
(e.g., administration)
Command Staff
Public Information Officer
Safety Officer
Liaison Officer
(Thinkers) (Doers) (Getters) (Payers)

Planning Operations Logistics Finance/Administration
Section Section Section Section
Medical Support Service Branch

(e.g., nursing) (e.g., food services)
General Staff Mental Health Support Branch

(e.g., counseling) (e.g., custodial)
Security
(e.g., security)
Figure 2.1 Incident Command System roles (as specified by the National Incident Management
System).
20 Stephen E. Brock
necessary crisis response background knowledge, (b) developing crisis response teams,
(c) establishing crisis response planning, and (d) refining crisis response procedural guidelines.
These activities have previously been documented in detail elsewhere (Brock, Jimerson, &
Hart, 2006; Brock, Nickerson, Reeves, & Jimerson, 2008; Brock et al., 2009; Brock &
Poland, 2002; Brock et al., 2001). For additional information regarding these activities the
reader may consult these publications.
Obtaining Background Knowledge

A prerequisite to school crisis response preparedness is the acquisition of necessary back-
ground knowledge. For example, it is important for the crisis response planner to have
an understanding of what the crisis response involves and what situations may require its
use. In addition, it is critical to know the defining characteristics of the person in crisis
and to understand how to provide crisis services. This section will review three specific
educational activities that I have found to be productive.
Literature Review
A primary strategy for obtaining crisis response background knowledge is to review the
available literature. Journal articles are often a valuable source of information, and my
review of this source has located several recent articles that do an excellent job of describ-
ing school crisis preparedness and response. These include Brock (2000); Crepeau-Hobson
and Summers (2011); Hatzichristiou, Issari, Lykitsakou, Lampropoulou, & Dimitropou-
lou (2011); and Nickerson, Brock, and Reeves (2006).
In addition to journal articles, there is an ever-growing library of school crisis response
books. The first edition of the current volume, for example, was one of the first books
devoted specifically to the school crisis response (Sandoval, 1988). In addition to the cur-
rent volume, other recently published books that provide a comprehensive review of the
school crisis response are Brock and Jimerson (in press), Brock et al. (2009), and Reeves,
Kanan, and Plog (2010).
Training Programs
A powerful complement to independent literature reviews is participation in a crisis interven-
tion and response training program. In the time since the publication of this book’s second
edition, a training program designed by and for school-based professionals has been devel-
oped. In this section brief descriptions of the National Association of School Psychologists’
(NASP) PREPaRE School Crisis Prevention and Intervention Training Curriculum (Brock
et al., 2009) are offered. In addition, a discussion of an initial PREPaRE program evalua-
tion is provided. As presented on the NASP web site, Table 2.1 provides a description of the
PREPaRE curriculum, and the next two sections offer more detail about its core workshops.
Crisis Prevention & Preparedness: Comprehensive School Safety Planning (Reeves et al.,
2006; 2011). Recently revised, the second edition of this 1-day PREPaRE workshop pro-
vides an overview of the school safety/crisis team’s roles and responsibilities, with a special
emphasis on prevention and preparedness. Participation in this session provides the knowl-
edge and resources needed to help establish and maintain comprehensive school safety/cri-
sis teams. Also referred to as “Workshop 1,” this session makes a clear connection between
ongoing school safety and crisis preparedness efforts, and is appropriate for anyone who
wants to understand how the multidisciplinary comprehensive school crisis team is orga-
nized and functions.
Preparing for the School Crisis Response 21
Table 2.1 The NASP PREPaRE Curriculum
PREPaRE provides educational professionals training on how to best fill the roles and responsibili-
ties generated by their participation on comprehensive school crisis teams. PREPaRE is one of the
first comprehensive, nationally available training curriculum developed by school-based profession-
als with firsthand experience and formal training. The curriculum is based on the assumptions that:
• the skill sets of school-based professionals are best utilized when they are embedded within a
multidisciplinary team that engages in crisis prevention, preparedness, response, and recovery;
• school crisis management is relatively unique and as such requires its own conceptual model;
and
• by virtue of their professional training and job functions, school-based mental health profes-
sionals are best prepared to address the psychological issues associated with school crises.
Specifically, the PREPaRE model emphasizes that, as members of a school crisis team, school men-
tal health professionals must be involved in the following specific hierarchical and sequential set of
activities:
• P—Prevent and PREPaRE for psychological trauma
• R—Reaffirm physical health and perceptions of security and safety
• E—Evaluate psychological trauma risk
• P—Provide interventions
• a—and
• R—Respond to psychological needs
• E—Examine the effectiveness of crisis prevention and intervention
The model also incorporates foundation knowledge provided by the U.S. Departments of Educa-
tion and Homeland Security. Specifically, the PREPaRE curriculum describes crisis team activities
as occurring during the four states of a crisis: (a) prevention, (b) preparedness, (c) response, and
(d) recovery. It also incorporates the incident command structure as delineated by the National
Incident Management System (NIMS).
Adapted from NASP (2011).
Crisis Intervention & Recovery: The Roles of School-Based Mental Health Profession-
als (Brock, 2006, 2011). Also recently revised, the second edition of this 2-day PREPaRE
workshop provides a focused examination of school-based mental health professionals’
roles and responsibilities, with a special emphasis on intervention and recovery. Participa-
tion in this session provides the knowledge and facilitates attainment of the skills needed
to provide crisis intervention assistance. Also referred to as “Workshop 2,” this session
provides guidance on how to (a) mitigate the impact of crisis, (b) reaffirm both physical
health and students’ perception that they are safe and secure, (c) evaluate degree of psy-
chological trauma, (d) respond to psychological needs, and (e) examine the effectiveness
of intervention and recovery efforts.
Initial Evaluations of PREPaRE. Recently, Brock, Nickerson, Reeves, Savage, and Woi-
taszewski (2011) investigated initial participant satisfaction, as well as the workshops’
effects on attitudes and knowledge. From an examination of the workshop evaluations and
pre- and posttests for approximately 1,000 workshop participants, it was suggested that
both workshops have a high degree of consumer satisfaction. In addition, when compared
to preworkshop attitudes, Workshop 1 participant responses indicated significant increases
in perceived crisis prevention and preparedness knowledge, confidence in the ability to col-
laborate with others to develop a crisis plan, enthusiasm about such collaboration, as well
as perceived importance of school crisis prevention and preparedness knowledge and skills.
For Workshop 2 participants, significant decreases in anxiety about providing crisis inter-
vention, fearfulness they might make a crisis intervention mistake, and increased confidence
in knowing what to do when asked to be part of a crisis team were documented.
22 Stephen E. Brock
Brock et al. (2011) also documented significant increases in workshop participants’ cri-
sis prevention, preparedness, intervention, and recovery knowledge. For Workshop 1 the
mean pretest score was 5.25 out of 10 and the mean posttest score was 8.79 out of 10,
which was a significant increase. For Workshop 2 the mean pretest score was 1.35 out of
5 and the mean posttest score was 3.80 out of 5, which was also a significant increase.
Finally, Brock et al. (2011) conducted a qualitative analysis of the open-ended ques-
tions employed by the workshop evaluation forms. From this analysis it was found that
29% of these written comments expressed appreciation for the curriculum’s active training
component (e.g., role playing, discussion), and 24% expressed appreciation of workshop
materials (24%). While 22% of these comments addressed the need for workshop format
adjustments, 15% specifically stated that nothing needed to be improved.
Internet Resources
Another resource for obtaining background knowledge is the Internet. While by far not
an exhaustive review of these resources, this section offers several web sites that I have
found to be helpful.
U.S. Department of Education (DoE). The Emergency Planning page of the DoE offers a
number of resources that can be helpful in preparing for the school crisis response (http://
www2.ed.gov/admins/lead/safety/emergencyplan/index.html). Among the many resources
available on this webpage are a planning guide (“Complete Crisis Planning Guide for
Schools and Communities,” U.S. DoE, 2007), and examples of promising practices in
school emergency response.
Federal Emergency Management Agency (FEMA). The FEMA “Ready” web site
includes a number of resources that can assist in crisis response planning (http://www.
ready.gov/). These include guidance on what to do before, during, and after an emer-
gency, how to make a crisis plan, and how to make a kit for disaster preparedness. Its
NIMS (National Incident Management System) Resource Center (http://www.fema.gov/
emergency/nims/) provides a number of resources for better understanding the NIMS and
its ICS. A special section of this webpage is devoted to the preparedness of children (http://
www.ready.gov/kids).
National Association of School Psychologists (NASP). The NASP School Safety and
Crisis Resources webpage includes a number of documents that can be helpful in pre-
paring for and responding to school-associated crisis events (http://www.nasponline.org/
resources/crisis_safety/index.aspx). Specific topics addressed include school safety and
violence prevention, suicide prevention and intervention, crisis response, media, trauma,
natural disasters, and war and terrorism. In addition, this page includes links to NASP’s
PREPaRE curriculum and its National Emergency Assistance Team (which offers direct
and indirect crisis response support).
The National Child Traumatic Stress Network (NCTSN). The NCTSN provides several
links to resources important to understanding, preventing, and responding to childhood
psychological trauma (http://nctsn.org/). Among its resources are guidance and tools for
responding to terrorism and disasters, a learning center for child and adolescent trauma,
and guidance on understanding child traumatic stress.
Building Crisis Response Teams

From guidance offered by Brock (2000), Brock et al. (2001), and Brock et al. (2009)
this section offers an examination of how to build a comprehensive school safety/crisis
response team. Although each of the team building activities discussed in this section is
essential to the comprehensive school crisis response, obtaining administrative support is
a prerequisite to system-wide crisis preparedness. Thus, while all of the activities described
in this section may occur simultaneously, this action is described first.
Obtaining Administrative Support

If the crisis response planning effort is a “top-down” effort (i.e., it is initiated by school
administration), then this step will be relatively straightforward. It will require adminis-
tration to be aware of the factors important to the initiation and implementation of any
school change effort. On the other hand, if the crisis response planning effort is a “bottom-
up” effort (i.e., it is initiated by individuals without administrative authority), then obtain-
ing administrative support will be more involved.
When nonadministrative personnel initiate crisis response planning, I recommend as a
first step the formation of a School Safety or Crisis Response Planning Committee (CRPC;
Brock, 2000). This committee should be representative of the district or the school(s)
within which the planning is to take place. CRPC efforts should focus on obtaining and
disseminating the knowledge needed to undertake crisis response planning, and then begin
to develop a rough outline of a crisis preparedness procedure. At this point the committee
will find itself in a position to approach school and/or district administration regarding
the desire to institutionalize crisis response planning.
My experience (Brock, 2000) suggests that it may not be surprising to find some admin-
istrations cool to this type of planning. There are many competing demands placed on
today’s schools. This fact combined with the unpleasant feeling generated by considering
traumatic circumstances may understandably generate resistance to crisis planning. My
advice in such a situation is to not let this resistance get in the way of planning. As with any
school change effort, timing is critical to the initiation of school crisis response prepared-
ness. There will come a time in the life of every school and school district when it is more
receptive to crisis preparedness. Unfortunately, this is often immediately after a significant
crisis event (Brock, 1994).
Defining Crisis Response Roles and Responsibilities

An essential crisis response team-building activity is to define specific crisis response roles
(Brock et al., 2001). Making use of the U.S. Department of Homeland Security’s (2008)
ICS, I recommend that individuals be identified as responsible for each of the roles specified
in Figure 2.1. Recommended team roles include the following: incident commander (and as
indicated a command staff), an operations section chief, a planning section chief, a logistics
section chief, and a finance/administration section chief.
Incident Commander. This individual should be an administrator or administrative des-
ignee (Purvis, Porter, Authement, & Boren, 1991). It is the first of five major functions
of the ICS and is the only one that is always staffed. This individual sets team objectives,
strategies, and priorities, and has overall responsibility for a crisis response. Following a
major (or mass) disaster this individual may activate a command staff. As illustrated in
Figure 2.1, this may include a public information officer (who coordinates communication
with parents and the media), a safety officer (who ensures crisis response team safety), and
a liaison officer (who is the primary contact for other agencies that are assisting in the crisis
response; Reeves et al., 2011).
Operations Section Chief. This individual directs all responses or tactical actions, and
is the person who has the greatest expertise in dealing with the given crisis situation. In
a health-related crisis it may be a school nurse, whereas in other types of crises wherein
24 Stephen E. Brock
the primary negative consequence is emotional distress the operations section chief may
be a school psychologist, school social worker, or counselor. Following a major (or mass)
disaster this individual may activate an operations section. As illustrated in Figure 2.1, this
section may require the services of several different individuals, including health, mental
health, and security personnel. The major activities of this section include developing
and implementing the strategies and tactics to address incident objectives; organizing,
assigning, and supervising response resources; managing staging areas (e.g., parent/student
reunification, media, medical triage areas); and organizing medical and mental health sup-
port for crisis victims (Reeves et al., 2011).
Planning Section Chief. This individual is responsible for the collection, evaluation,
and dissemination of crisis intelligence and information. He or she prepares action plans,
tracks the resources being used in a crisis response, documents the response, and develops
demobilization plans (Reeves et al., 2011).
Logistics Section Chief. This individual will be a part of a crisis response on an as-needed
basis, and helps to ensure that necessary resources (e.g., personnel, supplies, and equip-
ment) required to respond to the crisis are available. As illustrated in Figure 2.1, this section
may require the services of several different individuals, including custodial and cafeteria
workers. The activities of this section may include ordering, obtaining, and accounting for
essential personnel, equipment, and supplies; as well as providing communication resources,
food services, transportation, and medical services (to response personnel). Obviously, this
section will need to work closely with the finance/administration section chief to authorize
the funds needed to obtain crisis response resources (Reeves et al., 2011).
Finance/Administration Section Chief. This individual will be a part of a crisis response
on an as-needed basis, and provides any needed incident-specific financial management.
The activities of this section may include contract negotiation and monitoring, and cost
analysis. This is an especially critical function if the crisis qualifies for state or federal
emergency assistance (Reeves et al., 2011).
Defining Crisis Response Teams

In addition to identifying individual crisis response roles and responsibilities, crisis response
planning should also identify institutional roles and responsibilities. As I have conceptual-
ized, doing so involves the delineation of crisis response “levels” (Brock et al., 2001; Brock
et al., 2009). Specifically, it is recommended that a school crisis response plan make use of
multiple hierarchical teams.
School-Based Teams. The primary crisis response team is the school site-based team.
This team should be composed of school site personnel, with individuals designated to fill
each crisis response team role listed earlier. My experiences have found that well-prepared
school resources are typically able to manage most crisis situations independently. The
importance of the school-level response is highlighted by the fact that it can be very reas-
suring to students and parents to see familiar school staff members responding to a crisis
situation. Conversely, it can increase perceptions of threat and danger if the crisis response
team is composed of individuals not identified as being a part of the school community.
Such a response will communicate that the crisis event was so severe that school resources
are unable to manage the crisis (Brock et al., 2001). Of course, it needs to be recognized
that some crisis events are so severe that they will overwhelm available school site-level
crisis response resources (Brock et al., 2009). Because of this possibility it is essential to
have multiple hierarchical crisis response teams.
District Teams. If school site-level resources are unable or insufficient to independently
manage a crisis situation, then assistance from a school district-level crisis response team
should be made available. It is important to note that involvement of district-level resources
in a school crisis response should not be viewed as excusing site-level teams from the crisis
response. No one will know a school’s population better than those individuals who work
there regularly. Thus, site-level personnel will be critical to the successful implementation
of any district-level crisis response.
I recommend that the district-level team be similar in structure to school site-level teams
and make use of the ICS. However, on this district-level team, personnel will typically fill
most of the crisis response roles. In addition, it is expected that district-level team mem-
bers will have greater crisis response expertise than their site-level counterparts. Thus,
although the school site-level response is suggested to be preferable, consultation with the
district-level team should always be encouraged. Finally, because of their typically greater
expertise, a district-level team may play an important role in providing the training and
supervision needed to develop effective school site-level teams.
Regional Teams. Although it would be used infrequently, a regional-level crisis response
team is also recommended. My experiences have found this level of crisis response to be
critical following mass disasters (e.g., the Stockton school yard shooting, which left five
students dead and 30 wounded; Stockton Record, 2009). Having local school districts
enter into mutual aid agreements facilitates the establishment of such a team. These agree-
ments allow districts to share emergency response resources and might be considered an
insurance policy—a policy that a school district purchases by agreeing to send its own
trained staff to other school districts following mass disasters (Brock, 1998, 1999, 2001;
Brock et al., 2009). Also important in the development of a regional-level crisis response
team would be the identification and/or development of community resources (e.g., com-
munity mental health) that are available to assist schools after a crisis. Of course, any
agreements would have to be worked out with these resources in advance.
A regional-level team should be similar in structure to the school site-level team and
should employ the ICS. While a regional-level crisis response will be a very infrequent occur-
rence, this team may take on important crisis response preparedness responsibilities. Given
that it is likely this team will have access to the most highly trained local crisis responders,
the regional team is in a position to provide regional crisis response training programs.
Developing Crisis Response Plans

As conceptualized by my colleagues and myself (Brock et al., 2009), the development of
crisis response plans should include procedures for designating specific individuals to fill
the specific crisis response roles and ensuring that the resources needed to fill these roles are
available. In addition, the crisis plan should include several specific crisis response protocols.
Designating ICS Responsibilities and Identifying Resources

Once crisis response roles (see Figure 2.1) and responsibilities have been developed, this
procedure will be relatively straightforward. The crisis plan will need to document which
individuals have been designated to fill ICS roles. Alternates for these roles must also be
identified to address the contingency of a crisis response team member being unavailable.
Further, it will be important to ensure that the listing of individuals filling crisis response
team roles is updated at least annually. Doing so accounts for the fact that individuals may
move or decide they no longer wish to be a part of the crisis response team. For a listing of
additional ICS equipment and materials the reader is referred to Brock et al. (2009, p. 58).
In addition to assigning ICS roles, another important crisis planning issue is to ensure
that the materials and supplies needed to fill these roles are available. For example, a
26 Stephen E. Brock
central location from which the crisis response team will operate needs to be identified,
and should be equipped with computers, telephones, paper, pens, telephone directories,
emergency power, and portable two-way radios. Many times this base of operations will
be the school office.
Crisis Preparedness Protocols

Crisis plans need to have in place several important response protocols. These protocols,
as identified by Brock et al. (2009), are described below.
Student Evacuation and Assembly. Some crisis events (e.g., severe weather, bomb
threats) may require students be evacuated to student assembly areas within or outside
of the school. Important considerations when developing this protocol include selection
of specific evacuation sites and the special transportation needs of students with disabili-
ties. To facilitate evacuations it is important that schools develop crisis response boxes
(also known as “go kits”). A helpful aid in the development of such boxes is the Califor-
nia Department of Education’s Crisis Response Box (Lockyer & Eastin, 2000). This box
should contain all of the documents and materials developed by team members as part of
their crisis preparedness activities (e.g., psychological triage or risk screening materials; a
list of mental health referral resources; prepared statements; evacuation, bomb threat, and
traffic management procedures; medical first aid materials; crisis response team identifica-
tion badges, etc.). Other materials recommended for inclusion in the toolbox are a school
map, a set of school keys, a schedule of all classes, and a list of all students enrolled in the
school (Thompson, 1995).
Student Accounting and Caregiver Reunification. Crisis events are understandably often
associated with chaos and confusion. Given this reality it is essential that procedures be
in place that allow for a timely accounting of all students and staff members. Important
considerations when developing this protocol include how to document where students
needing medical attention have been taken, how to take attendance, and how to track down
missing/unaccounted-for individuals. Given the well-established importance of caregivers
to children who are coping with crisis (Charuvastra & Cloitre, 2008; Haden, Scarpa, Jones,
& Ollendick, 2007; Weems et al., 2007), it is critical that this protocol establish a procedure
for the careful and timely reunification of students with their parents. A set of checklists to
aid in the reunification of students and parents is available in Brock et al. (2009, pp. 63–66).
Exercise and Crisis Drills. In the best-case scenario, school crisis response is a relatively
infrequent activity. Thus, to ensure readiness, monthly meetings of the school crisis response
team should be held and crisis exercises or drills scheduled. These activities can include dis-
cussion-based exercises (i.e., orientation seminars and tabletop exercises) and operations-
based exercises (i.e., emergency specific drills, functional exercises, full-scale drills). For a
discussion of these activities the reader is referred to Brock et al. (2009, pp. 85–102).
Communications. Protocols need to be established to facilitate within-building, within-
school district, and school-community resource communications. Emergency communica-
tion options include an emergency channel, landlines, cell phones, e-mail, school intercoms,
walkie-talkies, reverse 911 calling systems, and written memos (Brock et al., 2009).
Media Relations. This protocol needs to identify a media staging area that is connected
to school grounds. It is from this area that media personnel are given updates regarding a
crisis situation. In addition to identifying who the school’s media spokesperson is, among
the important elements of this protocol are procedures for ensuring that members of the
media do not interfere with school functioning while at the same time working collab-
oratively with them, directions for how to hold a press conference, and procedures for
controlling access to family/community meetings (Brock et al., 2001; Brock et al., 2009).
Visitor Sign-In. It is not unusual for personnel who are not typically a part of a given
school’s staff to be on campus to assist in a crisis response. To track the comings and goings
of these unfamiliar individuals, a sign-in and sign-out procedure needs to be established.
This should include a strategy for the delivery and use of identification badges. Procedures
for getting messages to crisis response team members and support staff also need to be
developed (Brock et al., 2001).
Developing Crisis Response Procedural Guidelines

In addition to the preparedness tasks just described, it is critical for school crisis response
teams to develop crisis response procedural guidelines. As described by Brock et al. (2001),
these guidelines, which help to ensure that important crisis response tasks are not left
undone, include the following activities.
Assess the Crisis Situation

The first task to be completed following a crisis event is for the response team to assess
the crisis situation (Brock, 2002). This involves determining the crisis facts and estimat-
ing the potential school impact. This information needs to be made immediately available
to district office personnel and all crisis response team members. It can be used to decide
upon the level of crisis response required (e.g., school site-level vs. district-level). Informa-
tion sources that are helpful in obtaining crisis facts include law enforcement, medical
personnel, and the families of crisis victims.
Disseminate Crisis Information

After having gathered the available crisis facts, decisions need to be made about what
information is to be shared with staff and students, and how this will be done. Sharing
this information is often critical to a school crisis response as crisis rumors are often more
frightening than crisis facts. It is recommended that crisis facts be disseminated in as nor-
mal and natural an environment as possible. For example, teachers can read announce-
ments sharing crisis facts to students in their classrooms. Intercom announcements and all
school assemblies should be avoided because of differences in the developmental levels of
students; since one communication may not be appropriate for all students. The imperson-
ality of this mode of communication and the difficulty in answering questions also makes
mass communications undesirable.
In addition, when making decisions about what information to share with a school, it
may be appropriate to avoid mentioning particularly horrific and/or grisly details of the
traumatic circumstance. If such details are not publicly available and/or speculated upon,
then there will be no reason to discuss them. This recommendation stems from the obser-
vation that individuals can become traumatized after learning about the victimization of a
relative or close associate (American Psychiatric Association, 2000). However, no matter
how horrific the crisis facts, if students have questions about them, it will generally be
appropriate to answer them as honestly and directly as possible.
Identify Crisis Victims

As the crisis facts become apparent, crisis response personnel will begin to be able to iden-
tify both the physical and the psychological victims of the crisis event. Arguably, the most
important factor in determining degree of psychological trauma is proximity to the crisis
28 Stephen E. Brock
event (Pynoos et al., 1987). However, familiarity with crisis victims is also an antecedent
of psychological trauma (Milgram, Toubiana, Klingman, Raviv, & Goldstein, 1988). It is
essential that the crisis response procedural guidelines specify a protocol for identifying
and keeping track of crisis victims. Parent, teacher, and student referral procedures need
to be implemented to help ensure that no trauma victim slips through the cracks (Brock
et al., 2001; Brock et al., 2009).
Provide Crisis Intervention Services

As psychological trauma victims are identified, decisions need to be made regarding the
provision of crisis intervention services. When there are large numbers of psychological
trauma victims, a psychological triage will need to be conducted. Use of triage will help
response teams make crisis intervention treatment priority decisions and will help to ensure
that intervention matches crisis intervention needs. It will be important to carefully docu-
ment all crisis interventions. A question that needs to be addressed is whether individual
trauma victims require professional mental health intervention. Although it will typically
be a minority of students that will require such intensive assistance, the presence of any
degree of lethality (i.e., suicidal or homicidal thinking) and/or an inability to cope with the
traumatizing circumstances independently are the most frequent reasons for making imme-
diate professional mental health counseling referrals (Brock et al., 2001; Brock et al., 2009).
Debrief and Evaluate the Crisis Response

Finally, it is essential that crisis response procedural guidelines include activities designed
to care for the caregivers. Following a crisis response, all team members will need to be
offered support. Additionally, it will be important for the team to evaluate the effectiveness
of the response. No two crises are alike. Thus, given the opportunity for reflective thought,
all crises are potential learning experiences (Brock et al., 2001; Brock et al., 2009).
Concluding Comments
In concluding this chapter it is important to acknowledge that the best of plans are useless
if they are allowed to sit on a shelf collecting dust. As was discussed earlier, exercises and
drills are important if crisis response preparedness is to pass the test of time (Brock et al.,
2001; Brock et al., 2009). One strategy for ensuring the viability of these procedures is
to develop and adopt a school district crisis response policy (Brock, 1994, 2000). Ideally,
such policy would mandate that school personnel undertake crisis preparedness activities.
For example, a policy might require district administration to conduct “table top drills”
at school sites to evaluate crisis plans. Typically, such drills involve calling a crisis response
team together in a meeting room, presenting them with a crisis scenario, and then asking
them to talk through how they would respond. From such discussion, a crisis response
evaluator can assist school teams in identifying the strengths and weaknesses of a plan.
With planning and policies in place, crisis events may not be prevented, but a swift and
appropriate response by well-prepared educators will minimize their effect on the school.
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed. Text Rev.). Washington, DC: Author.
Brock, S. E. (1994, June). Crisis preparedness: Strategies for the development of a crisis intervention
policy. Communiqué, 22, 24–25.
——— (1998). School crisis intervention mutual aid: A county-level response plan. Communiqué,
27(3), 4–5.
——— (1999). School crisis intervention mutual aid: A county level response plan. In A. S. Canter &
S. A. Carroll (Eds.), Crisis prevention and response: A collection of NASP resources (pp. 91–94).
Bethesda, MD: National Association of School Psychologists.
——— (2000). Development of a school district crisis intervention policy. The California School
Psychologist, 5, 53–64. Retrieved from http://education.ucsb.edu/school-psychology/School-
Violence/PDF/Brock-CSP-2000.pdf
——— (2001, April). Crisis intervention mutual aid. Paper presented at the annual meeting of
National Association of School Psychologists, Washington, DC.
——— (2002). Estimating the appropriate crisis response. In S. E. Brock, P. J. Lazarus, & S. R. Jimer-
son (Eds.), Best practices in school crisis prevention and intervention (pp. 355–365). Bethesda,
MD: National Association of School Psychologists.
——— (2006). Crisis intervention and recovery: The roles of school-based mental health profession-
als. Bethesda, MD: National Association of School Psychologists.
——— (2011). Crisis intervention and recovery: The roles of school-based mental health profession-
als (2nd ed.). Bethesda, MD: National Association of School Psychologists.
Brock, S. E., & Jimerson, S. R. (Eds.). (in press). Best practices in school crisis prevention and inter-
vention (2nd ed.). Bethesda, MD: National Association of School Psychologists.
Brock, S. E., Jimerson, S. R., & Hart, S. R. (2006). Preventing, preparing for, and responding
to school violence with the National Incident Management System. In S. R. Jimerson & M. J.
Furlong (Eds.), Handbook of school violence and school safety: From research to practice (pp.
443–458). Mahwah, NJ: Erlbaum.
Brock, S. E., Nickerson, A. B., Reeves, M. A., & Jimerson, S. R. (2008). Best practices for school
psychologists as members of crisis teams: The PREPaRE Model. In A. Thomas & J. Grimes (Eds.),
Best practices in school psychology (Vol. 4, pp. 1487–1504). Bethesda, MD: National Association
of School Psychologists.
Brock, S. E., Nickerson, A. B., Reeves, M. A., Jimerson, S. R., Feinberg, T., & Lieberman, R. (2009).
School crisis prevention and intervention: The PREPaRE model. Bethesda, MD: National Asso-
ciation of School Psychologists.
Brock, S. E., Nickerson, A. B., Reeves, M. A., Savage, T. A., & Woitaszewski, S. A. (2011). Devel-
opment, evaluation, and future directions of the PREPaRE School Crisis Prevention and Inter-
vention Training Curriculum. Journal of School Violence, 10, 34–52. doi:10.1080/15388220.
2010.519268
Brock, S. E., & Poland, S. (2002). School crisis preparedness. In S. E. Brock, P. J. Lazarus, &
S. R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp. 274–288).
Brock, S. E., Sandoval, J., & Lewis, S. (2001). Preparing for crises in the schools: A manual for
buildng school crisis response teams (2nd ed.). New York: Wiley.
Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual
Review of Psychology, 59, 301–328. doi:10.1146/annurev.psych.58.110405.085650
Crepeau-Hobson, F., & Summers, L. L. (2011). The crisis response to a school-based hostage event:
A case study. Journal of School Violence, 10, 281–298. doi:10.1080/15388220.2011.578277
Haden, S. C., Scarpa, A., Jones, R. T., & Ollendick, T. H. (2007). Posttraumatic stress disorder
symptoms and injury: The moderating role of perceived social support for coping for young
adults. Personality and Individual Differences, 42, 1187–1198. doi:10.1016/j.paid.2006.09.030
Hatzichristiou, C., Issari, P., Lykitsakou, K., Lampropoulou, A., & Dimitropoulou, P. (2011). The
development of a multi-level model for crisis preparedness and intervention in the Greek educa-
tional system. School Psychology International, 32, 464–483. doi:10.1177/0143034311402918
Lockyer, B., & Eastin, D. (2000). Crisis response box: A guide to help every school assemble the
tools and resources needed for a critical incident response. Sacramento: California Department of
Education. Retrieved from http://www.cde.ca.gov/ls/ss/cp/documents/crisisrespbox.pdf
30 Stephen E. Brock
Milgram, N. A., Toubiana, Y. H., Klingman, A., Raviv, A., & Goldstein, R. (1988). Situational
exposure and personal loss in children’s acute and chronic stress reactions to a school bus disaster.
Journal of Traumatic Stress, 1, 339–352. doi:10.1007/BF00974769
National Association of School Psychologists. (2011). NASP resources: PREPaRE workshops.
Retrieved from http://www.nasponline.org/prepare/workshops.aspx
Nickerson, A. B., Brock, S. E., & Reeves, M. A. (2006). School crisis teams within an Incident Com-
mand System. California School Psychologists, 11, 63–72. Retrieved from http://www.caspsurveys.
org/new/pdfs/journal06.pdf
Purvis, J. R., Porter, R. L., Authement, C. C., & Boren, L. C. (1991). Crisis intervention teams in the
schools. Psychology in the Schools, 28, 331–339. doi:10.1002/1520–6807(199110)28:4<331::AID-
PITS2310280408>3.0.CO;2–5
Pynoos, R. S., Frederick, C., Nader, K., Steinberg, A., Eth, S., Nune, F., & Fairbanks, L. (1987).
Life threat and post traumatic stress in school-age children. Archives of General Psychiatry, 44,
1057–1063. doi:10.1001/archpsyc.1987.01800240031005
Reeves, M. A., Kanan, L. M., & Plog, A. E. (2010). Comprehensive planning for safe learning envi-
ronments: A school professional’s guide to integrating physical and psychological safety—Preven-
tion through recovery. New York: Routledge.
Reeves, M. A., Nickerson, A. B., Conolly-Wilson, C. N., Susan, M. K., Lazzaro, B. R., Jimerson,
S. R., & Pesce, R. C. (2011). Crisis prevention and preparedness: Comprehensive school safety
planning (2nd ed.). Bethesda, MD: National Association of School Psychologists.
Reeves, M. A., Nickerson, A. B., & Jimerson, S. R. (2006). Crisis prevention and preparedness: The
comprehensive school crisis team. Bethesda, MD: National Association of School Psychologists.
Sandoval, J. (Ed.). (1988). Crisis counseling, intervention, and prevention in the schools. Hillsdale,
NJ: Erlbaum.
Stockton Record. (2009, January 18). Remembering the tragedy: Jan. 17, 1989. Stockton, CA: Author.
Retrieved from http://www.recordnet.com/apps/pbcs.dll/section?Category=A_SPECIAL0252
Thompson, R. A. (1995). Being prepared for suicide or sudden death in schools: Strategies to restore
equilibrium. Journal of Mental Health Counseling, 17, 264–277. Retrieved from http://www.
amhca.org/news/journal.aspx
U.S. Department of Education, Office of Safe and Drug-Free Schools. (2007, January). Practical
information of crisis planning: A guide of schools and communities. Washington, DC: Author.
Retrieved from http://www2.ed.gov/admins/lead/safety/emergencyplan/crisisplanning.pdf
U.S. Department of Homeland Security. (2008, December). National Incident Management
System. Washington, DC: Author. Retrieved from http://www.fema.gov/pdf/emergency/nims/
NIMS_core.pdf
Weems, C. F., Watts, S. E., Marsee, M. A., Taylor, L. K., Costa, N. M., Cannon, M. F., . . . Pina, A.
A. (2007). The psychosocial impact of Hurricane Katrina: Contextual differences in psychological
symptoms, social support, and discrimination. Behaviour Research and Therapy, 45, 2295–2306.
doi:10.1016/j.brat.2007.04.013
3 Considering Culture in Crisis Work
Jonathan Sandoval
More rapidly than any other institution, our schools are going through tremendous changes
to accommodate new populations. The children and families they serve are becoming
increasingly diverse in a number of dimensions. According to 2010 census data, 54 percent
of U.S. children were White, non-Hispanic; 23 percent were Hispanic; 14 percent were
Black; 4 percent were Asian; and 5 percent were “all other races” (Federal Interagency
Forum on Child and Family Statistics, 2011). The percentage of children classified as His-
panic has grown from 9 percent of the child population in 1980 to 23 percent in 2010, and
is projected to rise to 39 percent in 2050. Other findings from the census are:
• In 2010, 20 percent of children were native-born children with at least one foreign-
born parent, and 3 percent were foreign-born children with at least one foreign-born
parent.
• In 2010, 33 percent of foreign-born children with foreign-born parents lived below
the poverty line, compared with 26 percent of native children with foreign-born par-
ents and 18 percent of native children with native parents.
• In 2009, 21 percent of school-age children spoke a language other than English at
home, and 5 percent of school-age children both spoke a language other than English
at home and had difficulty speaking English.
• In 2009, 63 percent of school-age Asian children and 66 percent of school-age His-
panic children spoke a language other than English at home, compared with 6 percent
of both non-Hispanic White and non-Hispanic Black school-age children.
• About 6 percent of school-age children spoke a language other than English at home
and lived in a linguistically isolated household in 2009. A linguistically isolated house-
hold is one in which all persons age 14 or over speak a language other than English at
home, and no person age 14 or over speaks English “very well” (Federal Interagency
Forum on Child and Family Statistics, 2011).
These statistics are national averages. Diversity statistics vary greatly across regions and
between urban, rural and suburban school districts, with large urban school districts hav-
ing much higher percentages of non-White students.
Much of this population diversity comes from immigration both from Mexico and Cen-
tral America, and also from economically depressed or war-torn areas of the world. Extra
stressors are present in the lives of immigrant and many other culturally diverse groups,
including poverty, discrimination, and need for assimilation. Many migrating families
have already experienced crisis events in their home country, such as torture, rape, and
loss of home and family. As a result, these children and their families may be particularly
vulnerable when school-related crises occur.
Many culturally diverse groups are also at the bottom of the economic pyramid in this
country. Immigrant fathers may have difficulty in finding jobs in this country that are at
the same income and status level as at home (Congress, 2000). Poverty will also be a factor
in how they respond and are able to cope when a crisis occurs. Lack of family resources
(e.g., not having the funds to properly bury a deceased family member) exacerbates trauma
(Lewis, 1970). Children in a family of newcomers are usually the first to acculturate to the
dominant U.S. culture, which causes additional problems and stresses for the family. Since
children are more linguistically competent in English, they are forced into roles normally
reserved for adults. The effects of cumulative stress or unresolved issues related to grief and/
or previous trauma make these individuals more at-risk for posttraumatic stress disorder.
In addition to this chapter, other relevant resources on working with culturally diverse chil-
dren and families are Congress (2000); Gielen, Draguns, and Fish (2008); Marsella, John-
son, Watson, and Gryczynski (2008); and Pedersen, Draguns, Lonner, and Trimble (2008).
Culture and Crisis

Everyone has a culture. In fact, individuals function in a number of cultures starting with
the family and including a national identity, a religious identity, an ethnic identity, or a
professional identity. The concept of culture is very complex (cf. Frisby, 1998). One simple
definition of culture is the shared language, ideas, beliefs, values, and behavioral norms
of a group of individuals with a group identity. Culture regulates how individuals interact
with one another and provides a structure for organization to occur. Culture is not a static
phenomenon; it is constantly evolving. Children come from a culture, but are exposed
early on to the school culture, which is often closely related to the dominant culture.
Children can be bicultural or even tricultural, when one considers that there may be a
separate adolescent culture.
The relationship of culture to crisis is manifold. It may help to determine what incident
is perceived as a crisis event, and it will impact how an individual deals with a crisis event.
Moreover it may dictate appropriate ways of helping an individual during a crisis reac-
tion. This chapter will cover these three topics, offer recommendations for crisis responder
training, and offer a model of culturally responsive crisis intervention.
What follows will emphasize the importance of considering culture when responding
to a crisis. But it must be remembered that an individual also has a personality and that
a personality may be consistent or inconsistent with the culture from which the person
comes. As a result, one cannot presume that an individual will share all of the ideas,
beliefs, values, and norms of the group with which he or she identifies. Individual and
regional variation is always great within a particular culture. In addition, an individual
may identify with more than one group, such as someone who considers herself gay,
African American, and Buddhist. In approaching someone with multiple identities, it
may be very difficult to predict which values and behaviors will be manifest. The safest
stance will be to be aware of the shared worldview of different cultures so they may
be recognized and used, but to proceed with caution to avoid stereotyping and making
unwarranted assumptions.
Attitudes and Beliefs of the Dominant Culture

Many scholars argue the dominant culture of the United States is derived from the White,
Anglo-Saxon, Protestant tradition (Spring, 2007). The core values include mutual respect,
individual rights, tolerance of differences, the rule of law, democracy, and individual
achievement. These values are expressed in connection with schooling, work, family, social
organization, property, and the environment. The core values of other cultures may or may
not contrast with those prevalent in the United States.
Considering Culture in Crisis Work 33
The dominant culture in the United States, for example, values independence and indi-
viduality. Competition is healthy. Achievement reflects individual effort. We value self-
expression, although not great displays of emotion. The culture advocates democratic
family relationships. Family ties are loose, and the parents, alone, are responsible for their
children. There is a belief that individuals can change and control events and that nature
can be dominated. Punctuality is important and it is possible to plan for the future.
In contrast, the Latino culture, for example, values interpersonal relationships and loy-
alty to the extended family. Dignity and honor are highly respected. Group cooperation
is more important than individual achievement. Extremes of emotion may be expressed.
Many relations are hierarchical, rather than democratic. There is a strong belief that events
are controlled by fate (God) rather than humans, and religion is integrated into everyday
life. Time is flexible and extendable.
One approach to understanding cultural differences has been to examine differences
in culture between countries. Hofstede, Hofstede, and Minkov (2010) have identified six
dimensions on which the national culture of a country can be ordered, based on large-scale
questionnaire studies. Although the intent was to identify cultural patterns in business
communications, these dimensions may be helpful in looking at cultural differences in
other types of communications common in a family’s country of origin.
The first dimension is Power Distance, or the degree to which equality or inequal-
ity between people is accepted. Individualism, contrasted with collectivism, is the second
dimension. Uncertainty Avoidance, the third dimension, concerns the level of acceptance
for uncertainty and ambiguity within a society. The fourth dimension is Masculinity versus
femininity, and refers to the extent that gender roles are strictly and traditionally defined.
The last two dimensions are Long-Term Orientation and Indulgence Versus Restraint. The
latter is the degree to which a society that allows relatively free gratification of basic and
natural human drives related to enjoying life and having fun versus suppressing gratifica-
tion. Knowing these societal preferences, which have been identified by Hofstede et al.
(2010) by country, may help the crisis counselor understand reactions to crisis and plan
culturally appropriate interventions.
Culture and the Crisis Responder

Most crisis workers come from the dominant culture or have assimilated to it. Because
assimilation is so powerful, members of the dominant culture are often unaware that their
values and attitudes are not universal and shared. As a result, there is utility in making
the values and attitudes of the dominant culture explicit. If the helper comes from a non-
dominant culture, it will be equally important for this professional also to acknowledge
the cultural “baggage” he or she brings to work.
Crisis responders will typically be middle-class, well-educated, English monolingual,
and assimilated into the western European culture. The victim may share that culture or
may come from an entirely different tradition and not be a native English speaker. If there
is a disjuncture between the culture of the crisis worker and the client, it will need to be
addressed. Ways of addressing the problem may be increased training for the crisis worker
or an appropriate referral. Ideally a crisis response team would be made up of helpers
from all of the cultures represented in the school. Unfortunately it is not often possible to
achieve this goal. Crises come at unpredictable times, and the diversity of many schools is
so great that it will be unfeasible to have trained personnel available for every student or
client at a moment’s notice.
Given that many crisis interveners are products of the dominant culture, a major question
is, “How can counselors with this worldview learn to work with members of a different
culture?” The answer is not a simple one. A first step is to learn about one’s own culture
and to recognize legitimate differences in others. Counselors are typically taught to suspend
their value judgements in working with others, but are not often prepared to work with oth-
ers with truly different concepts of how the world operates. What it takes to do this work
has been the object of some thought.
Competencies of the Multicultural Counselor

Sue and his colleagues have outlined the competencies needed for effective multicultural
counseling (Sue et al., 1998). They list three general dimensions: (a) Counselor awareness of
personal assumptions, values, and biases; (b) Understanding the worldview of the cultur-
ally different client, and (c) Developing appropriate intervention strategies and techniques.
Under each of these dimensions are listed a set of attitudes and beliefs, knowledge, and skills.
They believe that “becoming multiculturally competent means the ability to free one’s per-
sonal and professional development from the unquestioned socialization of our society and
profession” (Sue et al., 1998, p. 37). But it also means acquiring the skills outlined. In addi-
tion, “Multiculturally competent counselors also consider factors such as the impact of the
sociopolitical system on people of color in the United States, have knowledge and informa-
tion about particular cultural groups, and are able to generate a wide range of appropriate
verbal/nonverbal responses to client needs” (Pope-Davis & Dings, 1995, p. 288).
The process of gaining multicultural counseling competencies involves study, prolonged
exposure to other cultures, self-examination, and supervision. The first step is often mak-
ing counselors aware that they do have a set of culturally determined attitudes and beliefs.
Culture and the Perception of Crisis

Many events that frequently stimulate a crisis reaction in the dominant culture, such as a
death, a suicide, or a natural disaster, may or may not have a similar effect on members of
other cultures. By the same token, an event that would scarcely be noted in the dominant
culture, such as eating a particular taboo food by accident, would stimulate a crisis reaction
in another culture.
Young (1998) offers an example of a young adolescent living in public housing on wel-
fare who had been raped. Rather than being traumatized and entering into a crisis state as
a result of the sexual assault, the young woman expressed disappointment that the rape
had not resulted in a pregnancy, which would have led to an opportunity to move out on
her own. This is likely an extreme example, but should give the crisis worker a lesson to
be cautious in assuming that a given event will be perceived as a crisis.
Cultural lenses will also determine how a community views a crisis intervention. For
example, the traditional school celebration of St. Patrick’s Day (wearing green and making
shamrocks) shortly after a January school shooting in Stockton, California, caused misper-
ceptions by Southeast Asian students and families. These families thought the school was
glorifying the perpetrator as his first name happened to be Patrick. This misperception
triggered further distress requiring quick reeducation as to the cultural background of the
observance of this holiday with Irish roots.
It is also important in planning crisis interventions to ensure that response efforts
are equitably provided for all groups. While prejudice is an unfortunate occurrence in
every society, crisis workers should be cognizant of the possibility of perceptions that too
much is being done for one group and not enough for another, even if untrue in reality.
Consistency and fairness are principles that need to be applied to crisis response in order
to avoid perceptions of prejudicial treatment.
Culture and the Reaction to Traumatic Events
Traumatic events often result in crisis reactions that show themselves through a number of
symptoms such as fear, confusion, emotional numbing, and disordered sleep. The specific
symptoms of a crisis response may have a specific cultural manifestation. At the same time,
ordinary, culturally appropriate coping may seem dysfunctional to Western eyes.
For example, many individuals from Asian cultures are more likely to develop somatic
complaints in response to crisis. Another example of cultural patterns influencing responses
is that fears and nightmares may have a focus on spirits and ghosts.
Sometimes a reaction to a traumatic event will be culturally appropriate but will
seem to many North American professionals like a breakdown of ordinary coping.
Extreme outward expression of grief by wailing and crying followed by self-mutilation
and threats of suicide following the death of a loved one may be normal coping behav-
ior expected of a survivor in a particular culture. Klingman (1986) offers the example
of a medical staff considering sedating a grieving person when the perceived extreme
response was actually a normal one for a person from a Middle Eastern background. A
cultural informant or mentor from the school community will be very useful in indicat-
ing what normal reactions to various traumatic events are for families from a particular
culture.
On the other hand, what appears to be confusion and poor coping may be a lack of
understanding of English, rather than a crisis reaction. The confusion may stem from a
lack of comprehension rather than trauma-caused disorientation.
The reverse may also be the case: A naive crisis worker might incorrectly attribute con-
fusion and disorientation that are crisis-related to cultural differences or language prob-
lems. Sometimes resisting stereotypes can also lead to difficulty.
Additionally, knowledge of cultural reactions to trauma may inform the crisis worker
of strengths to tap for crisis intervention. For example, urban black families may have
multiple resources available to crisis victims as the extended family may reach deeply into
the community (Stack, 1974).
Implications of Culture for Crisis Counseling

The first chapter of this volume outlined a number of generic crisis counseling and crisis
intervention principles. As general principles, they must be modified for individuals, as
there will be wide variation within a cultural group. In addition, the general principles
might be modified to take cultural differences into account. In the following section, I
elaborate on some of these crisis counseling principles with respect to cultural issues.
Be Concerned and Competent

It is true that the crisis counselor must be seen as a potential resource who can help. Nev-
ertheless, how one comes to be seen as concerned and competent has cultural dynamics.
Social Status. Social status refers to a person’s position in a social order based on such
factors as gender, age, economic position, educational accomplishment, and so on. Each
culture may give status to particular individuals. Asian cultures, for example, defer to age;
other cultures may defer to the female head of the family. Few cultures afford high status to
children. In working with families during times of crisis, the crisis intervener’s status may
vary from group to group in a school. The age of the crisis counselor may be an advantage
in one group but not another. In so far as possible, it would be helpful to match counsel-
ors to clients so that the counselor has high status with respect to the culture. Since crisis
intervention is more directive than other forms of counseling, a high-status helper will be
more effective than a low-status one, all things being equal.
By the same token, in working with a family or community during a crisis it will be
important to direct communication and get cooperation from high-status individuals in
that group. In working with a migrant Mexican American family, for example, communi-
cations might first be directed at the father, acknowledging his status.
Dress. Many cultures have expectations for what is considered appropriate or modest
dress. In much of the world, men are expected to wear suits and women to wear dresses.
Modesty may involve covering the head or other parts of the body. Following a crisis, vic-
tims may not have access to traditional dress, and this may cause extra distress. Blankets
should always be available to cover the body. Crisis responders should attempt to dress
conservatively and professionally, as such an appearance will help inspire confidence as
well as show respect. A professional dressed in blue jeans, for example, might quickly lose
credibility with Southeast Asian clients.
Listen to the Facts of the Situation

In making psychological contact, attention should be given to a number of factors to
improve communication. Getting people to tell their stories requires establishing rapport
and using good, culturally appropriate listening skills. The counselor should attend to
communication styles, sociolinguistic issues, and nonverbal communication.
Communication Styles. Styles of communication can range from the assertive and volu-
ble to the quiet and indirect. Arabic families, for example, have an assertive style (Wilson,
1996). Often shouting is used for effect. An initial “no” may mean “yes” unless the no is
repeated several times. To be persuasive, it is appropriate to show emotion, repeat points,
and pound the table. It is usual to talk around the subject before coming to the point.
In contrast, in Asian cultures there is a subtle use of language and emotions (Li & Liu,
1993). Members of these groups value harmony and avoid confrontation and argument.
A third person may act as a mediator to facilitate communication between persons in
conflict. Individuals seldom express emotions. In contrast to the dominant culture that
values directness, Asian and many other cultures also may prefer to come to the point
of a conversation in an indirect manner. More patience in listening may be required with
individuals from these cultures than with individuals from the dominant culture.
Sociolinguistic Issues. In order not to violate an important cultural convention, it is usually
safe to observe good diplomatic protocol. In approaching individuals, they should be greeted
appropriately (e.g., “Hello”) and the helper should introduce him- or herself. Politeness is
paramount, and the helper should ask permission to speak and to do things for the individ-
ual in crisis. Saying “please” and “thank you” is important, as is acknowledging limitations
and weaknesses springing from a lack of cultural or linguistic knowledge, and apologizing
quickly when an error or gaff has been committed. Often it will be appropriate to apologize
in advance when the helper is uncertain about discussing a sensitive area. Special care should
be taken in asking questions. In many cultures asking direct questions is considered impolite.
Asking indirect questions (Benjamin, 1981) may yield a better response.
Nonverbal Communication
Attention to nonverbal communication is also important during a time of crisis. A num-
ber of dimensions, including eye contact and proximity, can be very different between
members of different cultures (Hall, 1959). Because these behaviors are subtle, counselors
may easily miss them.
Counselors are often advised to make good eye contact with clients. In our dominant
culture, we traditionally make direct eye contact to indicate we are attending to the client
and then allow our gaze to drift during conversation. In contrast, in Middle Eastern cul-
ture, sustained eye contact is the norm. In contrast, in Asian and Native American groups,
to show deference to elders, direct eye contact is avoided. A child from such a culture may
well be paying attention, even though he or she does not return eye contact.
In conversation, dominant culture members prefer space between discussants, up to five
feet. In contrast, both Hispanic and Arabic conversationalists will gravitate to a shorter
space, perhaps 2 feet, between discussants. Such close proximity would seem unnatural
to a member of the dominant culture. Crisis workers must not misinterpret violations of
“personal space” when clients end up closer than accustomed.
Some cultures use more gestures while speaking than do others. The eastern Mediter-
ranean cultures are particularly known for gesticulating as they speak. Smiling, giggling,
and laughing may be particularly misleading. In Asian culture, these all may denote sup-
pression of emotion rather than insensitivity. The same smile in a traditional Vietnamese
person may mean happiness or sorrow, agreement or disagreement, embarrassment or
confidence, comprehension or confusion! A smiling person from these cultures should not
be assumed to be unaffected by trauma.
The dominant culture views touching as appropriate following a traumatic event as it
helps a person in crisis to feel comforted and less alone. In many other contexts, touching
is not appropriate. Children from this tradition often find it comforting to be held when
upset. Nevertheless, physical contact should be initiated with great care. Hugging, patting,
or embracing between a helper and a client may be viewed as inappropriate in some cul-
tures (e.g., Hmong), although seen as appropriate in others (e.g., Hispanic). Cultures often
have strong traditions regarding the appropriateness of physical contact. In the dominant
culture, physical contact between males is rare. In contrast, within Asian cultures (Li & Liu,
1993) touching is acceptable between members of the same gender, and shaking hands or
holding hands is more acceptable than hugging. In a number of cultures (e.g., Hmong) it
is inappropriate to touch a child on the head, especially by a male. African Americans may
consider the act of a White American touching an African American child’s head to be racist.
Reflect the Individual’s Feelings

Crisis workers should be aware that expression of emotions is a highly important dimen-
sion of culture. Typically, following most other intervention models, persons in crisis are
encouraged to express their feelings about the traumatic event that happened to them.
Crisis counselors encourage those in crisis to surface and share their feelings, which are
reflected back and summarized by the counselor. Asian cultures traditionally suppress
emotions (Li & Liu, 1993) and may feel further stress when pressured by crisis counsel-
ors to focus on their feelings. Value may be placed on maintenance of dignity and inner
and emotional strength. Thus, emotions may be suppressed to maintain dignity.
In contrast, crisis counselors may become concerned or uncomfortable with the other
extreme. African American families often show very intense, demonstrative expressions
of their feelings in public, which may be perceived by Western culture as unrestrained and
crass (Willis, 1992).
Help the Child Realize That the Crisis Event Has Occurred
In many cultures, denial is seen as an acceptable coping strategy rather than as a defense.
In many Hispanic families, the adult reaction to a crisis event may be a decision to protect
and not tell the children what has occurred (M. Bellatin, personal communication, March
1995). Family secrets may be kept, and nobody asks or talks about such issues as illness,
death, sexual abuse, or suicide. Crisis workers should be aware that children coming from
a cultural background with this value might not have the opportunity to talk about their
experiences or feelings at home. In the Asian culture, denial and guilt may be part of the
cultural values since human suffering is seen as part of the natural order (Li & Liu, 1993).
In the Arabic culture, adults may resist discussing illness or death due to the belief that
such discussion can lead to misfortune or make a bad situation even worse (Wilson, 1996).
Implications of Culture for Crisis Intervention

In intervening on behalf of a child or family in the aftermath of a traumatic event, the
school mental health worker must also take culture into consideration. There are cultur-
ally acceptable ways of accomplishing each of the following tasks.
Facilitating the Reestablishment of a Social Support Network

Social support in many cultures comes from the family and from religious practices and
traditions. Religion is a particularly powerful form of support.
Religion
A religious tradition and the spirituality that goes with it are of enormous help during a
time of crisis. Within a religion are usually rituals associated with many of the crises people
encounter, particularly the loss of death. Knowledge of the grieving process and traditions
of various cultures are indispensable to crisis workers.
Religious worldviews that emphasize mystery about life and the role of fate or luck
permit believers to make sense of traumatic events and find meaning. I was impressed, for
example, with the helpfulness of exorcism by a Buddhist monk following a schoolyard
shooting in Stockton, which allowed the school’s Cambodian children to return to class
relatively peacefully a week following the incident. Facilitating other culturally relevant
healing rituals is very helpful following a crisis incident. Relaxation of strict separation
between church and state may facilitate a speedier and more positive crisis resolution.
On the other hand, religious injunctions and traditions can also precipitate a crisis when an
event takes on added dimensions because of strong taboos. A suicide or a sexual assault may
be a clear crisis in almost any culture, but have even more serious consequences in religions
in which these crises bring extra shame to a family or cause children to be unmarriageable.
According to Lee and Armstrong (1995), all cultural groups have traditional attitudes
about behavior defined as abnormal when it is outside of the culturally defined boundary
of optimal psychological functioning. In many cultures when individuals enter a crisis
state, they turn to individuals who are acknowledged within their communities as possess-
ing special insight and helping skills. The anthropological term shaman is used to cover
people called medicine man or woman, witch, witch doctor, sorcerer, or traditional healer.
Within the shamanic tradition, there is an emphasis on a holistic approach, nonordinary
reality, and the psycho-spiritual realm of personality (Lee & Armstrong, 1995). Although
many of the shaman’s practices and beliefs may be considered primitive and unsophisti-
cated to Western eyes, these traditional methods have served to give comfort to the victims
of crises for millennia.
If a child is from a shamanic culture, it may be useful to locate a traditional healer or
shaman from the community and consult with them as appropriate. Richardson (1991)
recommends that after exploring with a client his or her worldview, determining that the
child’s belief system includes traditional beliefs, and determining that the client or the family
could benefit from the services of a traditional healer, it will be appropriate to elicit the aid
of the shaman. Folk healers may be difficult to identify, since they are not known outside
their community, but the family or others in the community can help to locate them. The
Western crisis counselor should be available to participate, if invited, in ceremonial activi-
ties or practices that will help the client cope. The counselor must remember to respect the
skill of the healer even if he or she does not accept the system of healing. In preparing for
crises, having a referral system in place that includes traditional healers may be important.
In most religions, some days, weeks, and even months have a special significance. In
Western culture we are all familiar with Christmas, Lent, and Easter, not to mention a
semisecular feast day of Thanksgiving. We are also aware of Yom Kippur, Ramadan, and
the Day of the Dead, but we may not appreciate their significance for coping with a crisis
event. In scheduling events for crisis intervention or prevention, we must be aware of the
cultural calendar the families of the school may be following and avoid conflict. We must
also be aware of appropriate holidays when the focus may be on coping with a crisis and
support the use of this tool. For example, for families of Mexican heritage, the Day of the
Dead (following the Western Halloween) is a time to remember the departed, and come to
view death as a both a normal part of life and as a blessing.
Food
During times of crisis, food has often been an important solace, and meals are a time for
social interaction. Although under stress a person’s appetite tends to diminish, the need
for nourishment remains. In many cultures, for example, friends and neighbors provide
food to those who are grieving following a death. Since some foods have special meaning
as “comfort” food, it may be helpful to provide ethnically appropriate food to victims.
Sharing a simple drink (nonalcoholic) is often a way to start a relationship. Offering tea to
a Japanese client, for example, is a simple gesture that can help two people from different
cultures form a therapeutic alliance (Alexander & Sussman, 1995).
Music
Music has been proven to be beneficial as a tool in relaxation training and in other therapeutic
settings (Alexander & Sussman, 1995). Culturally appropriate music may be very helpful in
waiting rooms or other locations to facilitate coping during crisis situations. The use of music
has not been explicitly evaluated in crisis contexts, but it should be evaluated. I would predict
that it would have a welcoming effect on clients wary of a helper from a different culture.
Gifts
Small presents or gifts are used in many cultures to offer thanks or to commemorate a loss or
anniversary. Familiar examples are flowers at a funeral or a note of thanks. These concrete,
nonverbal expressions are important, and a gift of thanks following a crisis intervention
should be accepted graciously. Similarly appropriate gestures of culturally appropriate memo-
rialization from individuals, or on behalf of the school, will be helpful to a grieving family.
Engage in Focused Problem Solving

Helping individuals in crisis consider courses of action that will help them improve or
resolve an emotionally hazardous situation often is at the heart of counseling. Counseling
may be done individually or in groups, and in or outside of the context of the school.
Attitudes Toward Counseling
The acceptability of counseling as an aid to problem solving is culturally determined.
Mental health workers must pay particular attention to how clients and their cultures
perceive mental illness and the specific crisis. For example, within the Arabic culture, the
mentally ill are likely to be maintained within the family. Feelings of guilt may lead to
overprotection, denial, or isolation, resulting in rejection of a long-term therapeutic pro-
gram (Wilson, 1996). In the Hispanic culture, having mental problems related to a crisis
may be viewed as being “crazy,” which is considered very shameful and something to be
hidden from others. In the Asian culture, where it may be viewed negatively to single out
an individual as different, seeking help for a mental health problem might be perceived as
bringing shame to the family (Morrow, 1988). Strategies other than individual counseling
may be more acceptable. If individual work is necessary because of the focus on physical
health, public health services or medically based services may be more acceptable than
mental health services outside of a medical setting.
Group Work. Group intervention may be particularly appropriate for working with lin-
guistically and culturally diverse students or their parents in crisis (Esquivel, 1998). Esquivel
argues that group interventions are effective because they are consistent with a common
aspect of many cultures: a collective orientation and an emphasis on family and group
values. Since migration, poverty, and intergenerational conflict may disrupt many family
resources, the group serves as a substitute for family in emphasizing cooperation, cohesive-
ness, and interdependence among group members. A number of group techniques have been
devised to be culturally relevant. Some notable examples are Cuento therapy, using folk-
tales; hero-heroine modeling using biographical information; and Unitas, an intervention
using older peers to re-create family (Esquivel, 1998). Although not specifically developed
for crisis intervention, these techniques may be used or adapted for traumatic situations.
Support groups, in the form of school-based “neighborhood clubs,” have also been used
to help poor children cope and problem-solve following chronic exposure to urban vio-
lence (Ceballo, 2000). Support groups have the advantage of giving members a common
experience upon which to build trust and to interact.
Group work in the form of family therapy is another proven, valuable option (McGold-
rick, Giordano & Pearce , 1996). Issues of family conflict and acculturation can be resolved
and problem solving can be accomplished in this setting. Typically family therapy would be
provided by an outside resource via referral. Slaikeu (1990) points out that some cultures
will want to solve the crisis within the extended family rather than through follow-up with
a referral to an outside counselor or agency.
Language Issues
At this point, I address a particularly difficult issue with respect to cross-cultural crisis
counseling and intervention: language. One of the most important manifestations of cul-
ture is language. Many important cultural concepts cannot be satisfactorily translated
from one language to another, because the meaning is so ensconced in cultural values and
worldview. If possible, crisis interveners should speak the same language as their client.
Sue et al. (1998) stated,
Culturally skilled counselors take responsibility for interacting in the language requested
by the client; this may mean appropriate referral to outside resources. A serious prob-
lem arises when the linguistic skills of the counselor do not match the language of
the client. This being the case, counselors should (a) seek a translator with cultural
knowledge and appropriate professional background or (b) refer to a knowledgeable
and competent bilingual counselor. (p. 41)
Because crises occur suddenly and without warning, it may be difficult to find a linguistic
match between helpers and clients. Clearly, it would be best for crisis intervention with a
non-English speaker to be done by a crisis counselor who has demonstrated proficiency in
the child’s first language and sensitivity to the child’s culture. The availability of trained
speakers of some languages, such as Spanish, may be sufficient, but given the large number
of languages spoken in the United States, it will not be possible to match every non-English
speaker to a proficient helper of the native tongue. In this instance, there is little choice but
to work with interpreters.
Working with Interpreters. This training may be delivered with workshops or by con-
sultation with an experienced psychologist. Before working with an interpreter, the crisis
counselor must learn about the dynamics of the interpretation process. Some of these
dynamics include how to establish rapport with participants, how to anticipate the loss
of information inherent in the interpretation procedure, how to use the authority position
of the professional, how to use appropriate nonverbal communication, what method and
techniques of interpretation are available, how to obtain accurate translations, and how to
discourage personal evaluations by the interpreter (Figueroa, Sandoval, & Merino, 1984).
They must learn to avoid the common errors of untrained interpreters: omission, addition,
condensation, substitution, and role exchange (Vasquez & Javier, 1991)
The next task is to identify a potential interpreter (Sandoval & Duran, 1998). In the
school setting, there may be teacher aides or noncertificated staff members, such as com-
munity liaisons, who may be available. Parents and community members may also serve.
The best-educated native speaker is often the best candidate to serve as an interpreter,
since he or she will be able to learn what is needed quickly. However, a well-educated
person may have class and dialect differences from the child. In addition to the linguistic
competence of the potential interpreter, the individual’s personality will have to be taken
into account. The emphasis should be on someone who will be able to establish rapport
with the individual being counseled. McIvor (1994) argues, “although helpful, it is not
essential that they (interpreters) have knowledge of mental health issues, but it is essential
that they have a particular knowledge of the political and cultural background from which
the survivor comes. It is often ignored that the interpreter should be socially, ethnically and
politically acceptable to the survivor” (p. 268). A final point to be explored in selection is
the dialects of the language spoken by the potential interpreter. Newcomers to the United
States may speak unusual dialects that other speakers of the language may have difficulty
comprehending. The working-class French Creole spoken by the children of a Haitian
immigrant may be difficult for a Parisian French speaker to understand. Checking to verify
the dialect match between the children in the school and the interpreter is very important.
The third task is to prepare the interpreter. If interpreters are inexperienced, it will be nec-
essary to educate the individuals in the techniques of translating in crisis context. Interpreters
must learn ethical concepts, particularly the importance of keeping information confidential,
how not to elaborate responses or questions inappropriately, how to deal with physical
gestures and other kinesthetic information, and how to establish and maintain rapport. The
psychologist should go over any unusual terminology that might arise and should verify sen-
sitivity to dialect variations and cultural differences. The psychologist will be using the inter-
preter as a proxy and should feel confident that good professional practice will be followed.
If there is time, interpreters should also be schooled in the elements of psychological first aid.
The next step is to hold a preintervention conference with the interpreter in which
detailed planning for the intervention is carried out. The purpose of the session and any
background information should be discussed. Assuming the interpreter is familiar with
the culture of the child, the typical behaviors and attitudes of the child’s culture in stress-
ful situations can be reviewed for the psychologist. The interpreter is a cultural bridge
between the counselor and the client.
The fifth step is conducting the crisis intervention interview or group session. The ses-
sion should be a team effort to elicit the best outcome for the participants. The psycholo-
gist should direct the process and monitor the situation for signs of distress or failure of
the process. It may be necessary to consult with the interpreter about the process, but long
discussions in English in front of the client should be avoided.
The final step is a postsession conference with the interpreter to evaluate the process. It may
be useful to audio- or videotape the session if the client grants permission. The interpreter’s
impressions of the client should be noted. After the counseling session, the interpreter will
also be of assistance in following up on referral or communicating with parents or commu-
nity members who may help with providing needed support. They may also play a key role
in facilitating the return of absent students to school, including those who have been injured.
It is important to remember that individuals serving as interpreters will be subject to being
traumatized themselves, by recounting and reliving the crisis experience. They may identify
with the victim and may be forced to recall and relive similar crises in their own lives. The
crisis responder will wish to take time to carefully debrief the interpreter following the crisis
intervention (Brock, Sandoval, & Lewis, 2001). Some form of counseling might be appro-
priate for the interpreter, such as psychological first aid (Brymer et al., 2006).
Culturally Sensitive Crisis Intervention

By way of summary, we would like to propose the following additions to the standard pro-
tocol for crisis intervention. Although it is tempting to consider these additions only when
faced with an individual who is recognizably from a culture different from the intervener,
I believe that there is sufficient cultural diversity present in our population that it is appro-
priate to assume at the onset that any client encountered will come from a unique culture.
This unique culture must be taken into account. For a review of ethnocultural factors in
working with individuals and communities, see Norris and Alegria (2006).
Examine Fit of Individual and Cultural Norms

A first step will be to learn the extent to which the client has become acculturated to the
dominant culture. Informants can assist in this and careful interviewing can also detect an
individual’s worldview.
Consider What Culturally Relevant External Resources Are Available to

the Person in Crisis
Prime candidates for resources in many cultures are clergy, but these resources may also
be an influential neighborhood leader or politician. In non-Western (and Western) cultures
the family is an important system of support during times of crisis. Definitions of “family”
do differ considerably.
Determine the Client’s Capacity to Use the Resources

Not all individuals in crisis will be able to use either conventional resources or culturally
provided resources. Attitudes toward seeking help need to be examined.
Focus on Communication
Communication is more than just using language, although sharing a language will be
important in intervention. If you need to use an interpreter, be sure that communication
is still taking place.
Make Appropriate Referrals

As the first, and perhaps only person on the scene, do what you can to be helpful. Attend
to physical needs, offer appropriate reassurance and anticipatory guidance, and help those
in a crisis state to take positive action to facilitate coping. As soon as possible, however,
facilitate an appropriate referral to a culturally appropriate helper, and follow up to deter-
mine that a connection has been made.
A crisis is a time when the normal world is radically disrupted. But crises are not so
unusual that humankind has not been able to develop ways of dealing with them. As crisis
interveners, the best we can do is to be facilitators of processes that have been institution-
alized in culture to help individuals cope. We must honor and respect the culturally based
mechanisms available to comfort and heal those affected by traumatic events.
Implications for Prevention
Work with Communities

A first step in prevention is to begin working with different diverse communities in advance
of a crisis. Within these communities, school-based professionals should identify and estab-
lish relationships with influential leaders and attempt to find cultural mentors who can help
school staff understand traditions, values, and attitudes they will encounter among families.
These leaders can also be used in times of crisis to build the necessary bridges between the
school and families. Potential interpreters for use in an emergency can also be identified.
With the assistance of community members, school personnel can also identify families
who are already vulnerable, so that referrals to outside agencies may be facilitated. Estab-
lishing a full-service school is a helpful approach to building more resilient families.
Provide Information in Home Languages

Communication from the school to the home about crisis preparedness or about resources
in the aftermath of a traumatic event should be prepared in languages other than English.
The issue of translation is always difficult, but materials providing anticipatory guidance
for developmental crises, or lists of resources in times of traumatic crises, for example, can
be developed in many languages and distributed at appropriate times.
Address Social Issues

Although outside the purview of the school, responsible helping professionals can work
as citizens to advocate for social justice and equity. By joining with others to promote
employment opportunities, access to mental and physical health care, and educational
opportunities for families at or below the poverty line, school professionals can build bet-
ter capacity in diverse communities to negotiate hazardous events successfully.
Crisis counseling and interventions that are culturally appropriate may break some of the
“rules” of counseling, but will increase the probability that an individual will be restored
to effective functioning. Many children in schools are vulnerable to crisis reactions and in
responding to their needs, one size does not fit all.
REFERENCES
Alexander, C. M. & Sussman, L. (1995). Creative approaches to multicultural counseling. In J. G.

Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural
counseling (pp. 375–384). Thousand Oaks, CA: SAGE.
Benjamin, A. (1981). The helping interview (3rd ed.). Boston: Houghton Mifflin
Brock, S. E., Sandoval, J., & Lewis, S. (2001). Preparing for crises in the schools (2nd ed.). New
York: Wiley.
Brymer, M., Jacobs, A., Layne, C., Prynoos, R., Ruzek, J., Steinberg, A., . . . Watson, P. (2006).
Psychological first aid: Field operations guide (2nd ed.). Retrieved from www.nctsnet.org/nctsn_
assets/pdfs/pfa/2/PsyFirstAid.pdf
Cartledge, G., & Johnson, C. T. (1997). School violence and cultural sensitivity. In A. P. Goldstein
& J. C. Conoley (Eds.), School violence intervention: A practical handbook (pp. 391–425). New
York: Guilford Press.
Ceballo, R. (2000). The neighborhood club: A supportive intervention group for children exposed
to urban violence. American Journal of Orthopsychiatry, 70, 401–407.
Congress, E. P. (2000). Crisis intervention with culturally diverse families. In A. R. Roberts (Ed.),
Crisis intervention handbook: Assessment, treatment and research (pp. 430–448). New York:
Oxford University Press.
Esquivel, G. B. (1998). Group interventions with culturally and linguistically diverse students. In K.
C. Stoiber & T. R. Kratochwill (Eds.), Handbook of group intervention for children and families
(pp. 252–267). Boston: Allyn & Bacon.
Federal Interagency Forum on Child and Family Statistics. (2011). America’s children: Key national
indicators of well-being 2011. Retrieved from http://www.childstats.gov/pubs/
Figueroa, R. A., Sandoval, J., & Merino, B. (1984). School psychology with limited-English-profi-
cient (LEP) children: New competencies. Journal of School Psychology, 22, 121–143.
Frisby, C. L. (1998). Culture and cultural differences. In J. Sandoval, C. L. Frisby, K. F. Geisinger, J.
D. Scheueneman, & J. R. Grenier (Eds.), Test interpretation and diversity (pp. 51–73). Washing-
ton, DC: American Psychological Association.
Gielen, U. P., Draguns, J. G., & Fish, J. M. (2008). Counseling and psychotherapy: Investigating prac-
tice from scientific, historical, and cultural perspectives. New York: Routledge/Taylor & Francis.
Hall, E. T. (1959). The silent language. Greenwich, CT: Fawcett.
Hofstede, G., Hofstede, J., & Minkov, M. (2010). Cultures and organizations: Software of the mind
(3rd ed.). New York: McGraw-Hill.
Holzman, C. G. (1994). Multicultural perspectives on counseling survivors of rape. Journal of Social
Distress and the Homeless, 3, 81–97.
Klingman, A. (1986). School community in disaster: Planning for intervention. Journal of Commu-
nity Psychology, 16, 205–216.
Lee, C. C., & Armstrong, K. L. (1995). Indigenous models of mental health intervention. In J. G.
Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural
Lewis, O. (1970). A death in the Sanchez family. New York: Vintage.
Li, C., and Liu, T. C. (1993). How to work effectively with Asian-American families. NASP Com-
munique, 21(6), 23–26.
Marsella, A. J., Johnson, J. L., Watson, P., & Gryczynski, J. (2008). Ethnocultural perspectives on
disaster and trauma: Foundations, issues, and applications. International and cultural psychology.
New York: Springer Science + Business Media.
McGoldrick, M., Giordano, J., & Pearce, J. K. (1996). Ethnicity and family therapy (2nd. ed.). New
York, Guilford.
McIvor, R. J. (1994). Making the most of interpreters. British Journal of Psychiatry, 165, 268.
Morrow, R. D. (1988). Cultural Differences . . . Be Aware!” CASP Today, 38(3), 4–5.
Norris, F. H., & Alegria, M. (2006). Promoting disaster recovery in ethnic-minority individuals and
communities. In E. C. Ritchie, P. J. Watson, & M. J. Friedman (Eds.), Interventions following mass
violence and disasters: Strategies for mental health practices (pp. 319–342). New York: Guilford
Press.
Pedersen, P. B., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (2008). Counseling across cultures
(6th ed.). Thousand Oaks, CA: SAGE.
Pope-Davis, D. B., & Dings, J. G. (1995). The assessment of multicultural counseling competencies. In
J. G. Ponterotto, J. M. Casas, L A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural
Richardson, B. L. (1991). Utilizing the resources of the African American church: Strategies for
counseling professionals, In C.C. Lee & B. L. Richardson (Eds.), Multicultural issues in counsel-
ing: New approaches to diversity (pp. 65–75). Alexandria, VA: American Counseling Association.
Sandoval, J., & Duran, R. P. (1998). Language. In J. Sandoval, C. L. Frisby, K. F. Geisinger, J. D.
Scheueneman, & J. R. Grenier (Eds.), Test interpretation and diversity (pp. 181–211). Washing-
ton, DC: American Psychological Association.
Slaikeu, K. A. (1990). Crisis intervention: A handbook for practice and research (2nd ed.). Needham
Heights, MA: Allyn and Bacon.
Spring, J. (2007). The intersection of cultures (4nd. ed.). Boston: McGraw-Hill.
Stack, C. (1974). All our kin: Strategies for survival in a black community. New York: Harper.
Sue, D. W., Carter, R. T., Casas, J. M., Fouad, N. A., Ivey, A. E., Jensen, M., . . . Vazquez-Nutall, E.
(1998). Multicultural counseling competencies. Thousand Oaks, CA: SAGE.
Vasquez, C., & Javier, R. A. (1991). The problem with interpreters: Communicating with Spanish-
speaking patients. Hospital and Community Psychiatry, 42, 163–165.
Willis, W. (1992). Families with African American roots. In E. W. Lynch & M. J. Hanson (Eds.),
Developing cross-cultural competence: A guide for working with young children and their families
(pp. 121–150). Baltimore: Paul H. Brooks.
Wilson, M. (1996). Arabic speakers: Language and culture, here and abroad. Topics in Language
Disorders, 16(4), 65–80.
Young, M. (1998). Community crisis response team training manual: Second edition. Washington,
DC: National Organization for Victim Assistance.
4 School Entry, School Failure, and the
Discovery of Learning Disabilities
Colette L. Ingraham
Performance in school can be affected by a wide range of traumas. When one is experi-
encing a crisis in one’s life, it can influence one’s ability to concentrate, think, remember,
relate to others, and maintain one’s psychological balance and feelings of well-being. In
this respect, when a child is experiencing a crisis at home, in the community, or at school,
school achievement needs to be understood within a broader context than what takes
place in the classroom. Students who are experiencing a crisis need additional support
to help them cope with the crisis and to reduce lasting effects on their learning at school.
Some crises are directly related to what happens in school. This chapter identifies three
common school-related crises and describes students who are at risk of each crisis. The
first section discusses who is at risk of crises associated with school entry, perceived aca-
demic failure, and learning disabilities. The second section describes several strategies for
intervention and prevention of crises in school learning.
The three types of crises that impact student learning are the sources of numerous refer-
rals to school professionals. The competent professional who understands the dynamics
associated with each type of crisis is better able to provide rapid, effective intervention.
Within the National Association of School Psychologists (NASP) Practice Model (2010),
developing effective strategies at the prevention, early intervention, and crisis intervention
levels is contingent on understanding who may be at risk and how to mitigate these risk
factors and support resilience.
School Entry
Entry to school involves a wide range of new experiences for any child. The transitions
from home or preschool to school include learning a whole set of new skills, rules, expec-
tancies, and experiences. Classroom rules may differ from the rules of the home, and
the methods and consistency with which rules are enforced may also be different. Social
interaction takes place with new adults, peers, perhaps new languages and cultures, and
with a much larger number of similar-aged persons than previously experienced. There
are expectations for learning concepts, fine motor movements, sharing, demonstration of
knowledge, and so on that may represent new patterns of behavior. In fact, everything
about school may be new and unfamiliar.
Prevalence
Most children are able to make all of the adjustments needed to adapt to entrance to
school. But for some, school entry or attendance can become a crisis called school refusal
(sometimes called school phobia in earlier literature). Kearney (2006) uses the term school
refusal behavior to “encompass all subsets of problematic absenteeism, such as truancy,
School Entry, School Failure, and the Discovery of Learning Disabilities 47
school phobia, and separation anxiety” (p. 2). The same student may exhibit various
behaviors along a spectrum of absenteeism at different times—for example, being late to
school, refusing to go to school, and long periods of absenteeism—and these behaviors
are often interrelated. The incidence of school refusal is generally between 2–5% of all
school-aged children, and 4–5% for students who are 7–13 years of age (Fremont, 2003;
Wimmer, 2004). The mean onset for school refusal is between ages 10–11 (Bernstein,
2011; Kearney, 2006; Last & Perrin, 1993), but it is also seen in students ages 5–6 (during
school entry) and 13–16 (often reported as truancy), and when students transition from
one building to another. School refusal occurs among children of a variety of cultures and
countries. For example, there is concern about the incidence of school refusal in Japan
(Iwamoto & Yoshida, 1997) and Germany (Knollmann, Knoll, Reissner, Metzelaars, &
Hebebrand, 2010), although little is reported about specific ethnic differences in school
refusal. Last and Perrin (1993) report that among children seen at one clinic specializing
in anxiety disorders, 53.6% of the White and 30% of the African American clients dem-
onstrated clinical characteristics of school refusal. In the study, the mean age at intake was
12.6 (SD 3.5) and 11.6 (SD 3.8) for the White and African American groups, respectively,
and for both races, the rate of school refusal was higher in the low-socioeconomic status
(SES) group as compared to the high-SES group.
Refusal Types and Dynamics

Evans (2000) notes that recent efforts have focused on a functional classification of three
refusal subtypes, according to the variables that work to maintain school refusal: anxiety,
avoidance, and malingering. Correct identification of the subtype is critical to develop-
ing the appropriate intervention. Kearney (2006) recommends that when no clear medi-
cal reason for school refusal behaviors is seen, practitioners conceptualize school refusal
behaviors as involving reinforcements of four different types:
(a) To avoid school-based stimuli that provoke a sense of negative affect, anxiety, and/or
depression (e.g., avoiding specific teachers, peers, locations, or activities),
(b) To escape aversive social or evaluative situations (e.g., talking to peers or avoiding
doing a stressful activity such as public speaking),
(c) To pursue attention for significant others (e.g., wanting to stay with parent),
(d) To pursue tangible reinforcers outside of school (e.g., sleeping late, TV, playing, or delin-
quent behaviors) (p. 4).
He recommends use of the parent and child version of the School Refusal Assessment
Scale – Revised (2006) to help identify the specific function of the school refusal behaviors
as a first step in developing interventions.
There are different perspectives regarding the etiology of school refusal (Bernstein, 2011;
Evans, 2000; Kearney, 2006, 2008), but there is general agreement that school refusal is
often accompanied by anxiety disorders (Wimmer, 2008). The Anxiety and Depression
Association of America (ADAA) (2012) reports that starting school, moving, and other
stressful life events may trigger the onset of school refusal, as can fear of peers, something
bad happening, or leaving the parent. School refusal can often be a symptom of a deeper
psychological problem and 2–5% of school-aged children experience anxiety-based school
refusal. In a study by Kearney and Albano (2004), the following psychiatric disorders were
seen among youths with school refusal behaviors: 22.4% separation anxiety disorder,
10.5% generalized anxiety disorder, 4.9% major depression, 3.5% social anxiety disorder,
and 32.9% with no diagnosis.
48 Colette L. Ingraham
Intervention
Within the medical (ADAA, 2012; Bernstein, 2011; Fremont, 2003; Kearney, 2006) and
educational (Wimmer, 2003, 2008) literature, recommendations for treatments and inter-
ventions frequently involve approaches such as cognitive-behavior therapy, relaxation
training, systematic desensitization, and gradual reintroduction to school. In some cases,
pharmacotherapy is used in combination with other treatments of school-refusing chil-
dren, especially when the child is diagnosed with a DSM-IV disorder such as separation
anxiety or major depression (Kearney, 2006; King, Ollendick, & Tonge, 1995).
It is important for the family, school, and practitioners involved with treatment to work
together to develop a successful comprehensive plan for intervention (e.g., Carlson &
Christenson, 2005; Christenson, Sinclair, Lehr, & Godber, 2001; Christenson et al., 2008).
Once the child is attending school on a limited basis, the crisis counselor can work with
the teacher and parent to gradually increase the time at school. Increased school atten-
dance should be paired with strategies to increase the child’s comfort and self-confidence
at school by developing successful interpersonal and intrapersonal experiences within the
school setting. Gradually building the child’s self-esteem and self-efficacy as a student,
building an accurate self-perception, and increasing feelings of belonging with the class
are important to overcome any previously internalized negative self-image. Interventions
may include group participation; responsibilities such as monitor, partner, or tutor; and
pairing the student with welcoming peers for achievement tasks. The goals of follow-up
interventions may include increasing the child’s sense of self-efficacy in the school environ-
ment and maintaining feelings of self-worth, while modifying the accuracy of the child’s
self-image, if needed, so that it includes the newly experienced successes at school. This
type of follow-up is designed to promote continued positive mental health and informa-
tion processing once the behavioral symptoms of school attendance have been addressed.
Perceived Academic Failure

Many populations are at risk of academic failure and a host of systemic issues have been pro-
posed to promote educational equity and success (Adelman & Taylor, 2006; Durlak, 1997;
Esquivel, Lopez, & Nahari, 2007; Jones, 2009). There may be large groups of students who
are failing to meet school performance standards or who leave school before completion.
Although our nation has set a target of 90% high school graduation by the year 2020,
according to Building a Grad Nation (Balfanz, Bridgeland, Bruce, & Fox, 2012), 25% of
all U.S. youths and 40% of our nation’s minority youths are not finishing high school with
their peers. The incidence of school leavers is much higher in some communities and among
some ethnic groups, with ten states actually showing declines in graduation rates in 2009.
When there are groups of students not completing school, systemic interventions are
needed to address the concerns. Careful assessment of the situation involves an examination
of the curriculum, instructional approaches, school climate, expectations for performance,
dropout rates, etc., as a means to fully understand the factors that may be related to the
rates of failure. School professionals should look for patterns of referrals as a way to identify
groups of students who may be at risk of school failure and to develop effective systemic
interventions. If there are group trends, then the school staff should consider whether stu-
dents are getting pushed out by systemic factors, and if so, work to create changes in the con-
ditions that are leading many to leave school before completion. Reschly and Christenson
(2006) propose that “one of the most important activities for those interested in promoting
school completion is to first systematically monitor students for signs of disengagement. . . .
Interventions must address student engagement in a comprehensive way” (p. 109).
Sometimes individual students are identified as failing. Each year, school psychologists,
counselors, and student study teams or intervention assistance teams receive countless
referrals for students who have been identified by someone as failing in school. When the
reasons for school failure relate to the curriculum, instruction, or other systemic factors, the
intervention should address those concerns (Ingraham, 2002). The NASP Practice Model
(2010) advocates for a comprehensive and integrated continuum of services in schools as
part of NASP’s mission “to enhance the learning and mental health of all children and
youth” (p. 1). The NASP Practice Model “promotes a high level of services to meet the
academic, social, behavioral, and emotional needs of all children and youth” (p. 4). A part
of this model involves school-wide practices to promote learning, prevention, and services
responsive to the identified needs of a school; thus system-wide interventions are important
to create a school climate and learning environment where all students can learn.
Who Perceives the Failure?

When perceived academic failure relates to a specific student, then one of the first issues
that arise is who perceives the situation as an academic failure. The teacher, parent,
and/or student may perceive the student as failing in school, and it is important to clar-
ify in whose eyes the student is failing. In many cases, an indirect method of services
such as consultation is an effective way to address the concern. When the adults in the
student’s life are concerned about the student’s progress in school, school professionals
should begin with consultation to determine the nature and basis of the concern. At the
individual level of intervention, tutoring, individualized instruction, or other academic
interventions may be appropriate. Consistent with the NASP Practice Model (2010), in
situations where numbers of individuals with similar failure patterns are identified, sys-
temic interventions should be explored as a more appropriate means of prevention and
intervention of school failure.
Parent Perspective. When a parent raises the concern, a parent-teacher conference is
recommended to explore the similarities and/or differences in the adult perceptions of the
situation and ideas for intervention. Parents may be keenly attuned to their child’s school
performance and/or feelings about school and can be a source of early identification of stu-
dents who are experiencing difficulty in school. In some cases, parents may hold unrealistic
expectations for student performance. A conference can include sharing of information
about the student’s progress, observations of the student at home and school, and discus-
sion of the expectation for progress; all of which can help determine the course of action to
take. Parents and educators can develop powerful partnerships to support student learning
(Christenson, Whitehorse, & VanGetson, 2007; Lynch & Hanson, 2004).
Teacher Perspective. When the teacher perceives the student as failing, consultation with
the teacher may be the first step. Through consultation, one can learn the origins of the
teacher’s concern, including the definition, duration, pervasiveness, and evidence of the
student’s school performance. Depending on the consultant’s assessment of the problem
situation, a variety of consultation approaches may be used to work with the teacher to
increase the student’s academic success (e.g., Ingraham, 2000, 2007; Lambert, Hylander,
& Sandoval, 2004; Rosenfield, 2008). Classroom observations and collaborative study
of student work samples can lead to many successful instructional interventions (see
McCombs & Miller, 2007; Rosenfield, 2008). The consultant can use a problem-solving
approach (Conoley & Conoley, 1992; Kratochwill, 2008) to consider factors associated
with the curriculum or classroom environment, as well as psychological factors associated
with learning, such as those reflected in learner-centered principles (Lambert & McCombs,
1998; McCombs & Miller, 2007).
In cases where the student’s academic work has been problematic over time, a consultant
can work with the teacher to assess the problem and develop interventions (see Ames,
1992; Rosenfield & Gravois, 1996; Shinn & Walker, 2010). If the interventions devel-
oped through this individual consultation do not improve the student’s learning, a refer-
ral to the school’s intervention assistance team is justified. In cases where the student’s
performance has suddenly dropped, the consultant or counselor can explore any potential
changes in the student’s life that may account for a rapid decline, such as a major change
within the home or family, potential physical abuse, substance abuse, or trauma, etc. Depend-
ing on the nature of the crisis, other chapters of this book might be appropriate guides for
the crisis counselor.
Student Perspective. There are some cases of perceived academic failure where the indi-
vidual’s psychological approach to learning is part of the issue. In such cases, direct inter-
vention with the student may be needed. Students who experience performance anxiety,
fear of failure, fear of success, lasting depression, or a perceived crisis related to their
school performance may need direct and immediate attention by a responsible adult. In
these cases, the adult’s intervention can be informed by an understanding of some of the
psychological processes that can occur when a student is in crisis over a self-perceived
failure. Perceptions of academic failure vary from person to person and can occur at any
point during one’s schooling. Additionally, the antecedents and consequences of perceived
failure for any individual vary greatly. The psychological factors associated with the stu-
dent’s perception of academic failure are the focus of the remainder of this section.
From the student’s perspective, a crisis associated with a perceived academic failure may
be any academic event interpreted as a failure that relates to the student’s feelings of worth.
The number of students who experience some form of perceived academic failure each day
is great. Every day some students experience their first low grade on an assignment, some
are placed in the slowest reading group, some are sent home with notes of reprimand,
some are detained for misconduct or unfinished work, and some receive failing grades.
Depending on the student’s perception, any of these experiences could be interpreted as
an academic failure, and for some, a psychological crisis. For one student, a “B” grade on
a project may lead to feelings of success and pride, but for another student who may be
accustomed to grades of “A” or who was anticipating this project to earn a grade of “A,”
the “B” grade could lead to devastation and crisis. The impact of any of these experiences
on the student’s feelings of self-esteem and self-worth and coping and defending strategies
determines the extent to which the experience may result in a crisis situation for the student.
In the past 25 years, several psychological theories have emerged that help identify
groups of students who are susceptible to perceived academic failure. Theories of self-efficacy
(see review in Zimmerman, 2000), self-worth (Covington, 1992), school-related attribu-
tion (Weiner, 1986, 2000), and achievement goals theory (Ames, 1992) all suggest that
students who do not feel a sense of personal control, responsibility for achievement, and
mastery are at risk of negative self-perception and school failure. Some have demonstrated
that self-esteem is most threatened when the student receives negative feedback about his-
or herself in an area of self-concept that is highly valued by the individual (Harter, 1993;
Ingraham, 1986). Students who base their self-worth on their success in the classroom
may be more likely to experience crises related to perceived academic failure, compared
with students who do not care much about school performance because their social life (or
other area of interest) is the basis for their self-worth.
Some patterns of attribution, cognition, and learning predispose students to diminished
feelings of worth in the face of perceived failure. Among students who base at least some
of their self-esteem on their success in school, school failure may be particularly distressing
when the failure is attributed to stable internal causes such as low ability (Covington, 1992)
or to the student as a person, rather than the student’s recent actions (Kamins & Dweck,
1999). While some students can develop effective learning and thinking approaches on
their own, students with a history of academic failure are likely to have lower self-concepts
of ability, lower expectancies for future success, fewer problem-solving strategies, and feel-
ings of helplessness (Covington, 1992; Pintrich & Schunk, 1996; Stipek, 1993). Their skills
in self-regulation may also be affected (Berger, 2011). Some evidence suggests that students
who use self-regulatory skills related to their effort, called effortful control, achieve higher
grades and fewer school absences (Valiente, Lemery-Chalfant, Swanson, & Reiser, 2008).
Among high-achieving students, girls reported more frequent use of self-regulated learning
strategies and higher mastery goals than boys (Ablard & Lipshultz, 1998), suggesting that
the gender patterns may be linked with achievement levels.
Students with undeveloped or ineffective coping strategies may also be candidates for crisis
in the face of school failure. Goleman (1995) illustrated the importance of emotional learn-
ing and the high costs of what he called emotional illiteracy. It is important to know the right
problem-solving strategy for the problem at hand (Covington, 1992; Ingraham, 1985; Licht,
1983). Students who continue to use ineffective strategies increase feelings of frustration and
may eventually reduce school effort. Some have reported that students with learning disabili-
ties (Cullen & Boersma, 1982; Licht, 1983) may not have effective problem-solving strategies
in their repertoire of coping resources for school tasks, or they may attribute their successes
and failures to external rather than internal causes (Pintrich, Anderman, & Klobucar, 1994).
In addition, a student’s overall mood and level of self-esteem can influence the way he or she
thinks about a specific negative event (Sanna, Turley-Ames, & Meier, 1999).
Finally, students who experience test anxiety are at risk of crises related to school failure.
Huberty and Dick (2006) note that performance and test anxiety are far more common
than many professionals realize, and they can affect many areas of one’s life, including
achievement and social functioning. They estimate the prevalence of test anxiety to be
between 20% and 50% of elementary school-age children.
In addition to certain students who are at risk of school failure, as previously described,
there are also identifiable developmental transitions that are predictive of populations at
risk of school failure. The concurrence of cognitive, social, and emotional developmental
transitions, coupled with environmental changes at school, creates times of developmental
crisis. For example, students in Grades 3 and 4 are typically expected to concentrate lon-
ger, remember more, and demonstrate more academic skills than students in earlier grades.
These increased performance expectations occur at the same time that students are cogni-
tively more aware of how they compare with peers, and, with the emergence of cognitive
decentration, they may be more aware of how others perceive their abilities. Poor achieve-
ment, coupled with the alarm of parents, teachers, or even chiding peers, can lead to crisis
at this age due to the clear feedback that the student is not performing well. The student
who is not doing well in school may begin forming debilitating cognitive-affective patterns
that are not conducive to effective information processing or a negative self-evaluation
that may lead to feelings of helplessness and decreased motivation to try.
Given the potential for self-doubt in the classroom, the simultaneous change from the
primary playground to the upper-grade playground at recess may further contribute to the
child’s insecurity. Now the fourth grader may be interacting with older students, some-
times with new games and social rules for conduct, thus increasing the unfamiliarity and
potential threat to self-esteem. It is no surprise that students are often referred for difficul-
ties with academics, self-esteem, peer relations, frequent absences, and so forth around
this age. The frequency of referrals for school refusal at this age is also not surprising,
given the cognitive-affective dynamics taking place. Whenever the student is in transition
from one developmental phase to another, especially when developmental transitions are
accompanied by changes in the school environment, expectations, and social groupings,
self-esteem may be more vulnerable to crisis with any perceived academic failure.
Students with Disabilities and School Crises

When a student is initially diagnosed as having a disability, for some people, there is relief
in the discovery of some “reason” for the frustrations and difficulties in school. For others,
however, the initial diagnosis may be perceived as a crisis or source of major stress (Powell-
Smith & Vaughn, 2006). Families can respond to the initial diagnosis of a disability in a
range of ways (e.g., Harry, 1992), including thoughts that the school personnel made an
incorrect diagnosis or were trying to show that their child was crazy. Sometimes the parent
or student expresses feelings of denial, guilt, or depression at the time of diagnosis. For
some, placement into a special education program may be perceived as a failure or crisis,
whereas for others, it may be a welcomed opportunity for assistance. Several interventions
have been recommended to support the needs of the entire family of a child with disabili-
ties, and such intervention is very important in developing the context for all of the family’s
children to succeed (Powell-Smith & Vaughn, 2006).
The individualized educational program (IEP) team can provide useful assistance as the
diagnostic information is shared with parent and student, helping to support both during
this critical time. Families need information about the findings of the IEP team, commu-
nicated in terms that are clear and culturally familiar (Harry, 1992; Lynch & Hanson,
2004). For example, educators should be aware that the Spanish term “bien educado”
means well-mannered, not well-educated in terms of school achievement. Once the stu-
dent is placed in special education programs, careful monitoring of the student’s attitude,
behavior, and achievement is also important in order to provide early intervention when
needed, before the student experiences a crisis. There are many reasons to support inclu-
sion of students with disabilities in general education programs (NASP, 2002; Villa &
Thousand, 1995), including the finding that inclusion leads to greater self-esteem and
affective responses that support success in school (Falvey, Givner, & Kimm, 1995).
Developmental Disabilities
There are several ways in which students with disabilities are particularly vulnerable to crises
in school. According to present classifications, the most prevalent types of disabilities involve
disabilities with learning and/or development. Students with developmental delays are at risk
of failure at school both socially and academically because they may not be as intellectually
agile as their peers, both on the playground and in class. Academically, the student may have
difficulty learning at the same rate as agemates, and unless special instruction or curriculum
is provided, the student may be subject to academic frustration and/or failure.
Specific Learning Disabilities

Students with learning disabilities represent a special population that is at risk of school
failure, potential school-related crises, and challenged self-esteem (Mather & Ofiesh,
2005). Students with learning disabilities may have difficulty in one of the basic psycho-
logical processes, frequently in the area of auditory and/or visual information process-
ing. Even when using a response-to-intervention method to identify students with special
needs, a student may experience repeated failed attempts at intervention before an effective
educational program is designed and implemented. A student with a specific learning
disability may experience difficulty following directions, comprehending information,
remembering, or articulating thoughts. Many of these areas of difficulty are exactly the
types of skills needed to succeed in the typical educational program. These are also the
same skills that are needed to use logical information-processing and problem-solving
strategies in solving nonacademic, social, or personal problems. Consequently, the student
with a learning disability may also have limited resilience skills to cope with a crisis. Diffi-
culties with making a plan, sustaining concentration, and ignoring distractions are common
in many students with learning disabilities. The ability to contain emotional frustration
over a failure, to put a failure into proper perspective, and to continue experimenting with
alternate strategies may be very difficult for the student with disabilities.
Dynamics of Failure
The self-esteem and self-confidence of students with disabilities may be threatened by percep-
tions of being different from peers and by difficulties with social interaction. Students with
learning disabilities often have difficulty in social judgment, in understanding cause-effect
relationships, in inhibiting inappropriate behavior, and/or in articulating their thoughts to
others. Problems in anticipating events and in self-expression can interfere with satisfying
peer relations and social behaviors. Gresham (1997) concluded that “students with mild dis-
abilities have poorer social skills than 75% to 90% of their nondisabled peers . . .” (p. 42).
Gresham (2010) summarized the research on evidence-based social skills and described
social skills and prosocial behavior patterns as protective factors that can be trained.
Adjusting to transitions, new environments, new teachers or routines, and new social
groupings may be especially problematic for students with disabilities. Unless they have
good coping strategies, positive self-esteem, and high self-confidence, students with dis-
abilities may be vulnerable to self-esteem threats associated with uncertain or unfamiliar
educational experiences. Students with disabilities may benefit from extra support during
times of change and transition in order to prevent experiences of crisis. Because these stu-
dents are commonly identified for special education services, it is relatively easy to antici-
pate and plan ways to ease the transitions for students with disabilities. Educators can
carefully plan any transitions or changes in the educational program so that the student is
prepared in advance of the changes. Anticipatory guidance, role play, narrative counseling,
buddy systems, and similar techniques can provide needed support.
In addition to interventions within the school and classroom, some of the most impor-
tant preventive interventions for students with disabilities involve working with the fami-
lies of the students. Fish (1995) and Powell-Smith and Vaughn (2006) describe several
approaches for supporting families in adjusting to a student with a disability and empow-
ering the family to be a strong support system for the student’s success. These approaches
begin with a family-centered perspective that includes the family, rather than just the
child, as the focus of support and intervention. Best practices for working with parents
of children with disabilities include educational/information sharing, advocacy, support,
facilitation of healthy family functioning, and individualized services to the student and
family that attend to the family’s uniqueness and sociocultural background. Easler, God-
ber, and Christenson (2008) summarize excellent suggestions for a systemic approach to
supporting school-family partnerships.
Intervention for School-Related Crises

Effective intervention for students experiencing a crisis involves attention to the student’s ecol-
ogy, protective and risk factors, potential support system, and the student’s own psychologi-
cal cognitive-affective processes. Within the psychological domain, attention to self-concept,
self-esteem, and patterns of information processing is especially important. School profession-
als can use knowledge about the cognitive-affective processes associated with a crisis reaction
to provide intervention services that go beyond the traditional crisis intervention strategies
of calming affect and restoring stability in functioning. School professionals can also teach
students effective coping strategies, thereby supporting students in recovering from the imme-
diate crisis and developing skills for mastery over future situations.
Crisis intervention for problems with school learning involves two levels. First, the
crisis counselor provides emotional support and structuring during the initial steps in
crisis intervention. Here the goals are to calm the individual and provide emotional and
physical safety. The first-level approaches for crises with school learning resemble other
types of crisis counseling. This crisis counselor’s assessment of the individual’s psycho-
logical resources, functioning, and coping capacity is useful in planning the appropriate
second-level intervention. Some highly resilient students will be ready to begin problem
solving shortly after crisis counseling begins, whereas other students may have experi-
enced devastation that leads to immobilization and pervasive feelings of self-doubt and
helplessness. The types of goals appropriate for second-level intervention will depend on
the nature of the crisis, the developmental level of the student, and the crisis counselor’s
assessment of the student’s cognitive-affective processing.
Providing Emotional Support

For students who are experiencing a debilitating reaction to a school-related crisis, the
early goals of the intervention involve carefully rebuilding the student’s sense of self-efficacy
and mastery. The first tasks should involve small goals with reasonable opportunities
for success, outcomes that are clearly attributable to the student’s own efforts, and a
noncompetitive setting. Initially, this sense of mastery and satisfaction can come from
simple accomplishments such as organizing one’s supply case or backpack, feeding the
class animals, or collecting student assignments for a teacher. The purpose of these initial
tasks is to take some action that breaks the anxiety/depression/immobilization cycle while
producing some visible form of accomplishment. Simple, tangible accomplishments offer
concrete proof of one’s efforts and symbolize mastery and order over one’s environment.
If the student is ready for tasks in the academic realm, intervention might include plan-
ning a schedule to complete the night’s homework assignment, or dividing the book report
assignment into manageable pieces and deciding what to do first. The level of complexity
of the task and the amount of independent effort involved will depend on two factors:
(a) the crisis counselor’s assessment of the amount of coping resources available in the
student’s repertoire at the time of the crisis, and (b) the perceived magnitude of the failure
that resulted in the crisis.
Addressing Destructive Attributions. Once the student overcomes the initial emotional reac-
tion to the crisis, other strategies can be used to redirect the cognitive-affective processing into
constructive patterns. For example, cognitive-behavior approaches and attribution retraining
are useful for students who show dysfunctional information-processing characteristics such
as learned helplessness. The goal of the training is to reinforce students for attributing the
causes to controllable internal attributions such as effort. When the student fails, the student
is encouraged to think that it was due to insufficient effort rather than inability or external
causes. Specific and focused interventions can be very successful at improving students’ aca-
demic self-concept and developing more effective attributional patterns (Craven, Marsh, &
Debus, 1991; see Weiner, 2000, for a summary of attribution theory). Not surprisingly, high
self-efficacy, self-confidence, and self-esteem are considered important individual characteris-
tics of resilient children and youth (Doll & Lyon, 1998; Goldstein & Brooks, 2005).
The literature includes some specific suggestions for the types of reinforcements and
classroom strategies that are most effective for students with different attributional pat-
terns. Educators can use interactional approaches to meet the needs of some students and
self-directed learning for others. Children who tend to attribute failure to internal causes
such as low ability—the most common attributional pattern for children who have a his-
tory of failure—benefit from programs that use social reinforcement or tutoring (Bugental,
Whalen, & Henker, 1977; Cullen & Boersma, 1982; Licht, 1983) as opposed to programs
that rely on self-instruction. Children in general or special education programs who attri-
bute achievement internally and who have high levels of perceived control, on the other
hand, achieve better with reward systems and classroom structures that use self-talk or
self-controlling motivational approaches (Ames, 1992; Bugental et al., 1977; Covington,
1992). Once again, the crisis counselor’s assessment of the attributional patterns of the
student are key to selecting the most effective type of reinforcement during recovery from
the crisis.
Problem-Solving Skills. Instruction in problem solving is another strategy that is effec-
tive after the student has emotionally recovered from the immediate crisis. Typical steps in
problem solving include: (a) define the problem, (b) examine variables, (c) consider alter-
natives, (d) develop a plan, (e) take action, and (f) evaluate results. The crisis counselor
can link the problem-solving process with the student’s attributions about the outcomes
of problem solving as a way to mediate constructive cognitive-affective processes. These
strategies teach students to identify which strategies are working and to take credit for
their successes, thereby building accuracy of self-concept of ability and feelings of mastery.
The modification of self-concept and self-confidence requires meaningful reinforcement
and repeated experience, especially in the initial phases of overcoming a crisis. Approaches
that offer sustained interaction between the helping adult and the student are needed to
rebuild constructive cognitive-affective patterns. Attribution retraining, problem solving,
and cognitive restructuring are only three recommended approaches for intervention with
children who have experienced failure in school.
An innovative approach for the reconstruction of meaning is to use narrative counsel-
ing techniques to support the development of problem-solving skills. Narrative counsel-
ing originated in the social constructionist and family systems perspectives. It is proposed
as a tool to transform the practice of school counseling and work with difficult cases for
conflict resolution in schools (Winslade & Monk, 2006). In narrative counseling, the
problem is given a name and externalized so that it can be examined by the individuals
involved (Beaudoin & Walden, 1998). In contrast to other models of counseling in which
the counselor might encourage the student to accept responsibility and ownership of the
problem, narrative counseling asks the client to objectify the problem as an entity of its
own that can creep into one’s thoughts and behaviors. For example, if the client has given
the name “anger” to when she feels someone is treating her unfairly, the counselor might
ask the student who is angered by peer teasing: “What did you do when you started to
see that anger was entering the picture?” Beaudoin (2010) has some excellent suggestions
for integrating narrative counseling and brain research to boost social-emotional skills
in children.
Classroom Intervention
Interventions at the classroom level are also important to consider. When classroom envi-
ronments are based on principles of mastery learning (Ames, 1992; Covington, 1992;
McCombs & Miller, 2007), cooperative learning (Johnson & Johnson, 2012; Slavin,
Karweit, & Wasik, 1994), and/or supporting the development of emotional intelligence
(Goleman, 1995) and resilience (Doll, Zucker, & Brehm, 2004), a classroom climate may
develop that serves to reduce or prevent school failure and individual psychological crises
in learning. Wilson (1995) discussed ways that teachers’ groupings of students and the
types of feedback they provide students can influence the students’ self-concept develop-
ment. Doll, Spies, LeClair, Kurien, and Foley (2010) use the Class Maps Survey to measure
student perceptions of classroom learning environments.
Whatever approach the crisis counselor uses in the second level of intervention, the
underlying counseling goals are similar. At the individual level, the student is encouraged
to modify his or her self-concept to match reality, to gain broader perspective on the situ-
ation, and to plan steps to cope with the previous crisis. As the student regains access to
coping strategies (and possibly learns new ways to handle situations), the counselor helps
articulate what the resilience skills are and how the student is developing mastery over
his or her feelings, thoughts, and behaviors. This metacognitive process helps the student
conceptualize the coping strategies that were useful and develops internal attributions and
efficacy for their successful use. Finally, the counselor helps the student transfer effective
strategies from other areas of life to the problematic situation. The counselor can seek the
involvement of different members of the student’s ecology, such as parents, teachers, and
peers, in developing a support system to sustain the new learning. At the family, class-
room, or systems level, the goal is to develop environments and support systems to sus-
tain healthy development and learning and promote resilience in the face of crises. Here,
approaches such as consultation, collaboration, parent education, and inservices can be
used to empower key adults to support healthy student functioning.
Steve’s case is an example of a frequent type of school crisis. His IEP team is moving him
from a self-contained special day class to a regular fifth-grade class with support from the
resource teacher. He is afraid of the change because he has grown accustomed to the special
class, and he feels unsure of how he will survive most of the day with 30 other students in his
new class. He remembers, with terror and embarrassment, his experiences in school before
his placement into a special class in the second grade. During the second level of intervention,
the counselor helps Steve focus on the coping skills he already has, helping him realize how
to apply these to the fearful transition. The counselor might ask questions such as:
What are the rules in your current special class? How did you learn the rules of your
class?
What happens when you do something right? How did you learn what the teacher
expects of you? What can you do if you need help?
The counselor directs Steve’s attention to his knowledge of rules and expectations, and
his clues for learning these. Then the counselor helps Steve anticipate what to expect in the
new class and how to use his resilience strategies to adjust more successfully. Finally, it is
important for Steve to have a very concrete awareness of the resources and strategies to assist
him in the new class if he needs help or feels panic. Rehearsing strategies for getting help,
regaining his composure, and using tools such as lists or written reminders will assist him
during the transition period. Using narrative counseling, the counselor can ask Steve what
he could do if he noticed that fear was starting to rise up. The crisis counselor also consults
with Steve’s receiving teacher and parents about ways to make Steve’s transition smoother.
Together, they develop a transition plan that gradually introduces Steve into the new class-
room environment, beginning with one period a day, then one day a week, and increasing
as Steve is ready for greater inclusion in the regular class. In addition, they identify a student
in the new class who will act as a buddy to Steve both in the classroom and during breaks.
Steve is introduced to the peer before the move to the new class. Steve’s parents and teachers
are watching for ways to reinforce Steve’s successful adaptation to his new class.
Prevention of School Crises and Early Intervention

Many types of school-related crises can be reduced through prevention programs, antici-
patory guidance, and well-timed intervention. The following five guidelines are central to
planning effective prevention and early intervention services for children at risk of crises
associated with school and are consistent with comprehensive approaches in the NASP
Practice Model (2010).
Intervene Early in the Child’s Development

The development of emotional patterns that lead to success in life begins very early (Gole-
man, 1995), and student feelings of self-worth are often tied to the success or failure
experiences of students in school (Covington, 1992). There appears to be a critical age
in the child’s development when lasting attitudes and patterns of processing information
are formed. Comparison of developmental theories and numerous developmental studies
suggests that around the age of 10, children are susceptible to some of the dysfunctional
self-perception and attribution patterns that perpetuate school failure (Ingraham, 2002).
Once patterns of low self-esteem, lack of internal success attributions, or overly defensive
protection of self-esteem set in, they are increasingly difficult to modify. Prevention activi-
ties in the second and third grade might teach students skills in resilience, self-regulation,
and productive information-processing, prior to the critical cognitive-affective transition
that takes place around age 10. Programs that support the development of healthy emo-
tional and cognitive patterns (e.g., Covington, 1992; Durlak, 1997; Goldstein & Brooks,
2005; McCombs & Miller, 2007) can begin at the preschool level or earlier.
Support the Use of Effective School-Wide Instructional Practices

Three key elements of the curriculum and instructional process may help prevent school-
related crises: (1) curriculum that is relevant and connected to students’ life experiences,
(2) instructional approaches that build on the learning styles and previous experiences of the
students, and (3) opportunities to become reflective and resourceful learners. Educational
approaches that use reflective thinking, ongoing evaluation of one’s work, and curriculum
that is integrally connected to the students’ life experiences can create vibrant classrooms
that foster educational success, self-understanding, and effective psychological functioning
(Doll et al., 2004).
Instructional approaches that support learners in developing an understanding of their
own thoughts, approaches, problem-solving abilities, and self-perception can prevent
some school-related crises. Learner-centered principles (APA, 1993) were developed by
the American Psychological Association in an effort to disseminate much of the science
about learning and psychological functioning. Several resources can support the school’s
development of innovative and meaningful learning opportunities for students at the class-
room and/or systems level (e.g., Doll et al., 2004; Wilson, 1995).
Develop School-Wide Prevention Programs

An effective prevention program has several components (Adelman & Taylor, 2000, 2006;
Cowan et al., 1996; Nastasi, Moore, & Varjas, 2004; Slavin et al., 1994). Two aspects of
prevention programs are significant—those that promote resilience and those that prevent
or reduce risk factors (Doll & Lyon, 1998). It is important for the philosophy and actions
of the school staff and community to communicate the worth of each student, regard-
less of their level of achievement (McCombs & Miller, 2007). Students need an oppor-
tunity to develop their self-concept in a variety of areas—academic, social, physical, and
other domains. Specific performance feedback about what parts are done well, what needs
improvement, and suggestions for how to improve helps students to develop an accurate
self-concept and to identify strategies for improvement. Academic material at the appro-
priate level for each student is important for success to be within reach, thereby reducing
feelings of frustration, avoidance, and failure. Teachers need support and information to
help them (a) plan instructional activities within the levels of functioning of their students,
and (b) provide feedback in ways that support the development of constructive cognitive-
affective processes. When the school has a positive climate for learning and development,
prevention programs then can focus on students at risk of difficulty within the positive
school environment. For example, the Primary Mental Health Project (Cowan et al., 1996)
has evolved over several decades as a program designed to promote emotional wellness
among children in schools. It provides intervention and support for students who are
often overlooked in traditional intervention efforts. The Children’s Institute is continuing
to promote programs that strengthen social and emotional health for children (see http://
www.childrensinstitute.net/programs).
The major emphasis of a program designed to prevent school crises is one that supports
the development of effective learning strategies, accurate and comprehensive self-percep-
tion, problem solving, and resilience. Students need to develop and practice resilience and
coping strategies, in addition to problem solving and decision making (e.g., Doll et al.,
2004; Goldstein & Brooks, 2005; Goleman, 1995; McCombs & Miller, 2007; McWhirter,
McWhirter, McWhirter, & McWhirter, 2013; Shure, 1992).
Another important component in a school-wide prevention program is specific instruc-
tion and practice in seeking support when needed. The first step is to teach students how
to know when they need help. Then students need to know how to seek help in appropri-
ate ways. Help seeking that is necessary, focused on specific content features, and targeted
at appropriate help providers is considered most adaptive (Newman & Schwager, 1995).
The school curriculum can offer students instruction and practice in analyzing, search-
ing for causes of events, determining all the steps involved in a task, and making use of
problem-solving strategies and a variety of thinking skills. This includes practice in plan-
ning and carrying out multistep solutions. Additionally, students can be taught skills in
conflict resolution (Johnson & Johnson, 1995) and peer helping (McWhirter et al., 2013),
two strategies for reducing school problems and building the self-esteem of those who are
helpers. Research with seventh graders indicates that students with positive self-regard,
especially self-perceived peer social competence, were less vulnerable to victimization than
those with low self-regard (Egan & Perry, 1998). Egan and Perry concluded that “poor
self-concept may play a central role in a vicious cycle that perpetuates and solidifies a
child’s status as a victim of peer abuse” (p. 299). Numerous programs are available for
bullying prevention and intervention (see Chapter 6 and Lazarus & Pfohl, 2010, for a
review of resources).
A school climate of cooperation is also important in supporting student academic and
psychological success (National School Climate Center, 2008). Doll, Spies, and Champion
(2012) studied the multitude of ways that ecological school mental health services impact
students’ academic success. A cooperative school climate also helps in reducing violence
and conflicts (Johnson & Johnson, 1995, 2003). The Comer model (1996) is an example
of a model built on participatory community involvement that improves the school climate
and the success for all students. There is growing attention to the importance and develop-
ment of positive school climate (e.g., Doll et al., 2004, 2010; NASP 2010; NSCC, 2008).
Good prevention and intervention programs in school are strengthened when parents
and teachers are involved and educated in issues that can affect their children’s develop-
ment and success. Workshops, inservices, articles in the school newsletter, and infor-
mational fliers for parents can provide parents and teachers with information about a
wide range of issues that can affect the lives of students, with valuable suggestions for
how to respond in ways that support students (see http://www.nasponline.org/resources/
freepubs.aspx for downloadable materials). Preservice and inservice programs for teach-
ers and other educators can support the development of meaningful home-school part-
nerships to increase the involvement of parents in their children’s education. Attention
to the potential cultural diversity between families and school personnel is particularly
important in building successful home-school bridges (Brown, 1997; Edens, 1997; Gold-
stein & Brooks, 2005; Ingraham & Meyers, 2000; Lynch & Hanson, 2004; Nastasi et al.,
2004; Rogers et al., 1999).
Some excellent resources are available to support the development of prevention pro-
grams for a variety of risk factors and to support resilience (e.g., Beaudoin & Taylor, 2009;
Cowan et al., 1996; Doll & Cummings, 2008; Doll, et al., 2004; Durlak, 1997; Goldstein
& Brooks, 2005; Johnson & Johnson, 1995; Lewis, Sugai, & Colvin, 1998; McWhirter
et al., 2013; NASP, 2010; NSCC, 2008; Shinn & Walker, 2010). An examination of many
of the recent media and curriculum catalogues reveals a wide variety of books, films,
software programs, and materials that can be used for school-wide prevention programs.
Plan Early Intervention for At-Risk Populations

Through planning, early interventions can be developed for individuals and groups of stu-
dents likely to become at-risk of school difficulties. Anticipatory guidance prior to major
transitions, developmental crises, and other predictable times of difficulty is a cost-effective
and advisable intervention strategy. Groups of students who are identified as at-risk of
school crises, such as students changing schools, students failing classes, or students show-
ing early signs of dysfunctional cognitive-affective processing, are obvious targets for early
intervention. When students are going to experience a major change in their educational
experience or placement, careful planning for the transition can reduce the prevalence
of crises. At the individual level, teachers and parents can be on alert for early signs of
negative cognitive-affective patterns and can seek early intervention. Students who make
statements such as “I can never do anything right,” “Why should I even try—I won’t get
it anyway,” “I have to get a B or I might as well have failed” could be identified for early
intervention programs. Statements like these show perceptions of low self-efficacy, low
self-concept of ability, or unrealistic expectations for performance.
Use Consultation and Intervention Assistance Teams

Consultation, an indirect form of services delivered by an individual or team, can be used
to develop early interventions before situations escalate to a crisis level. When teachers and
parents have access to professionals trained in consultation service delivery, they can seek
appropriate help regarding their concerns about students. Consultation can help identify
and intervene with factors related to the current crisis and can support the consultee in
generalizing newly learned problem-solving strategies to future situations. At the individual
level, consultation can help identify factors contributing to the current problem situation
and it can support the teacher or parent in developing effective interventions (Conoley &
Conoley, 1992; Ingraham, 2000, 2007; Lambert et al., 2004). Consultation teams (e.g.,
Rosenfield & Gravois, 1996) can generate ideas for interventions and draw upon the exper-
tise of a variety of school professionals. Consultation may provide a more cost-effective
method of intervention in school-related crises than direct services such as individual coun-
seling. Moreover, it may more effectively intervene on contextual variables, such as the
curriculum or teacher-student relationship, that may be part of the problem situation.
Summary
Many school-related crises can be prevented or reduced in intensity through early inter-
vention. With an ecological approach to working with the student’s family, teachers, and
peers, support systems can be mobilized to offer the most effective types of interventions to
foster student success in school. In general, prevention of school-related crises is enhanced
when schools involve parents and teachers as partners in promoting learning, develop-
ment, and resilience. Learning goals for each student should include the development of
self-worth and self-efficacy, skills in problem solving and conflict resolution, and strate-
gies for positive learning and social interaction. From a cognitive-affective perspective,
goals for individuals should include: (a) development of an accurate, well-articulated,
and diversified self-concept, and (b) information processing patterns that allow the stu-
dent to assess the causes of school success and failure and to modify strategies based on
achievement feedback. Students who know how to seek out performance information are
better prepared to solve problems and reduce anxiety associated with the unknown, new
situations, and changes in routine. Students who have an array of personal resources and
strategies at hand are more resilient. Students who know when they need help and how to
seek assistance are better equipped to solve problems and prevent crises.
School professionals who are knowledgeable about the dynamics of healthy and dysfunc-
tional cognitive-affective processes are in a better position to develop comprehensive ser-
vices, consistent with the NASP Practice Model (2010), and to intervene at both individual
and systems levels. At the individual level, school-related crises are often integrally associ-
ated with perceived threats to self-esteem and self-worth. The crisis counselor who under-
stands the relationship of crisis with self-esteem and information processing is prepared to
carefully assess the dynamics of the crisis and plan effective interventions. At the classroom,
school, or systems level, the context for learning and the school climate can have a signifi-
cant impact on the prevalence and intensity of school-related crises. School professionals
can collaborate in the development of a school climate that enhances learning, develop-
ment, and well-being. The prevalence of crises with school learning can be greatly reduced
with prevention and early intervention. Durlak (1997) estimated that prevention programs
have reduced the incidence of school failure by 26–90%, depending on the specific study
and measured outcomes. His emphasis on developing prevention programs with multiple
levels of intervention (individual, groups, schools) is very consistent with the premises of
the NASP Practice Model and contemporary models of service delivery.
REFERENCES
Ablard, K. E., & Lipshultz, R. E. (1998). Self-regulated learning in high-achieving students: Rela-
tions to advanced reasoning, achievement goals, and gender. Journal of Educational Psychology,
90, 94–101.
Adelman, H. S., & Taylor, L. (2000). Moving prevention from the fringes into the fabric of school
improvement. Journal of Educational and Psychological Consultation, 11(1), 7–36.
Adelman, H. S., & Taylor, L. (2006). The implementation guide to student learning supports in the
classroom and schoolwide: New directions for addressing barriers to learning. Thousand Oaks,
CA: Corwin Press.
American Psychological Association. (1993). Learner-centered psychological principles: Guidelines
for school redesign and reform. Washington, DC: Presidential Task Force on Psychology in Educa-
tion, American Psychological Association.
Ames, C. (1992). Classroom goals, structures, and student motivation. Journal of Educational Psy-
chology, 84, 261–271.
Anxiety and Depression Association of America. (2012). School refusal. Retrieved from http://www.
adaa.org/print/living-with-anxiety/children/school-refusal
Balfanz, R., Bridgeland, J. M., Bruce, M., & Fox, J. H. (2012). Build a grad nation: Progress and
challenge in ending the high school dropout epidemic, annual update. America’s Promise Alli-
ance. Retrieved from http://www.americaspromise.org/Our-Work/Grad-Nation/Building-a-Grad-
Nation.aspx
Beaudoin, M. (2010). The skill-ionaire in every child: Boosting children’s socio-emotional skills
using the latest in brain research. San Francisco: Goshawk.
Beaudoin, M., & Taylor, M. E. (2009) Responding to the culture of bullying and disrespect (2nd
ed.). Thousand Oaks, CA: Corwin Press.
Beaudoin, M., & Walden, S. (1998). Working with groups to enhance relationships. Duluth, MN:
Whole Person Associates.
Berger, A. (2011). Self-regulation: Brain, cognition, and development. Washington, DC: American
Psychological Association.
Bernstein, B. E. (2011). Separation anxiety and school refusal. Retrieved from http://emedicine.
medscape.com/article/916737-overview#showall
Brown, D. (1997). Implications of cultural values for cross-cultural consultation with families. Jour-
nal of Counseling & Development, 76, 29–35.
Bugental, D. B., Whalen, C. K., & Henker, B. (1977). Causal attributions of hyperactive children and
motivational assumptions of the two behavior-change approaches: Evidence for an interactionist
position. Child Development, 48, 874–884.
Carlson, C., & Christenson, S. L. (Eds.). (2005). Evidence-based parent and family interventions in
school psychology [Special issue]. School Psychology Quarterly, 20(4).
Christenson, S. L., Reschly, A. L., Appleton, J. J., Berman, S., Spanjers, D., & Varro, P. (2008). Best
practices in fostering student engagement. In A. Thomas & J. Grimes (Eds.), Best practices in
school psychology V (pp. 1099–1120). Bethesda, MD: National Association of School Psycholo-
gists.
Christenson, S. L., Sinclair, M. F., Lehr, C. A., & Godber, Y. (2001). Promoting successful school
completion: Critical conceptual and methodological guidelines. School Psychology Quarterly,
16(4), 468–484.
Christenson, S. L., Whitehouse, E. L., & VanGetson, G. R. (2007). Partnering with families to
enhance students’ mental health. In B. Doll & J. A. Cummings (Eds.), Transforming school men-
tal health services: Population-based approaches to promoting the competency and wellness of
student services (pp. 69–101). Thousand Oaks, CA: Corwin Press.
Comer, J. (Ed.). (1996). Rallying the whole village: The Comer Process for reforming education.
New York: Teachers College Press.
Conoley, J. C., & Conoley, C. W. (1992). School consultation: Practice and training (2nd ed.). Bos-
ton: Allyn & Bacon.
Covington, M. V. (1992). Making the grade. New York: Cambridge.
Cowan, E. L., Hightower, A. D., Pedro-Carroll, J. L., Work, W. C., Wyman, W. C., Haffey, W. G.
(1996). School-based prevention for children at risk: The primary mental health project. Wash-
ington, DC: American Psychological Association.
Craven, R. G., Marsh, H. W., Debus, R. L. (1991). Effects of internally focused feedback on enhance-
ment of academic self-concept. Journal of Educational Psychology, 83, 17–27.
Cullen, J. L., & Boersma, F. (1982). The influence of coping strategies on the manifestation of
learned helplessness. Contemporary Educational Psychology, 7, 346–356.
Doll, B. (2010). Positive school climate. Principal Leadership, December, 12–16. Retrieved from
http://www.nasponline.org/resources/principals/School_ClimatePLDec10_ftsp.pdf
Doll, B., & Cummings, J. (2008). Transforming school mental health services: Population-based
approaches to promoting the competency and wellness of children. Thousand Oaks, CA: Corwin
Press in cooperation with the National Association of School Psychologists.
Doll, B., & Lyon, M. A. (Eds.). (1998). Resilience applied: The promise and pitfalls of school-based
resilience programs mini-series [Special issue]. School Psychology Review, 27(3).
Doll, B., Spies, R., & Champion, A. (2012). Contributions of ecological school mental health ser-
vices to students’ academic success. Journal of Educational and Psychological Consultation, 22,
44–61. doi:10.1080/10474412.2011.649642
Doll, B., Spies, R. A., LeClair, C. M., Kurien, S. A., & Foley, B. P. (2010). Student perceptions
of classroom learning environments: Development of the ClassMaps survey. School Psychology
Review, 39(2), 203–218.
Doll, B., Zucker, S., & Brehm, K. (2004.) Resilient classrooms: Creating healthy environments for
learning. New York: Guilford.
Durlak, J. A. (1997). Successful prevention programs for children and adolescents. New York: Plenum.
Easler, A. N., Godber, Y., & Christenson, S. L. (2008). Best practices in supporting school-family
partnerships. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology V (pp. 916–
936). Bethesda, MD: National Association of School Psychologists.
Edens, J. H. (1997). Home visitation programs with ethnic minority families: Cultural issues in par-
ent consultation. Journal of Educational and Psychological Consultation, 8, 373–383.
Egan, S. K., & Perry, D. G. (1998). Does low self-regard invite victimization? Developmental Psy-
chology, 34, 299–309.
Esquivel, G. B., Lopez, E. C., & Nahari, S. (Eds.).(2007). Handbook of multicultural school psychol-
ogy. Mahwah, NJ: Erlbaum/Routledge.
Evans, L. D. (2000). Functional school refusal subtypes: Anxiety, avoidance, and malingering. Psy-
chology in the Schools, 37, 183–191.
Falvey, M. A., Givner, C. C., & Kimm, C. (1995). What is an inclusive school? In R. A. Villa &
J. S. Thousand (Eds.), Creating an inclusive school (pp. 1–12). Alexandria, VA: Association for
Supervision and Curriculum Development.
Fish, M. (1995). Best practices in working with parents of children with disabilities. In A. Thomas
& J. Grimes (Eds.), Best practices in school psychology, III (pp. 1061–1070). Washington, DC:
National Association of School Psychologists.
Fremont, W. P. (2003). School refusal in children and adolescents. American Family Physician, 68,
1555–1561.
Goldstein, S., & Brooks, R. B. (Eds.). (2005). Handbook of resiliency in children. New York:
Springer.
Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ. New York: Batman.
Gresham, F. M. (1997). Social skills. In G. G. Bear, K. M. Minke, & A. Thomas (Eds.), Children’s
needs II: Development, problems and alternatives (pp. 39–50). Bethesda, MD: National Associa-
tion of School Psychologists.
Gresham, F. M. (2010). Evidence-based social skills interventions: Empirical foundations for instruc-
tional approaches. In M. R. Shinn & H. M. Walker (Eds.), Interventions for achievement and
behavior problems in a three-tier model including RTI (pp. 337–362). Bethesda, MD: National
Association of School Psychologists.
Harry, B. (1992). Making sense of disability: Low-income, Puerto Rican parents theories of the
problem, Exceptional Children, 59, 27–40.
Harter, S. (1993). Causes and consequences of low self-esteem in children and adolescents. In R. F.
Baumeister (Ed.), Self-esteem: The puzzle of low self-regard (pp. 87–116). New York: Plenum.
Huberty, T. J., and Dick, A. C. (2006). Performance and test anxiety. In G. G. Bear & K. M. Minke
(Eds.), Children’s needs III: Development, prevention and intervention (pp. 281–291). Bethesda,
Ingraham, C. L. (1985). Cognitive-affective dynamics of crisis intervention for school entry, school
transition and school failure. School Psychology Review, 14, 266–279.
——— (1986). Dimensions of self-concept and valuation and their relationship with self-esteem,
effort and grades: A cross-sectional analysis (Doctoral dissertation). Retrieved from Dissertation
Abstracts International. (47, 837A).
——— (2000). Consultation through a multicultural lens: Multicultural and cross- cultural consul-
tation in schools. School Psychology Review, 29(3), 320–343.
——— (2002). School and learning: School entry, school failure, and the discovery of learning dis-
abilities. In J. Sandoval (Ed.), Handbook of crisis counseling, intervention, and prevention in the
schools (pp. 59–82). Mahwah, NJ: Erlbaum.
——— (2007). Focusing on consultees in multicultural consultation. In G. B. Esquivel, E. C. Lopez,
& S. Nahari (Eds.), Handbook of multicultural school psychology (pp. 98–118). Mahwah, NJ:
Erlbaum/Routledge.
Ingraham, C. L., & Meyers, J. (Eds.). (2000). Multicultural and cross-cultural consultation in
schools [Special issue]. School Psychology Review, 29(3).
Iwamoto, S., & Yoshida, K. (1997). School refusal in Japan: The recent dramatic increase in inci-
dence is a cause for concern. Social Behavior & Personality, 25, 325–319.
Johnson, D. W., Johnson, R. T. (1995). Reducing school violence through conflict resolution. Alex-
andria, VA: Association for Supervision and Curriculum Development.
——— (2003). Field testing integrative negotiations. Peace and Conflict: Journal of Peace Psychol-
ogy, 9(1), 39–68.
——— (2012). Introduction to cooperative learning: An overview of cooperative learning. Edina,
MN: Cooperative Learning Institute and Interaction Book Company. Retrieved from http://www.
co-operation.org/?page_id = 65
Jones, J. (Ed.). (2009). The psychology of multiculturalism in the schools: A primer for practice,
training, and research. Bethesda, MD: National Association of School Psychologists.
Kamins, M. L., & Dweck, C. S. (1999). Person versus process praise and criticism implications for
contingent self-worth and coping. Developmental Psychology, 35, 835–847.
Kearney, C. A. (2006). Dealing with school refusal behavior: A primer for family physicians. Journal
of Family Practice, 55(8), 685–693.
——— (2008). Helping school-refusing children and their parents: A guide for school-based profes-
sionals. New York: Oxford University Press.
Kearney, C. A., & Albano, A. M. (2004). Functional profiles of school refusal behavior. Behavior
Modification, 28(1), 147–161.
King, N. J., Ollendick, T. H., & Tonge, B. J. (1995). School refusal: Assessment and treatment.
Boston: Allyn and Bacon.
Knollmann, M., Knoll, S., Reissner, V., Metzelaars, J., & Hebebrand, J. (2010). School avoidance
from the point of view of child and adolescent psychiatry. Deutsches Arzteblatt International,
107(4), 43–49. doi:10.3238/arztebl.2010.0043 retrieved from http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2822958/
Kratochwill, T. R. (2008). Best practices in school-based problem-solving consultation: Applications
in prevention and intervention systems. In A. Thomas & J. Grimes (Eds.), Best practices in school
psychology V (pp. 1673–1688). Bethesda, MD: National Association of School Psychologists.
Lambert, N. M., Hylander, I., & Sandoval, J. H. (Eds.). (2004). Consultee-centered consultation:
Improving the quality of professional services in schools and community organizations. Mahwah,
NJ: Lawrence Erlbaum Associates.
Lambert, N. M., & McCombs, B. L. (Eds.). (1998). How students learn: Reforming schools through
learner-centered education. Washington, DC: American Psychological Association.
Last, C. G., & Perrin, S. (1993). Anxiety disorders in African-American and White children. Journal
of Abnormal Child Psychology, 21, 153–164.
Lazarus, P. H., & Pfohl, W. (2010). Bullying prevention and intervention: Information for educa-
tors. Bethesda, MD: National Association of School Psychologists. Retrieved from http://www.
nasponline.org/resources/bullying/Bullying_Info_Educators.pdf
Lewis, T. J., Sugai, G., & Colvin, G. (1998). Reducing problem behavior through a school-wide
system of effective behavior support: Investigation of a school-wide social skills training program
and contextual interventions. School Psychology Review, 27, 446–459.
Licht, B. G. (1983). Cognitive-motivational factors that contribute to the achievement of learning
disabled children. Journal of Learning Disabilities, 16, 483–490.
Lynch, E. W., & Hanson, N. J. (Eds.). (2004). Developing cross-cultural competence: A guide for
working with children and their families (3rd ed.). Baltimore, MD: Paul H. Brookes.
Mather, N., & Ofiesh, N. (2005). Resilience and the child with learning disabilities. In S. Goldstein
& R. B. Brooks (Eds.), Handbook of resiliency in children (pp. 239–255). New York: Springer.
McCombs, B. L., & Miller, L. (2007). Learner-centered classroom practices and assessments: Maxi-
mizing student motivation, learning, and achievement. Thousand Oaks, CA: Corwin.
McWhirter, J. J., McWhirter, B. T., McWhirter, E. H., & McWhirter, R. J. (2013). At-risk youth: A
comprehensive response (5th ed.). Belmont, CA: Brooks/Cole, Cengage Learning.
Nastasi, B. K., Moore, R. B., & Varjas, K. M. (2004). School-based mental health services: Creat-
ing comprehensive and culturally specific programs. Washington, DC: American Psychological
Association.
National Association of School Psychologists. (2002). Position statement on inclusive programs
for students with disabilities. Retrieved from http://www.nasponline.org/about_nasp/pospaper_
ipsd.aspx
National Association of School Psychologists. (2010). Model for comprehensive and integrated school
psychological services: NASP practice model. Bethesda, MD: Author. http://www.nasponline.org/
standards/2010standards/2_PracticeModel.pdf
National Association of School Psychologists. (2012). Promote the professions with NASP down-
loadable materials. Bethesda, MD: Author. Retrieved from http://www.nasponline.org/resources/
freepubs.aspx
National School Climate Center. (2008). The school climate challenge: Narrowing the gap between
school climate research and school climate policy, practice guidelines and teacher educational
policy. National School Climate Center, Center for Social and Emotional Education, and National
Center for Learning and Citizenship at Education Commission of the States. Retrieved from http://
www.ecs.org/html/projectsPartners/nclc/docs/school-climate-challenge-web.pdf
Newman, R. S., & Schwager, M. T. (1995). Students’ help seeking during problem solving: Effects
of grade, goal, and prior achievement. American Educational Research Journal, 32, 352–376.
Pintrich, P. R., Anderman, E. M., & Klobucar, C. (1994). Intraindividual differences in motivation
and cognition in students with and without learning disabilities. Journal of Learning Disabilities,
27, 360–370.
Pintrich, P. R., & Schunk, D. H. (1996). Motivation in education: Theory, research, and applica-
tions. Englewood Cliffs, NJ: Merrill/Prentice Hall.
Powell-Smith, K. A., & Vaughn, B. J. (2006). Families of children with disabilities. In G. G. Bear
& K. M. Minke (Eds.), Children’s needs III: Development, prevention, and intervention (pp.
689–703). Bethesda, MD: National Association of School Psychologists.
Reschly, A., & Christenson, S. L. (2006). School completion. In G. G. Bear & K. M. Minke (Eds.),
Children’s needs III: Development, prevention, and intervention (pp. 103–112). Bethesda, MD:
Rogers, M. R., Ingraham, C. L., Bursztyn, A., Cajigas-Segredo, N., Esquivel, G., Hess, R., . . .
Nahari, S. G. (1999). Providing psychological services to racially, ethnically, culturally, and lin-
guistically diverse individuals in the schools: Recommendations for practice. School Psychology
International Journal, 20, 243–264.
Rosenfield, S. A. (2008). Best practices in instructional consultation and instructional consultation
teams. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology V (pp. 1645–1659).
Rosenfield, S. A., & Gravois, T. A. (1996). Instructional consultation teams: Collaborating for
change. New York: Guilford Press.
Sanna, L. J., Turley-Ames, K. J., & Meier, S. (1999). Mood, self-esteem, and simulated alternatives
thought-provoking affective influences on counterfactual direction. Journal of Personality and
Social Psychology, 76, 543–558.
Shure, M. B. (1992). I can problem solve (ICPS): An interpersonal cognitive problem-solving pro-
gram. Champaign, IL: Research Press.
Slavin, R. E., Karweit, N. L., & Wasik, B. A. (Eds.). (1994). Preventing early school failure: Research,
policy and practice. Boston: Allyn & Bacon.
Stipek, D. J. (1993). Motivation to learn: From theory to practice (2nd ed.). Needham, MA: Allyn
and Bacon.
Valiente, C., Lemery-Chalfant, K., Swanson, J., & Reiser, M. (2008). Prediction of children’s aca-
demic competence from their effortful control, relationships, and classroom participation. Journal
of Educational Psychology, 100(1), 67–77. doi:10.1037/0022- 0663.100.1.67
Villa, R. A., & Thousand, J. S. (Eds.). (1995). Creating an inclusive school. Alexandria, VA: Associa-
tion for Supervision and Curriculum Development.
Weiner, B. (1986). An attributional theory of achievement and emotion. New York: Springer-Verlag.
——— (2000). Intrapersonal and interpersonal theories of motivation from an attributional per-
spective. Educational Psychology Journal, 12(1), 1–14.
Wilson, M. (1995). Best practices in systems influences on children’s self-concept. In A. Thomas
& J. Grimes (Eds.), Best practices in school psychology, III (pp. 359–368). Washington, DC:
Wimmer, M. B. (2003). School refusal: Assessment and intervention within school settings. Bethesda,
——— (2004). School refusal: Information for educators. Bethesda, MD: National Association of
School Psychologists. Retrieved from http://www.nasponline.org/families/schoolrefusal.pdf
——— (2008). School refusal. Principal Leadership, April, 10–14. Retrieved from http://www.
nasponline.org/resources/principals/School%20Refusal%20April%20NASSP.pdf
Winslade, J., & Monk, G. (2006). Narrative counseling in schools: Powerful & brief (2nd ed.).
Thousand Oaks, CA: Corwin, SAGE.
Zimmerman, B. J. (2000). Self-efficacy: An essential motive to learn. Contemporary Educational
Psychology, 25, 82–91.
5 Divorce: Crisis Intervention and
Prevention with Children of Divorce
and Remarriage
Andrew M. Lamden
& Jonathan Sandoval
A reasonable estimate is that 45–50% of all U.S. marriages will end in dissolution, with
the rate highest for African Americans and lowest for Mexican Americans born outside the
country (Amato, 2010). Most divorces occur during a couple’s children-rearing years and
have important consequences for children. For this chapter on divorce, we will include con-
sideration of “informal divorces” of couples with children who are not married, since four
in ten children in the United States are born outside marriage (National Center for Health
Statistics, 2009). We will also not distinguish between separation and formal divorce. All
changes in family structure are hazardous for children’s development and may precipitate a
crisis reaction. In fact, divorce and marital separation are second only to the death of a parent
as stressful events for youngsters (Coddington, 1972). Given that approximately two percent
of children living in the United States are faced with parental divorce each year (Emery &
Forehand, 1994) and the speculation that 25% of children experience a parental breakup
by age 14 (Baydar, 1988), it is crucial to understand the impact that divorce has on children.
When divorce results in a crisis, there is a need to develop and implement effective
means of addressing these difficulties. This issue continues to be the focus of research-
ers and mental health clinicians who work with large numbers of children. Researchers
have investigated how crisis intervention techniques can best be adapted to ameliorate the
negative, long-term effects of familial disruption on youngsters (Goldman & King, 1985;
Johnston, Roseby, & Kuehnle, 2009; Kalter, Pickar, & Lesowitz, 1984; Pedro-Carroll &
Cowen, 1985; Shechtman & Mor, 2010; Stolberg & Cullen, 1983; Wallerstein & Kelly,
1980). However, most divorce-related child research conducted over the past two decades
has led to a better understanding of how parental conflict and parenting styles, within
marriage or divorce, affect children. In fact, many recent studies have found that the
adjustment problems of children of divorce can in part be accounted for by the experiences
of these children within marriages that later end in divorce (Buehler et al., 1998; Cum-
mings & Davies, 1994; Kelly, 2000; McNeal & Amato, 1998). Clearly, this information
has important implications for intervention and treatment.
In addition, new studies have focused on the number of family structure transitions as
important in determining child and adolescent outcomes. Divorce may lead to stability for
children or may lead to a number of different and changing family structures, which are
disruptive (Amato, 2010). For example, Sun and Li (2009) found that academic perfor-
mance postdivorce was better in children growing up in stable postdivorce families than in
families who experienced multiple transitions. Treatment and intervention may be needed
for some time postdivorce.
Andrew Lamden would like to thank Mariam J. King, Ruth K. Goldman, and Susan Zegans for their contributions
to the chapters in the first and second editions of this book.
Divorce: Crisis Intervention and Prevention 67
This chapter will review some of the earlier, as well as more current, divorce research.
Efforts at adapting a spectrum of preventive mental health techniques, including those of
crisis intervention, to fit the unique aspects of marital crises as they affect children and
school systems will be the focus. The central program described here attempts to treat chil-
dren and families at different stages of resolution to the marital crisis: the newly separated
or divorced family, the remarried family, and the chronically embattled divorced family.
Other recently developed programs will briefly be described.
The School and Divorce

During times of familial disruption or conflict, school can offer children nurturance and
continuity as well as a place where age-appropriate developmental tasks can be pursued:
One 7-year-old whose parents had recently divorced was having nightmares. In his
dollhouse play he showed a little boy awake at night while everyone else slept. The boy
runs around the house from room to room. “I dream that the house is falling apart,
but sometimes I have good dreams. I dream that I’m in school and I’m making things.”
For this child, a client of the first author, the school environment was a supportive one in
which he could develop and be less hindered by his preoccupations at home.
Our interest in working in the schools is rooted in the belief that an individual’s capac-
ity to cope with familial change and the resulting stress is partially dependent on the
quality of support and guidance available from extrafamilial organizations in which that
person functions (Peterson, Leigh, & Day, 1984; Stolberg & Cullen, 1983). The single
most important formal institution providing such support outside the home is the school
(Drake, 1981; Drake & Shellenberger, 1981; Kelly & Wallerstein, 1979). Because the
school as a system is confronted with large numbers of families attempting to cope with
the transitions brought about by divorce, strategies for intervention must be designed
to address the needs of not only the affected individual student, but also the classroom
teacher and the school as a whole. In this chapter, we describe programmatic efforts
designed to accommodate the organizational structure of the school to the structure of
the postdivorce family. Schools, however, are faced with problems in their ability to offer
support to students from these families. In addition to dealing with anxiety and depres-
sion, many of these youngsters develop learning and behavioral problems secondary to the
stress of the familial disruption.
The Hazard of Divorce for Children

Divorce, separation, and remarriage are processes that introduce rapid, multiple structural
changes and require adaptation of all family members. Anxiety experienced at this time
increases a child’s need for a stable “holding environment” (Winnicott, 1971), while the
nature of these familial changes temporarily undermines the capacity to parent (Waller-
stein & Kelly, 1980), leaving the child vulnerable to even greater anxiety and depression.
Because the changes required are of such great magnitude, it is likely that the family
system will have difficulty providing nurturance, sustaining intimacy, and containing
anxiety. For some families, this failure is transitory, with the family structure restabilizing
two to three years after separation. For others, there is a permanent familial disequilib-
rium, resulting in what Hunter and Schuman (1980) have described as the “chronically
reconstituting family.”
68 Andrew M. Lamden & Jonathan Sandoval
Unlike other stressful events, such as a death in the family, the announcement of a
divorce does not rally the support of the community. In fact, the members of the divorc-
ing family may find themselves excluded from the social/familial network that provides
support in other crisis situations. The media and public often view divorced families as
seriously flawed structures and environments, whereas the married or intact family has
generally been considered to be a more positive and nurturing environment for children.
This perception may or may not be true.
Children’s Reactions to Divorce

Numerous writers have described the behavioral changes and disruption in the child’s
ability to learn associated with the stress of parental separation and divorce (Guidubaldi,
1984; Hetherington, Bridges, and Isabella, 1998; Wallerstein & Kelly, 1980). Divorce has
been associated with lowered academic performance and achievement test scores, although
the differences are modest between children experiencing divorce and children with never
divorced parents (Frisco, Muller, & Frank, 2007; McLanahan & Sandefur, 1994). Of note
is that children with divorced parents have poorer school attendance, watch more TV, do
less homework, and have less parental supervision of their schoolwork—patterns that are
primarily attributable to family disruption (McLanahan, 1999).
Behavioral problems are also common. Teachers report an increase in restlessness,
aggression toward peers, tendency to daydream, and inability to concentrate following
a divorce or separation. These behaviors vary with the developmental level of the child.
Preschoolers/Kindergartners
In Wallerstein and Kelly’s (1980) initial study, which focused on postseparation reactions,
they noted that 2- and 3-year-olds regressed in their behaviors. These toddlers, struggling
with issues of mastery, often lost recently acquired toilet-training skills and showed signs
of separation anxiety, such as clinging behavior or the converse of reaching out too quickly
to strangers. Children between 3 3/4 and 4 3/4 years frequently displayed bewilderment,
irritability, aggressive behavior, and self-blame (Gardner, 1976; Hetherington, 1979).
Although Wallerstein and Kelly address themselves primarily to the affective component
in divorce-related responses, Neal (1983) extends their work into the cognitive domain.
He found that the youngest group (3- to 6-year-olds) understands parental divorce entirely
from an egocentric perspective. They link feelings of attachment to physical closeness, and
therefore when one parent moves away from the child, the syllogistic assumption is that
the child did something wrong to cause this physical distance. Misconceptions about the
reasons for the marital breakup occur frequently. Furthermore, feelings of loss and sad-
ness, fears of abandonment, deprivation, yearning for the noncustodial parent, and confu-
sion about the divorce create frequent conflicts for children at this age.
Latency-Age Children
Wallerstein and Kelly (1980) report that early elementary school–aged children (ages 7 to
8) appeared sad, were observed to be deeply grieving, and experienced feelings of split loy-
alty and fantasies of responsibility and reconciliation. Despite their greater understanding
of the divorce, they seemed unable to lessen their suffering. By contrast, older latency-aged
children (9 to 10 years), while experiencing feelings of loneliness, shame, intense anger,
rejection, and helplessness, along with continued loyalty conflicts, appeared more able to
utilize adult interventions.
Kurdek and Berg (1983) report that 9- to 12-year-olds could adjust to the divorce bet-
ter if they experienced an internal locus of control and if they had good interpersonal
understanding. Favorable adjustment was positively related to children’s perceptions that
factors were under their control and that they understood issues in terms of psychological
feelings and relationships rather than along concrete dimensions.
Adolescents
A recent large-scale study reports that when conflict was low after divorce, adolescents in
joint physical custody were better adjusted, but not in high-conflict postdivorce situations
(Maccoby & Mnookin, 1992). Springer and Wallerstein (1983) examined the responses
to divorce of a nonclinical population of young adolescents, ages 12–14. They describe
five hallmarks of these young peoples’ reactions to the marital rupture: (a) keen ability
to attend to parental relationships and burgeoning ability to judge each parent and his
or her behavior as individual; (b) a deep sense of loss of the intact family and loss of
hope for what that family might have been; (c) profound concern that overt parental
conflicts will become public, leading the adolescent to experience shame and embarrass-
ment; (d) increased rivalry with siblings accompanied by an increased dependency on the
intact sibling subsystem; and (e) an ability to maintain distance from the parental discord
by sporting a “cool” stance, use of sarcasm and humor, and use of extrafamilial sources of
interest and support. In those cases where the adolescent was not able to maintain dis-
tance, there was a strong alliance or identification with one parent. These young people
were more easily drawn into loyalty conflicts that impaired their normal development.
Custodial parents’ negative disclosures about the other parent following a divorce are
related to the closeness and satisfaction of the parent–adolescent relationship; however,
negative disclosures are also associated with depression and anxiety (Afifi, Afifi, & Coho,
2009; Afifi & McManus, 2010).
Adults
The focus of this chapter is on children. However, it is important to note that divorce has
a long-term negative effect on adults who have experienced parental divorce at or before
adolescence (Hetherington & Kelly, 2002; Huurre, Junkkari, & Aro, 2006; Wallerstein &
Lewis, 2004). Compared to those from nondivorced families, adults with divorced families
have lower educational attainment, more negative life events including divorce, and more
risky health behavior. Females particularly report more psychological problems including
depression, and more problems in interpersonal relations (Huurre et al., 2006).
Factors Placing Children at Risk
Marital Conflict and Divorce

Researchers have pointed out that marital conflict is a more important predictor of child
adjustment than is divorce itself or postdivorce conflict (Buehler et al., 1998; Kline, John-
ston & Tschann, 1991). Several large longitudinal studies found that as many as half of
the behavioral and academic problems of children coming from marriages whose parents
later divorced were observed 4 to 12 years prior to the separation. The symptoms of
these children currently in intact families were similar to those reported in children with
divorced parents: conduct disorders, antisocial behaviors, difficulty with peers and author-
ity figures, depression, and academic and achievement problems (Cherlin et al., 1991).
Regardless of parents’ marital status, high marital conflict experienced during childhood
has been linked to increased depression and other psychological disorders in young adults
(Amato & Keith, 1991; Zill, Morrison, & Coiro, 1993).
A national survey study found that high levels of marital and family discord prior to
divorce accounted for much of the link between parental divorce and measures of edu-
cational attainment (Furstenberg and Teitler, 1994). However, other research points as
well to the reduced resources and lowered parental monitoring after divorce as impor-
tant factors influencing achievement (McLanahan & Sandefur, 1994). Important to note,
moreover, is that when fathers are involved with the child’s school and schoolwork after
separation, there is less decline in academic functioning. Children with involved fathers get
better grades, are less likely to get suspended or expelled, and appear to like school better
(Nord, Brimhall, & West, 1997).
For adolescents a marked increase in absenteeism and tardiness is often present in chil-
dren of divorce (Goldman, 1981). Children with divorced parents are also less likely to
earn a college degree, in part because parental aspirations for educational attainment
increase for adolescents in never-divorced families but decrease for adolescents in divorced
homes (McLanahan, 1999).
Recent studies report smaller differences between the adjustment and achievement
problems when comparing children of divorce and children in never-divorced families.
However, aspects of the divorce experience clearly increase the risk for many children, par-
ticularly for those in high-conflict situations as their parents separate and divorce (Emery,
1999; Hetherington, 1999; McLanahan, 1999).
The pioneering and most comprehensive of the studies was conducted over a period of 10
years by Wallerstein and Kelly. The results of this research, with 60 families with 131 chil-
dren from Northern California for 10 years (many of the families continue to be followed
beyond the 25-year mark), yielded a rich source of clinical and conceptual material (Waller-
stein, 1983, 1984; Wallerstein & Kelly, 1980). Five years postdivorce, Wallerstein and Kelly
note that approximately one third of the children in their study were faring well and consid-
ered themselves happy. Approximately one third were doing reasonably well and were able
to pursue academic goals, and the remaining continued to be at least moderately depressed.
Various factors, including age of the child, gender, family dynamics, and resources available
for support, have enormous impact on how children cope with divorce.
Risk Factors Linked to Parental Conflict Style

Research clearly indicates that the intensity and frequency of parental conflict after divorce,
the style of conflict, its manner of resolution, and the presence of buffers to ameliorate
the effects of high conflict are the most important predictors of child adjustment (Kelly,
2000). In older children and adolescents, severity of conflict had the largest and most
consistent impact on adjustment. Intense conflict leads to more externalizing (disobedi-
ence, aggression, delinquency) and internalizing (depression, anxiety, poor self-esteem)
symptoms in both boys and girls, when compared to children experiencing low-intensity
conflict. Buehler et al. (1998) found that overtly hostile conflict styles (e.g., physical and
verbal affect, and behaviors such as slapping, screaming, contempt, or derision) were
more strongly associated with externalizing and internalizing behaviors in children of all
ages than either covert conflict styles or frequency of conflict. In addition, severe marital
conflict that focuses on the child is more predictive of child behavior problems than is
frequency of marital conflict or conflict that is not child-centered. Children who are the
focus of conflict express more self-blame, shame, and fear of being drawn into the conflict
(Grych & Fincham, 1993).
Current studies indicate that frequency of parental conflict, one of the earliest and most
common measures used in marital research, has been demonstrated repeatedly to play a
role in adjustment, in that high-frequency conflict is linked to more negative effects on
children (Johnston, 1994).
Researchers have also studied the manner in which mothers and fathers are affected
by marital conflict and divorce. Mothers in high-conflict marriages tend to be less warm
and empathic toward their children, more rejecting, more erratic and harsh in discipline,
and use more guilt and anxiety-inducing disciplinary techniques, compared to mothers in
low-conflict marriages. These more negative parenting behaviors are also associated with
poorer social awareness and social withdrawal in the child (Belsky, Youngblade, Rovine,
& Volling, 1991; Cummings & Davies, 1994; Fincham, Grych, & Osborne, 1994; Harriet
& Ainslie, 1998; Kline, Johnston & Tschann, 1991).
Fathers in high-conflict marriages withdraw more from the parenting role and from
their children compared to fathers in low-conflict marriages, and tend to remain less active
after divorce. It is generally accepted that mothers are the holders of the father-child
relationship, both during marriage and after divorce, and that mothers’ attitudes toward
fathers’ parenting roles affect the extent of fathers’ parenting more so than fathers’ own
attitudes (Doherty, 1998; Pleck, 1997). Angry mothers may exclude fathers in order to
preserve power and control during and after the marriage or divorce. Thus, for the child
in the high-conflict marriage, the consequence may be not only less paternal involvement,
but also more negative interactions with and feelings of rejection by the father as well.
Risk Factors Linked to Gender

In numerous studies over the past three decades, children with divorced parents have been
reported to be more aggressive, impulsive, and to engage in more antisocial behaviors,
when compared to matched samples of children with never-divorced parents (Kelly, 2000).
While some earlier studies reported that boys from divorced families had more externalizing
problems than did girls, others have not. In a more recent, nationally representative sample
of 618 married and divorced-never-remarried families assessed at two points in time, no
gender differences could be linked to divorce (Vandewater & Lansford, 1998). Rather, in
the overall population boys had significantly more externalizing behaviors than did girls,
regardless of family structure. Of significance is that the study also did not support earlier
reports that depression and anxiety were more common for girls than boys as a result of
divorce. Hetherington (1999) points to the complexity of the gender-age adjustment issue,
in that adjustment and achievement in boys and girls after divorce were found to vary by
age, time since divorce, type of parenting, and type and extent of parental conflict.
Risk Factors Linked to Age

Research findings regarding the risk factors correlated with the child’s age at the time of
divorce and the length of time spent in the divorced household are contradictory. The work
of Hetherington, Cox, and Cox (1978) suggests that more detrimental effects are associ-
ated with children of younger ages, a finding supported by Kurdek and Berg (1983), who
report that older children have fewer adjustment problems.
The Guidubaldi study (Guidubaldi, Perry, & Cleminshaw, 1983) indicates that older girls
adjust better to divorce than younger girls do, with the reverse being true for boys. This find-
ing is further supported by a 2-year follow-up in which fifth-grade girls from divorced fami-
lies were most indistinguishable from those in intact homes, whereas fifth-grade boys show
an increase in problems over those presented in first grade (Guidubaldi, 1984). However
for families with extreme and continuing high conflict after divorce, more emotional and
behavioral problems existed for children with more frequent transitions and shared access,
particularly among girls than for children in sole custody situations (Johnston, 1994).
Risk Factors Linked to Parental Adjustment and Environment

Closure or resolution of the divorce happens at both the level of the family as a whole
and the individual level. Wallerstein (1983) has conceptualized the child’s resolution
of the divorce as a series of developmental tasks. These tasks follow a particular time
sequence, beginning with the critical events of the parental separation and culminating in
young adulthood. However, persistent, intense marital discord and marital dissatisfaction,
including discipline, parent–child aggression, and affective responses, pervasively under-
mine the quality of parenting (Fincham et al., 1994), and have a negative impact on the
child’s ability to successfully master the important developmental tasks associated with
divorce resolution.
Kurdek and Berg (1983) have identified parent-related factors that influence positive
adjustment following marital breakup. They found that “children’s divorce adjustment
is significantly related to their mothers’ use of social support systems, to their mothers’
own divorce adjustment, to low maternal stress levels, and to low interpersonal con-
flict” (p. 58). Several studies have indicated that maternal depression is an important risk
factor in general and for children of divorce (Taylor & Andrews, 2009).
The quality of the interaction with the noncustodial parent figured significantly, whereas
the frequency and regularity of the visits were not significantly related to good adjustment.
After divorce, there is no buffering effect provided by the nonresidential parent when the
child experiences erratic, hostile, or depressed parenting in the custodial residence. However,
buffers have been identified in research that help protect children in high-conflict marriages,
including a good relationship with at least one parent or caregiver, parental warmth, the
support of siblings; and for adolescents, having good self-esteem and peer support (Emery,
1999; Neighbors, Forehand & McVicar, 1993). A positive school environment can also
provide a crucial buffer when the child’s home and family life is increasingly chaotic. When
some of these buffering factors are present at the time of divorce, adjustment is improved.
Developmental Factors
Attachment theory offers another explanation of why some children demonstrate resil-
iency during the period of adjustment and others develop a crisis response (Faber & Wit-
tenborn, 2010). Children with secure attachment bonds are able to regulate affects and
maintain close connections with their parents, in spite of the fact that parents may be less
available to them. Divorce may also increase the likelihood of a child developing an inse-
cure attachment (Tippelt & Konig, 2007).
Conceptualizing a Comprehensive Model of Prevention

Earlier crisis intervention studies have helped us understand emotional responses to loss
(Caplan, 1981). Lindemann’s (1944) pioneering work is aimed at reducing the traumatic
effects of catastrophic loss when individuals are the victims of natural disasters. Bowlby
(1980, 1982), Ainsworth (1969), and Mahler, Pine, and Bergman (1975) studied the
impact of attachment, separation, and loss on the child. Special attention was given to
the young child’s attempt to master the temporary or permanent loss of the primary care-
taking figure at particular developmental phases.
Children experiencing the crisis of divorce frequently must deal with ongoing or repeated
experiences of loss coupled with feelings of rejection. In many cases, the decision to divorce
is preceded by one or more parental separations involving the departure of one parent
from the existing family (Bloom, Asher, & White, 1978). The child faces the additional
complexity of knowing that the parental decision to separate and divorce was made by
choice, which at some level is experienced by the youngster as a rejection. Typically, the
youngster is also expected to develop relationships with subsequent parent substitutes and
newly acquired siblings. Competition for attention and affection and feelings of isolation
are frequent occurrences.
Although many writers have described efforts at treating children of divorce in groups,
little was previously written that conceptualizes the activity group as part of an overall
preventive approach to children as members of schools and communities (Drake, 1981).
As the realization becomes clearer that the “typical” American family is no longer the
“norm,” the need for organizational changes to accommodate the multiplicity of actual
family structures also becomes clearer. Although a direct counseling service with students
represents one way of helping them cope with stress, a broader preventive perspective
is necessary. The original concept for helping children cope with divorce through group
intervention was developed in conjunction with the School Services Program of the Center
for the Family in Transition (Wallerstein, 1980). A school-based intervention incorporat-
ing activity groups for children of divorced families, along with ongoing teacher training
and consultation, plus parent involvement, was designed. Through collaboration with
administrators and faculty, the group interventions became an avenue for helping to cre-
ate system changes for families in transition at both the school and family level. Over the
subsequent years to the present, recent researchers, educators, and mental health profes-
sionals have further developed and implemented divorce-related groups (DeLucia-Waack,
2011; Pedro-Carroll, 1999; Roseby, Johnston, Gentner, & Moore, 2005).
Effective Administrative Changes

At the administrative level many educators and administrators have been encouraged to
look critically at their policies toward nonresidential parents. Issues including the redesign
of registration forms to include both parents and the establishment of policies encourag-
ing issuance of duplicate report cards, parent–teacher conferences, and school calendars
have been addressed and implemented within many schools. Due to limitations in time
and economic resources, these changes have taken place slowly and with more effort than
one would expect. For example, administrators continue to develop guidelines for fac-
ulty members faced with the complexities of conducting parent–teacher conferences with
parents who do not reside together. As Ricci (1979) points out, children continue to need
both parents. The refusal of social institutions, such as the schools, to open up avenues
that encourage responsible relationships on the part of both parents with their children
only serves to weaken family ties in the postdivorce family. It is through administrative
consultation aimed at effecting such changes that school psychologists and counselors can
best apply a model of primary prevention in their schools.
Working with Teachers

In a preventive intervention, it is clear that one cannot work effectively within a system
by offering service to one segment without understanding the nature of the impact on the
related segments, and without developing plans to address the impact. It is only by helping
teachers acquire greater understanding of a child’s classroom behavior as a response to
this disruption. By developing more effective strategies for aiding a student’s learning,
despite the disruption, one is able to support individual or group work with the child.
The following case serves as an illustration of how collaborative efforts with teachers
can lead to a better understanding of a child’s school performance, increase empathy for
the youngster, and enhance the possibility of reaching the student educationally through
the use of alternative strategies:
A frustrated teacher complained of the immature quality of one girl’s illustration for
an essay, using it as an example of the generally poor quality of the student’s work.
The clinician was able to reframe the “immaturity” in this particular illustration of a
house and a bunny rabbit in a sunny field by talking about this 12-year-old’s desperate
need for mothering and comfort, which were triggered by the assigned topic, “Those
were the Good Ol’ Days.” When seen in light of a longing for the pre-divorce family,
this child’s “immature” work was less frustrating to the teacher.
In-service training for teachers has been used to educate them about children’s reac-
tions to marital crisis. We have found that Wallerstein’s (1983) conceptualization of the
child’s resolution of the divorce as a series of developmental tasks is a useful educational
concept. Elucidating common age-specific postdivorce behaviors and how these might be
seen in the classroom is equally important. Vignettes and case presentations are used as a
way of helping groups of teachers think about how they cope with troublesome classroom
behavior, and how they deal with nonresidential parents. For example, one often-voiced
complaint on the part of teachers is the difficulty in handling the anger of the latency-age
boy, which often surfaces as “acting up” in class and refusing to do school work. In several
cases where these youngsters’ nonresidential fathers were invited by the teacher to discuss
the problem and become an active part of the teacher–parent team, the children’s trouble-
some behavior lessened.
Programs for Parents

There are several excellent books for parents to help them learn about divorce and children
(e.g., Pedro-Carroll, 2010). However, many parents will need the structure of an organized
program led by a professional. Programs aimed at parents not only help them mediate
relationships with a spouse, but also help them find ways to lessen the effect of divorce on
children. One example is Kid’s Turn (Cookston & Fung, 2011; Hannibal, 2006). These
programs may be implemented in the community or sponsored by the school, and may
be court-ordered (Blaisure & Geasler, 2006). Parents are given strategies for working
through the divorce and information about how children typically adjust to divorce, given
their age. They are given skills for communicating with children and with the child’s other
parent. A particular focus is on improving parenting skills (Cookston & Fung, 2011).
Program evaluation studies have yielded promising results, although many suffer from
methodological flaws (Amato, 2010).
Individual Counseling Interventions
General Considerations
References are drawn primarily from the seminal work of Wallerstein and Kelly (1980),
which remains the richest source of clinical data regarding age-specific risk and postdivorce
interventions. More recent work by Roseby, Johnston, Gentner and Moore (2005), and
Pedro-Carroll, Sutton and Wyman (1999), elaborate on Wallerstein’s ideas and provide
detailed examples of school interventions. In their article on brief interventions (1977),
Kelly and Wallerstein describe the divorce-specific assessment (particularly useful to school
psychologists). They evaluate the following factors: (a) each child’s overall developmental
achievements; (b) each child’s unique responses to, and experiences with, the divorce; and
(c) the support systems available to each child. In particular, they are concerned with how
the child understood the meaning of the divorce.
In formulating school-based interventions for children with familial disruptions, the
following must be considered: (a) a youngster may be experiencing a chronic and highly
stressful series of events lasting in some cases for the entirety of the youngster’s school
years; (b) a youngster may be experiencing a set of indirectly related transitions such as
loss of home, change in neighborhood or school, and so on, increasing the stress of the
actual familial disruption; (c) a youngster may simultaneously lose the support of extrafa-
milial figures and be particularly needy of nurturance from empathic adults with whom he
or she spends time; and (d) a youngster’s capacity to cope with stress is dependent on his
or her sex, age, developmental temperament, and problem-solving skills.
Interventions with Preschoolers

Wallerstein and Kelly (1980) suggest that interventions with preschoolers who do not
have a history of emotional difficulties should focus primarily on the parents. The central
intent should be to help parents communicate more effectively with their preschooler and
better understand the causes of the child’s distress. Frequently, preventive interventions
involve stabilizing aspects of both the care-taking situation and visits with the noncus-
todial parent.
Interventions with Young Elementary School Children

Interventions for this age group need to take cognizance of the child’s realistic under-
standing of the basis for the divorce. Just as children of this age generally have difficulty
in talking about issues involving strong feelings, they have considerable trouble in talking
about their parents’ divorce. Wallerstein and Kelly (1980) found it necessary to develop
an indirect technique for discussing the multiple and complex feelings that arose from
the marital disruption. For example, the therapist would recount what such an experi-
ence was like for other youngsters of the same age, while specifically utilizing familial
information unique to this child’s situation in order to help the child express the pain-
ful feelings. Thus, the “divorce monologue” was born. Kalter et al. (1984) and Roseby
et al. (2005) describe similar storytelling approaches utilizing fantasy, displacement, and
projection.
Adolescents
Adolescents, as they move into formal operational thought, are better able to use tradi-
tional talk therapy. Cognitive behavioral therapy or nondirective counseling can help them
identify emotions and conceptualizations that are not adaptive in their current situations.
They are also moving away from the family and transferring their frame of reference from
the family to peers and adult role models, and are better able to conceptualize the future.
Resources for individual or family therapy may not be available, however. One of the more
useful methods of intervention in the school is the divorce group.
Group Interventions
Research in crisis theory and its application has shown that individuals who receive cogni-
tive guidance and emotional support for coping with a stressful situation have a reduced
risk for developing mental and physical illnesses. The use of group techniques in meeting
the needs of individuals in stressful situations has proven successful. Often, in fact, chil-
dren who have lived with conflict show a marked preference for group over individual
treatment. In a group, they can reduce some of the shame about their family situation and
find out that they are “not the only one” (Johnston et al., 2009; Roseby et al., 2005), thus
normalizing the divorce experience.
Beginning with the work of Cantor (1977, 1979), time-limited counseling groups have
been used to help students whose parents recently were separated or divorced and who
show signs of behavioral disruptions. Typically, these groups are offered to older elemen-
tary school students of both sexes. Content centers on a child’s confusion concerning the
reasons for the divorce, loyalty conflicts, visitation issues, problems with stepparents and
siblings, and so on. Children report that sharing reactions to typical divorce-related issues
offers them support and comfort. When postgroup interviews are held, group members
uniformly indicate that the groups were of help to them.
Roseby and Johnston (1997) and Pedro-Carroll, Sutton and Wyman (1999) describe
successful school-based group intervention programs. A 2-year follow-up of a school-
based group for young children of divorce reports significant decrease in postdivorce
anxiety, and overall improvement in coping (Pedro-Carroll, 1999). Stolberg and Cullen
(1983) and Stolberg and Garrison (1985) describe groups that are part of a multimodel
prevention program designed to facilitate postdivorce adjustment of mothers and children.
Their 12-session children’s groups were structured to include weekly meetings of one hour
each with small groups of students ages 7 to 13. Participants were from families who were
within 33 months of parental separation. Relaxation, impulse and anger control tech-
niques, and communication skills were taught through methods that included modeling
and role playing. Outcome data indicate that the child participants attained better self-
concepts at the end of 12 sessions. At the 5-month follow-up, child participants also were
found to have improved social skills.
Pedro-Carroll and her colleagues (Pedro-Carroll, 1985; Pedro-Carroll & Cowen, 1985;
Pedro-Carroll & Jones, 2005) report on children’s school groups in which they used a
variation of Stolberg and Cullen’s (1983) strategies for teaching effective coping skills
to children in the postdivorce family. Their 10-week-long groups included students from
fourth to sixth grade, with widely varying lengths of time from the parental divorce.
In the first three sessions, the main goal is to build support for children by giving them
opportunities to share common feelings related to the parental divorce and to help clarify
common misconceptions about divorce. This process is accomplished by the use of film-
strips on parent–child reactions to marital dissolution and discussions of feelings common
to children in the divorcing family. Sessions 4 through 9 attempt to help children learn
social problem-solving skills. Using role playing and discussion, leaders emphasize defin-
ing problems, thinking of ways to solve problems or recognizing that a problem cannot be
solved by the child alone, and recognizing consequences of behavior.
With the acquisition of better coping skills, children feel less out of control and the
tendency to act out is decreased as the sense of mastery increases. Sessions 10 and 11 are
spent focusing on understanding the causes of anger and helping youngsters to express
anger appropriately. The final sessions are used to help children arrive at more differen-
tiated views of the family through discussion of various family forms, and to terminate
the group. The participants reported an increased sense of mastery as well as a decreased
sense of isolation and confusion. Positive effects of the group intervention were seen both
clinically and statistically.
Setting Up the Group

This section discusses issues involved in conducting direct group interventions on the
school site with elementary and junior high school students. Our experience has come
from working as outside consultants in suburban public school systems in California.
Group Structure. Groups met once weekly for 50–75 minutes over a 6- to 12-week
period. Variation in duration and number of group sessions was dictated by the vagaries
of the school calendar. Our preference is for a 1-hour weekly meeting, over a 10-week
period. This is the general consensus of the length of session and number of weeks in the
literature referred to previously.
Group Heterogeneity. Groups have included children from families in which the initial
disruption ranged from 10 years to 3 months prior to the start of the group intervention.
Those children with greater distance from the initial familial disruption helped those chil-
dren for whom the divorce and resulting trauma were more recent. This is a finding con-
firmed by Kalter and his colleagues (Kalter, Schaefer, Lesowitz, Alpern, & Pickar, 1988).
In some groups, not all of the children had experienced the loss of the intact family as
a result of divorce. Children were also included whose parents, although never married
did live together and coparent, subsequently terminated their living arrangements. As in
most of the group interventions described in the literature, our groups were primarily
mixed gender groups, with five to eight children in each. Less than five children is too few
because the loss of a member due to absenteeism is a common phenomenon and more
than eight children does not allow enough time for the discussion of individual concerns.
Establishing same-gender groups for young adolescents has some advantages over mixed-
gender groups. Because parental dating and sexuality are especially important concerns
at this age, single-gender groups allow these young people to discuss their perceptions of
parental sexuality without the burden of concurrently feeling strong heterosexual pulls
toward others in the group.
Confidentiality. Confidentiality, always an important issue in treatment, assumes a mag-
nitude not easily grasped until one actually works in the school setting. Group members
have a history with one another before the group starts, as do their parents and teachers.
Addressing the issue of confidentiality with all concerned is vital. The extension of the
group over a period of 10 to 12 weeks helps surmount the greater resistances to disclosure
caused by the fact that children see and know one another in a context other than the
group setting.
An example of such a problem was experienced when two young adolescents who
were boyfriend and girlfriend were asked to be in the same group. Although they initially
complied, their difficulty in discussing the recent divorce of their parents in front of one
another was insurmountable, and eventually both left the group. Letting students know
prior to the group who the participants may be is a prudent move that gives children and
leaders time to assess the previously established interpersonal relationships among chil-
dren. Although this raises a new question of confidentiality, on balance this seems minor
in comparison with selecting a compatible group.
Pregroup Interviews. Considerable attention was given to differentiating longstand-
ing psychopathology from reactive responses to the familial change. The group leader
conducted individual interviews with each child participant that lasted between 1 and
2 hours. Wallerstein’s (1983) conceptualization of the child’s resolution of divorce as a
series of developmental tasks, the Kinetic Family Drawing (K-F-D) (Burns, 1987), and the
Coopersmith Scale of Self-Esteem (Coopersmith, 1967), along with the divorce-specific
assessment technique (Wallerstein & Kelly, 1980), were utilized to gain the necessary diag-
nostic information for structuring group interventions.
Postgroup Interviews. An individual interview was carried out within 1 month of the
final group session. Its purpose was to evaluate the child’s subjective response to the group,
to offer an opportunity to discuss specific family and school problems in greater depth,
and to offer the child an opportunity to request the group leader’s help in dealing with
significant adults in his or her life. In some cases this resulted in family sessions or confer-
ences among school personnel, child, and parents in order to address problems that the
child had reported. The vast majority of participants (95%) expressed enthusiasm over
group participation, and stated that the peer support they had gained was critical to them.
Follow-Up Interviews. In those schools where we have worked on-site for a period of
years, we have employed a follow-up with the students, their parents, and faculty partici-
pants. These interviews take place approximately 9 to 10 months after the initial group
intervention. The extent of the follow-up varies with information provided either by fac-
ulty or through our own observations regarding youngsters at risk. Depending on the
students’ postdivorce adjustment, a variety of interventions are instituted, ranging from
special class placement and referrals for psychological treatment to consultation and col-
laboration with parents and/or faculty and administration.
Assessing Referrals to the Group and Determining Group Content

Although the literature just reviewed describes excellent school-based group interven-
tions, writers have not sufficiently demonstrated how such interventions address either
the child’s particular family situation or the stage of resolution the child has reached. Most
of the programs that have been described in the literature accept children into groups with
widely varying time from divorce. However, this heterogeneity may result in groups where
the crisis of coping with the actual divorce is not the primary need of the participant. Inclu-
sion of children with many years’ distance from the marital rupture may shift the focus of
the group from one of a crisis intervention to a model characterized by the tenets of tertiary
prevention. Thus, the demands for collateral work with parents and teachers increase.
In the group itself, issues involving adjustment to the postdivorce family and “working
through” loss, disappointment, and anger rather than coping with crisis come to the fore.
How such a group may facilitate working through can be seen in the following example:
One group participant was a child whose father had recently returned from a vaca-
tion announcing he had remarried while away. Not only was the child not invited to
the wedding, he was not even told of plans for the marriage. During a group meet-
ing when this child happened to be absent, the group planned a picnic. Knowing the
child’s struggle with feelings of being left out and powerless, the group leader met
with the child individually to let him know of the proposed plan. During this meeting
the group leader commented on the similarity between the two circumstances and the
child was able to acknowledge his feelings.
Because of the probable mandate to provide treatment for students exhibiting problems
at school, and due to the constraints of time placed on the school psychologist or coun-
selor, it is not likely that these professionals will be able to offer group interventions to an
entire school population. When screening students referred to groups and determining the
actual content of group sessions, the following should be considered.
We have found that those participants who had experienced a familial change within
two years of participation benefited most from the group. They were able to use the group
to lessen confusion, increase coping skills, and gain emotional support. Children with
longstanding difficulties and no recent familial change benefited less from the standard-
ized group format. However, when individualized group sessions were combined with
collateral work with parents and teachers to meet specific needs of children in the latter
group, more benefit accrued. By using historical information gained in individual inter-
views, group sessions that differed significantly from group to group could be constructed.
Group activities were “tailor-made” to address specific issues in the youngsters’ histories.
For example, in one group of students with great disparity in length of time from initial
marital separation, the common themes of all sessions related to parental remarriage.
Sibling rivalry and problems of having to share with stepparents were addressed through
interpreting the competition among group members for attention from the leader and their
response to including a new member in the group. In another group with several children
from remarried families, family trees were constructed. Over half of the participants “dis-
covered” that their grandparents had been divorced. The feelings that they might have in
common with their parents as “children of divorce” became the focus of discussion.
Some group activities lend themselves particularly well to being used with many differ-
ent groups while retaining their individual nature. For instance, “Dear Abby” letters can
be written by the group leader prior to meeting, posing problems from the lives of the
particular group members. These can then be answered as part of a group activity. Journals
can be used in many ways during a group to give a sense of privacy and individuality. For
example, sketchbooks in which youngsters can write to the group leader between sessions
and receive answers confidentially can give a sense of continuity to the group, “holding”
youngsters between sessions. During the final session, after discussing how children can
use their peer group for support, group photos added to the journal give children a con-
crete group remembrance to leave with.
Parent Participation
A school administrator or pupil personnel employee made initial contact with the custo-
dial parent, and almost without exception consent was given for the child’s participation
in a group. Following this, a letter detailing group goals and logistics was sent along with
a written consent form. The custodial parent was then engaged in a face-to-face contact
with the group leader either (a) in an individual, pregroup interview, (b) a one-time evening
meeting for parents of all participating children with individual postgroup interviews, or
(c) a series of four evening group meetings designed to parallel the children’s group. The
choice of format evolved during the 5 years of our work in the schools and is based on
availability of clinical time and the perceived needs of the parents and school. All parents
were requested to complete a questionnaire about their child that asked for school history,
previous psychotherapy, description of current custody arrangements, and their view of
the child’s strengths and weaknesses. Parents were told that the information would be kept
confidential and would not become part of the child’s school record.
Included in the questionnaire was a request to contact the child’s noncustodial parent.
Because research clearly indicates that children who have continued stable contact with
both parents generally fare better in the postdivorce family, we believe that inclusion of the
noncustodial parent in school-related activities is crucial to good postdivorce adjustment.
We found that in most families in which both parents still resided in the same geographic
area, permission to contact the noncustodial parent was readily given. Parent group meet-
ings were less specifically child-focused than individual consultations with parents. Group
participants used the meetings primarily to relieve a myriad of divorce-related feelings,
including anger, guilt, shame, and worry. However, these psycho-educational parent
groups can also be used to provide information about the effects of family conflict in
general and then translate these general issues into more specific problems of individual
children (Roseby & Johnston, 1997).
Teacher Participation
Consistent involvement of teachers is an important facet of creating successful preven-
tion models for the school system. Although direct work with families, either in group
or individual interventions, must be carried out by a person with professional mental
health training, it is the teacher who will have the greatest cumulative effect on the largest
number of students and therefore must be a central collaborator in this process. Of major
importance as well are administrators who make policy determinations regarding how the
needs of single-parent and remarried families will be incorporated in their schools. Our
intervention thus has included a strong emphasis on consultation with teachers regarding
the child participants in our groups. After discussing their referral suggestions, each class-
room teacher was asked to fill out two written evaluations at the beginning and end of the
group. These evaluations helped teachers focus their attention on students in a behavior-
specific way. During the course of the group, the leader was available for weekly consulta-
tions with the teachers of participating youngsters. In many instances such consultations
took the form of a 5-minute check-in. In some cases, the group leader facilitated conjoint
conferences among teachers, parents, and students in an effort to enhance communication
about a student’s school progress.
The cumulative effect of such consultative efforts has been considerable. At the second-
ary prevention level, the classroom teachers involved in this approach have come away
with an informed stance vis-à-vis these families. This is reflected in their more thoughtful
approach to including nonresidential parents in academic planning, in their sensitivity to
the language with which they describe nonintact families, and in the development of skills
to recognize what may be a reactive depression to the family change.
Summary
Given the prevalence of divorce in the United States, coupled with the clear evidence that
many youngsters have resultant learning problems, school personnel must become prepared
to engage in prevention strategies with this population. Evidence has mounted sufficiently to
indicate that the school may well be the single most comprehensive continuing resource for
children during the divorce crisis. This places the school psychologist or counselor in a unique
position to intervene broadly at the systems level and develop appropriately varied and com-
prehensive programs to meet this community need. Examples of preventive school-based pro-
grams that address the multiple and frequently chronic stressors affecting the lives of children
and adolescents experiencing divorce were described. The need to assess each youngster’s
respective resolution of the divorce and accommodation to the postdivorce family as criti-
cal elements in planning on-site, time-limited psycho-education groups was also highlighted.
Further, given the nature of the stressor and the resultant family disequilibrium, often continu-
ing beyond a 2- or 3-year period, the school becomes a primary (if not exclusive) source of
ongoing support and guidance for youngsters. Educators and mental health professionals are
able to provide short-term group interventions for students in the larger context of teacher,
administrator, and parent collaboration. The effectiveness of this model lies in ongoing but
brief contacts with identified children at risk, their families, and school personnel, as required.
REFERENCES
Afifi, T. D., Afifi, W. A., & Coho, A. (2009). Adolescents’ physiological reactions to their parents’ nega-
tive disclosures about the other parent in divorced and nondivorced families. Journal of Divorce &
Remarriage, 50(8), 517–540. doi:10.1080/10502550902970496
Afifi, T. D., & McManus, T. (2010). Divorce disclosures and adolescent’s physical and mental health
and parental relationship quality. Journal of Divorce & Remarriage, 51, 83–107. doi:10.1080/
10502550903455141
Ainsworth, M. (1969). Object relations, dependency and attachment: A theoretical review of the
infant mother relationship. Child Development, 40, 969–1025.
Amato, P. R. (2010). Research on divorce: Continuing trends and new developments. Journal of
Marriage and Family, 72(3), 650–666. doi:10.1111/j.1741–3737.2010.00723.x
Amato, P. R., & Gilbreth J. G. (1999). Nonresident fathers and children’ well-being: A meta-analysis.
Journal of Marriage and Family, 61, 557–573.
Amato, P. R., & Keith, B. (1991). Parental divorce and adult well-being: A meta-analysis. Journal
of Marriage and Family, 53, 43–58.
Amato, P. R., Loomis L., & Booth A. (1995). Parental divorce, parental marital conflict, and off-
spring well-being during early adulthood. Social Forces, 73, 895–916
Baydar, N. (1988). Effects of parental separation and reentry into union on the emotional well-being
of children. Journal of Marriage and the Family, 50, 967–981.
Belsky, J., Youngblade, L., Rovine, M., & Volling, B. (1991). Patterns of marital change and parent-
child interaction. Journal of Marriage and Family, 53, 487–498.
Blaisure, K. A., & Geasler, M. J. (2006). Educational interventions for separating and divorcing
parents and their children. In M. Fine & J. Harvey (Eds.), Handbook of divorce and relationship
dissolution (pp. 575–602). Hillsdale, NJ: Erlbaum.
Bloom, B. L., Asher, S. J., & White, S. W. (1978). Marital disruption as a stressor: A review and
analysis. Psychological Bulletin, 85, 867–894.
Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss, sadness and depression. New York: Basic Books.
——— (1982). Attachment and loss: Retrospect and prospect. American Journal of Orthopsychiatry,
52, 664–678.
Brown, F. B. (1980). Children from one-parent families. Phi Delta Kappan, 62, 537–540.
Buehler, C., Krishnakumar, A., Stone, G., Anthony, C., Pemberton, S., Gerard, J., & Barber, B.
(1998). Interparental conflict styles and youth problem behaviors: A two-sample replication study.
Journal of Marriage and Family, 60, 119–132.
Burns, R. C. (1987). Kinetic-house-tree-person drawings (K-H-T-P): An interpretative manual. New
York : Brunner/Mazel.
Cantor, D. W. (1977). School-based groups for children of divorce. Journal of Divorce, 1, 183–187.
——— (1979). Divorce: A view from the children. Journal of Divorce, 2, 357–361.
Caplan, G. (1981). Mastery of stress: Psychosocial aspects. American Journal of Psychiatry, 138,
413–420.
Cherlin, A., Furstemberg, F., Chase-Lansdale, L., Kiernan, K., Robins, P., Morrison, D., & Teitler, J.
(1991). Longitudinal studies of divorce on children in Great Britain and the United States. Science,
252, 1386–1389.
Coddington, R. D. (1972). The significance of life events as etiologic factors in the diseases of children—
II. A study of a normal population. Journal of Psychometric Research, 16, 205–213.
Cookston, J. T., & Fung, W. W. (2011). The kids’ turn program evaluation: Probing change within
a community-based intervention for separating families. Family Court Review, 49(2), 348–363.
doi:10.1111/j.1744–1617.2011.01376.x
Coopersmith, S. (1967). The antecedents of self esteem. San Francisco: Freeman.
Cummings, E. M., & Davies, P. T. (1994). The impact of parents on their children: An emotional
security perspective. In R. Vesta (Ed.), Annals of child development (Vol. 10, pp. 167–208). Bristol,
PA: Jessica Kingsley Publishers.
DeLucia-Waack, J. L. (2011). Children of divorce groups. In G. L. Greif & P. H. Ephross (Eds.),
Group work with populations at risk (3rd ed., pp. 93–114). New York: Oxford University Press.
Doherty, W. J. (1998). Responsible fathering: An overview and conceptual framework. Journal of
Marriage and the Family, 60, 277–292.
Drake, E. A. (1981). Helping children cope with divorce: The role of the school. In I. R. Stuart &
L. E. Abt (Eds.), Children of separation and divorce: Management and treatment (pp. 147–172).
New York: Van Nostrand Reinhold.
Drake, E. A., & Shellenberger, S. (1981). Children of separation and divorce: A review of school
programs and implications for the psychologist. School Psychology Review, 10, 54–61.
Emery, R. (1999). Marriage, divorce, and children’s adjustment (2nd ed.). Thousand Oaks, CA: SAGE.
Emery, R. E., & Forehand, R. (1996). Parental divorce and children’s well-being: A focus on resilience.
In R. J. Haggerty & L. R. Sherrod (Eds.), Stress, risk, and resilience in children and adolescents:
Processes, mechanisms, and interventions (pp. 64–99). New York: Cambridge University Press.
Faber, A. J., & Wittenborn, A. K. (2010). The role of attachment in children’s adjustment to divorce
and remarriage. Journal of Family Psychotherapy, 21(2), 89–104. doi:10.1080/08975353.2010.4
83625
Fincham, F. D., Grych, J. H., & Osborne, L. N. (1994). Does marital conflict cause child maladjust-
ment? Directions and challenges for longitudinal research. Journal of Family Psychology, 8, 128–140.
Frisco, M. L., Muller, C., & Frank, K. (2007). Parents’ union dissolution and adolescents’ school per-
formance: Comparing methodological approaches. Journal of Marriage and Family, 69, 721–741.
Furstenberg, F. F., & Teitler, J. O. (1994). Reconsidering the effects of marital disruption: What hap-
pens to children of divorce in early adulthood? Journal of Family Issues, 15, 173–190.
Gardner, R. (1976). Psychotherapy with children of divorce. New York: Jason Aronson.
Goldman, R. K. (1981). Teachers look at children of divorce in the classroom. Corte Madera, CA:
Center for the Family in Transition.
Goldman, R. K., & King, M. J. (1985). Counseling children of divorce. School Psychology Review,
14, 278–290.
Goldman, R. K., King, M. J., & Lamden, A. (1983, April). School-based interventions with children of
divorce. Paper presented at the meeting of the American Orthopsychiatric Association, Boston, MA.
Grych, J., & Fincham, F. (1993). Children’s appraisal of marital conflict: Initial investigations of the
cognitive-contextual framework. Child Development, 64, 215–230.
Guidubaldi, J. (1984). Differences in children’s divorce adjustment across grade level and gender: A
report from the NASP-Kent State Nationwide Project. Kent, OH: Kent State University.
Guidubaldi, J., Cleminshaw, H., & Perry, J. D. (1985). The relationship of parental divorce to health
status of parents and children. Special Services in the Schools, 1, 73–87.
Guidubaldi, J., Perry, J. D., & Cleminshaw, H. K. (1983). The legacy of parental divorce: A nation-
wide study of family status and selected variables on children’s academic and social competencies.
Kent, OH: Kent State University.
Guidubaldi, J., Perry, J. D., Cleminshaw, H. K., & McLoughlin, C. S. (1983). The impact of parental
divorce on children: Report of a nationwide NASP study. School Psychology Review, 12, 300–323.
Hannibal, M. E. (2006). Good parenting through your divorce: The essential guidebook to helping
your children adjust and thrive—Based on the leading national program. New York: Da Capo Press.
Harrist, A. W., & Ainslie, R. C. (1998). Marital discord and child behavior problems: Parent-child rela-
tionship quality and child interpersonal awareness as mediators. Journal of Family Issues, 19, 140–163.
Hetherington, E. M. (1979). Divorce: A child’s perspective. American Psychologist, 34, 851–858.
Hetherington, E. M. (Ed.). (1999). Coping with divorce, single parenting, and remarriage: A risk and
resiliency perspective. Mahway, NJ: Lawrence Erlbaum.
Hetherington, E. M., Bridges, M., & Isabella, G. M. (1998). What matters? What does not? Five
perspectives on the association between marital transitions and children’s adjustment. American
Psychologist, 53, 167–184.
Hetherington, E. M., Cox, M., & Cox, R. (1978). Play and social interaction in children following
divorce. Journal of Social Issues, 35, 26–49.
Hetherington, E. M., & Kelly, J. (2002). For better or for worse: Divorce reconsidered. New York:
Norton.
Hunter, J. E., & Schuman, N. (1980). Chronic reconstitution as a family style. Social Work, 26,
446–451.
Huurre, T., Junkkari, H., & Aro, H. (2006). Long-term psychosocial effects of parental divorce: A
follow-up study from adolescence to adulthood. European Archives of Psychiatry and Clinical
Neuroscience, 256(4), 256–263. doi:10.1007/s00406–006–0641-y
Jacobson, D. S. (1978a). The impact of marital separation/divorce on children. Journal of Divorce, 1,
341–360.
——— (1978b). The impact of mental separation/divorce on children: III. Parent-child communication
and child adjustment, and regression analysis of findings from overall study. Journal of Divorce, 2,
175–194.
Johnston, J. R. (1994). High conflict divorce. The future of children, 4, 165–182. doi: 10.2307/1602483
Johnston, J., Roseby, V., & Kuehnle, K. (2009). In the name of the child: A developmental approach to
understanding and helping children of conflicted and violent divorce (2nd ed.). New York: Springer.
Kalter, N., Pickar, J., & Lesowitz, M. (1984). School-based developmental facilitation groups for
children of divorce: A preventive intervention. American Journal of Orthopsychiatry, 54, 613–623.
Kalter, N., & Rembar, J. (1981). The significance of a child’s age at the time of parental divorce.
American Journal of Orthopsychiatry, 51, 85–100.
Kalter, N., Schaefer, M., Lesowitz, M., Alpern, D., & Pickar, J. (1988). School-based support groups
for children of divorce: A model of brief intervention. In B. H. Gottlieb (Ed.), Marshaling social
support: Formats, processes, and effects (pp. 165–185). Newbury Park, CA: SAGE.
Kelly, J. B. (1994). The determination of child custody. The Future of Children: Children and
Divorce, 4, 121–142.
——— (2000). Children’s adjustment in conflicted marriage and divorce: A decade review of
research. Journal of Child and Adolescent Psychiatry, 39, 963–973.
Kelly, J. B., & Wallerstein, J. S. (1977). Brief interventions with children in divorcing families. American
Journal of Orthopsychiatry, 47, 23–26.
——— (1979). Children of divorce. The National Elementary Principal, October, 52–58.
Kline, M., Johnston, J. R., & Tschann, J. M. (1991). The long shadow of marital conflict: A model of
children’s postdivorce adjustment. Journal of Marriage and the Family, 53, 297–309. doi:10.2307/
352900
Kurdek, L. A., & Berg, B. (1983). Correlates of children’s adjustment to their parents’ divorce. New
Directions for Child Development, 19, 47–60.
Lamb, M. E. (Ed.). (1997). The role of the father in child development (3rd ed.). New York: Wiley.
Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psy-
chiatry, 101, 141–148.
Maccoby, E., & Mnookin R. (1992). Dividing the child. Cambridge, MA: University Press.
Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York:
Basic Books.
McLanahan, S. S. (1999). Father absence and the welfare of children. In E. M. Hetherington (Ed.), Cop-
ing with divorce, single parenting, and remarriage: A risk and resilience perspective (pp. 117–145).
Mahwah, NJ: Lawrence Erlbaum Associates.
McLanahan, S. S., & Sandefur, G. (1994). Growing up with a single parent: What hurts, what helps.
Cambridge, MA: Harvard University Press.
McNeal, C., & Amato, P. R. (1998). Parents’ marital violence: Long-term consequences for children.
Journal of Family Issues, 19, 123–139.
National Center for Health Statistics. (2009). Health, United States, 2008 with special feature on the
health of young adults and chartbook. Hyattsville, MD: U.S. Department of Health and Human
Services.
Neal, J. H. (1983). Children’s understanding of their parents’ divorces. New Directions for Child
Development, 19, 3–14.
Neighbors, B., Forehand, R., & McVicar, D. (1993). Resilient adolescents and interpersonal conflict.
Nord, C. W., Brimhall D., & West J. (1997). Fathers’ involvement in their children’s schools. Wash-
ington, DC: National Center for Education Statistics.
Pedro-Carroll, J. (1985). Children of divorce intervention program procedures manual. Unpublished
manuscript, University of Rochester-Center for Community Study, Rochester, NY.
——— (2010). Putting children first: Proven parenting strategies for helping children thrive through
divorce. New York: Avery/Penguin.
Pedro-Carroll, J. L., & Cowen, E. L. (1985). The children of divorce intervention project: An inves-
tigation of the efficacy of a school-based prevention program. Journal of Consulting and Clinical
Pedro-Carroll, J. L., & Jones, S. H. (2005). A preventive play intervention to foster children’s resil-
ience in the aftermath of divorce. In L. A. Reddy, T. M. Files-Hall, & C. E. Schaefer (Eds.), Empiri-
cally based play interventions for children. Washington, DC: American Psychological Association.
Pedro-Carroll, J. L., Sutton, S. E., & Wyman, P. A. (1999). A two-year follow-up evaluation of a
preventive intervention for young children of divorce. School Psychology Review, 28, 467–476.
Peterson, G. W., Leigh, G. K., & Day, R. D. (1984). Family stress theory and the impact of divorce on
children. Journal of Divorce, 7(3), 1–20.
Pleck, J. H. (1997). Parental involvement: Levels, sources, and consequences. In M. E. Lamb (Ed.), The
role of the father in child development (pp. 66–103). New York: Wiley.
Ricci, I. (1979). Divorce, remarriage and the schools. Phi Delta Kappan, March, 509–511.
Roseby, V., & Johnston, J. R. (1997). High-conflict, violent, and separating families: A group treat-
ment manual for school-age children. New York: Free Press.
Roseby, V., Johnston, J., Gentner, B., & Moore, E. (2005). A safe place to grow: A group treatment
manual for children in conflicted, violent and separating homes. Binghamton, NY: Haworth.
Shechtman, Z., & Mor, M. (2010). Groups for children and adolescents with trauma-related symp-
toms: Outcomes and processes. International Journal of Group Psychotherapy, 60(2), 221–244.
doi:10.1521/ijgp.2010.60.2.221
Springer, C., & Wallerstein, J. S. (1983). Young adolescents’ responses to their parents’ divorces. New
Directions for Child Development, 19, 15–27.
Stolberg, A. L., & Cullen, P. M. (1983). Preventive interventions for families of divorce: The divorce
adjustment project. New Directions for Child Development, 19, 71–82.
Stolberg, A. L., & Garrison, K. M. (1985). Evaluating a primary prevention program for children of
divorce: The divorce adjustment project. American Journal of Community Psychology, 13, 111–124.
Sun, Y., & Li, Y. (2009). Postdivorce family stability and changes in adolescents’ academic per-
formance: A growth-curve model. Journal of Family Issues, 30(11), 1527–1555. doi:10.1177/
0192513X09339022
Taylor, R., & Andrews, B. (2009). Parental depression in the context of divorce and the impact on
children. Journal of Divorce & Remarriage, 50(7), 472–480. doi:10.1080/10502550902970579
Tippelt, G. G., & Konig, L. (2007). Attachment representations in 6-year old children from one and
two parent families in Germany. School Psychology International, 28, 313–330.
Vandewater, E., & Lansord, J. (1998). Influences of family structure and parental conflict on children’s
well-being. Family Relations, 47, 323–330.
Wallerstein, J. S. (1983). Children of divorce: The psychological tasks of the child. American Journal
of Orthopsychiatry, 54, 444–458.
——— (1984). Children of divorce: Ten-year follow-up of young children. American Journal of
Orthopsychiatry, 54, 449–458.
Wallerstein, J. S., & Kelly, J. B. (1980). Surviving the breakup: How children and parents cope with
divorce. New York: Basic Books.
Wallerstein J. S., & Lewis J. (2004). The unexpected legacy of divorce: Report of a 25-year study.
Psychoanalytic Psychology, 21, 353–370.
Winnicott, D. W. (1971). Playing and reality. London: Tavistock.
Zill, N., Morrison, D., & Coiro, M. (1993). Long-term effects of parental divorce on parent-child
relationships, adjustment, and achievement in young adulthood. Journal of Family Psychology, 7,
91–103.
6 Bullying: Students Hurting Students
Juliana Raskauskas
Bullying is an unprovoked attack intended to cause distress and discomfort to others.

Although bullying has been a problem for centuries, it is only in the past 20–30 years that
it has become a topic of scholarly investigation and concern, first in Scandinavia (Olweus,
1978, 1993) and later in other parts of Europe and the world (see Jimerson, Swearer, &
Espelage, 2010; Smith et al., 2002). Serious study of this phenomenon in the United States
did not really start until 1998, motivated by a rash of school shootings and findings that
indicated that school shooters were all victimized by bullies at school (Vossekuil, Fein,
Reddy, Borum, & Modzeleski, 2002).
The Problem of Bullying
Definition of Bullying
Bullying is said to occur when a child is the target of any behavior that is (a) harmful or
done with intent to harm; (b) repeated or occurs over time; and is (c) characterized by an
imbalance of power, such that the victim does not feel he or she can stop the interaction
(Espelage & Swearer, 2003; Olweus, 2001). The power imbalance of bullying may not
be dependent on physical strength, but may be due to imbalance in personality, social
status, or number of bullies. Bullying is typically directed at same-gender peers, occurs
within familiar social groups, and often multiple children are involved in the bullying event
(Craig, Pepler, & Atlas, 2000; Greene, 2000).
Included under the umbrella of bullying is a broad spectrum of aggressive behaviors
ranging from nonverbal harassment (e.g., stares and glares), teasing, gossip spreading,
ostracism/exclusion, sexual harassment, ethnic slurs, unreasonable detainment/imprison-
ment, destruction of property, extortion, and physical assault (Espelage & Swearer, 2003;
Olweus, 2001; Ross, 1996). Bullying can be delivered face-to-face, indirectly through
other people, or through the use of technology (Olweus, 1993; Raskauskas & Stoltz,
2007; Vandebosch & Van Cleemput, 2009). The foregoing definition is used in research
and programs about school bullying, but many legal definitions across states behaviorally
define bullying and don’t necessarily require multiple occurrences (Greene, 2010; Swearer,
Espelage & Napolitano, 2009).
This chapter is an updated version of the chapter “Bullying” prepared by Dorothea M. Ross, PhD, of Bainbridge
Island, Washington for the second edition of this text. Parts of the original chapter have been included or modi-
fied without being specifically credited. The majority of information provided in the Counseling Interventions
section was contributed by Dr. Ross.
86 Juliana Raskauskas
Definition of Cyber Bullying
The integration of social technology into the lives of youth today has given rise to a new
form of bullying called cyber bullying. In 2010, Tokunaga created a single integrated
definition from all those previously used in the research: “Cyber bullying is any behavior
performed through electronic or digital media by individuals or groups that repeatedly
communicates hostile or aggressive messages intended to inflict harm or discomfort on
others” (p. 278). The emphasis on power imbalance is often left out of cyber bullying defi-
nitions due to the assumption (founded or not) that the anonymous nature of technology
creates a power imbalance. Rather than define cyber bullying, some studies have instead
asked students if they have been bullied by technology, referencing the definition of school
bullying that inserts power imbalance indirectly.
Cyber bullying primarily makes use of indirect modes of bullying, such as spreading
gossip, rumors, secrets, insults, threats, mean names, and facilitating exclusion (Mishna,
Saini, & Solomon, 2009; Tokunaga, 2010). Some students even go online and pretend
to be the victim or pretend to be someone else to harass the victim (Vandebosch & Van
Cleemput, 2009). Vandebosch and Van Cleemput (2009) add that cyber bullying is mostly
indirect but could be direct through destruction of property, like purposefully sending
virus-infected files, changing passwords, or stealing/altering cell phones. Regardless of the
similarity to bullying, Dempsey, Sulkowski, Nichols, and Storch (2009) concluded from
their research that cyber bullying is a distinct form of bullying, as opposed to an extension
of traditional forms of bullying.
Incidence and Prevalence

The way that bullying and cyber bullying definitions are operationalized in the litera-
ture varies widely. Frequency of bullying and cyber bullying depend on differences in
definitions used, whether direct and indirect forms are included, types of questionnaires,
wording of items, and other methodological differences. Keeping these caveats in mind,
the literature clearly supports the following statements: 15–20% of students are bullied
often enough for them to consider it a serious problem (Crick & Grotpeter, 1995; Orpinas
& Horne, 2006). Nansel et al. (2001) found with a nationally representative sample of
15,686 youth (grades 6–10) that 30% of students had moderate to frequent involvement
in bullying, with 13% bully only, 11% victim only, and 6% with both. This study used one
item to self-identify involvement without providing a clear definition. Bradshaw, Sawyer,
and O’Brennan (2007) found, using a full definition, that 23% of students in grades 4
to 12 were bullied frequently in the past month. Similarly, prevalence reports for cyber
bullying range in the literature from 6% to 38% (see Hinduja & Patchin, 2009). Despite
discrepancies in the exact number of students affected, the research indicates that a sizable
percentage of students are impacted by bullying.
Personal and Social Costs

Bullying affects everyone in the school—those who are bullied, the bullies themselves,
and bystanders who witness the bullying. Bullying creates a climate of fear and anxiety in
a school that can act as a deterrent to learning and engagement for all students (Greene,
2003; Rueger, Malecki, & Demary, 2011; Schwartz, Gorman, Nakamota, & Tobin, 2005).
Bullying others is associated with poor academic performance, missing class due to dis-
ciplinary actions, and deteriorating relationships with teachers and classmates (Orpinas
& Horne, 2006; Thijs & Verkuyten, 2008). Bullying behavior in childhood is associated
Bullying: Students Hurting Students 87
with delinquency in adolescence and abusive relationships or crime perpetration in adult-
hood (Olweus, 1993; Perren & Hornung, 2005). Generally this is because bullies learn
that aggressive strategies are successful in helping them achieve goals.
Being a victim of bullying has also been associated with lower levels of academic achieve-
ment and higher school avoidance (Schwartz et al., 2005; Thijs & Verkuyten, 2008). It
should not be surprising that children who are distracted in class due to fear of bullying
can fall behind in class and often have a difficult time catching up again.
Being victimized by peers has also been associated with higher levels of distress, specifi-
cally higher anxiety, lower self-esteem, and more depressive symptoms, depression, and
suicide ideation (Barchia & Bussey, 2010; Hawker & Boulton, 2000; Meland, Rydning,
Lobben, Breidablik, & Ekeland, 2010; Thijs & Verkuyten, 2008). Rueger, Malecki, and
Demary (2011) found that psychosocial and academic effects occur at the onset of bul-
lying, but that not all of these effects abate without intervention after the bullying stops.
Organization of the Chapter

The personal and social costs of bullying make this an important topic for anyone who
works with children to be aware of. Next, social learning/social-cognitive theory and ecologi-
cal model explanations of bullying are reviewed. Then profiles of those at risk for involvement
(bullies, victims, and bully-victims) are explained followed by a discussion of prevention and
intervention methods. Interventions conducted individually with victims or bullies and those
that instead take a holistic approach with all children involved are presented.
Overview of Causes of the Problem

Many theories have been used to try to explain bullying and its effects. Two major theo-
retical frameworks that are used most extensively in bullying research are: social learning/
social-cognitive theory, a learning approach in which children learn from models, and the
ecological model, an approach focusing on systems.
Social Learning/Social-Cognitive Theory

Social learning theory is based on the premise that children can learn behaviors through
(a) direct transmission from reinforcement and punishment and (b) observing others and
the consequences they receive. Under the banner of this model, children who are aggres-
sive have adult or peer models who display inappropriate behaviors that they then imitate
in their own social interactions (see Bandura, 1977). Troy and Sroufe (1987) report that
some victims invite peers to victimize them as a way of establishing interaction with them.
This may be because these children do not have the skills to interact in nonabusive ways,
due to the fact the victim or bully role has been modeled at home. Likewise, children
whose parents use physical punishment (e.g., Espelage & Swearer, 2003; Ross, 2003; Seeds,
Harkness, & Quilty, 2010) or who are abused in the home (Duncan, 2004; Nickerson,
Mele, & Osborne-Oliver, 2010) are more likely to bully others, presumably due to parents
modeling the use of aggression.
Social-cognitive theory grew out of the social learning perspective and the need to account
for the role of complex cognitions that mediate between reinforcement and punishment or
observational learning and behavior (Bandura, 1986), such as children’s thoughts about self-
efficacy, outcome expectations, causal attributions, and coping strategies (Orpinas & Horne,
2006; Raskauskas, 2005). Social-cognitive theory has been used in schools to address (a) the
environment (increasing awareness and reporting strategies); (b) bullies (lowering aggressive
behavior through eliminating skill deficiencies or rewards for aggression); and (c) victims
(changing causal attributions and coping strategy selection) (Andreou, 2001; Orpinas,
Horne, & Multisite Violence Prevention Project, 2004; Raskauskas, 2005).
Ecological Model
The ecological model is a specialized form of systems theory that describes the complex
relationship of multiple factors that contribute to or prevent behavior, including bully-
ing (Orpinas et al., 2004). The model includes proximal and distal influences usually
conceptualized as concentric circles or multiple layers (Bronfenbrenner & Morris, 2006).
The most inner circle or core is the individual. The next layers encompass the influence
of proximal, or immediate, relationships like parents, peers, friends, siblings interacting
with the child or with each other. Above that are the parents’ work environments, school
organization/policies, and other organizations that can indirectly influence behavior and
cognition. The outer layers are the effects of culture and community and/or the influence
of chronological time on all of the relationships, institutions, and experiences within the
circles below (Bronfenbrenner, 1977, 1979).
The ecological model has been explicitly applied to bullying involvement (Espelage &
Swearer, 2003; Swearer et al., 2006). Factors that contribute to bullying involvement include
personal factors (e.g., social competence, emotional regulation), family factors (e.g., aggres-
sion, supervision, relationships strength), peer factors (e.g., climate, staff training, policies),
and community factors (e.g., violence, resources, connections) (Swearer et al., 2009). Swearer
et al. (2006) tested the ecological model in explaining involvement in bullying among middle
school students using peer attitudes toward bullying, school climate, neighborhood context,
and negative affect for bullying. Findings indicated that the total model was not significant
but that favorable peer attitudes and negative school climate strongly predicted bullying
behavior. This finding is consistent with the ecological model and the authors suggest that
future studies include different or more variables from the surrounding systems.
Profiles of At-Risk Groups: Risk and Protective Factors

Characteristics of those involved in bullying, risk factors, and effects on students will be
reviewed in the subsequent sections. Those involved in bullying are often classified into
specific categories: (a) Bullies or bully-only children are engaged in bullying behavior but
are not victimized by others; (b) Victims or victim-only children score high on victimization
but do not score high on bullying behavior; (c) Bully-victims both bully others and are being
bullied themselves; and (d) Bystanders are children who witness bullying that occurs but are
not actively engaged in bullying or targeted by others. Children who are not classified into
any of these categories are commonly labeled not involved. The defining characteristics for
each classification will be discussed ahead along with identified correlates and differences.
This information is descriptive, and since research is largely correlational directional rela-
tionships cannot be inferred as some of the characteristics may be protective factors, risk
factors, moderating or mediating factors, or outcomes/effects of involvement in bullying.
Bullies
To explain the behavior of bullies, prior research on bullying has largely used one of two
models. One model explains bullying in terms of bullies’ social skill deficits, whereas the
other model explains bullying in terms of bullies’ skillful pursuit of power, control, and
dominance (Olthof, Goossens, Vermade, Aleva, & van der Meulen, 2011; Pellegrini &
Long, 2002; Salmivalli & Peets, 2009). In line with the first model, cross-national research
has shown that bullies report more moral disengagement (Pornari & Wood, 2010) and
lower moral awareness (Menesini et al., 2003) as well as less empathy (Jolliffe & Far-
rington, 2006; Raskauskas, Gregory, Harvey, Rifshana, & Evans, 2010) than their peers.
They are also more likely to demonstrate hostile attribution bias which is a social informa-
tion processing problem where others’ behavior is perceived by the bully as hostile when
it is not. This conclusion justifies the bully’s own aggression in return (Newman, Murray,
& Lussier, 2001; Pornari & Wood, 2010).
Despite stereotypes of bullies as social outcasts and loners who bully because they lack
social competence, many studies have shown that they are often socially skilled (Hymel
Schonert-Reichl, Bonanno, Vaillancourt, & Henderson, 2010; Orpinas & Horne, 2006).
In line with the second view that bullies do so to gain position, power, or dominance,
Garandeau and Cillessen’s (2006) review of literature found that most bullies do have
social competencies that support their bullying behavior. Phillips (2007) even found that
adolescents are aware of their strategic use of bullying to achieve dominance goals. Find-
ings that support both models of bullying may be due to subgroups within the bullying
classification. Olthof and colleagues (2011) found two subgroups of bullies: a group of
bullies who have a strong desire to be dominant and another group who do not.
Bullies are often perceived by peers to be powerful and popular (LaFontana & Cillessen,
2002; Olthof et al., 2011). On the other hand, peer reports have revealed that bullies are
often rejected (not liked) by their classmates (Olthof et al., 2011; Salmivalli et al., 1996).
Despite not being liked by many, most bullies do have friends, enjoy peer relationships,
and belong to larger social clusters than victims or bully-victims. They tend to affiliate
with friends who exhibit similar frequencies of aggression and bullying (Espelage, Holt,
& Henkel, 2003; Shin, 2010).
Bullies persistently report low quality relationships with parents (see Nickerson et al., 2010
for review). The majority of children who bully are insecurely attached with their parents
(Monks, Smith, & Swettenham, 2005; Troy & Sroufe, 1987). Bullies perceive lower levels of
parental support, particularly emotional support, than children who are not bullies (Demaray
& Malecki, 2003). Bullies, both traditional and online, are also more likely to report infre-
quent parental supervision (Schwartz McFayden-Ketchum, Dodge, Pettit, & Bates, 1999;
Ybarra & Mitchell, 2004b).
Finally, a risk factor for bullying behavior is gender. It has been consistently found that
boys are more likely to be bullies than girls (Espelage & Swearer, 2003; Nansel et al.,
2001; Olweus, 1993; Raskauskas, Gregory et al., 2010). At one time it was considered
that gender differences might be artificial, that girls may engage in as much bullying but
utilize different forms. Girls are socialized to use indirect aggression and are more likely to
engage in covert forms of bullying like gossip and exclusion, often called relational aggres-
sion, than physical bullying (Crick & Grotpeter, 1995; Orpinas & Horne, 2006; Wang,
Iannotti, & Nansel, 2009). Still, research found the assumption that gender differences
were artificial was incorrect based on two key findings: (a) girls engage in physical bully-
ing as well, just not as much as boys; and (b) relational aggression does not account for all
gender differences in prevalence. This is because males engage in relational aggression but
are more likely to use other forms as well, whereas girls use primarily relational aggression
(Espelage & Swearer, 2003; Tomada & Schneider, 1997).
Unlike school bullying, for which it is consistently found that males are more likely to be
bullies, it is not so clear for cyber bullying. Some research shows that males are more likely
to be cyber bullies (Li, 2006); other research shows that females are (Willard, 2007), and
still other research has found no difference (Smith et al., 2008; Ybarra & Mitchell, 2004b).
Additional research on gender differences in participation in cyber bullying is needed.
Victims
Passive victims or victims of bullying have a very different profile characterized by with-
drawn behavior and psychosocial indicators. Victims tend to be more submissive, have
fewer leadership skills, are more withdrawn and less cooperative (Perren & Alsaker,
2006). Children who are victimized are commonly described as being anxious or insecure,
which manifests in a tendency to seek attention from others (Olweus, 1993; Schwartz,
2000). Young children who are shy or withdrawn with peers, and older children who
are shy entering a new school with a stable population are at heightened risk for bullying
(Ross, 1996, 2003).
Certain psychological traits can put children at increased risk for victimization by peers.
Victims tend to have an external locus of control and to engage in self-blame and learned
helplessness behaviors (Meland et al., 2010; Raskauskas, 2010a). In younger grades, vic-
tims often react to frustrations with crying and emotional outbursts, which demonstrates
a lack of emotional inhibition to peers (Garner & Hinton, 2010; Olweus, 1993).
Having friends can be protective against bullying. Being in the company of at least one
friend has been found to significantly decrease the likelihood of being victimized (Hodges
& Perry, 1999; Kochenderfer & Ladd, 1996). Negative effects of victimization can also be
buffered by positive peer affiliation. Associations with friends who can provide protection
or comfort against bullying is buffering, while having friends not capable of providing pro-
tection can contribute to internalizing problems and victimization (Hodges & Perry, 1999;
Pellegrini & Long, 2002). Inadequate or troubled peer relations unable to provide protection
against peer victimization are often found among children with troubled home relationships.
In relationships with parents, victims, like bullies, tend to be insecurely attached. Troy
and Sroufe (1987) conducted a longitudinal study and found that all of the children clas-
sified as victims in their study had a history of being insecurely attached to their parents.
On the other hand, victims also report the most parental support when compared to bul-
lies, bully-victims, and children not involved. There tends to be enmeshment in victims’
parent-child relationships, characterized by both emotionally intense positive interactions
and overprotectiveness, both of which have been shown to increase risk for victimization
(e.g., Finnegan, Hodges, & Perry, 1998; Ladd & Ladd, 1998; Ross, 2003).
Victims of cyber bullying differ from other victims in some ways. Unlike with tradi-
tional bullying, Vandebosch and Van Cleemput (2009) found that victims of cyber bullying
scored higher on social competence than other groups. It is possible that cyber victims are
targeted by peers with lower social competence using technology because of the anonymity
afforded. Similarly, while having friends is associated with less victimization by traditional
forms of bullying, it was not associated with less cyber bullying (Wang et al., 2009).
Despite these findings, cyber victims tend to be more similar to traditional victims than
not (Kowalski, Limber, & Agatston, 2008; Ybarra, Mitchell, Wolak, & Finkelhor, 2006).
Both have lower self-esteem (Kowalski et al., 2008; Hinduja & Patchin, 2009), higher
social anxiety (Juvonen & Gross, 2008; Ybarra & Mitchell, 2004a, 2004b), and higher
depression (Perren, Dooley, Shaw, & Cross, 2010; Raskauskas, 2010b).
Bully-Victims
Bully-victims are also sometimes called provocative victims or aggressive victims. While
bully-victims are not qualitatively different from those who are only victims or only bullies
(Pollastri, Cardemil, & O’Donnell, 2010; Sekol & Farrington, 2010), their experiences when
bullied tend to be more extreme, meaning bully-victims are the group most strongly affected
by bullying (Demaray & Malecki, 2003; Dukes, Stein, & Zane, 2009; Schwartz, 2000).
Unlike passive victims, who are withdrawn, bully-victims display anxious and aggres-
sive reactions that make them targets of peer aggression (Schwartz, 2000). Dukes, Stein,
and Zane (2009) claimed that females are more likely to be bully-victims than males.
In contrast, Carlyle and Steinman (2007) claim that males are more likely to be bully-
victims, necessitating further research in the area. Bully-victims tend to be younger and
less socially conscientious, and also tend to have problems with emotional display rules
and poorer emotional self-regulation than victims or not-involved classmates (Garner &
Hinton, 2010; Sekol & Farrington, 2010).
Bully-victims’ behavioral and emotional regulation issues tend to lead to difficulty
with peers (Pellegrini & Long, 2002; Schwartz, 2000). Perren and Alsaker (2006) found
that bully-victims tend to be less cooperative and report low peer support, peer rejection,
and having no playmates (Farmer et al., 2010; Meland et al., 2010; Pellegrini & Long,
2002). When bully-victims do associate with peers they are most likely to associate with
other aggressive children like bullies or other bully-victims (Perren & Alsaker, 2006;
Shin, 2010).
Bully-victims also tend to have troubled relationships with parents. They tend to be
insecurely attached and specifically show high levels of avoidant attachment (Espelage &
Swearer, 2003; Ireland & Power, 2004). They also report the lowest levels of perceived
parental support when compared to victims, bullies, and not-involved children (Demaray
& Malecki, 2003). Similar to bullies, parents of bully-victims tend to be high on overpro-
tective or neglectful behavior and low in monitoring and warmth (Ross, 2003). Nickerson,
Mele, and Osborne-Oliver (2010) theorized that the lack of affection and low monitoring
of parents may leave bully-victims feeling like they have to fend for themselves. This in
conjunction with aggressive modeling can lead to an alternation between the helplessness
of victimization and coercive power tactics of bullying.
Bully-victims can also be found in cyber bullying, although this area has not been stud-
ied as extensively. Vandebosch and Van Cleemput (2009) found that cyber victims were
more likely to also have been involved in cyber bullying as a bully or bystander. This higher
percentage of bully-victims may be due to retaliation by victims. Burgess-Proctor, Patchin,
and Hinduja (2008) found that 27% of victims responded to cyber bullying by bullying the
person back, 25% do nothing, and 17% avoided the computer or stayed offline. Twyman,
Conway, Taylor, and Comeaux (2010) conclude that a majority of cyber bully-victims are
also bully-victims in traditional bullying experiences. Consistent with traditional bullying
research, when cyber bully-victims are found they report high levels of aggression, depres-
sion, and somatic symptoms (Gradinger, Strohmeier, & Spiel, 2009; Perren et al., 2010;
Ybarra & Mitchell, 2004a, 2004b).
An area that needs more investigation is the classification of bully-victim when consid-
ering both traditional and cyber bullying. This is because one may be victimized in one
setting and a bully in another. Youths who have been targets of bullying at school are more
likely to engage in online aggression (Ybarra & Mitchell, 2004b; Ybarra et al., 2006).
Willard (2007) documented that targets of online aggression have sought out revenge at
school when perpetrators were known, often using physical aggression.
Bystanders
The negative effects of school bullying are not limited to the main participants, but instead
spread out to include bystanders who witness the bullying and others in the school who
hear about it. There is no specific profile for bystanders but research indicates that most
bullying occurs with other students present (Craig et al., 2000). Bystanders can be divided
into different roles based on whether they take action to join the bully or help the victim
(Salmivalli, 2010; Salmivalli & Peets, 2009). Salmivalli (2010) points out that bystanders
are trapped in a social dilemma:
On the one hand, they understand that bullying is wrong and they would like to do
something to stop it—on the other hand, they strive to secure their own status and
safety in the peer group. However, if fewer children rewarded and reinforced the bully,
and if the group refused to assign high status for those who bully, an important reward
for bullying others would be lost. (p. 117)
Many intervention programs attempt to empower students to take action to assist vic-
tims who are being bullied (see Orpinas & Horne, 2006). However, some bystanders may
not have the skills or the knowledge to stop bullying, may feel guilty for not doing any-
thing, and may become secondary victims of the bullying process (Newman et al., 2001).
Any intervention should include specific strategies and skills if it is advocating for students
to intervene in bullying they see.
There is no existing research on bystanders of cyber bullying. This is an interesting area to
consider. Who would be the bystanders? Those who view the bullying page but don’t post,
those who are aware of others’ cyber bullying behavior and do nothing? Those who pass
around embarrassing or abusive videos of people they don’t know to their friends or post the
link on their social networking site? This needs to be addressed by research on cyber bullying.
Methods for the Identification of Bullies and Victims

There is increasing concern in the literature about the accuracy of methods for the iden-
tification of bullies and victims. A variety of methods have been used, including peer-
nominations, teacher-nominations, questionnaires, direct observation, and individual
interviews. Ahmad and Smith (1990) compared different methods with middle school and
junior high school students and found that only half of the respondents who admitted to
bullying on a questionnaire also admitted to it in an interview. They concluded that self-
reports were more valid than individual interviews or teacher- and peer-nominations. This
may be due, in part, to student embarrassment from being involved in bullying and not
wanting to admit to being a bully or a victim in interviews.
Anonymous self-reporting is the most commonly used method for identification. One
measure used a lot is the Olweus Bully/Victim Questionnaire, or OBQ (Olweus, 1996,
2010). The OBQ, like most surveys, includes a definition of bullying and questions about
the frequency or amount of bullying experienced. This requires the retention and applica-
tion of the definition when answering the questions, but children may not understand the
definition or may revert to their own understanding of the word bullying when answering.
Self-reporting, however, is more accurate than other methods in predicting the relation-
ships between bullying and negative effects (Olweus, 2010), most likely because the self-
perception of victimization would be related more to mental health. Juvonen, Nishina, and
Graham (2001) assert that self-reporting and peer- or teacher-reporting describe different
aspects of the bullying experience (subjective self-views vs. social reputation), and both
methods provide useful information.
When using peer nominations (or sociometric measures) students are presented with a
roster of names (and/or pictures) of classmates and asked to nominate a fixed number as
the students who are picked on or pick on others. A similar method is used for establishing
popularity and peer rejection (Olweus, 2010). Peer nominations offer several advantages,
the most important one being that peers are more aware of which students bully others,
because a substantial amount of bullying occurs when no school personnel are present
(Crick & Grotpeter, 1995; Perry, Kusel, & Perry, 1988). However, peer nominations have
not consistently been found to have high correspondence with self-reporting (Olweus,
2010; Orpinas & Horne, 2006).
Prevention Programs for Schools

The whole school approach has been shown to be the most effective prevention effort for
schools (Espelage & Swearer, 2003; Olweus, 1993). The basic premise of this approach is
that (a) bullying is an intentional and purposeful act; and (2) bullying is affected by and cre-
ates the school climate. Therefore, bullying can be controlled provided that there is a strong
commitment and willingness to work together on the part of all those involved: school
personnel, other professionals, parents, and students (Olweus, 1993; Ross, 2003). To stop
bullying, intervention is needed that can accomplish two changes. First, the bullying must
be stopped and firm comprehensive action taken to ensure the safety of the victims. Second,
the social behavior of the bullies and victims must be changed. The bullies must stop attack-
ing other children and redirect their energy in more positive directions. The victims must
learn to be more assertive and to acquire the verbal and social skills appropriate to their age
and grade level. Some of the social behavior problems can be modified in the classroom but
others, such as the victim learning to be more assertive, may require individual intervention.
More information about specific interventions is provided in the next section.
Before a whole school campaign is initiated, it is common to assess the baseline level of
bullying. The next step is to put in place a policy or code of conduct that changes the school
climate in the school (Greene, 2003). A policy should include a definition of bullying, how
bullying is reported, clear enforceable sanctions, support for victims, and training for pre-
vention efforts. A code of conduct is a whole school disciplinary policy with a clearly stated
set of rules for behavior in and around the school, effectively communicated to all students,
and enforced without exception. For violations of the code, nonphysical sanctions such as
deprivation of privileges should be used (Olweus, 1993; Swearer, Limber, & Alley, 2009).
Telephone Hotlines or Reporting Boxes

There is a cluster of antisocial behaviors that thrive on a bed of secrecy and bullying in
schools is one such behavior (Espelage & Swearer, 2003; Ross, 2003). It follows that
an important part of bullying prevention either as part of the whole school approach or
separately is to make the school a telling school. Any child who is bullied by another child
or adult, or who sees another child being bullied, is urged to report the incident (Orpinas
& Horne, 2006). Designated personnel should have advice for students about what to do
when bullied; some strategies are provided in Table 6.1 (Ross, 2003).
Children who report such incidents must be guaranteed anonymity because revealing
the reporter’s identity to the bully can escalate (and justify to the bully) the bullying behav-
ior against the victim. It is the responsibility of everyone in a telling school to help stop
bullying, so no one, student, faculty, or staff, should be a passive bystander. It is essential
to distinguish between legitimate telling (telling to get help for others, in cases of behaviors
that injure others or damage property) and tattling (telling to get someone in trouble for
rule-breaking). Traditionally, “telling on” someone, or “narcing,” is viewed as bad within
the peer group. That is why anonymous reporting hotlines and reporting boxes are often
more effective then requiring students to come to a teacher in person.
A hotline is an open line on which any student who is concerned about bullying may
talk with designated school personnel. This telephone procedure allows students to voice
anonymously their concerns and describe bullying encounters without identifying either
Table 6.1 Advice to Students About Being Bullied
When you are being bullied:

Be firm and clear—look them in the eye and tell them to stop
Get away from the situation as quickly as possible
Tell an adult what has happened straight away
After you have been bullied:
Tell a teacher or another adult in your school
Tell your family
If you are scared to tell a teacher or an adult on your own, ask a friend to go with you
Keep on speaking up until someone listens
Don’t blame yourself for what has happened
When you are talking about bullying with an adult, be clear about:
What has happened to you
How often it has happened
Who was involved
Who saw what was happening
Where it happened
What you have done about it already
Source: Ross (2003).
themselves or the bullies. A hotline allows students to talk to an adult and develop some
plan for handling the bullying. There are several existing hotlines in countries around the
world that provide support for students dealing with bullying or cyber bullying. The head
of a hotline in New Zealand for children being bullied was asked whether students called
about bullying: “Not at first, at first they just called to see if there was really someone
there on the line that they could talk to. After a while they started calling about bullying”
(J. Carroll, personal communication, May 17, 2005).
Anonymous reporting boxes work the same way. Boxes are provided in public places
and students can submit concerns or reports of events anonymously. It doesn’t have to be
a box, per se; one school reported that it has a rule that students can drop the note on any
teacher’s desk and the teacher will investigate. The Kia Kaha program in New Zealand
includes anonymous reporting boxes, and in a nationwide evaluation of their program,
teachers and education officers reported that this was one of the most successful pieces of
the program (Raskauskas, 2006).
A major drawback of reporting boxes and hotlines is an initial increase in reporting that
makes some educators believe they are not working. All bullying programs raise awareness
of the problem first and will lead to telling by students who have been enduring for a while.
Another drawback is that it requires staff to respond. While on one hand this is good, on
the other, if staff are not adequately trained they can respond in ways that actually support
or increase the bullying. For example, if faculty approaches the problem by singling out the
bully or addressing him or her in a way that the anonymity of the victim is compromised,
it can increase the risk to that student. If students see that staff do not respond to their
anonymous reports or that they are increasing risk by identifying them to the bully, they
and classmates will be less likely to tell in the future.
Bullying Curriculum
There are many existing antibullying and bullying prevention programs that schools can
access. Some key programs are mentioned elsewhere in this chapter in other sections, such
as Method of Shared Concern, Life Skills Training, Promoting Alternate Thinking Strate-
gies, and Promoting Issues in Common. Orpinas and Horne (2006) recommend school
programs that match the school’s goals, have shown evidence of success, and have cultural
relevance to the school’s students and their specific needs. Based on their review, Orpinas
and Horne identified some programs that would be useful for many schools; a selection of
these programs is summarized below:
1. Olweus Bullying Prevention Program (Grades 3–10). As the father of the whole
school approach, Dr. Olweus’s program is designed to improve peer relationships to
make the school a safer place for all students through coordinated prevention efforts
that require commitment from all stakeholders: students, teachers, staff, parents, and
the wider community (Olweus, 1993). Developed in Norway, this program has been
successfully used in many countries in world, and has been shown to be effective in
the United States by Limber, Nation, Tracy, Melton, and Flerx (2004).
2. Targeting Bullying Program (Grades 5–9). This is an intervention based on the ecolog-
ical model that reduces bullying through collaborative efforts of stakeholders such as
students, teachers, parents, and school personnel. The program is described in Swearer
and Espelage (2004) and has been found to be useful in preventing and reducing bul-
lying.
3. Back off Bully (Grades K–5). This program specifically targets bullying through skill-
building classroom trainings. It teaches all students and teachers/staff to become help-
ful bystanders to reduce the power imbalance of bullying (Twemlow et al., 2001).
4. Bully Busters (Grades K–8). This is a program designed to increase awareness about
bullying and increase teachers’ skills to respond to bullying (Horne, Bartolomucci, &
Newman-Carlson, 2003). Research has shown the program is effective in increasing
knowledge and ability to prevent and respond to bullying as well as reduction in dis-
cipline referrals after the program (Orpinas & Horne, 2006).
5. Bully Proofing (Grades K–8). Bully Proofing reduces and prevents bulling through
teaching materials and a parent component. Evaluation of this program has shown
a reduction in bullying (Bonds & Stoker, 2000; Garrity, Jens, Porter, Sager, & Short-
Camilli, 2004).
It is important to note that implementation of any new program will require training of
staff and obtaining buy-in from stakeholders. The efforts need to be consistent and sup-
ported by all. Programs often require time away from other activities for educators so they
should be introduced slowly to avoid overload.
Intervention Strategies
Nation (2007) points out that there are two models for approaching intervention for bul-
lying: (a) victim-inclusive; and (b) victim- or bully-focused.
Victim-Inclusive Approaches
Victim-inclusive approaches propose that bullying interactions are a byproduct of the
dynamics of the relationship between the bully (or group of bullies) and the victim; inter-
vention must therefore include both. Commonly used strategies that fall into this category
are: restorative justice, method of shared concern, and classroom meetings/bully courts.
Restorative Justice. Restorative justice is a way of dealing with unjust behavior by pro-
viding conditions in which the bully recognizes his or her fault and the harm that has been
done and then undertakes action to put things right. Typically this is facilitated through a
meeting involving the victim, bully, and related others. It is like a group intervention, with
the group making it clear to the bully that the behavior is unacceptable. The purpose of
the meeting is to induce appropriate emotional response (e.g., empathy, shame, guilt) in the
bully, while supporting the victim and reintegrating him or her in the school community.
Under favorable conditions this approach has had positive and lasting effects on bullies
(Burssens & Vettenburg, 2006), but its success is limited by the willingness for everyone
to engage in a process that lets the bully atone rather than a process that punishes or gains
revenge (Rigby & Bauman, 2010).
Method of Shared Concern. The method of shared concern goes a step beyond restorative
justice and puts more problem-solving responsibility on the participants. Method of shared
concern is a method started by Swedish psychologist Anatol Pikas (2002). It uses the no-
blame approach, in which it does not accuse or punish bullies, but rather is interested in
creating positive relationships between those involved and helping the victim feel safe. It
is facilitated through a series of meetings with everyone involved with the incident. Rigby
and Bauman (2010) summarize the steps:
1. Information about the bullying incident is gathered indirectly. The victim is not inter-
viewed at this time.
2. The bullies are interviewed individually after the information has been gathered. No
one is accused; instead the facilitator shares a concern about the plight of the victim
and tries to get the bully to (a) acknowledge the bad aspects of what happened and
empathize with the victim, and (b) suggest how the matter can be resolved.
3. The victim is interviewed and is told what is happening. This may lead to additional
meetings with the bullies or to the next step.
4. After talking with the victim, a meeting is held with the group. The facilitator works
with the victim, bullies, and others to reach a final agreed solution. It is believed this
approach can give back to victims some of the power they have lost through the bul-
lying interactions.
Class Meetings and Bully Courts. Class meetings and bully courts go even further and
put almost all responsibility for addressing bullying in the hands of students. Regular class-
room meetings (at least once a week) can provide a forum for students to discuss bullying
issues and ways to get along with others as well as open a dialogue between teachers and
students. Having a process through which students can suggest topics for the classroom
meeting ahead of time makes it a place for students to voice objection to certain behav-
iors. Clear rules need to be established ahead of time to make sure that interactions are
positive and not done in a way that publically shames people. Bullying can be reduced by
having students contribute to establishing classroom rules that promote good social skills
and encourage empathy, like being respectful of others, helping those who are bullied, and
including everyone when you play.
Bully courts are gatherings of students that hear concerns of peers and facilitate problem
solving and punishment. With bully courts, any child can lodge a complaint about another
child in the class who has done something bad to them. Complaints must be in writing
and deposited in a special box or special place. Representatives are elected or appointed
to serve on the “bully court,” which hears student-to-student complaints. First, both par-
ties promise to tell the truth. Then the complainant describes the problem and the accused
child rebuts. Both children can produce witnesses and members of the class may ask ques-
tions. The involved students are then sent outside while the class discusses the case. A vote
is taken to decide if the accused is guilty or innocent. If guilty, the class decides on the
punishment, with the teacher acting as moderator to ensure that the meeting is orderly
and the punishment an appropriate one that can be completed in the school setting. If the
accused is judged to be innocent, the complainant must apologize (Ross, 2003). This is
different from conflict resolution programs because conflict resolution works only for con-
flict (disagreement that can be mediated between equals), whereas bully courts can address
both bullying (issues where unequal power balance exists) and conflict.
Other common victim-inclusive approaches not reviewed here include peer mediation,
befriending, student watch programs, peer counseling, and quality circles.
Victim- or Bully-Focused Interventions

Victim- or bully-focused interventions are based on the idea that victimization is, in part
at least, the product of poor skills (social, cognitive, or behavioral) of the victim or bully
(Nation, 2007). Interventions are therefore directed only at the victim or bully. Commonly
used strategies that fall into this category are: social-cognitive interventions, counseling
strategies, and support groups.
Social-Cognitive Interventions
This group of interventions is based on social-cognitive theory, focusing on social and
personal influences on behavior (e.g., Bandura, 1986). Personal and social skills important
to intervention with victims and bullies are: outcome expectations, coping responses, self-
efficacy, and self-control (Orpinas & Horne, 2006). Among other things, in an interven-
tion students need to be provided with clear consequences for aggressive behaviors, anger
management skills, empathy training, and stress reduction techniques. Conflict resolution
and communication skills can also help in most of these interventions to create self-efficacy
as they role-play nonaggressive behavior or assertive responses of victims. Teachers often
also need training on consistently enforcing rules and reinforcing desired prosocial behav-
iors but not inadvertently reinforcing negative or unwanted behaviors.
At its most basic form, social-cognitive training is social skills/assertiveness train-
ing. Many schools use social skills programs as antibullying programs (e.g., Life Skills,
Peace Builders, Second Step, etc.). Arora (1991) has reported impressive success with a
small support group of severely bullied high school students through teaching assertive-
ness behavior. Over a period of several months, the participants were taught appropriate
responses to bullying situations and given ample opportunity to rehearse them in role play.
The skills and techniques taught included refusing to do what the bully wanted, handling
name-calling and critical comments, resisting pressure, and seeking help from bystanders.
The Life Skills Training (LST) program for grades 6–9 is designed to build students’ social
skills. Target skills of this program include goal setting, assertiveness, conflict resolution,
coping and stress reduction, and other general social skills. Similarly, Promoting Alter-
native THinking Strategies (PATHS) for grades K–5 builds social and emotional compe-
tency, social cognition, and problem solving in children. Both of these programs have been
shown to reduce aggression (see Orpinas & Horne, 2006).
Counseling Interventions
Counseling interventions do not just build skills but also address cognitions and emotions
involved in bullying. Schools should provide counseling services for the victim, bully, and
any child who is concerned about the bullying. Bystanders can be upset by bullying wit-
nessed, feelings of helplessness it triggers, or guilt about their own reluctance to assist the
victim (Salmivalli, 2010). Bullies need to consider why their victims behave as they do,
as well as how they feel as victims. Victims also need to have some insight into what has
brought the bullies to their current unacceptable level of aggression in addition to consid-
ering ways (if any) in which they could respond to the bullying that could end the cycle.
Promoting Issues in Common (PIC). In Breaking the Cycle of Violence, Hazler (1996)
described a three-step therapeutic technique called Promoting Issues in Common (PIC) spe-
cifically for counseling bullies and victims. This technique has limited application in that it
is appropriate largely for bullies and victims in conflict who previously have had a neutral
or positive relationship that they would like to reestablish. In any case, without help neither
the bully nor victim is able to take the first step toward any level of reconciliation.
With PIC the first step is gaining control of an ongoing conflict situation and creating
conditions that will facilitate effective counseling. Obviously, counseling cannot begin
when one person is still actively bullying another because tension will be too high to work
with the two. It is important to show appropriate concern and withhold judgments of who
is in the wrong in order to convey to participants and bystanders that more information
must be obtained before a final judgment is made.
The second step in the PIC model focuses on an individual interview, first with the bully,
and then with the victim to evaluate the problem situation. Both are likely to need indi-
vidual counseling sessions to provide help with their own problems prior to helping with
the relationship problem, which is best handled with joint counseling.
The third step in the PIC technique focuses on providing direct interventions rather than
specific therapeutic tactics. Decisions on direct interventions are made on the basis of how
much each individual is in need of personal therapy. It is important to delay working in
pairs or larger groups until the therapist is confident that the individual is independently
prepared to do so.
Prior to joint meetings the victim and bully must have their personal concerns clearly
identified, understand how the joint meeting will help them, and know which issues they
have in common. The PIC technique emphasizes an ongoing model for improvement that
relies less and less on the therapist for improving the relationship and more and more on
the participants to do so. The rationale for termination and a preview of the final session
should be discussed in the next-to-last meeting. In the final meeting, a review of the full
extent of the students’ development is made and assurance is given that extra help is avail-
able if it proves to be necessary.
Brief Therapy: Solution-Focused Counseling. Solution-focused counseling (Murphy,
1997) is another counseling strategy. It is a brief therapy technique that uses problem
solving to promote change in school problems in a relatively short time. It focuses on small
changes, such as a noticeable improvement in the problem, without necessarily aiming
for the complete elimination of it. The therapist asks the student what he or she wants to
accomplish, instead of making assumptions about the student’s goal. The therapist always
seeks the student’s input before offering any suggestions of his own, never argues with the
student, does not lecture or persuade as some counselors do, and never focuses on what the
student is doing wrong. Solution-focused counseling maintains that students already have
the resources and strengths necessary for improving a situation and effective counseling
helps them discover these resources.
The first step in the solution-focused counseling is the interview. An interview some-
times results in a solution to the problem by shifting the way the student views the prob-
lem. Children are helped and report fewer negative effects when given the opportunity to
talk about their victimization and when validated that it is not just them and they are not
at fault (Ross, 1996, 2003).
During the first counseling session the formulation of specific goals is crucial for a suc-
cessful outcome. During this session the counselor must decide if the student appears to
be genuinely interested in stopping bullying. It is important to be aware of the forces that
may be against stopping. Bullies are often respected and sometimes even admired by a siz-
able number of students, and they often have a group of loyal followers (Salmivalli et al.,
1996; Swearer et al., 2009). The bully may be apprehensive about losing face if he stops
bullying. It is advisable, therefore, to set reasonably attainable goals such as stopping bul-
lying completely on specified days of the week as a beginning, then gradually increasing
the nonbullying days, or not letting a specific child “get to them.” Any ideas should be
suggested in a tentative way, possibly when you are discussing goals—for example, “What
would you think of this idea for a start . . .?” It would be helpful to discuss responses the
bully could make to his friends if asked why he is not bullying. It is essential to have the
student report any bullying he engages in on the nonbullying days and, if possible, have
school personnel note any bullying activity because bullies tend to deny charges of bullying
(Olweus, 1993; Ross, 1996, 2003).
The decision to terminate counseling should be made when the student is clearly on
track toward resolving the problem. It must be a collaborative decision between the coun-
selor and the student. Solution-focused counseling is especially suited to the time con-
straints and heavy caseloads of school counselors. It is conceptually simple and does not
require extensive formal training (Ross, 2003).
Support Groups
Children with specific problems whose needs are not being met by existing organizations
may benefit from participating in support groups. These groups satisfy a wide range of
needs, such as the need for gaining peer acceptance, or dealing with divorce or a recent
death in the family. Before joining a support group, many children feel that they are alone
in their suffering. Interacting with other children with similar problems can lessen their
feelings of isolation; in this way a support group would be ideal for the victims of bullying
(see Ross, 2003).
In addition to providing emotional support for the victims, one goal of the support
group setup is to introduce behavior changes that would provide them with protection
against bullying. The group format is ideal for practice in role play, along with reversal of
roles as a way of showing the victim how it feels to be a bully. It is also excellent for asser-
tiveness training as a means of changing the passive demeanor typical of many victims.
For group approaches to the problem of teasing at school see Ross (1996, pp. 179–207).
However, some have indicated that support groups may not be useful for victims of bul-
lying if it does not teach skills and/or makes them feel stigmatized. Also support groups
may not be successful for bullies if they are unstructured and provide discussions between
bullies that reinforce aggressive behavior (Orpinas & Horne, 2006). Still, support groups
have been successful in UK schools as an intervention strategy for bullying (see Robinson
& Maines, 2007).
Conclusion
Legislation in most states defines bullying and the need for schools to take action to
prevent and intervene in it (Swearer et al., 2009). As bullying becomes more prominent
in the public awareness and concern over it increases, even more action is being taken to
improve laws and protect students. For example, in California the laws were updated in
2009 to include cyber bullying (California AB 86). The wording was changed so that bul-
lying includes “acts that constitute sexual harassment, hate violence, or severe or pervasive
intentional harassment, threats, or intimidation and that are committed personally or by
means of an electronic communication device or system.” This change also allows for
school officials to suspend students for bullying, including cyber bullying.
In 2011, Seth’s Law (AB 9) was passed in California after a string of bullying-related
suicides were brought out in the media. This bill tightens antibullying policies in California
schools by ensuring that all schools have clear and consistent policies, institute better train-
ing and clearer guidelines for teachers and administrators, and establish shorter timelines
for investigating claims of bullying. AB 9 was developed to help create a respectful and safe
environment for all students. Previous laws had said that schools should have a policy about
bullying but did not give much guidance about what that meant for schools and students.
Policies and training are the first step to creating that positive school climate that will
reduce bullying and foster support between students. However, it is just one step. As dis-
cussed in this chapter, social skill development and student education are also important
components. There are also a percentage of students involved in bullying who will need
targeted intervention and/or counseling to stop problem behaviors, alter social cognitions,
and build skills in order to escape the cycle of bullying.
REFERENCES
Ahmad, Y., & Smith, P. K. (1990). Behavioral measures: Bullying in schools. Child Psychology and
Psychiatry, 12, 26–27.
Andreou, E. (2001). Bully/victim problems and their association with coping behavior in conflictual
peer interactions among school-age children. Educational Psychology, 21(1), 59–66. doi:10.1080/
01443410125042
Arora, T. (1991). The use of victim support groups. In P. K. Smith & D. Thompson (Eds.), Practical
approaches to bullying (pp. 36–47). London: David Fulton.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
——— (1986). Social foundations of thought and action: A social cognitive theory. Englewood
Cliffs, NJ: Prentice Hall.
Barchia, K., & Bussey, K. (2010). The psychological impact of peer victimization: Exploring social-
cognitive mediators of depression. Journal of Adolescence, 33, 615–623. doi:10.1016/j.adoles-
cence.2009.12.002
Bonds, M., & Stoker, S. (2000). Bully-proofing your middle school. Longmont: Sopris West.
Bradshaw, C. P., Sawyer, A. L., & O’Brennan, L. M. (2007). Bullying and peer victimization at
school: Perceptual differences between students and school staff. School Psychology Review, 36,
361–382. Retrieved from http://web.ebscohost.com.proxy.lib.csus.edu/ehost/pdfviewer/pdfviewer?
sid=5fd29703–95c5–43ae-9f14-fb3fa50b8ecb%40sessionmgr13&vid=117&hid=13
Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psy-
chologist, 32, 513–531. doi:10.1037/0003–066X.32.7.513
——— (1979). Contexts of child rearing: Problems and prospects. American Psychologists, 34,
844–850. doi:10.1037/0003–066X.34.10.844
Bronfenbrenner, U., & Morris, P. A. (2006). The bioecological model of human development. In R. M.
Lerner & W. Damon (Eds.), Handbook of child psychology: Vol 1. Theoretical models of human
development (6th ed., pp. 793–828). Hoboken, NJ: John Wiley.
Burgess-Proctor, A., Patchin, J. W., & Hinduja, S. (2008). Cyberbullying and online harassment:
Reconceptualizing the victimization of adolescent girls. In V. Garcia & J. Clifford (Eds.), Female
crime victims: Reality reconsidered. Upper Saddle River, NJ: Prentice-Hall.
Burssens, D., & Vettenburg, N. (2006). Restorative group conferencing at school: A constructive
response to serious incidents. Journal of School Violence, 5, 5–17. Retrieved from http://www.
informaworld.com.proxy.lib.csus.edu/openurl?genrearticle&iddoi:10.1300/J202v05n02_02
Carlyle, K., & Steinman, K. (2007). Demographic differences in the prevalence, co-occurrence and
correlates of adolescent bullying at school. Journal of School Health, 77, 623–629. Retrieved from
www.cinahl.com/cgi-bin/refsvc?jid225&accno2009708484
Craig, W. M., Pepler, D., & Atlas, R. (2000). Observations of bullying in the playground and in the
classroom. School Psychology International, 21, 22–36. doi:10.1177/0143034300211002
Crick, N. R., & Grotpeter, J. K. (1995). Relational aggression, gender, and social-psychological
adjustment. Child Development, 66, 710–722. doi:10.2307/1131945
Demaray, T. R., & Malecki, M. K. (2003). Perceptions of the frequency and importance of social sup-
port by students classified as victims, bullies, and bully/victims in an urban middle school. School
Psychology Review, 32, 471–489. Retrieved from http://web.ebscohost.com.proxy.lib.csus.edu/ehost/
pdfviewer/pdfviewer?sid5fd29703–95c5–43ae-9f14-fb3fa50b8ecb%40sessionmgr13&vid19&hid13
Dempsey, A., Sulkowski, M., Nichols, R., & Storch, E. (2009). Differences between peer victimization
in cyber and physical settings and associated psychosocial adjustment in early adolescence. Psychol-
ogy in the Schools, 46, 962–972. doi:10.1002/pits.20437
Dukes, R. L., Stein, J. A., & Zane, J. I. (2009). Effect of relational bullying on attitudes, behavior and
injury among adolescent bullies, victims and bully-victims. Social Science Journal, 46(4), 671–688.
doi:10.1016/j.soscij.2009.05.006
Duncan, R. D. (2004). The impact of family relationships on school bullies and their victims. In D. L.
Espelage & S. M. Swearer (Eds.), Bullying in American schools: A social-ecological perspective on
prevention and intervention (pp. 227–244). Mahwah, NJ: Erlbaum.
Espelage, D. L., Holt, M. K., & Henkel, R. R. (2003). Examination of peer-group contextual effects on
aggression during early adolescence. Child Development, 74, 205–220. doi:10.1111/1467–8624.00531
Espelage, D. L., & Swearer, S. M. (2003). Research on school bullying and victimization: What have
we learned and where do we go from here? School Psychology Review, 32, 365–383. Retrieved
from http://web.ebscohost.com.proxy.lib.csus.edu/ehost/pdfviewer/pdfviewer?sid5fd29703–95c5–
43ae-9f14-fb3fa50b8ecb%40sessionmgr13&vid23&hid13
Farmer, T. W., Petrin, R. A., Robertson, D. L., Fraser, M. W., Hall, C. M., Day, S. H., & Dadisman,
K. (2010). Peer relations of bullies, bully-victims, and victims: The two social worlds of bullying
in second-grade classrooms. Elementary School Journal, 110, 364–392. doi:10.1086/648983
Finnegan, R. A., Hodges, E. V. E., & Perry, D. G. (1998). Victimization by peers: Associations with
children’s reports of mother-child interaction. Journal of Personality and Social Psychology, 75,
1076–1086. doi:10.1037/0022–3514.75.4.1076
Garandeau, C., & Cillessen, A. (2006). From indirect aggression to invisible aggression: A conceptual
view on bullying and peer group manipulation. Aggression and Violent Behavior, 11, 641–654. doi:
10.1016/j.avb.2005.08.005
Garner, P. W., & Hinton, T. S. (2010). Emotional display rules and emotion self-regulation: Asso-
ciations with bullying and victimization in community-based after school programs. Journal of
Community & Applied Social Psychology, 20, 480–496. doi:10.1002/casp.1057
Garrity, C., Jens, K., Porter, W., Sager, N., & Short-Camilli, C. (2004). Bully-proofing your elementary
school: Working with victims and bullies. Longmont, CO: Sopris West.
Gradinger, P., Strohmeier, D., & Spiel, C. (2009). Traditional bullying and cyberbullying: Identification
of risk groups for adjustment problems. Journal of Psychology, 271(4), 205–213. doi:10.1027/0044–
3409.217.4.205
Greene, M. B. (2000). Bullying and harassment in schools. In R. Mosher & C. Frantz (Eds.), Shocking
violence (pp. 72–101). Springfield, IL: Charles C. Thomas.
——— (2003). Counseling and climate change as treatment modalities for bullying in school.
International Journal for the Advancement of Counseling, 25, 293–302. doi:10.1023/B:ADCO.
0000005528.59128.32
——— (2010). State bullying laws with definitions. Retrieved from http://njbullying.org/documents/
statelawswithdefinitions.doc
Hawker, D. S. J., & Boulton, M. J. (2000). Twenty years’ research on peer victimization and psycho-
social maladjustment: A meta-analytic review of cross-sectional studies. Journal of Child Psychol-
ogy and Psychiatry, 41, 441–455. doi:10.1111/1469–7610.00629
Hazler, R. J. (1996). Breaking the cycle of violence: Intervention for bullies and victims. Bristol, PA:
Accelerated Development.
Hinduja, S., & Patchin, J. W. (2009). Bullying beyond the schoolyard: Preventing and responding to
cyberbullying. Thousand Oaks, CA: Corwin Press.
Hodges, E. V. E. & Perry, D. G. (1999). Personal and interpersonal antecedents and consequences of vic-
timization by peers. Journal of Personality and Social Psychology, 76, 677–685. doi:10.1037/0022–
3514.76.4.677
Horne, A. M., Bartolomucci, C. L., & Newman-Carlson, D. (2003). Bully busters: A teacher’s man-
ual for helping bullies, victims, and bystanders. Champaign, IL: Research Press.
Hymel, S., Schonert-Reichl, K. A., Bonanno, R. A., Vaillancourt, T., & Henderson, N. R. (2010).
Parent-child relationships and bullying. In S. R. Jimerson, S. M. Swearer, & D. L. Espelage
(Eds.), Handbook of bullying in schools: An international perspective (pp. 101–119). New York:
Routledge.
Ireland, J. L., & Power, C. L. (2004). Attachment, emotional loneliness, and bullying behavior: A study
of adult and young offenders. Aggressive Behavior, 30, 298–312. doi:10.1002/ab.20035
Jimerson, S. R., Swearer, S. M., & Espelage, D. L. (2010). Handbook of bullying in schools: An inter-
national perspective. New York: Routledge.
Jolliffe, D., & Farrington, D. P. (2006). Examining the relationship between low empathy and bully-
ing. Aggressive Behavior, 32, 540–550. doi:10.1002/ab.20154
Juvonen, J., & Gross, E. F. (2008). Extending the school grounds?—Bullying experiences in cyber-
space. Journal of School Health, 78, 496–505. Retrieved from www.cinahl.com/cgi-bin/refsvc?
jid225&accno2010003107
Juvonen, J., Nishina, A., & Graham, S. (2001). Peer harassment, psychological adjustment, and school
functioning in early adolescence. Journal of Educational Psychology, 92, 349–359. doi:10.1037/0022–
0663.92.2.349
Kochenderfer, B. J., & Ladd, G. W. (1996). Peer victimization: Cause of consequence of school mal-
adjustment. Child Development, 67, 1305–1317. doi:10.2307/1131701
Kowalski, R. M., Limber, S. P., & Agatston, P. W. (2008). Cyber bullying: Bullying in the digital age.
Malden, MA: Blackwell.
Ladd, G. W. & Ladd, B. (1998). Parenting behaviors and parent-child relationships: Correlates of peer
victimization in kindergarten? Developmental Psychology, 34, 1450–1458. doi:10.1037/0012–
1649.34.6.1450
LaFontana, K. M., & Cillessen, A. H. N. (2002). Children’s perceptions of popular and unpopular
peers: A multimethod assessment. Developmental Psychology, 38, 635–647. doi:10.1037/0012–
1649.38.5.635
Li, Q. (2006). Cyberbullying in schools: A research of gender differences. School Psychology Inter-
national, 27, 157–170. doi:10.1177/0143034306064547
Limber, S. P., Nation, M., Tracy, A. J., Melton, G. B., & Flerx, V. (2004). Implementation of the
Olweus Bullying Prevention Program in the southeastern United States. In P. K. Smith, D. Pepler, &
K. Rigby (Eds.), Bullying in schools: How successful can interventions be? (pp. 55–79). Cambridge,
UK: Cambridge University Press.
Meland, E., Rydning, J. H., Lobben, S., Breidablik, A., & Ekeland, T. (2010). Emotional, self-conceptual,
and relational characteristics of bullies and the bullied. Scandinavian Journal of Public Health, 38,
359–367. doi:10.1177/1403494810364563.
Menesini, E., Sanchez, V., Fonzi, A., Ortega, R., Costabile, A., & Feudo, L. F. (2003). Moral emotions
and bullying: A cross-national comparison of the differences between bullies, victims, and outsid-
ers. Aggressive Behavior, 29, 515–530. doi:10.1002/ab.10060
Mishna, F., Saini, M., & Solomon, S. (2009). Ongoing and online: Children and youth’s percep-
tions of cyber bullying. Children & Youth Services Review, 31, 1222–1228. doi:10.1016/j.childy-
outh.2009.05.004
Monks, C. P., Smith, P. K., & Swettenham, J. (2005). Psychological correlates of peer victimization in
preschool: Social cognitive skills, executive function and attachment profiles. Aggressive Behavior,
31, 571–588. doi:10.1002/ab.20099
Murphy, J. J. (1997). Solution-focused counseling in middle and high schools. Alexandria, VA: Ameri-
can Counseling Association.
Nansel, T. R., Overpeck, M., Pilla, R. S., Ruan, W. J., Simons-Morton, B., & Scheidt, P. (2001).
Bullying behaviors among US youth: Prevalence and association with psychosocial adjustment.
JAMA, 285, 2094–2100. doi:10.1001/jama.285.16.2094
Nation, M. (2007). Empowering the victim: Interventions for children victimized by bullies. In J. E.
Zins, M. J. Elias, & C. A. Maher (Eds.), Bullying, victimization, and peer harassment: A handbook
of prevention and intervention (pp. 239–255). New York: Haworth Press.
Newman, R. S., Murray, B., & Lussier, C. (2001). Confrontation with aggressive peers at school:
Students’ reluctance to seek help from the teacher. Journal of Educational Psychology, 93, 398–
410. doi:10.1037/0022–0663.93.2.398
Nickerson, A. B, Mele, D., & Osborne-Oliver, K. M. (2010). Parent-child relationships and bullying.
In S. R. Jimerson, S. M. Swearer, & D. L. Espelage (Eds.), Handbook of bullying in schools: An
international perspective (pp. 187–198). New York: Routledge
Olthof, T., Goossens, F. A., Vermade, M. M., Aleva, E. A., & van der Meulen, M. (2011). Bullying
as strategic behavior: Relations with desired and acquired dominance in the peer group. Journal
of School Psychology, 49, 339–359. doi:10.1016/j.jsp.2011.03.003
Olweus, D. (1978). Aggression in the schools: Bullies and whipping boys. Washington, DC: Hemi-
sphere.
——— (1993). Bullying at school: What we know and what we can do. Cambridge, MA: Blackwell.
——— (1996). The revised Olweus bully/victim questionnaire. Mimeo, Research Center for Health
Promotion (HEMIL). Bergen, Norway: University of Bergen.
——— (2001). Peer harassment: A critical analysis and some important issues. In J. Juvonen & S.
Graham (Eds.), Peer harassment in school: The plight of the vulnerable and victimized (pp. 3–20).
New York: Guilford Press.
——— (2010). Understanding and researching bullying: Some critical issues. In S. R. Jimerson, S. M.
Swearer, & D. L. Espelage (Eds.), Handbook of bullying in schools: An international perspective
(pp. 9–34). New York: Routledge
Orpinas, P., & Horne, A. M. (2006). Bullying prevention: Creating a positive school climate and
developing social competence. Washington, DC: American Psychological Association.
Orpinas, P., Horne, A. M., & Multisite Violence Prevention Project (2004). A teacher-focused approach
to prevent and reduce students’ aggressive behavior—The GREAT teacher program. American Jour-
nal of Preventative Medicine, 26, 29–38. doi:10.1016/j.amepre.2003.09.016
Pellegrini, A. D. & Long, J. D. (2002). A longitudinal study of bullying, dominance, and victimization
during the transition from primary school through secondary school. British Journal of Develop-
mental Psychology, 20, 259–280. doi:10.1348/026151002166442
Perren, S., & Alsaker, F. D. (2006). Social behavior and peer relationships of victims, bully-victims,
and bullies in kindergarten. Journal of Child Psychology & Psychiatry, 47, 45–57. doi:10.1111/
j.1469–7610.2005.01445.x
Perren, S., Dooley, J., Shaw, T., & Cross, D. (2010). Bullying in school and cyberspace: Associations
with depressive symptoms in Swiss and Australian adolescents. Child and Adolescent Psychiatry
and Mental Health, 4, 28–38. Retrieved from http://www.capmh.com/content/4/1/28
Perren, S., & Hornung, R. (2005). Bullying and delinquency in adolescence: Victims’ and perpetrators’
family and peer relations. Swiss Journal of Psychology, 64, 51–64. doi:10.1024/1421–0185.64.1.51
Perry, D. G., Kusel, S. J., & Perry, L. C. (1988). Victims of peer aggression. Developmental Psychol-
ogy, 24, 807–814. doi:10.1037/0012–1649.24.6.807
Phillips, D. A. (2007). Punking and bullying strategies in middle school, high school, and beyond.
Journal of Interpersonal Violence, 22, 158–178. doi:10.1177/0886260506295341
Pikas, A. (2002). New developments of the shared concern method. School Psychology Interna-
tional, 23, 307–326. doi:10.1177/0143034302023003234
Pollastri, A. R., Cardemil, E. V., & O’Donnell, E. H. (2010). Self-esteem in pure bullies and bully/
victims: A longitudinal analysis. Journal of Interpersonal Violence, 25, 1489–1502. doi:10.1177/
0886260509354579
Pornari, C. D., & Wood, J. (2010). Peer and cyber aggression in secondary school students: The role
of moral disengagement, hostile attribution bias, and outcome expectancies. Aggressive Behavior,
36, 81–94. doi:10.1002/ab.20336
Raskauskas, J. (2005). Role of attribution style and coping strategy selection in the relationship
between peer victimization and outcomes among economically disadvantaged students (Unpub-
lished doctoral dissertation). University of California, Davis.
——— (2006). Evaluation of the Kia Kaha Anti-Bullying Programme for students in years 5–8.
Research Report to the New Zealand Police. Wellington, New Zealand.
——— (2010a). Multiple peer victimization among elementary school students: Relations with
social-emotional problems. Social Psychology of Education Journal, 13, 523–539. doi10.1007/
s11218–010–9124–0
——— (2010b). Text-bullying: Associations with traditional bullying and depression among New
Zealand adolescents. Journal of School Violence, 9, 74–97. doi:10.1080/15388220903185605
Raskauskas, J., & Stoltz, A. (2007). Relations between traditional and internet bullying among
adolescent females. Developmental Psychology, 43, 564–575. doi:10.1037/0012–1649.43.3.564
Raskauskas, J. L., Gregory, J., Harvey, S. T., Rifshana, F., & Evans, I. M. (2010). Bullying among
primary school children in New Zealand: Relationships with prosocial behaviour, and classroom
climate. Educational Research, 52(1), 1–13. doi:10.1080/00131881003588097
Rigby, K., & Bauman, S. (2010). How school personnel tackle cases of bullying: A critical examina-
tion. In S. R. Jimerson, S. M. Swearer, & D. L. Espelage (Eds.), Handbook of bullying in schools:
An international perspective (pp. 455–469). New York: Routledge.
Robinson, G., & Maines, B. (2007). Bullying: A complete guide to the support group method. Bristol,
UK: Lucky Duck.
Ross, D. M. (1996). Childhood bullying and teasing: What school personnel, other professionals,
and parents can do. Alexandria, VA: American Counseling Association.
——— (2003). Bullying. In J. Sandoval (Ed.), Handbook of crisis counseling, intervention, and
prevention in the schools (pp. 105–136). Mahwah, NJ: Lawrence Erlbaum.
Rueger, S. Y., Malecki, C. K., & Demary, M. K. (2011). Stability of peer victimization in early adolescence:
Effects of timing and duration. Journal of School Psychology, 49, 443–464. Retrieved from http://www.
sciencedirect.com.proxy.lib.csus.edu/science?_obMiamiImageURL&_cid272058&_user521814&_
piiS0022440511000288&_checky&_origin&_coverDate31-Aug-2011&viewc&wchpdGLzVlt-zSk
Wz&md5d95d1e476766fa0a37c4cc7dc8b6477d/1-s2.0-S0022440511000288-main.pdf
Salmivalli, C. (2010). Bullying and the peer group: A review. Aggression and Violent Behavior, 15,
112–120. doi:10.1016/j.avb.2009.08.007
Salmivalli, C., Lagerspetz, K., Bjorkqvist, K., Osterman, K., & Kaukiainen, A. (1996). Bullying as
a group process: Participant roles and their relations to social status within the group. Aggressive
Behavior, 22, 1–15. doi:10.1002/(SICI)1098–2337(1996)22:1<1::AID-AB1>3.0.CO;2-T
Salmivalli, C., & Peets, K. (2009). Bullies, victims, and bully-victim relationships in middle school
and early adolescence. In K. H. Rubin, W. M. Bukowski, & B. Laursen (Eds.), Handbook of peer
interaction, relationships, and groups (pp. 322–340). New York: Guilford.
Schwartz, D. (2000). Subtypes of victims and aggressors in children’s peer groups. Journal of Abnor-
mal Child Psychology, 28, 181–192. doi:10.1023/A:1005174831561
Schwartz, D., Gorman, A. H., Nakamota, J., & Tobin, R. L. (2005). Victimization in the peer
group and children’s academic functioning. Journal of Educational Psychology, 97, 425–435.
doi:10.1037/0022–0663.97.3.425
Schwartz, D., McFayden-Ketchum, S., Dodge, K. A., Pettit, G. S., & Bates, J. E. (1999). Early
behavior problems as a predictor of later peer group victimization: Moderators and media-
tors in the pathways of social risk. Journal of Abnormal Child Psychology, 27(3), 191–204.
doi:10.1023/A:1021948206165
Seeds, P. M., Harkness, K. L., & Quilty, L. C. (2010). Parental maltreatment, bullying, and adoles-
cent depression: Evidence for the mediating role of perceived social support. Journal of Clinical
Child and Adolescent Psychology, 39, 681–692. doi:10.1080/15374416.2010.501289
Sekol, I., & Farrington, D. (2010). The overlap between bullying and victimization in adolescence residen-
tial care. Children & Youth Services Review, 32,, 1758–1769. doi:10.1016/j.childyouth.2010.07.020
Shin, Y. (2010). Psychosocial and friendship characteristics of bully/victim subgroups in primary
school children. School Psychology International, 31, 372–388. doi:10.1177/0143034310377296
Smith, P. K., Cowie, H., Olafsson, R. F., & Liefooghe, A. P. (2002). Definitions of bullying: A
comparison of terms used, and age and gender differences in a fourteen-country international
comparison. Child Development, 73, 1119–1133. doi:10.1111/1467–8624.00461
Smith, P. K., Mahdavi, J., Carvalho, M., Fisher, S., Russell, S., & Tippett, N. (2008). Cyberbullying:
Its nature and impact in secondary school pupils. Journal of Child Psychology and Psychiatry, 49,
376–385. doi:10.1111/1467–8624.00461
Swearer, S. M., & Espelage, D. L. (2004). Introduction: A social-ecological framework of bullying
among youth. In D. L. Espelage & S. M. Swearer (Eds.), Bullying in American schools: A social-
ecological perspective on prevention and intervention (pp. 1–12). Mahwah, NJ: Erlbaum.
Swearer, S. M., Espelage, D. L., & Napolitano, S. A. (2009). Bullying prevention and intervention:
Realistic strategies for schools. New York: Guilford Press.
Swearer, S. M., Limber, S. P., & Alley, R. (2009). Developing and implementing an effective anti-
bullying policy. In S. M. Swearer, D. L. Espelage, & S. A. Napolitano (Eds.), Bullying prevention
and intervention: Realistic strategies for schools (pp. 39–53). New York: Guilford Press.
Swearer, S. M., Peugh, J., Espelage, D. L., Siebecker, A. B., Kingsbury, W. L., & Bevins, K. S. (2006).
A social-ecological model for bullying prevention and intervention in early adolescence. In S. R.
Jimerson & M. J. Furlong (Eds.), Handbook of school violence and school safety (pp. 257–273).
Mahwah, NJ: Lawrence Erlbaum.
Thijs, J., & Verkuyten, M. (2008). Peer victimization and academic achievement in a multiethnic
sample: The role of perceived academic self-efficacy. Journal of Educational Psychology, 100,
754–764. doi:10.1037/a0013155
Tokunaga, R. S. (2010). Following you home from school: A critical review and synthesis of research
on cyberbullying victimization. Computers in Human Behavior, 26, 277–287. doi:10.1016/j.
chb.2009.11.014
Tomada, G., & Schneider, B. H. (1997). Relational aggression, gender, and peer acceptance: Invari-
ance across culture, stability over time, and concordance among informants. Developmental Psy-
chology, 33, 601–609. doi:10.1037/0012–1649.33.4.601
Troy, M., & Sroufe, L. A. (1987). Victimization among preschoolers: Role of attachment relation-
ship history. Journal of the American Academy of Child and Adolescent Psychiatry, 2, 166–172.
doi:10.1097/00004583–198703000–00007
Twemlow, S. W., Fonagy, P., Sacco, F. C., Gies, M. L., Evans, R., & Ewbank, R. (2001). Creating a
peaceful school learning environment: A controlled study of an elementary school intervention to
reduce violence. American Journal of Psychiatry, 158, 808–810. doi:10.1176/appi.ajp.158.5.808
Twyman, K., Conway, S., Taylor, L., & Comeaux, C. (2010). Comparing children and adolescents
engaged in cyberbullying to matched peers. CyberPsychology, Behavior & Social Networking, 13,
195–199. doi:10.1089/cyber.2009.0137
Vandebosch, H., & Van Cleemput, K. (2009). Cyberbullying among youngsters: Profiles of bullies
and victims. New Media Society, 11, 1349–1371. doi:10.1177/1461444809341263
Vossekuil, B., Fein, R. A., Reddy, M., Borum, R., & Modzeleski, W. (2002). The final report and
findings of the safe schools initiative: Implications for the prevention of school attacks in the
United States. Washington, DC: US Secret Service and US Department of Education.
Wang, J., Iannotti, R., & Nansel, T. R. (2009). School bullying among adolescents in the United
States: Physical, verbal, social exclusion, spread rumors, and cyber. Journal of Adolescent Health,
45, 368–375. doi:10.1016/j.jadohealth.2009.03.021
Willard, N. E. (2007). Cyberbullying and cyberthreats: Responding to the challenge of online social
aggression, threats, and distress. Champaign, IL: Research Press.
Ybarra, M. L. & Mitchell, K. J. (2004a). Online aggressors/targets, aggressors, and targets: A com-
parison of associated youth characteristics. Journal of Child Psychology and Psychiatry, 45, 1308–
1316. doi:10.1111/j.1469–7610.2004.00328.x
——— (2004b). Youth engaging in on-line harassment: Associations with caregiver-child relation-
ships, internet use, and personal characteristics. Journal of Adolescence, 27, 319–336. doi:10.1016/j.
adolescence.2004.03.007
Ybarra, M. L., Mitchell, K. J., Wolak, J., & Finkelhor, D. (2006). Examining characteristics and asso-
ciated distress related to Internet harassment: Findings from second youth Internet safety survey.
Pediatrics, 118, e1169–e1177. doi:10.1542/peds.2006–0815
7 Child Maltreatment
Linda Webster
Martha cringed as her mother approached her with an angry look on her face. “Mama,
mama! I’m sorry. I’ll be good. What did I do wrong?” “You were born!” her mother
screamed as she pushed Martha into the small dark closet and locked the door. “No,
Mama! Please! Please!” Martha sobbed. Martha heard her mother leave the house
with a loud bang of the door and the house became quiet. Soon however, the rats who
lived within the walls began to emerge, biting Martha on the ankles where her skin was
exposed. She attempted to bat them away, screaming for her mother. Although this may
seem like an extreme case, there are many children who face home lives this stressful or
worse. School personnel can be of great help to these children, and have an important
role to play in their lives.
Definitions and Prevalence of Maltreatment

Prevalence: Child maltreatment is defined as physical and sexual abuse, but also includes
emotional or psychological maltreatment, neglect or negligent treatment, and many forms
of exploitation that results in harm or potential harm to a child’s health, survival, devel-
opment, or dignity. There are minimum standards set by the Federal Child Abuse Preven-
tion and Treatment Act (CAPTA) (42 U.S.C.A §5106g) (U.S. Department of Health and
Human Services, 2005), but each state is responsible for providing its own definitions. As
amended in 2010, CAPTA defines child abuse and neglect as, at a minimum: Any recent
act or failure to act on the part of a parent or caretaker which results in death, serious
physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which
presents an imminent risk of serious harm.
Physical Abuse
Physical abuse is nonaccidental physical injury that results from punching, beating, kick-
ing, biting, shaking, throwing, stabbing, choking, hitting, or burning. The U.S. Depart-
ment of Health and Human Services reported that Children’s Protective Service agencies
received an estimated 123,599 referrals in 2009, the latest data available at the time of
this writing (U.S. DHHS, 2010). Physical abuse made up approximately 10.8% of the
maltreatment reported in 2009.
Sexual Abuse
Sexual abuse includes activities perpetrated upon a child by an adult, such as fondling a
child’s genitals or requiring a child to fondle the adult’s genitals, penetration, incest, rape,
sodomy, indecent exposure, and exploitation through prostitution or the production of
Child Maltreatment 107
pornographic materials. There were 65,964 cases involving sexual abuse reported in 2009
(U.S. DHHS, 2010). Sexual abuse made up 7.6% of the maltreatment reported in 2009.
Neglect
The definition of neglect can involve a failure on the part of the caregiver to provide nec-
essary food or shelter (physical neglect), failure to provide necessary medical or mental
health treatment (medical neglect), failure to educate a child or attend to special educa-
tion needs (educational neglect), inattention to the child’s emotional needs, or permitting
the child to use alcohol or other drugs (emotional neglect). Neglect makes up the largest
percentage of children who experience maltreatment, and constituted 78.3% of the mal-
treatment reported in 2009, with a total of 543,035 cases reported (U.S. DHHS, 2010).
Psychological Abuse or Emotional Maltreatment

This category includes the restriction of movement, patterns of belittling, blaming, threat-
ening, frightening, discriminating against or ridiculing, rejection, and hostile treatment. The
prevalence of emotional maltreatment can only be estimated as it is difficult to substantiate
and often overlaps with other types of child maltreatment (Egeland, 2009; O’Hagan, 1995;
Trickett, Kim, & Prindle, 2011; Trickett, Mennen, Kim, & Sang, 2009). Psychological mal-
treatment constituted 7.6% of the maltreatment reported in 2009, but it is almost always
present when other forms of maltreatment are identified (U.S. DHHS, 2010).
The duplicate victim rate was 10 victims per 1,000 children in the population, while
the unique victim rate was 9.2 victims per 1,000 children. The duplicate count of child
victims counts a child each time he or she is found to be a victim of any form of child
maltreatment. The number of estimated duplicate victims was 754,000 while the estimated
unique victims was 695,000. Children in the age group of birth to 1 year had the highest
rate of victimization at 20.6 per 1,000. Boys accounted for 48.5% of the children victim-
ized, while girls accounted for 51.2%. African American children accounted for 21.9%
of children victimized, while Hispanic children accounted for 21.4%, and White children
accounted for 44.8%. For unique victims, more than 75% of the children experienced
neglect (78.3%), 17.6% suffered physical abuse, and 9.2% suffered sexual abuse. Fifty-
one states reported a total of 1,537 fatalities, with a national estimate of 1,560 children
who died from abuse and neglect. The overall rate of child fatalities was 2.07 deaths per
100,000 children, with 79.4% younger than 4 years of age. Boys had a higher fatality rate
than girls at 2.51 boys per 100,000. The rate for girls was 1.73 per 100,000. More than
30% (32.6%) of child fatalities were a sole result of neglect. More than 40% (40.8%) of
fatalities were caused by multiple types of maltreatment.
More than 80% (81.2%) of duplicate perpetrators of child maltreatment were parents,
with 84.2% being a biological parent of the child. Other perpetrators included relatives
and unmarried partners of parents. Less than half (45.2%) were men, while more than
half (53.6%) were women. More than 80% (84.2%) were between the ages of 20 and 49
years, while 36.3% were between 20 and 29 years of age.
Maltreatment as a Psychological Crisis

Children who have experienced maltreatment often suffer from what is referred to as “com-
plex trauma” (Briere & Spinazzola, 2005; Cook, Blaustein, Spinazzola, & van der Kolk,
2003; Courtois, 2008), a term that denotes experiences of trauma that occur repeatedly and
cumulatively within the context of family and intimate relationships. Although complex
108 Linda Webster
trauma can occur in adults (for example, battered women), children present a significant
vulnerability due to the impact of maltreatment across multiple domains of development
and functioning. Typically, the effects of complex trauma refer to child maltreatment
that is chronic and begins in early childhood. Child maltreatment is particularly damaging
as it is inflicted by family members, and/or there is failed protection from the primary
caregivers. Maltreatment and the associated trauma include the immediate impact, as well
as the long-term effects of sexual abuse, physical abuse, emotional abuse, neglect, and wit-
nessing domestic violence. It is the psychological damage, however, that constitutes the core
of the definition of complex trauma, and is considered to be the most damaging, although
often the most difficult to substantiate (Egeland, 2009). The impact of complex trauma
spans multiple domains and includes impairment in attachment, biology, affect regulation,
dissociation, behavioral regulation, cognition, and self-concept (Cook et al., 2003; De Bel-
lis, 2001; Schore, 2001); and this is where the “complex” in complex trauma derives.
Attachment
The attachment relationship and the complementary caregiving system are essential to
the well-being of the developing infant and child (George & Solomon; 2008; Solomon &
George, 2011). A central premise of attachment theory is that the child’s early experiences
with a primary caregiver impacts on the child’s interpersonal relationships as well as emo-
tional regulation across the lifespan. Bowlby (1979) hypothesized that early attachment
experiences and the representations of those experiences affect relationships, self-esteem,
and self-regulation of emotion and behavior. Under optimal conditions of responsive and
sensitive caregiving, the attachment system is flexibly integrated and organized in such a
way that allows the infant to seek comfort when he or she needs it, and pursue exploration
of the environment when threats in the environment are minimal. However, under condi-
tions associated with neglect, rejection, and abuse, the child develops defensive processes
that serve to keep painful feelings and thoughts from consciousness. It is these defensive
processes that subsequently impact adaptation and functioning. Children who have been
abused or neglected learn that caregivers are unreliable or actively hostile and malevolent,
and they often come to view themselves as unworthy of care (Beeghly & Cicchetti, 1994;
Kim & Cicchetti, 2006).
Child maltreatment has been consistently associated in the research literature with disor-
ganized attachment (Cyr, Euser, Bakermans-Kranenburg, & van Ijzendoorn, 2010; Shonk &
Cicchetti, 2001; Stronach et al., 2011; van Ijzendoorn, Schuengel, & Bakermans-Kranenburg,
1999; Weinfield, Whaley, & Egeland, 2004). Disorganized attachment occurs when the child
is either frightened of the caregiver, or experiences the caregiver as frightened herself and
thus unavailable to the child (Main & Hesse, 1990). Disorganized attachment leaves the
child vulnerable to attachment anxiety, and results in a collapse of behavioral strategies
for managing stress (Main & Morgan, 1996)—that is, the child is afraid to approach the
very person that he or she instinctually seeks during stress. Behavioral manifestations may
include freezing, stilling, obvious behavioral signs of apprehension, or helplessness (Main
& Solomon, 1990). Disorganized children experience a dysregulation of affect that they
are not able to defend against, nor resolve (Lyons-Ruth & Jacobvitz, 2008; Moss, Bureau,
St-Laurent, & Tarabulsy, 2011; Solomon & George, 2011; Solomon, George, & DeJong,
1995). In older children and adolescents, this may take the form of controlling behavior
that can be either caregiving (overly solicitous of the caregiver) or punitive (coercive), and
is in essence a form of role-reversal (Main & Cassidy, 1988; Solomon & George, 2011).
Disorganized attachment places the child at significant risk for maladaptive outcomes (Carl-
son, 1998; Lyons-Ruth, Alpern, & Repacholi, 1993; Lyons-Ruth, Connell, Grunebaum,
& Botein, 1990; Moss, Rousseau, Parent, St-Laurent, & Saintonge, 1998; Solomon et al.,
1995), including both internalizing and externalizing behavior problems.
Biology
De Bellis (2001) developed a psychobiological model of the impact of maltreatment as
a trauma on the developing biological stress system. In addition to the effects of direct
assault associated with physical and sexual abuse, the biological effects of maltreatment
include dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which is respon-
sible for releasing glucocorticoids to enhance stress coping (Carpenter et al., 2007; De
Bellis, 2001, 2005; Heim & Nemeroff, 2009). The dysregulation of this neural system
can result in cognitive, motor, and sensory functioning deficits (De Bellis, 2004, 2005; De
Bellis, Hooper, Spratt, & Woolley, 2009; De Bellis, Hooper, Woolley, & Shenk, 2010),
which may facilitate the development of psychopathology by impairing behavioral and
emotional regulation (van der Kolk, 2005). Interestingly, secure attachments and respon-
sive and sensitive caregiving appear to be especially important influences on HPA func-
tioning and development in the early years (Gunnar & Quevedo, 2008), and may form a
protective factor for children who experience maltreatment. In other words, children who
experience maltreatment, but who have sensitive and responsive caregiving, are buffered
or protected against the negative impact of maltreatment on the HPA axis functioning.
Schore (2002) reasoned that traumatic attachments, such as those involved in maltreat-
ment, impact the developing limbic and autonomic nervous systems of the developing right
brain. These areas are thought to be associated with processing negative emotions such as
fear and the retrieval of autobiographical memory, respectively (Hariri, Bookheimer, &
Mazziotta, 2000; Morris, Ohman, & Dolan, 1999; Schore, 2001; Whalen et al., 1998).
Schore (2002) argues that the research findings available have strong implications for
understanding the etiology of disorders of affect regulation, and he hypothesizes that the
structural changes that occur as a result of these traumatic attachments result in ineffec-
tive stress coping mechanisms that leave the individual vulnerable to the development of
posttraumatic stress disorder (PTSD).
Affect Regulation
Disturbances in emotion regulation have long been linked to the development of psycho-
pathology (e.g., Cicchetti, Ackerman, & Izard, 1995; Eisenberg et al., 2001; Hill, Degnan,
Calkins, Keane, 2006; Suveg & Zeman, 2004). Child maltreatment has also been associ-
ated with the development of psychopathology, including anxiety, depression, suicidality,
disruptive behavior disorders, conduct problems, and delinquency (Bolger & Patterson,
2001; Cook et al., 2005; Grotevant et al., 2006; Kim & Cicchetti, 2006, 2010; McCabe,
Lucchini, Hough, Yeh, & Hazen, 2005; Ryan & Testa, 2005). It has been proposed that
child abuse and neglect may contribute to the development of externalizing problems as
a result of inadequate affective regulation, involving difficulties inhibiting behavior and
controlling attention and cognitive processing (Briere & Richards, 2007; Briere, Hodges,
& Gobbout, 2010; Olson, Schilling, & Bates, 1999; Oosterlaan & Sergeant, 1996; Roth-
bart, Posner, & Hershey, 1995).
Dissociation
Dissociation is considered to be a key component of complex trauma (Cook et al., 2005),
and it is thought that its use develops as a method to avoid the pain of abuse (including
110 Linda Webster
emotional abuse) as it is occurring (Haugaard, 2004a). Dissociation involves altered states
of consciousness, and is defined as “the failure to integrate or associate information and
experience in a normally expectable fashion” (Putnam, 1997, p.7). Of interest is that
dissociation is thought to be connected to the biological stress response system (Putnam,
1997). Putnam (1997) postulated that there are three primary functions of dissociation:
detachment from the self in order to protect the self from experiencing the trauma, the
automatization of behavior during the traumatic event, and the compartmentalization of
painful memories and feelings, the latter being similar to Bowlby’s notion of segregated
systems (Bowlby, 1980).
Liotti (2004, 2006) has noted similarities between the classic manifestations of dis-
organized attachment in the Strange Situation—for example, freezing, confusion,
temporal-spatial disorientation, or contradictory verbal or nonverbal behaviors—and
dissociative phenomena. The Strange Situation was a laboratory procedure designed
by Mary Ainsworth to measure the quality of attachment in infant-caregiver dyads
(Ainsworth, Blehar, Waters, & Wall, 1978). Dissociation, from an attachment perspec-
tive, involves the development of multiple contradictory internal representations of
the self in relationship with the attachment figure (Cortina, 2003). Under conditions
of stress that result in the activation of the attachment behavioral system, segregated,
unintegrated perceptual and emotional experiences related to early trauma can disrupt
the integrative functions of the individual’s consciousness, memory, and identity (Liotti,
2004). In support of this hypothesis, Ogawa, Sroufe, Weinfield, Carlson, and Egeland
(1997) found that the best predictors of symptoms of dissociation at age 19 were dis-
organized attachment at 12–18 months and mothers’ psychological unavailability from
zero to 24 months. Of interest was that the experience of sexual or physical abuse did
not continue to predict dissociative symptoms after caregiving was accounted for. This
suggests that caregiving is a pathway, or a mediator, through which the trauma exerts
its negative impact.
The extensive use of dissociation can lead to difficulties with behavioral regulation,
affect regulation, and cognition (thoughts and memories) (Macfie, Cicchetti, & Toth,
2001; Putnam, 1997). Indeed, it has been argued that repeated use of dissociation during
maltreatment (or other experiences) can sensitize the brain to its use through the strength-
ening of the neural pathways used to dissociate (Depue, Collins, & Luciana, 1996).
Behavioral Regulation
Child maltreatment, particularly chronic and severe maltreatment, is significantly associ-
ated with the development of aggressive and disruptive behavior problems (Grotevant
et al., 2006; Lansford et al., 2007; McCabe et al., 2005; Ryan & Testa, 2005; Teisl &
Cicchetti, 2008), as well as internalizing problems such as depression and anxiety (Lans-
ford et al., 2002; Milot, Ethier, St-Laurent, & Provost, 2010; Toth, Manly, & Cicchetti,
1992) and in particular posttraumatic stress disorder (Koenen, Moffitt, Poulton, Martin,
& Caspi, 2007; Scheeringa, 2008). Maltreated children are more likely to be overactive,
impulsive, impatient, and noncompliant; they are also more likely to exhibit disruptive
behavior in the classroom and to be more disrespectful with teachers (Anthonysamy &
Zimmer-Gembeck, 2007; Erickson, Egeland, & Pianta, 1989; Ouyang, Fang, Mercy, Perou,
& Grosse, 2008). Many of these problems are thought to have, at their core, deficits in
emotional regulation, particularly negative emotions such as anxiety, anger, and sadness
(DeKlyen & Greenberg, 2008). Behavioral and emotional regulation is important for
psychosocial adjustment as children with behavioral regulation problems are at greater
risk for poor peer and social relationships and the development of psychopathology (Hill
et al., 2006; Kim & Cicchetti, 2010; Teisl & Cicchetti, 2008). Long-term effects of child
maltreatment include the development of borderline personality disorder (Haugaard,
2004b), depression and substance abuse, and antisocial and violent behavior (Arias, 2004,
Harris, Lieberman, & Marans, 2007; Kaplow & Widom, 2007).
Cognition
De Bellis (2005) reasons that child maltreatment, in particular severe stress, interferes
with normal development of the prefrontal cortex, where executive functions, such as
planning, decision making, working memory, and attention, reside. De Bellis, Hooper,
Spratt, & Woolley (2009) recently conducted a study with neglected children, and found
significantly lower intelligence, language, and learning/memory and attention/executive
functions than a comparative group of controls. Significant differences remained even
after controlling for intelligence. Impairments in executive functioning may lead to prob-
lems with effective coping skills, such as impairments in the ability to redirect attention
and inhibit negative thoughts, or reexamine cognitive distortions. Memory, learning, and
spatial information processing may also be affected (Cicchetti, Rogosch, Howe, & Toth,
2010; Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006), as well as language
development (De Bellis, 2001; Gilbert et al., 2009).
Crick and Dodge (1994) propose a social information-processing model that involves
six stages of cognitive processing. These sequential steps include encoding of social cues,
interpretation of these cues, clarification of goals, accessing or constructing a response,
deciding upon a response, and acting upon the decision. Distortions in any of these phases
of processing have been associated with problems in social adjustment and peer relations,
particularly for aggressive behavior (Dodge, Pettit, McClasky, & Brown, 1986, 1995;
Slaby & Guerra, 1988). Research with maltreated children has demonstrated signifi-
cant deficits in information processing, with maltreated children showing a bias towards
misperceiving anger (Pollak, Cicchetti, Hornung, & Reed, 2000; Pollak & Sinha, 2002;
Rieder & Cicchetti, 1989).
Maltreated children are also more likely to have poor academic performance compared
to nonmaltreated peers, receive lower scores on standardized tests and lower grades, and
are more frequently recommended for grade retention (Dodge Reyome, 1993; Ecken-
rode, Laird, & Doris, 1993; Kendall-Tackett & Eckenrode, 1996; Leiter, 2007; Veltman
& Browne, 2001). By early elementary grades, maltreated children are more frequently
referred for special education (Shonk & Cicchetti, 2001). In a recent study, Coohey,
Renner, Hua, Zhang, and Whitney (2011) found that children who had experienced mal-
treatment and who also had poor daily living skills (as measured by an adaptive behavior
scale) performed more poorly in math and reading over time.
Self-Concept
Sensitive and responsive caregiving allows children to develop a sense of the self as worthy
of care and of others as dependable and trustworthy (Bowlby, 1982), while insensitive,
neglectful, or harsh caregiving makes it more likely that the child will come to view him-
or herself as ineffective and unworthy of care, and view others as uncaring and insensitive
(Kim & Cicchetti, 2006). Children who have been subject to maltreatment may develop a
sense of the self as ineffective and helpless, and several studies have indeed found that mal-
treated children have less positive self-concepts (Bolger, Patterson, & Kupersmidt, 1998;
Cicchetti & Rogosch, 1997; Kim & Cicchetti, 2006; Toth, Cicchetti, MacFie, Maughan,
& Vanmeenen, 2000; Turner, Finkelhor, & Ormrod, 2010).
112 Linda Webster
Theories Regarding the Causes of Maltreatment
Risk Factors
Maltreating families often live in chaotic, unstable, and disorganized environments (Cic-
chetti & Valentino, 2006) where there is tolerance of violence, inadequate housing, and
poverty (Pala, Unalacak, & Unluoglu, 2011). Psychiatric problems and substance abuse,
child prematurity, low birth weight, reactive temperament, maternal youth, depression, low
education, unemployment, and lack of social support are also associated with risk for child
maltreatment (Hurme, Alanko, Anttila, Juven, & Swedstrom, 2008; Palusci, 2011; Wu
et al., 2004; Zhou, Hallisey, & Freymann, 2006). Not surprisingly, intimate partner abuse is
associated with child maltreatment (Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004),
as is the perpetrator having a history of having been a victim of child maltreatment them-
selves (Dixon, Hamilton-Giachritsis, & Browne, 2005; Egeland, Jacobvitz, & Sroufe, 1988;
Pears & Capaldi, 2001). Research estimates that 15.5 million children live in families in
which domestic abuse occurs at least once a year, and 7 million children live in families with
severe intimate partner violence (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green,
2006). Exposure to domestic violence constitutes what George and Solomon (2008) refer to
as “failed protection” regardless of whether the child is also subject to violence, as witnessing
the caregiver being attacked is akin to being attacked oneself. Exposure to domestic violence
is associated with a wide range of emotional and psychological difficulties (Evans Davies, &
DiLillo, 2008; Holt, Buckley, & Whelan, 2008), and when domestic violence is paired with
child abuse the outcomes are significantly worse (Herrenkohl, Sousa, Tajima, Herrenkohl,
& Moylan, 2008). Hostile, neglectful, or inconsistent parenting is also more commonly
seen in maltreating families (Rogosch, Cicchetti, & Aber, 1995), and maltreating parents
are more likely to use threat, punishment, coercion, and power assertion to gain compliance
from their children (Chilamkurti & Milner, 1993; Lorber, Felton, & Reid, 1984).
A history of juvenile delinquency is also associated with child maltreatment. For exam-
ple, Colman, Mitchell-Herzfeld, Kin, and Shady (2010) tracked 999 juvenile delinquents
released from a juvenile correction facility in New York State, and found that by age 28,
two thirds of the girls had been investigated by child protective services for child maltreat-
ment. Moffitt and Caspi (1999) found that delinquency in childhood and adolescence
predicted intimate partner violence in adulthood, and Giordano, Millhollin, Cernkovich,
Pugh, and Rudolph (1999) found that self-reported delinquency in adolescence predicted
relationship violence 10 years later. Individuals with delinquent histories often have high
rates of early childbearing (Huizinga, Loeber, & Thornberry, 1993; Thornberry, Wei,
Stouthamer-Loeber, & Van Dyke, 2000), and teens are less likely to have effective parent-
ing (George & Lee, 1997), which may result in their being more susceptible to the stresses
of parenting and more inclined to engage in child maltreatment.
Other approaches to the causes of maltreatment cite broader structural and ecologi-
cal factors such as poverty and unemployment (Coulton, Crampton, Irwin, Spilsbury,
& Korbin, 2007), although some argue that it is more likely that the effects are indirect
through the caregiving system (Gonzalez & MacMillan, 2008; Zielinski & Bradshaw,
2006). For example, socioeconomic risk such as low educational level, low income, and
adolescent or single parenthood may stress the parent such that it has a negative impact on
the quality of parental caregiving by reducing sensitivity and responsiveness.
Protective Factors
Although a great deal of the research on child maltreatment has focused on the maladap-
tive outcomes associated with maltreatment, there is a growing literature on protective
factors. A protective factor may influence, modify, ameliorate, or alter how a particular
risk factor may operate; protective factors provide a buffer against the development of
psychopathology. Research has identified three areas in which protective factors might
operate: at the level of the individual, the family, and the community (Afifi & MacMillan,
2011). Individual-level protective factors include personality factors such as ego resilience
(the ability to modify responses and reactions in a flexible manner), ego overcontrol (the
ability to inhibit impulses), and positive self-esteem (Cicchetti, Rogosch, Lynch, & Holt,
1993; Cicchetti & Rogosch, 1997; Kim, Cicchetti, Rogosch, Manly, 2009). Intelligence
as a protective factor in child maltreatment has yielded inconsistent results (Afifi & Mac-
Millan, 2011). Family-level protective factors, as might be expected, include positive and
supportive relationships, the provision of alternative, supportive care (such as foster care),
and improved parenting skills, and family coherence (Howell, Graham-Bermann, Czyz, &
Lilly, 2010; Sagy & Dotan, 2001; Spaccarelli & Kim, 1995). Parental support and belief in
the child have been found to be key mediating factors in positive adaptation for children
who have experienced maltreatment (Cohen & Mannarino, 2000). Cook et al. (2005)
argue that there are three important components to parents’ responses, which include
believing and validating their child’s experience, tolerating the child’s emotional states,
and managing their own emotional response. This is not to imply that parents cannot or
should not have an emotional reaction to the abuse of their child, but rather that they
should make attempts to separate their own needs from the needs of the child and buffer
the child from their own emotional reaction (Finkelhor & Kendall-Tackett, 1997).
Importantly, Egeland, Jacobvitz, and Sroufe (1988) found three factors that interrupted
the cycle of abuse with mothers who had been abused themselves but who provided ade-
quate care for their children: receiving emotional support from an alternative, nonabusing
adult during childhood; participating in a therapy experience of at least six months’ dura-
tion; and having an emotionally supportive and satisfying relationship with a significant
other as an adult. Protective factors at the community level include positive peer relation-
ships, health services programs, nonfamily member social support, and religion (Afifi &
MacMillan, 2011; Brayden et al., 1993; Mersky, Topitzes, & Reynolds, 2011).
Primary Prevention
Given recent research on the profound negative impact of child maltreatment, particularly
on brain development, in addition to the costs of remediation of the effects of child abuse
and the intergenerational cyclic nature of maltreatment, it is easy to make the argument
that preventing child maltreatment in the first place is more efficient and cost-effective
than treating it later (Kilburn & Karoly, 2008).
Parent Education
Parent education programs attempt to prevent child maltreatment by improving parenting
skills, increasing parental knowledge of child development, and training parents in positive
behavior management. There is some evidence that these programs are effective in reduc-
ing the risk factors of child maltreatment, such as increasing knowledge of child develop-
ment, increasing the use of positive discipline, and decreasing the use of spanking (Barth,
2009; Geeraert, Van, Noortgate, Grietens, & Onghena, 2004; Lundahl, Nimer, & Par-
sons, 2006). Parent-Child Interaction Therapy (PCIT) is an intervention that attempts to
modify the way that parents interact with their children so that their children exhibit fewer
behavior problems (Eyberg & Robinson, 1982; Eyberg, 1988). PCIT is based upon social
learning theory and attachment theory, and uses live and individualized therapist coaching
to assist parents to maintain consistent limits, to ignore minor disruptive behaviors, and
114 Linda Webster
to increase attention to position interactions. Parents initially learn specific skills of posi-
tive communication and behavior management with their children. They practice these
skills, with parents being told to follow their child’s lead, to describe the child’s activity and
to provide praise for their child’s positive behavior. At the same time, parents are learning
to ignore inappropriate behavior by withdrawing their attention, and by notifying the child
that when their behavior is compliant, they will reengage with them. Parents are coached to
use more praise, and to minimize negative communication. This serves to enhance the
parent-child relationship, and to improve caregiver sensitivity. Once the relationship has
taken on a more positive tone, parents are taught and coached on how to manage their
child’s noncompliant behavior with the use of clear and direct commands, choices, and
time-outs. PCIT has been found to be effective in preventing maltreatment (Thomas &
Zimmer-Gembeck, 2011) as well as with known maltreating parent-child dyads (Timmer,
Urquiza, Zebell, & McGrath, 2005).
Since child temperament characteristics and the presence of externalizing behaviors are
associated with increased child maltreatment (Stith et al., 2009), it seems reasonable to
hypothesize that targeting parenting training on how to manage more difficult and chal-
lenging behaviors with positive discipline may help reduce maltreatment. Mersky et al.
(2011) investigated the impact of the Chicago Child-Parent Center Preschool program in
a longitudinal study that followed children until the age of 18. These researchers found
that family support, increased parental involvement, maternal educational attainment,
and decreased family problems all contributed significantly to the reduction of actual child
maltreatment. This suggests that improving parental involvement through school-home
collaboration and helping to provide access to counseling for families who are experienc-
ing difficulties may be helpful in reducing maltreatment. Given that teen parents may be
at higher risk for child maltreatment, it may be beneficial to target parent education pro-
grams at pregnant and parenting teens.
Child Sexual Abuse Prevention Programs

These programs are almost exclusively school-based, and provided at the late elementary
level. Children are taught about body ownership, and good and bad touching. Targeted
skills include how to recognize abusive situations, saying no, and how to disclose abuse.
Most of the research on these types of programs indicates that they are effective in increas-
ing knowledge of sexual abuse and skills in protective behaviors; however, whether the
programs actually reduce the incidence of sexual abuse is unknown (Mikton & Butchart,
2009). Programs that are presented over four or more sessions, and that provide behav-
ioral skills training such as skill rehearsal, shaping, and reinforcement, have been found to
produce the highest effect sizes (Davis & Gidyez, 2000).
Home Visitation Programs

Home programs involve having a trained professional deliver support, education, and
information in the home to prevent child maltreatment. Services also include child health
and caregiving education. Overall, the research on these programs suggests that they are
effective in reducing risk factors for child maltreatment (see Mikton & Butchart, 2009, for
a review). Only one program, however, the Nurse Family Partnership (Olds et al., 1997;
Olds, 2008) has a proven track record in reducing actual child maltreatment. The Nurse
Family Partnership (NFP) is grounded in theories of human ecology, social-cognitive the-
ory, and attachment. The program registers low-income women who are expecting their
first child, and program nurses visit the homes during pregnancy and after the birth of the
child. The frequency of the visitation varies with the needs of the families, with more visits
during crises. The nurses attempt to help the women improve their prenatal health, help
parents improve their parenting, and help with future planning such as completing educa-
tion, finding work, and planning future pregnancies. Positive parent-child interaction is
promoted by facilitating parents’ understanding of their children’s communication, state
of mind, and developmental needs.
Ecological Interventions
From an ecological perspective (Bronfenbrenner, 1979), interactions exist between all lev-
els of the ecology, although factors and influences that are closer to the child are logically
expected to have more direct influence on the child’s behavior and development. Never-
theless, prevention efforts aimed at impacting the exosystem may serve to reduce child
maltreatment. For example, the reduction of poverty through job training and placement,
improving neighborhoods by reducing crime and increasing safety, and decreasing home-
lessness may all contribute to the reduction of child maltreatment (see Stagner & Lansing,
2009, for a review).
Crisis Intervention
The goal of immediate crisis intervention is to preclude later symptom development by
helping children to express their feelings, lessen their distress, and reinforce coping strate-
gies before inappropriate defensive mechanisms can become entrenched (Webb, 2007).
Counseling Guidelines
The following are general guidelines for immediate crisis intervention with maltreated
children.
Meet the Reporting Requirement. Federal and state law requires all school personnel to
report any “reasonable suspicion” of child maltreatment immediately. You don’t have to
know with certainty that the abuse occurred; you only have to reasonably suspect that it
occurred. Most states require a phone call to the local children’s protective agency or the
police immediately, followed by a written report.
Be Directive. Focus on immediate concerns and the welfare of the child. Provide the
child with developmentally appropriate information about the reporting process, your
responsibility to report and take action to protect him or her, the role of the police
and child protective services, and what will happen in the immediate future. For some
children, and in some circumstances, the disclosure and the events that follow it may
be traumatizing in themselves. Attempt to reassure the child, but be careful not to
provide false reassurance. Arrange for the child’s belongings to be brought to her, and
address the child’s concerns about schoolwork, homework, recess, etc. Attempt to make
the child as physically comfortable as possible and address any physical needs such as
hunger or thirst.
Reduce Blame. Emphasize that the child is not responsible for the abuse. Provide praise
for the courage that it takes to disclose. Emphasize that you will take appropriate steps to
ensure the child’s safety and wellbeing. It may be helpful to promote a cognitive reframe
and positive self-talk that reduces feelings of responsibility, helplessness, and inadequacy
(Arvidson et al., 2011). It may also be helpful to provide psychoeducation about trauma
reactions, instruction in positive coping strategies (Scheeringa, Weems, Cohen, Amaya-
Jackson, & Guthrie, 2011), abuse-specific cognitive restructuring, and the building of
116 Linda Webster
executive functions to increase the child’s ability to engage in problem solving, planning,
and anticipation (Arvidson et al., 2011).
Clarify Thoughts and Feelings. Restate and paraphrase the child’s thoughts and feelings
in order to demonstrate understanding and acceptance. Children need an opportunity to
express their feelings, which may be overwhelming, in the context of a close therapeu-
tic alliance. These feelings may include helplessness, shame, and vulnerability (Kearney,
Wechsler, Kaur, & Lemos-Miller, 2010).
Gently challenge maladaptive thoughts such as self-blame, and acknowledge that the
child may have mixed feelings about the abuse and the abuser in some cases. Some children
may be very suspicious of adults and resistant to revealing much in the way of thoughts
and feelings. In this situation, it is important to acknowledge their concerns (even if they
are not directly stated), and respect the fact that trust must be earned. Trauma-focused
cognitive-behavioral therapy focuses on helping the child to understand the relationship
between thoughts and feelings, and the importance of cognitive processing of the abuse
experience (Cohen, Mannarino, & Deblinger, 2006b; Deblinger, Mannarino, Cohen, Run-
yon, & 7 Steer, 2011; Scheeringa et al., 2011).
Maintain a Neutral Attitude. Convey an attitude of openness and a calm and supportive
acceptance of the disclosure. Ask questions calmly and from a neutral position (Courtois,
2008). Discussing the trauma may evoke a traumatic response in the child, such as being
flooded with overwhelming emotions, and the clinician should be alert to any indication
that disclosure is resulting in disorganization and dysregulation. If this occurs, the clinician
should stop any inquiry and help the child manage his or her emotions. The child’s safety
and welfare take precedence over disclosure of details.
The ARC Framework

Blaustein and colleagues (Arvidson et al., 2011; Blaustein & Kinniburgh, 2010; Kinni-
burgh et al., 2005) developed a framework for intervening with children and adolescents
who have experienced complex trauma. Known as the ARC framework (Attachment,
self-Regulation, and Competency), it is grounded in research and theory about complex
trauma, and it acts as a guide to inform interventions are designed that attempt to address
the core domains that are impacted by complex trauma (Cook et al., 2005), while at the
same time recognizing the need for interventions that are tailored to meet individual needs
and the context surrounding the trauma. The model incorporates interventions at the
individual, family, and systemic levels. The core domains are distilled here, and with sug-
gestions adapted to the school environment.
Attachment. This domain encompasses the caregivers in the child’s life, including par-
ents and foster parents, but also relatives and school personnel. The focus is on creat-
ing healthy attachments between children and caregivers, and the provision of a safe
environment. Interventions that focus on increasing sensitivity and responsiveness (Cic-
chetti, Rogosch, & Toth, 2006) and improving positive parenting practices (Cohen et al.,
2006a) have been found to be effective with parents of maltreated children. In the Min-
nesota Longitudinal Study, an important factor that discriminated between adequate
and inadequate parenting was related to the caregiver’s psychological understanding of
the child (Brunnquell, Crichton, & Egeland, 1981; Egeland & Brunnquell, 1979). For
example, Erickson and Egeland (1987) found that mothers of maltreated toddlers had
a lack of understanding of the psychological complexity of their child’s negativism and
age-appropriate assertions of independence, and often took the view that the child was
purposefully being manipulative or trying to make them angry. Thus, a major component
of any intervention for caregivers is gaining a better understanding of child development,
including accurate interpretation of their child’s thoughts, feelings, and behaviors, and
learning how to manage their own affect in response to the child so that they are not
just reacting to the child’s behavior. This can be accomplished with psychoeducation and
training regarding the impact of complex trauma, supplemented with consultation to help
parents and teachers accurately read and respond to the child’s cues and the emotional
needs underlying the child’s potentially distressing behaviors. Adults must continually
recognize that the child is doing the best that he or she can, given the set of challenges
the child is faced with in combination with the resources available. The child may have
learned maladaptive coping strategies as a means of managing overwhelming experiences
and emotions. Training in positive behavioral management and the implementation of
school-wide positive behavioral support can help all children, and especially children
who have been maltreated. The other component is the creation of a safe environment.
In general, schools are safe places for children, but additional attention should be placed
on ensuring a sense of safety, reducing victimization by peers, and providing a structured
and predictable environment by establishing rituals and routines.
Self-Regulation. This domain targets the child’s ability to regulate and modulate emo-
tional experience. This is typically accomplished through individual therapy, but can be
enhanced by caregivers who provide external relation for the child until they can man-
age his or her own emotions and develop adaptive coping skills. This involves affect
identification, which includes training children to accurately identify their feelings, to
connect their feelings to experiences (both past and present), and to accurately read the
emotional cues of others. Many children also need education and training in how to
express their emotions in an adaptive manner as many have learned maladaptive means
such as explosive anger, avoidance, and dissociation. Finally, they need training in how
to modulate affect and shift their attention in order to attain a more comfortable level
of arousal. Training can include controlled breathing methods, muscle relaxation, and
the use of visualization or imagery. Teachers can assist children in the regulation of emo-
tions by helping them recognize emotional states, cuing them to use skills, and offering
comfort and encouragement coupled with feedback and praise when the child is effective
in managing his or her emotions.
Trauma-focused cognitive-behavioral therapy has also been found useful for work with
maltreated children (e.g., Deblinger et al., 2011; Heflin & Deblinger, 2006; Scheeringa
et al., 2011). This approach focuses on education regarding child maltreatment (with an
emphasis on sexual abuse), coping skills training, parenting skills including appropriate
disciplinary strategies, conflict resolution, and how to manage strong emotions. Although
this approach is not a component of the ARC model, it would seem to fit nicely with
the ARC’s goals of improving regulation and attachment relationships. Developmental
approaches emphasize the organization and reorganization of attitudes, expectations,
and behavior over time, versus a focus on discrete behavioral skills (Sroufe, 1989), and
the focus is on the reciprocal nature of both the organism and the environment in devel-
opment. Developmental approaches also focus on the interaction between vulnerability
and risk factors, and promotive and resilient factors, and view resilience as a process that
develops over time within the context of supportive relationships (Egeland, Carlson, &
Sroufe, 1993).
Cohen, Mannarino, and Deblinger (2006b) advocate that the therapist help to identify,
explore, and correct the child’s cognitive errors. Cognitive errors can take two forms: those
that are inaccurate, and those that are accurate but unhelpful. An example of an inaccu-
rate cognition occurs when the child believes that the maltreatment was his or her fault,
or that he or she should have known that the perpetrator was a sex abuser. An unhelpful
cognition is one that might be accurate, but focuses on the most traumatizing realities of
118 Linda Webster
the abuse. For example, the child may focus on the fact that the family is now dissolved
because of his or her disclosure. In each case, it is important to correct the errors and let
the child know that it was not his or her fault, the child couldn’t have known, and that he
or she is not responsible for the family’s break-up.
Thought-stopping, positive self-talk, and positive imagery are strategies that can help
children to interrupt intrusive and distressing thoughts, and to learn how to have control
over their thoughts and emotions (Wekerle, Miller, Wolfe, & Spindel, 2006). Children can
be taught self-statements such as “It is not my fault,” “I am not responsible for the abuse,”
and “I am not responsible for the break-up of my family.” This may help reduce intrusive
thoughts regarding the abuse and diminish the need for compulsive reenactment of the
abuse (Cohen et al., 2006b; Terr, 1991; Vickerman & Margolin, 2007; Webb, 2007).
Competence. The competency domain targets the expected normal developmental
accomplishments associated with the child’s age—for example, peer relationships and
appropriate relationships with adults in his or her life, the development of a positive self-
concept, a sense of self-worth and a sense of agency, and cognitive competencies such as
language development, academic achievement, and executive functions (sustained atten-
tion, planning, impulse inhibition, etc.). Maltreated children may respond to social skills
training and friendship building groups. They may need training in anger management
skills, problem-solving skills, and the ability to tolerate distress in themselves and others.
Some children may need help in their ability to negotiate boundaries. The promotion of
academic success may be pivotal for children who have experienced maltreatment (Cic-
chetti & Rogosch, 1997; Jaffee & Gallop, 2007). Coohey et al. (2011) also argue for
interventions in daily living skills, such as attention to detail, self-regulation, and self-
motivation. Given their impaired relationships with adults, many maltreated youngsters
may need instruction and support on how to successfully approach adults, such as teach-
ers, for help when they are beyond their own resources.
Group Work with Abused Children. Group work typically targets beliefs and attitudes
about the abuse, changing cognitions about the abuse, and gaining control over intru-
sive thoughts or reexperiencing of the trauma. Additional goals include learning to trust,
share, recognize feelings, develop social skills, and learn to manage conflict appropriately
(Nisivoccia & Lynn, 2007). Group settings can be an excellent place to provide psycho-
education about the effects of abuse, and to provide new learning about relationships—
specifically, that abuse is unacceptable. Kolko and Swenson (2002) also recommend pro-
viding education that helps children learn to distinguish between acceptable discipline and
abuse. Addressing these goals within the group setting can allow children and teens the
opportunity to learn from one another. Children often experience a sense of relief that they
are not alone in their experiences, symptoms, or circumstances—activating the therapeutic
factor of universality (Yalom & Molyn, 2005). As children and teens share their stories of
abuse and resolution of that abuse, they can receive support and validation from others,
and gain hope from the successes of their peers (Vickerman & Margolin, 2007). Group
work also helps children to understand that they can help each other, and increases their
social networks (Lynn & Nisivoccia, 2001; Nisivoccia & Lynn, 2007).
Conclusion
Child maltreatment is a multifaceted phenomenon that exerts both short-term and long-term
negative effects in multiple domains of functioning, including attachment, biology, affect
regulation, dissociation, behavioral regulation, cognition, and self-concept (Cook et al.,
2003; De Bellis, 2001; Schore, 2001). Mental health professionals must consider function-
ing across these domains, as well as individual differences, developmental considerations,
and the challenges the child faces along with the available resources. Because of the nature
and complexity of maltreatment, these children need a flexible model of intervention that
can address a continuum of concerns as well as contextual variables, familial strengths
and vulnerabilities, and resources and challenges at the school and community levels.
Interventions should draw heavily upon the research on child maltreatment, as well as
developmental psychology and psychopathology, and should attempt to impact multiple
ecological systems. Development is a dynamic process, and the specific competencies and
resources that will be targeted for any one child will vary. The school-based mental health
professional is in a critical position to provide both direct and indirect interventions and
supports for children who have been maltreated.
REFERENCES
Afifi, T. O., & MacMillan, H. L. (2011). Resilience following child maltreatment: A review of pro-
tective factors. La Revue Canadienne de Psychiatrie, 56(5), 266–272.
Ainsworth, M. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psycho-
logical study of the Strange Situation. Hillsdale, NJ: Erlbaum.
Anthonysamy, A., & Zimmer-Gembeck, M. J. (2007). Peer status and behaviors of maltreated chil-
dren and their classmates in the early years of school. Child Abuse & Neglect, 31, 971–991.
Arias, I. (2004). The legacy of child maltreatment: Long-term health consequences for women. Jour-
nal of Women’s Health, 13, 468–473.
Arvidson, J., Kinniburgh, K., Howard, K., Spinazzola, J., Strothers, H., Evans, M., . . . Blaustein,
M. E. (2011). Treatment of complex trauma in young children: Developmental and cultural
considerations in application of the ARC model. Journal of Child & Adolescent Trauma, 4,
34–51.
Barth, R. P. (2009). Preventing child abuse and neglect with parent training: Evidence and opportu-
nities. The Future of Children, 19, 95–118.
Becker-Blease, K. A., & Freyd, J. J. (2008). A preliminary study of ADHD symptoms and correlates:
Do abused children differ from nonabused children? Journal of Aggression, Maltreatment, &
Trauma, 17, 133–140.
Beeghly, M., & Cicchetti, D. (1994). Child maltreatment, attachment, and the self system: Emer-
gence of an internal state lexicon in toddlers at high social risk. Development and Psychopathol-
ogy, 6, 5–30.
Blaustein, M., & Kinniburgh, K. (2010). Treating traumatic stress in children and adolescents: How
to foster resilience through attachment, self-regulation, and competence. New York: Guilford
Press.
Bolger, K. E., & Patterson, C. J. (2001). Pathways from child maltreatment to internalizing prob-
lems: Perceptions of control as mediators and moderators. Development and Psychopathology,
13, 913–940.
Bolger, K. E., Patterson, C. J., & Kupersmidt, J. B. (1998). Peer relationships and self-esteem among
children who have been maltreated. Child Development, 69, 1171–1197.
Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.
——— (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. New York: Basic Books.
——— (1982 [1969]). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.
Brayden, R. M., Altemeier, W. A., Dietrich, M. S., Tucker, D. D., Christensen, M. J., McLaughlin, F.
J., Sherrod, K. B. (1993). A prospective study of secondary prevention of child maltreatment. The
Journal of Pediatrics, 122, 511–516.
Briere, J., Hodges, M., & Gobbout, N. (2010). Traumatic stress, dysregulation, and dysfunctional
avoidance: A structural equation model. Journal of Traumatic Stress, 23(6), 767–774.
Briere, J., & Richards, S. (2007). Self-awareness, affect regulation, and relatedness: Differential
sequels of childhood versus adult victimization experiences. Journal of Nervous and Mental Dis-
ease, 195, 497–503.
120 Linda Webster
Briere, J., & Spinazzola, J. (2005). Phenomenology and psychological assessment of complex post-
traumatic states. Journal of Traumatic Stress, 18(5), 401–412.
Bronfenbrenner, U. (1979). Contexts of childrearing: Problems and prospects. American Psychologist,
34, 844–850.
Brunnquell, D., Crichton, L., & Egeland, B. (1981). Maternal personality and attitude in distur-
bances of child-rearing. Journal of Orthopsychiatry, 51, 680–691.
Carlson, E. A. (1998). A prospective longitudinal study of disorganized/disoriented attachment.
Child Development, 69, 1107–1128.
Carpenter, L. L., Carvalho, J. P., Tyrka, A. R., Weir, L. M., Mello, A. F., Mello, M. F., . . . Price, L. H.
(2007). Decreased adrenocorticotropic hormone and cortisol responses to stress in healthy adults
reporting significant childhood maltreatment. Biological Psychiatry, 62, 1080–1087.
Chilamkurti, C., & Milner, J. S. (1993). Perceptions and evaluations of child transgressions and
disciplinary techniques in high- and low-risk mothers and their children. Child Development, 64,
1801–1814.
Cicchetti, D., Ackerman, B. P., & Izard, C. E. (1995). Emotions and emotion regulation in develop-
mental psychopathology. Development and Psychopathology, 7, 1–10.
Cicchetti, D., & Rogosch, F. A. (1997). The role of self-organization in the promotion of resilience
in maltreated children. Development and Psychopathology, 9, 797–815.
Cicchetti, D., Rogosch, F. A., Howe, M. L., & Toth, S. L. (2010). The effects of maltreatment and
neuroendocrine regulation on memory performance. Child Development, 81, 1504–1519.
Cicchetti, D., Rogosch, F. A., Lynch, M., & Holt, K. D. (1993). Resilience in maltreated children:
Processes leading to adaptive outcomes. Developmental Psychopathology, 5, 629–647.
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachments in infants in
maltreating families through prevention interventions. Development and Psychopathology, 18,
623–649.
Cicchetti, D., & Valentino, K. (2006). An ecological-transactional perspective on child maltreat-
ment: Failure of the average expectable environment and its influence on child development. In
D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 3. Risk, disorder, and
adaptation (pp. 129–201). Hoboken, NJ: John Wiley & Sons.
Cohen, J. A., & Mannarino, A. P. (2000). Predictors of treatment outcome in sexually abused chil-
dren. Child Abuse & Neglect, 24, 983–994.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006a). Treating trauma and traumatic grief in
children and adolescents. New York: Guilford Press.
Cohen, J. A., Mannarino, A. P., Murray, L. K., & Ingelman, R. (2006b). Psychosocial interventions
for maltreated and violence-exposed children. Journal of Social Issues, 62, 737–766.
Colman, R. A., Mitchell-Herzfeld, S., Kin, D. H., & Shady, T. A. (2010). From delinquency to the
perpetration of child maltreatment: Examining the early adult criminal justice and child welfare
involvement of youth released from juvenile justice facilities. Children and Youth Services Review,
32, 1410–1417.
Coohey, C., Renner, L. M., Hua, L., Zhang, Y. J., & Whitney, S. D. (2011). Academic achievement
despite maltreatment: A longitudinal study. Child Abuse & Neglect, 35, 688–699.
Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (Eds.). (2003). Complex trauma in chil-
dren and adolescents. National Child Traumatic Stress Network. Retrieved from www.ncts.org/
sites/default/files/assets/pdfs/ComplexTrauma_All.pdf
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., . . . van der Kolk, B.
(2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390–398.
Cortina, M. (2003). Defensive processes, emotions and internal working models: A perspective from
attachment theory and contemporary models of the mind. In M. Cortina & M. Marrone (Eds.),
Attachment theory and the psychoanalytic process (pp. 271–306). London: Whurr.
Coulton, C., Crampton, D., Irwin, M., Spilsbury, J., & Korbin, J. (2007). How neighborhoods
influence child maltreatment: A review of the literature and alternative pathways. Child Abuse &
Neglect, 31, 1117–1142.
Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychologi-
cal Trauma: Theory, Research, Practice, & Policy, 8(1), 86–100.
Crick, N. R., & Dodge, K. A. (1994). A review and reformulation of social information processing
mechanisms in children’s social adjustment. Psychological Bulletin, 115, 74–101.
Cyr, C., Euser, E. M., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2010). Attach-
ment security and disorganization in maltreating and high-risk families: A series of meta-analyses.
Development and Psychopathology, 22, 87–108.
Davis, K. M., & Gidyez, C. A. (2000). Child sexual abuse prevention programs: A meta-analysis.
Journal of Clinical Child Psychology, 29(2), 257–265.
De Bellis, M. D. (2001). Developmental traumatology: The psychobiological development of mal-
treated children and its implications for research, treatment, and policy. Development and Psy-
chopathology, 13, 539–564.
——— (2004). Neurotoxic effects of childhood trauma: Magnetic resonance imaging studies of
pediatric maltreatment-related posttraumatic stress disorder versus nontraumatized children with
generalized anxiety disorder. In J. M. Gorman (Ed.), Fear and anxiety: Benefits of translational
research (pp. 151–170). Washington, DC: American Psychiatric.
——— (2005). The psychobiology of neglect. Child Maltreatment, 10, 150–172.
De Bellis, M. D., Hooper, S. R., Spratt, E. G., & Woolley, D. P. (2009). Neuropsychological find-
ings in childhood neglect and their relationships to pediatric PTSD. Journal of the International
Neuropsychobiological Society, 15, 868–878.
De Bellis, M. D., Hooper, S. R., Woolley, D. P., & Shenk, C. E. (2010). Demographic, maltreatment,
and neurobiological correlates of PTSD symptoms in children and adolescents. Journal of Pediat-
ric Psychology, 35(5), 570–577.
Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & 7 Steer, R. A. (2011). Trauma-
focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment
length. Depression and Anxiety, 28, 67–75.
DeKlyen, M., & Greenberg, M. T. (2008). Attachment and psychopathology in childhood. In J. Cas-
sidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications
(2nd ed., pp. 637–665). New York: Guilford Press.
DePrince, A. P., Weinzierl, K. M., & Combs, M. D. (2009). Executive function performance and
trauma exposure in a community sample of children. Child Abuse & Neglect, 33, 353–361.
Depue, R., Collins, P., & Luciana, M. (1996). A model of neurobiology-environment interaction in
developmental psychopathology. In M. Lensenweger & J. Haugaard (Eds.), Frontiers of develop-
mental psychopathology. New York: Oxford University Press.
Dixon, L., Hamilton-Giachritsis, C., & Browne, K. (2005). Attributions and behaviors of parents
abused as children: A mediational analysis of the intergenerational continuity of child maltreat-
ment (part 1). Journal of Child Psychology and Psychiatry, 46(1), 47–57.
Dodge, K. A., Pettit, G. S., Bates, J. E., & Valente, E. (1995). Social information-processing patterns
partially mediate the effect of early physical abuse on later conduct problems. Journal of Abnor-
mal Psychology, 104, 632–643.
Dodge, K. A., Pettit, G. S., McClasky, C. L., & Brown, M. M. (1986). Social competence in children.
Monographs of the Society for Research in Child Development, 51, 1–85.
Dodge Reyome, N. (1993). A comparison of the school performance of sexually abused, neglected,
and non-maltreated children. Child Study Journal, 23, 17–38.
——— (1994). Teacher ratings of the achievement-related classroom behaviors of maltreated and
non-maltreated children. Psychology in the Schools, 31, 253–260.
Eckenrode, J., Laird, M., & Doris, J. (1993). School performance and disciplinary problems among
abused and neglected children. Developmental Psychology, 29, 53–62.
Egeland, B. (2009). Taking stock: Childhood emotional maltreatment and developmental psychopa-
thology. Child Abuse & Neglect, 33, 22–26.
Egeland, B., & Brunnquell, D. (1979). An at-risk approach to the study of child abuse: Some prelimi-
nary findings. Journal of the American Academy of Child Psychiatry, 18, 219–235.
Egeland, B., Carlson, E. A., & Sroufe, L. A. (1993). Resilience as a process. Development and Psy-
chopathology, 5, 517–528.
Egeland, B., Jacobvitz, D., & Sroufe, L. A. (1988). Breaking the cycle of abuse. The Child, 59,
1080–1088.
122 Linda Webster
Eisenberg, N., Cumberland, A., Spinrad, T. L., Fabes, R. A., Shepard, S. A., Reiser, M., . . . Guthrie,
I. K. (2001). The relations of regulation and emotionality to children’s externalizing and internal-
izing problem behavior. Child Development, 72, 1112–1134.
Erickson, M. F., & Egeland, B. (1987). A developmental view of the psychological consequences of
maltreatment. School Psychological Review, 16(2), 156–168.
Erickson, M. F., Egeland, B., & Pianta, R. (1989). The effects of maltreatment on the development
of young children. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research
on the causes and consequences of child abuse and neglect (pp. 647–684). New York: Cambridge
University Press.
Evans, S. E., Davies, C., & DiLillo, D. (2008). Exposure to domestic violence: A meta-analysis of
child and adolescent outcomes. Aggression and Violent Behavior, 13, 131–140.
Eyberg, S. (1988). PCIT: Integration of traditional and behavioral concerns. Child and Family
Behavior Therapy, 10, 33–46.
Eyberg, S., & Robinson, E. A. (1982). Parent-child interaction training: Effects on family function-
ing. Journal of Clinical Child Psychology, 11(2), 130–137.
Finkelhor, D., & Kendall-Tackett, K. (1997). A developmental perspective on the childhood impact
of crime, abuse, and violent victimization. In D. Cicchetti & S. L. Toth (Eds.), Developmental
perspectives on trauma: Theory, research, and intervention (pp. 1–32). Rochester, NY: University
of Rochester Press.
Geeraert, L., Van, D., Noortgate, W., Grietens, H., & Onghena, P. (2004). The effects of early pre-
vention programs for families with young children at risk for physical child abuse and neglect: A
meta-analysis. Child Maltreatment, 9, 277–291.
George, C., & Solomon, J. (2008). The caregiving system: A behavioral systems approach to parent-
ing. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical
applications (2nd ed., pp. 833–856). New York: Guilford Press.
George, R. M., & Lee, J. B. (1997). Abuse and neglect of children. In R. A. Maynard (Ed.), Kids hav-
ing kids: Economic costs and social consequences of teen pregnancy (pp. 205–230). Washington,
D.C.: The Urban Institute Press.
Gilbert, R., Widom, C. S., Browne, K., Fergusson, D., Webb, E., & Janson, S. (2009). Burden and
consequences of child maltreatment in high-income countries. Lancet, 373, 68–81.
Giordano, P. C., Millhollin, T. J., Cernkovich, S. A., Pugh, M. D., & Rudolph, J. L. (1999). Delin-
quency, identity, and women’s involvement in relationship violence. Criminology, 37(1), 17–40.
Gonzalez, A., & MacMillan, H. L. (2008). Preventing child maltreatment: An evidence-based
update. Journal of Postgraduate Medicine, 54, 280–286.
Grotevant, H. D., van Dulmen, M. H. M., Dunbar, N., Nelson-Christinedaughter, J., Christensen,
M., Fan, X., & Miller, B. C. (2006). Antisocial behavior of adoptees and nonadoptees: Prediction
from early history and adolescent relationships. Journal of Research on Adolescence, 16, 105–131.
Gunnar, M. R., & Quevedo, K. M. (2008). Early care experiences and HPA axis regulation in
children: A mechanism for later trauma vulnerability. Progress in Brain Research, 167, 137–147.
Hariri, A. R., Bookheimer, S. Y., & Mazziotta, J. C. (2000). Modulating emotional responses: Effects
of a neurocortical network on the limbic system. Neuroreport, 11, 43–48.
Harris, W. W., Lieberman, A. F., & Marans, S. (2007). In the best interests of society. Journal of
Child Psychology & Psychiatry, 48, 392–411.
Haugaard, J. J. (2004a). Recognizing and treating uncommon behavioral and emotional disorders
in childhood and adolescents who have been severely maltreated: Dissociative disorders. Child
Maltreatment, 9(2), 146–153.
——— (2004b). Recognizing and treating uncommon behavioral and emotional disorders in child-
hood and adolescents who have been severely maltreated: Borderline personality disorders. Child
Maltreatment, 9(2), 139–145.
Hazen, A. L., Connelly, C. D., Kelleher, L., Landsverk, J., & Barth, R. (2004). Intimate partner vio-
lence among female caregivers of children reported for child maltreatment. The Child, 28, 301–319.
Heflin, A. H., & Deblinger, E. (2006). Treatment of a sexually abused adolescent with posttraumatic
stress disorder. In M. A. Reinecke, F. M. Dattilio, & A. Freeman (Eds.), Cognitive therapy with chil-
dren and adolescents: A casebook for clinical practice (2nd ed., pp. 214–246). New York: Guilford.
Heim, C., & Nemeroff, C. B. (2009). Neurobiology of posttraumatic stress disorder. CNS Spectrums,
14, 13–24.
Herrenkohl, T. I., Sousa, C., Tajima, E. A., Herrenkohl, R. C., & Moylan, C. A. (2008). Intersection of
child abuse and children’s exposure to domestic violence. Trauma, Violence & Abuse, 9(2), 84–99.
Hill, A. L., Degnan, K. A., Calkins, S. D., & Keane, S. P. (2006). Profiles of externalizing behavior
problems for boys and girls across preschool: The roles of emotion regulation and inattention.
Developmental Psychology, 42, 913–928.
Holt, S., Buckley, H., & Whelan, S. (2008). The impact of exposure to domestic violence on children
and young people: A review of the literature. Child Abuse & Neglect, 32, 797–810.
Howe, M. L., Cicchetti, D., & Toth, S. L. (2006). Children’s basic memory processes, stress, and
maltreatment. Development and Psychopathology, 18, 759–770.
Howell, K. H., Graham-Bermann, S. A., Czyz, E., & Lilly, M. (2010). Assessing resilience in pre-
school children exposed to intimate partner violence. Violence & Victims, 25, 150–164.
Huizinga, D., Loeber, R., & Thornberry, T. P. (1993). Longitudinal study of delinquency, drug use,
sexual activity, and pregnancy among children and youth in three cities. Public Health Reports,
108, 90–96.
Hurme, T., Alanko, S., Anttila, P., Juven, T., & Swedstrom, E. (2008). Risk factors for physical child
abuse in infants and toddlers. The European Journal of Surgery, 18, 387–391.
Jaffee, S. R., & Gallop, R. (2007). Social, emotional and academic competence among children who
have had contact with child protective services: Prevalence and stability estimates. Journal of the
American Academy of Child & Adolescent Psychiatry, 46, 757–765.
Jaycox, L. (2004). CBITS: Cognitive Behavioral Intervention for Trauma in Schools. Longmont,
CO: Sopris.
Kaplow, J. B., & Widom, C. S. (2007). Age of onset of child maltreatment predicts long-term mental
health outcomes. Journal of Abnormal Psychology, 116, 176–187.
Kearney, C. A., Wechsler, A., Kaur, H., & Lemos-Miller, A. (2010). Posttraumatic stress disorder
in maltreated youth: A review of contemporary research and thought. Clinical Child & Family
Psychology Review, 13, 46–76.
Kendall-Tackett, K. A., & Eckenrode, J. (1996). The effects of neglect on academic achievement
and disciplinary problems: A developmental perspective. Child Abuse & Neglect, 20, 161–169.
Kilburn, M. R., & Karoly, L. A. (2008). The economics of early childhood policy: What the dismal
science has to say about investing in children. Santa Monica, CA: Rand Corporation.
Kim, J., & Cicchetti, D. (2006). Longitudinal trajectories of self-system processes and depressive
symptoms among maltreated and nonmaltreated children. Child Development, 77, 624–639.
——— (2010). Longitudinal pathways linking child maltreatment, emotion regulation, peer rela-
tions, and psychopathology. Journal of Child Psychology & Psychiatry, 51(6), 706–716.
Kim, J., Cicchetti, D., Rogosch, F. A., & Manly, J. T. (2009). Child maltreatment and trajectories of
personality and behavioral functioning: Implications for the development of personality disorder.
Developmental Psychopathology, 21, 889–912.
Kinniburgh, K., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2005). Attachment, self- regula-
tion, & competency: A comprehensive intervention framework for children with complex trauma.
Psychiatric Annals, 35, 424–430.
Koenen, K. C., Moffitt, T. E., Poulton, R., Martin, J., & Caspi, A. (2007). Early childhood factors
associated with the development of post-traumatic stress disorder: Results from a longitudinal
birth cohort. Psychological Medicine, 37, 181–192.
Kolko, D. J., & Swenson, C. (2002). Assessing and treating physically abused children and their
families: A cognitive-behavioral approach. Thousand Oaks, CA: SAGE.
Lansford, J., Dodge, K. A., Pettit, G. S., Bates, J. E., Crozier, J., & Kaplow, J. (2002). A 12-year
prospective study of the long-term effects of early child physical maltreatment on psychological,
behavioral, and academic problems in adolescence. Archives of Pediatrics Adolescent Medicine,
156(8), 824–830.
Lansford, J., Miller-Johnson, S., Berlin, L., Dodge, K., Bates, J., & Pettit, G. (2007). Early physical
abuse and later violent delinquency: A prospective longitudinal study. Child Maltreatment, 12(3),
233–245.
124 Linda Webster
Leiter, J. (2007). School performance trajectories after the advent of reported maltreatment. Child
and Youth Services Review, 29, 363–382.
Liotti, G. (2004). Trauma, dissociation and disorganized attachment: Three strands of the single
braid. Psychotherapy: Theory, Research, Practice, Training, 41, 472–486.
——— (2006). A model of dissociation based on attachment theory and research. Journal of Trauma
and Dissociation, 7, 55–74.
Lorber, R., Felton, D. K., & Reid, J. B. (1984). A social learning approach to the reduction of coer-
cive processes in child abusive families: A molecular analysis. Advances in Behavior Research and
Therapy, 6, 29–45.
Lundahl, B. W., Nimer, J., & Parsons, B. (2006). Preventing child abuse: A meta-analysis of parent
training programs. Research on Social Work Practice, 16, 251–262.
Lynn, M., & Nisivoccia, D. (2001). Crisis intervention activity groups in the schools. In A. Drewes,
L. Carey, & C. Schaefer (Eds.), School-based play therapy (pp. 177–193). New York: Wiley.
Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classification
and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool
classroom. Child Development, 64, 572–585.
Lyons-Ruth, K., Connell, D. B., Grunebaum, H. U., & Botein, S. (1990). Infants at social risk: Mater-
nal depression and family support services as mediators of infant development and security of
attachment. Child Development, 61, 85–98.
Lyons-Ruth, K., & Jacobvitz, D. (2008). Attachment disorganization. In J. Cassidy & P. R. Shaver
(Eds.), Handbook of attachment: Theory, research, and clinical applications. (2nd ed., pp. 666–
697). New York: Guilford Press.
MacFie, J., Cicchetti, D., & Toth, S. (2001). The development of dissociation in maltreated pre-
school-aged children. Development and Psychopathology, 13, 233–254.
Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age 6: Predict-
able from infant attachment classifications and stable over a 1-month period. Developmental
Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to infant disor-
ganized attachment status: Is frightened and/or frightening parental behavior the linking mecha-
nism? In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool
years: Theory, research, and intervention (pp. 161–182). Chicago: University of Chicago Press.
Main, M., & Morgan, H. (1996). Disorganization and disorientation in infant Strange Situation
behavior: Phenotypic resemblance to dissociative states. In L. K. Michel & W. J. Ray (Eds.), Hand-
book of dissociation: Theoretical, empirical, and clinical perspectives (pp. 107–138). New York:
Plenum Press.
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented dur-
ing the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.),
Attachment in the preschool years: Theory, research, and intervention (pp. 121–161). Chicago:
University of Chicago Press.
McCabe, K. M., Lucchini, S. E., Hough, R. L., Yeh, M., & Hazen, A. (2005). The relation between
violence exposure and conduct problems among adolescents: A prospective study. American Jour-
nal of Orthopsychiatry, 75, 575–584.
McDonald, R., Jouriles, E. N., Ramisetty-Mikler, S., Caetano, R., & Green, C. E. (2006). Estimating
the number of American children living in partner-violent families. Journal of Family Psychology,
20, 137–142.
Mersky, J. P., Topitzes, J. D., & Reynolds, A. J. (2011). Maltreatment prevention through early
childhood intervention: A confirmatory evaluation of the Chicago child-parent center preschool
program. Children and Youth Services Review, 33, 1454–1463.
Mikton, C., & Butchart, A. (2009). Child maltreatment prevention: A systematic review of reviews.
Bull World Health Organization, 87, 353–361.
Milot, T., Ethier, L. S., St-Laurent, D., & Provost, M. (2010). The role of trauma symptoms in the devel-
opment of behavioral problems in maltreated preschoolers. Child Abuse & Neglect, 34, 225–234.
Moffitt, T. E., & Caspi, A. (1999). Findings about partner violence from the Dunedin Multidisciplinary
Health and Development Study (NCJ 170018). Washington, DC: National Institute of Justice.
Morris, J. S., Ohman, A., & Dolan, R. J. (1999). A subcortical pathway to the right amygdala
mediating “unseen” fear. Proceedings of the National Academy of Sciences of the United States
of America, 96, 1680–1685.
Moss, E., Bureau, J., St-Laurent, D., & Tarabulsy, G. M. (2011). Understanding disorganized attach-
ment at preschool and school age: Examining divergent pathways of disorganized and controlling
children. In J. Solomon and C. George (Eds.), Disorganized Attachment and Caregiving (pp.
52–79). New York: Guilford Press.
Moss, E., Rousseau, D., Parent, S., St-Laurent, D., & Saintonge, J. (1998). Correlates of attachment
at school age: Maternal reported stress, mother-child interaction, and behavior problems. Child
Nadeem, E., Jaycox, L. H., Kataoka, S. H., Langley, A. K., & Stein, B. D. (2011). Going to scale:
Implementing a school-based trauma intervention. School Psychology Review, 40(4), 549–568.
Nisivoccia, D., & Lynn, M. (2007). Helping forgotten victims: Using activity groups with children
who witness violence. In N. B. Webb (Ed.), Play therapy with children in crisis: Individual, group,
and family treatment (3rd ed., pp. 294–321). New York: Guilford Press.
Ogawa, J. R., Sroufe, L. A., Weinfield, N. S., Carlson, E. A., & Egeland, B. (1997). Development and
the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample.
Development and Psychopathology, 9, 855–879.
O’Hagan, K. P. (1995). Emotional and psychological abuse: Problems of definition. Child Abuse &
Neglect, 19(4), 449–461.
Olds, D. L. (2008). Preventing child maltreatment and crime with prenatal and infancy support of
parents: The nurse-family partnership. Journal of Scandinavian Studies in Criminology and Crime
Prevention, 9, 2–24.
Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., . . . Luckey, D.
(1997). Long-term effects of home visitation on maternal life course and child abuse and neglect:
Fifteen-year follow-up of a randomized trial. JAMA, 278, 637–643.
Olson, S. L., Schilling, E. M., & Bates, J. E. (1999). Measurement of impulsivity: Construct coher-
ence, longitudinal stability, and relationship with externalizing problems in middle childhood and
adolescence. Journal of Abnormal Child Psychology, 27, 151–165.
Oosterlaan, J., & Sergeant, J. A. (1996). Inhibition in ADHD, aggressive, and anxious children: A bio-
logically based model of child psychopathology. Journal of Abnormal Child Psychology, 24, 19–36.
Ouyang, L., Fang, X., Mercy, J., Perou, R., & Grosse, S. D. (2008). Attention- deficit/hyperactivity
disorder symptoms and child maltreatment: A population-based study. Journal of Pediatrics, 153,
851–856.
Pala, B., Unalacak, M., & Unluoglu, I. (2011). Child maltreatment: Abuse and neglect. Dicle Medi-
cal Journal, 38, 121–127.
Palusci, V. J. (2011). Risk factors and services for child maltreatment among infants and young
children. Children and Youth Services Review, 33, 1374–1382.
Pears, K. C., & Capaldi, D. M. (2001). Intergenerational transmission of abuse: A two- generational
prospective study of an at-risk sample. The Child, 25(11), 1439–1461.
Pollak, S. D., Cicchetti, D., Hornung, K., & Reed, A. (2000). Recognizing emotion in faces: Devel-
opmental effects of child abuse and neglect. Developmental Psychology, 36, 679–688.
Pollak, S. D., & Sinha, P. (2002). Effects of early experience on children’s recognition of facial dis-
plays of emotion. Developmental Psychology, 38, 784–791.
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New
Rieder, C., & Cicchetti, D. (1989). Organizational perspective on cognitive control functioning and
cognitive-affective balance in maltreated children. Developmental Psychology, 25, 382–393.
Rogosch, F. A., Cicchetti, D., & Aber, J. L. (1995). The role of child maltreatment in early deviations
in cognitive and affective processing abilities and later peer relationships problems. Development
& Psychopathology, 7, 591–609.
Rogosch, F. A., Cicchetti, D., Shields, A., & Toth, S. L. (1995). Parenting dysfunction in child mal-
treatment. In M. H. Bornstein (Ed.), Handbook of parenting: Vol. 4. Applied and practical parent-
ing (pp.127–159). Hillsdale, NJ: Erlbaum.
126 Linda Webster
Rothbart, M. K., Posner, M. I., & Hershey, K. L. (1995). Temperament, attention, and developmental
psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol. 1.
Theory and methods (pp. 315–340). New York: Wiley.
Ryan, J. P., & Testa, M. F. (2005). Child maltreatment and juvenile delinquency: Investigating the
role of placement and placement stability. Children and Youth Services Review, 27(3), 227–249.
Sagy, S., & Dotan, N. (2001). Coping resources of maltreated children in the family: A salutogenic
approach. Child Abuse & Neglect, 25, 1463–1480.
Scheeringa, M. S. (2008). Developmental considerations for diagnosing PTSD and acute stress dis-
order in preschool and school-aged children. American Journal of Psychiatry, 165, 1237–1239.
Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-
focused cognitive-behavioral therapy for posttraumatic stress disorder in three- through six-year-old
children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52(8), 853–860.
Schore, A. N. (2001). The effects of relational trauma on right brain development, affect regulation,
and infant mental health. Infant Mental Health Journal, 22, 201–269.
——— (2002). Dysregulation of the right brain: A fundamental mechanism of traumatic attachment
and the psychopathogenesis of posttraumatic stress disorder. Australian and New Zealand Journal
of Psychiatry, 36, 9–30.
Shonk, S. M., & Cicchetti, D. (2001). Maltreatment, competency deficits, and risk for academic and
behavioral maladjustment. Developmental Psychology, 37(1), 3–17.
Slaby, R. G., & Guerra, N. G. (1988). Cognitive mediators of aggression in adolescent offenders: 1.
Assessment. Developmental Psychology, 24, 580–588.
Solomon, J., & George, C. (2011). The disorganized attachment-caregiving system: Dysregulation
of adaptive processes at multiple levels. In J. Solomon and C. George (Eds.), Disorganized attach-
ment and caregiving (pp. 1–24). New York: Guilford Press.
Solomon, J., George, C., & DeJong, A. (1995). Children classified as controlling at age six: Evi-
denced of disorganized representational strategies and aggression at home and at school. Develop-
ment and Psychopathology, 7, 447–463.
Spaccarelli, S., & Kim, S. (1995). Resilience criteria and factors associated with resilience in sexually
abused girls. Child Abuse & Neglect, 19, 1171–1182.
Sroufe, L. A. (1989). Relationships, self, and individual adaptation. In A. J. Sameroff & R. N. Emde
(Eds.), Relationship disturbances in early childhood: A developmental approach (pp. 70–94). New
York: Basic Books.
Stagner, M. W., & Lansing, J. (2009). Progress toward a prevention perspective. The Future of
Children, 19(2), 19–38.
Stith, S. M., Liu, T., Davies, C., Boykin, E., Alder, M. C., Harris, J. M., . . . McPherson, M. (2009).
Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression and Vio-
lent Behavior, 14, 13–29.
Stronach, E. P., Toth, S. L., Rogosch, F., Oshri, A., Manly, J. T., & Cicchetti, D. (2011). Child mal-
treatment, attachment security, and internal representations of other and mother-child relationships.
Child Maltreatment, 16(2), 137–145.
Suveg, C., & Zeman, J. (2004). Emotion regulation in children with anxiety disorders. Journal of
Clinical Child and Adolescent Psychology, 33, 750–759.
Teicher, M. H., Andersen, S. L., Polcari, A., Andersen, C. M., & Navalta, C. P. (2002). Develop-
mental neurobiology of childhood stress and trauma. Psychiatric Clinics of North America, 25,
397–426.
Teisl, M., & Cicchetti, D. (2008). Physical abuse, cognitive and emotional processes, and aggressive/
disruptive behavior problems. Social Development, 17, 1–23.
Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry,
148(1), 10–20.
Thomas, R., & Zimmer-Gembeck, M. (2011). Accumulating evidence for Parent-Child Interaction
Therapy in the prevention of child maltreatment. Child Development, 82(1), 177–192.
Thornberry, T. P., Wei, E. H., Stouthamer-Loeber, M., & Van Dyke, J. (2000). Teenage fatherhood
and delinquent behavior (Juvenile Justice Bulletin, NCJ 178899). Washington, DC: Office of
Juvenile Justice and Delinquency Prevention.
Timmer, S. G., Urquiza, A. J., Zebell, N. M., & McGrath, J. M. (2005). Parent-Child Interaction
Therapy: Application to maltreating parent-child dyads. Child Abuse & Neglect, 29, 825–842.
Toth, S. L., Cicchetti, D., MacFie, J., Maughan, A., & Vanmeenen, K. (2000). Narrative representa-
tions of caregivers and self in maltreated pre-schoolers. Attachment and Human Development, 2,
271–305.
Toth, S. L., Manly, J. T., & Cicchetti, D. (1992). Child maltreatment and vulnerability to depression.
Development and Psychopathology, 4(1), 97–112.
Trickett, P. K., Kim, K., & Prindle, J. (2011). Variations in emotional abuse experiences among
multiply maltreated young adolescents and relations with developmental outcomes. Child Abuse
& Neglect, 35, 876–886.
Trickett, P. K., Mennen, F. E., Kim, K., & Sang, J. (2009). Emotional abuse in a sample of multi-
ply maltreated, urban young adolescents: Issues of definition and identification. Child Abuse &
Neglect, 33, 27–35.
Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). The effects of adolescent victimization on self-
concept and depressive symptoms. Child Maltreatment, 15, 76–90.
U.S. Department of Health and Human Services, Administration on Children, Youth, and Families.
(2005). Definitions of child abuse and neglect: Summary of state laws. State Statutes Series 2005.
Washington, DC: National Clearinghouse on Child Abuse and Neglect Information.
U.S. Department of Health and Human Services, Administration for Children and Families, Admin-
istration on Children, Youth and Families, Children’s Bureau. (2010). Child maltreatment 2009.
Available from http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#can
van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children
with complex trauma histories. Psychiatric Annals, 35, 401–408.
van Ijzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disorganized attach-
ment in early childhood: Meta-analysis of precursors, concommittants, and sequelae. Development
and Psychopathology, 11, 225–249.
Veltman, M. W. M., & Browne, K. D. (2001). Three decades of child maltreatment research: Impli-
cations of the school years. Trauma, Violence, and Abuse, 2, 215–239.
Vickerman, K. A., & Margolin, G. (2007). Posttraumatic stress in children and adolescents exposed
to family violence: II. Treatment. Professional Psychology: Research and Practice, 38(6), 620–628.
Watts-English, T., Fortson, B. L., Gibler, N., Hooper, S. R., & De Bellis, M. D. (2006). The psycho-
biology of maltreatment in childhood. Journal of Social Issues, 62, 717–736.
Webb, N. B. (2007). Play therapy with children in crisis: Individual, group, and family treatment
(3rd ed.). New York: Guilford Press.
Weinfield, N. S., Whaley, G. J. L., & Egeland, B. (2004). Continuity, discontinuity, and coherence
in attachment from infancy to late adolescence: Sequelae of organization and disorganization.
Attachment & Human Development, 6(1), 73–97.
Wekerle, C., Miller, A. L., Wolfe, D. A., & Spindel, C. B. (2006). Childhood maltreatment. Cam-
bridge, MA: Hogrefe & Huber.
Whalen, P. J., Rauch, S. L., Etcoff, N., McInerney, S. C., Lee, M. B., & Jenike, M. A. (1998). Masked
presentations of emotional facial expressions modulate amygdale activity without explicit knowl-
edge. Journal of Neuroscience, 18, 411–418.
Wu, S. S., Ma, C. X., Carter, R. L., Ariet, M., Feaver, E. A., Resnick, M. B., & Roth, J. (2004). Risk
factors for child maltreatment: A population-based study. Child Abuse & Neglect, 28, 1253–1264.
Yalom, I., & Molyn, L. (2005). The theory and practice of group psychotherapy (5th ed.). New
York: Basic Books.
Zhou, Y., Hallisey, E. J., & Freymann, G. R. (2006). Identifying perinatal risk factors for infant
maltreatment: An ecological approach. International Journal of Health Geographics, 5, 53–64.
Zielinski, D. S., & Bradshaw, C. P. (2006). Ecological influences on the sequelae of child maltreat-
ment: A review of the literature. Child Maltreatment, 11, 49–62.
8 Helping Children Cope With Grief
Aubrey Uresti
School-based mental health specialists must prepare to work with students who are
bereaved resulting from a death or other losses. Losses that trigger grief include suicide of
a loved one, abandonment by a caregiver, school-based or community violence, incarcera-
tion or deportation of family members, or other crisis events. Grief is a complex, universal
issue that has been widely explored by psychologists over the past 50 years. Much of the
research about grief focuses on the impact of loss on adults. However, children also experi-
ence death and loss. Mannarino and Cohen (2011) report that “400,000 youth younger
than age 25 will experience the death of a family member each year. Also, current statistics
indicate that 1.9 million children younger than age 18 have lost one or both parents (Chil-
dren’s Bereavement Center of South Texas, 2008)” (p. 23). Yet research about the grieving
process of children and adolescents is less frequently reported, and information about
counseling interventions is slowly emerging. Because a child’s developmental understand-
ing of grief differs from adults, it is not uncommon for adults to dismiss, ignore, or fail
to see the signs of grief in children. Adolescents, too, can suffer from this sort of neglect.
Grief can have a dramatic impact on a student’s ability to function in school. Grounded in
theory and best practices, school counselors and school psychologists must play a key role
in providing school-based support for grieving students.
In this chapter, foundational theories about grief, along with the role of school mental
health specialists, will be joined to explore common themes present for grieving children and
adolescents. The chapter suggests prevention and intervention strategies to raise awareness,
promote healthy bereavement, and prevent maladaptive responses for individuals, groups,
and school communities facing issues connected to death and loss. The development and
implementation of these counseling interventions for the school mental health specialist will
be discussed from an integrative theoretical perspective, combining core elements and influ-
ences from Rogerian, Gestalt, existential, family systems, art, and play therapies.
The difficult feelings common to grief can leave a mourner with a sense of powerless-
ness; however, the process of grief requires active engagement for both adults and children.
Grief is work. Grief brings up other unfinished issues or losses. Grief affects people psy-
chologically, socially, and physically. Grief will be influenced by your relationship with the
deceased, your coping tools, your history, your cultural and religious background, your
overall level of stress, the circumstances of the death, your level of support and self-care
(Dopp & Cain, 2012; Freud, 1917; Jarratt, 1994; Kübler-Ross, 1969; Kübler-Ross & Kes-
sler, 2005; Rando, 1991; Tatelbaum, 2008; Worden, 2008).
The experience of grief forces us to exist in a world inhabited by fear, worry, and mystery
far greater than we can imagine until we enter it. A world that Wolfelt (2009) describes as
a “‘no place’ wilderness” (p. 27), grief requires the mourner to be open to the impossibility
of its reality in order to change. Paradoxically, this step towards grief opens the path for
normal, clean, uncomplicated grief, which has healing potential. Ignoring or repressing
Helping Children Cope With Grief 129
this journey can lead to what is known as unresolved or “complicated grief” (Edgar-
Bailey & Kress, 2010; James, Friedman, & Landon Matthews, 2001; Lichtenthal, Currier,
Neimeyer, & Keesee, 2010; Mannarino & Cohen, 2011; Packman, Horsley, Davies, &
Kramer, 2006; Paris, Carter, Day, & Armsworth, 2009; Tatelbaum, 2008; Worden, 2008),
a maladaptive, pathological, or arrested response that leaves the mourner stuck in cycles
of endless pain. Venturing into the world of grief is the only way through it.
Grief Within a Developmental Context

Bowlby (1980) claimed that children can process grief successfully if they were able to
form secure attachments prior to the loss, and if they are informed about the loss in a
direct and honest way and allowed to ask for clarification and to participate in grief with
the support of others. When children experience a loss and are unable to process it in a
healthy way, they may become “stuck” at the developmental stage and age at which the
loss occurred. Thus, grief itself can interfere with the normal developmental tasks faced by
children and adolescents. A very young child may be developmentally incapable of under-
standing that death is permanent, personal, and universal (Bowlby, 1980; Holland, 2008;
Kübler-Ross, 2008; Paris et al., 2009; Piaget, 1967; Rando, 1991; Worden, 2008; Yalom,
2009); while this lack of understanding is developmentally appropriate, it can hinder the
child’s ability to grieve (Rando, 1991).
In the concrete operational stage, between ages 7–11 (Piaget, 1967; Piaget & Inhelder,
2000), children are likely to make broad, general conclusions about death, which can be
exacerbated by the euphemistic language of adults. Euphemisms like “Rita Mae has gone
to a better place” are confusing to children. If a child hears, “God needed another angel”
as an explanation for the death of a loved one, the child may conclude that God is self-
ish, or that God takes only people who could become angels. Kübler-Ross (2008) warns
against overpraising a child for being “good” in response to a recent death, because the
child may conclude that misbehaving may bring the person back. Children engage in “if
only” and “magical thinking” patterns (Di Ciacco, 2008; Holland, 2008; James et al.,
2001; Jarratt; 1994; Kessler, 2007; Kübler-Ross, 2008; Paris et al., 2009; Rando, 1991;
Tatelbaum, 2008). An example of this would be a child who secretly believes, “I have to
find Daddy because he is lost.” Because “magical thinking” is common among children
and may include erroneous conclusions about the death or their role in it, they need to
tell their version of the story so that any mistaken or fantastical ideas can be corrected to
reduce the likelihood that they will internalize guilt or shame (Doka, 2000; Rando, 1991).
Children often grieve alone because adults do not know how to support them. Their
responses to grief can be confusing to adults, because children may appear indifferent
or defensive about the loss. Children cannot sustain intense emotions for prolonged or
uninterrupted periods of time, and they need more breaks during the grieving process than
adults (Mannarino & Cohen, 2011; Packman et al., 2006; Tatelbaum, 2008). This is not
necessarily an unhealthy or avoidant behavior, but rather a protective or coping strategy
in that, while the psyche of a child is capable of accessing intense emotion, the cognitive
capacity for understanding this intensity is not fully formed.
Although many adults experience grief as energy draining, James et al. (2001) argue that
loss for children also creates emotional energy that needs to be released. Verbal processing
is more limited for children, who need mediums like art and play for expression (Axline,
2002; Corr, 2004; Edgar-Bailey & Kress, 2010; Holland, 2008; Kaufman & Kaufman,
2006; Oaklander, 1988; Packman et al., 2006; Tatelbaum, 2008). School-based practitio-
ners must remember that children often act out their feelings primarily through play, so
providing them with opportunities to reexperience the events associated with the death can
130 Aubrey Uresti
Table 8.1 Typical Responses to Grief According to Age and School-Related Stages
Infants and Toddlers

Infants and toddlers experience tremendous potential for growth in all domains of life—advancing
as cognitive beings with the emotional need for comfort, safety, and trust.
The younger an infant is when a loss occurs, the more difficult it will be for others to determine
the importance and impact of the loss (Bowlby, 1980).
At 0–6 months, the reactions to loss do not parallel those of a toddler, child, or adolescent; around
7 months to 1 1/2 years, responses resemble those of children and adolescents (Bowlby, 1980).
Infants and toddlers will exhibit signs of grief, including shock, anger, longing, despair, and even
depression or detachment if they do not receive support from key adults (Bowlby, 1980).
Self-regulation and self-soothing, hallmarks of this age range, are impaired (Di Ciacco, 2008).
Symptoms include sleep disturbances, behavioral outbursts, emotional withdrawal, and difficulty
establishing connections with others (Di Ciacco, 2008; Holland, 2008; Packman et al., 2006).
Developmental delays may occur in all areas, hindering the child’s ability to function later in
school (Di Ciacco, 2008).
Preschool
The preschool-age child attempts to assert agency and gain mastery over the environment.
Grief may appear only intermittently in outward ways, though it may be constantly present within
the child’s internal landscape (Packman et al., 2006; Rando, 1991; Tatelbaum, 2008).
Preschoolers will often react very strongly to a loss and will not understand that death is perma-
nent (Di Ciacco, 2008; Kübler-Ross, 2008; Paris et al., 2009).
Anger and anxiety can be paramount if the child is not given an adequate explanation of what
happened; this can lead to temper tantrums and aggression (Di Ciacco, 2008; Rando, 1991).
“Magical thinking” is characteristic of this stage, so preschoolers may think they caused the death
and experience guilt and fear as a result (Boyd Webb, 2011; Di Ciacco, 2008; Holland, 2008;
James et al., 2001; Jarratt, 1994; Kessler, 2007; Kübler-Ross, 2008; Paris et al., 2009; Rando,
1991; Tatelbaum, 2008).
Children at this stage are prone to psychosomatic manifestations of grief like stomachaches or
abnormal appetite (Di Ciacco, 2008; Packman et al., 2006; Tatelbaum, 2008).
Elementary School
In elementary school, children learn to navigate the social world beyond their family of origin and
face questions about right, wrong, fairness, and injustice.
Children may have a more fully developed cognitive understanding of death, but few, if any, skills
to cope with loss (Rando, 1991).
By age 6 or 7, children usually understand that death is permanent (Boyd Webb, 2011;
James et al., 2001; Paris et al., 2009).
Elementary school children may be especially prone to denial as a response to loss, which may
result in others thinking the loss has not affected them (Rando, 1991).
Children may be more likely to cry alone (Dyregrov, 2008; Kübler-Ross, 2008; Rando, 1991).
Although “magical thinking” diminishes over time, children may engage in fantasies about the
loss, which they may or may not share with adults (Di Ciacco, 2008; Holland, 2008; James et al.,
2001; Jarratt, 1994; Kessler, 2007; Kübler-Ross, 2008; Paris et al., 2009; Tatelbaum, 2008).
Children may act out in school. Typical behaviors include impulsivity, hyperactivity, decreased tol-
erance for change (Bowlby, 1973, 1980; Di Ciacco, 2008; Holland, 2008; Jarratt, 1994; Packman
et al., 2006; Rando, 1991; Tatelbaum, 2008).
(Continued)
Table 8.1 (Continued)
Children may struggle academically, regardless of accommodations or ability. Basic skills necessary
for educational success (e.g., study skills, concentration, organization) may be affected as well (Di
Ciacco, 2008; Dyregrov & Dyregrov, 2008).
Children may experience difficulty establishing and maintaining friendships (Di Ciacco, 2008).
Middle School
Nestled between childhood and adolescence, moral compass at hand and a confusing course to
chart into a world with new depths of meaning, the middle schooler’s mind awakens to existential-
ism while the heart embraces emotional complexity.
At this stage, abstract thought and reasoning shift the perspective from factual information about
death to conceptual meaning about loss (Di Ciacco, 2008; Dyregrov, 2008).
A range of reactions can be expected, including overcompensating for the loss by “growing up
quickly,” becoming withdrawn or regressing into an earlier stage of childhood, or acting out in
anger (Bowlby, 1973, 1980; Holland, 2008; Jarratt, 1994; Rando, 1991; Tatelbaum, 2008).
Preadolescents will also act out in defiance and promiscuity—they need to be held and given per-
mission to cry (Kübler-Ross, 2008).
Intrusive thoughts, problems with concentration, and stifled creativity due to decreased spontane-
ity impact academic ability (Dyregrov, 2008; Dyregrov & Dyregrov, 2008).
Preadolescents may experience survivor guilt, especially with the loss of a sibling (Di Ciacco, 2008;
Holland, 2008; McGoldrick & Walsh, 2005; Packman et al., 2006; Paris et al., 2009; Sarnoff
Schiff, 1978; Worden, 1996).
High School
The adolescent struggles with balancing the conflicting affects of angst and apathy with a burgeon-
ing, yet unstable, assertion of identity.
Grieving teenagers face challenges similar to those of children.
Typical adolescent developmental tasks are complicated by grief and prevent the adolescent from
receiving much needed support; these include communication with others, especially adults, con-
cerns about the perceptions of others, and identity formation (Rando, 1991).
Regression may feel even more threatening to the teenager than to a younger child because of the
developmental need for independence and progress toward maturity (Bowlby, 1973, 1980; Hol-
land, 2008; Jarratt, 1994; Rando, 1991; Tatelbaum, 2008).
Because teenagers tend towards anger already, this emotion may rise to the surface more readily
and lead to obsession with death and/or depression if left unchecked (Duffy, 2005; Packman et al.,
2006; Rando, 1991; Tatelbaum, 2008).
Acting out may include risk-taking behaviors such as alcohol and substance abuse, sexual promis-
cuity, and dangerous or impulsive activities (e.g., reckless driving or thrill-seeking behaviors) (Di
Ciacco, 2008; Duffy, 2005; Holland, 2008).
Normal physiological changes coupled with loss contribute to a compromised immune system in
adolescents, increasing the risk of illness and lengthening recovery time (Di Ciacco, 2008).
be very useful. Play is to children what “processing” is to adults—an attempt to adapt to

and master the experience of loss (Rando, 1991).
From childhood through adolescence, regression is a common response to loss, as is
being restless, preoccupied with the loss, and searching for the loved one (Bowlby, 1973,
1980; Holland, 2008; Jarratt, 1994; Rando, 1991; Tatelbaum, 2008). School-based
132 Aubrey Uresti
practitioners should also anticipate anger as a typical symptom of grief. For young chil-
dren, anger may appear in the form of tantrums; by middle or high school, anger can lead
to risk-taking behaviors. When unexpressed, anger can result in complicated grief and
depression for children of all ages. Table 8.1 presents a description of developmentally
appropriate reactions to grief and loss.
Models of Grief
The debate over the exact nature of grief, how one moves through grief, and who is capa-
ble of experiencing it continues. The next sections outline the differences between grief and
depression, discuss common responses to grief, and present some of the most influential
thinkers in the area of bereavement.
Distinguishing Between Mourning and Melancholia

Freud’s work as it concerns grief and loss primarily arose from his writings on “mourn-
ing” versus “melancholia.” Freud underscored a distinction between these two responses,
noting that mourning is a normal response to loss that fades and is resolved naturally over
time. Melancholia is more closely related to what we would call depression today, including
diminished interest in life’s activities, impaired functioning, profound and debilitating sad-
ness, and even the inability to love oneself or others. However, Freud stated that this last
piece—particularly the rejection of self—was the primary area in which melancholia and
mourning were different, and that the two responses were otherwise remarkably similar.
Mourning involves a necessary but temporary reduction in the life force, especially in terms
of its attachment to the source of the loss (i.e., the deceased), with the ultimate goal of letting
go and recovering the ability to love and attach in healthy ways elsewhere (Freud, 1917).
This point is the subject of ongoing controversy and has caused scholars beyond Freud to
consider and revise their own understanding of continued attachment to the deceased.
The process of grief, Freud notes, is so painful that it is surprising that most of us con-
sider it to be a normal occurrence throughout the course of our lives. Freud describes grief
as “work” undertaken by the ego or consciousness of the individual. Melancholia, on the
other hand, in some ways is an attack on the ego or self (Freud, 1917). It is important for
school counselors and school psychologists working with bereaved students to understand
the ways in which grief and depression may overlap, to recognize that grief is not in itself
depression, and to be able to identify the indicators that depression may be emerging along
with grief in order to find the best treatment for the student.
Kübler-Ross’s Five Stages of Grief

Perhaps the most well-known approach to understanding death is the five stages of grief
experienced by the dying person, which were first outlined by Dr. Elisabeth Kübler-Ross in
On Death and Dying (1969) and later reexamined with regard to those grieving a death in
On Grief and Grieving (2005) by Kübler-Ross and Kessler. The stages were not intended
as a static, all-inclusive, or prescriptive model. Instead, they were meant to foster aware-
ness about themes connected to the process of healing from a loss.
Denial. The first stage introduces the concept of denial, which can serve as a defense
mechanism. Rather than a literal rejection of the facts, denial often appears in the form
of questions—Is this a dream? Is this really happening? Is this true? Kübler-Ross and Kes-
sler (2005) describe it as follows: “Denial helps us to pace our feelings of grief. There is a
grace in denial. It is nature’s way of letting in only as much as we can handle” (p. 10). In
time, questioning shifts as a person begins to wonder how the loss could have happened
and what, if anything, could have changed the situation. The reality and permanence of
the loss become more tolerable and begin to settle in the mourner.
Anger. A feeling that emerges strongly, anger appears in many different forms and
demands space, release, and expression. Feelings of anger can be (mis)directed at the per-
son who died, the self, God, or the cause of death. While it may generally be perceived as
an undesirable or socially unacceptable emotion, anger can lead the way to an onslaught
of other emotions and is a healthy, normal aspect of the grieving process. Anger allows
access to a level of deep and authentic feeling that fosters healthy movement through grief.
Bargaining. Resembling a type of limbo state, bargaining is not a rejection of feelings in
the same way as denial; rather, it is a break from grief. The space afforded by bargaining
allows for rumination and supposition as opposed to questioning; for example, the griever
may suggest various propositions or scenarios in which the loved one will either be spared
from death or will return. This can take the form of “if-then” thinking, such as, “If the
angels bring my brother back, I will never fight with him again.” In some ways, bargaining
parallels the “magical thinking” of childhood. It could be thought of as “wistful thinking”
that has consequences for one’s ability to reconcile responsibility regarding the death and
the feelings of grief. Reality doesn’t escape the mourner in this stage; when the break ends,
the mourner always returns to the same place—steeped in the grieving process.
Depression. An infinite abyss of sadness, depression is a normal response to loss. Like
anger, depression carries a stigma or taboo in our society. There are criteria for diagnosing
clinical depression, which is generally viewed as a “problem emotion” and it is commonly
treated with medication. However, with regard to grief, depression is indicative of a per-
son’s ability to access the depth of despair, hurt, and darkness or heaviness that is brought
on by the loss. Some signs of depression include disinterest in things that once gave pleasure,
changes in appetite, sleep disturbances, and isolation. Depression is an indispensable part
of grief and an emotional response congruent with loss. Certainly if the depressive state
meets the criteria for clinical depression, and/or impairs healthy functioning—that is, it
is maladaptive—then additional interventions or referrals could be necessary. However,
depression related to bereavement should not be stigmatized, pathologized, or marginal-
ized, but allowed to exist. It is healthy and necessary pain.
Acceptance. Because there is so much we cannot know about death and yet we are all
going to die, many people feel an understandable sense of fear and dread about the real-
ity of death. I believe that this fear contributes to wishful misconception that the stage of
acceptance is the “final stage,” resulting in a feeling of peace, adjustment, and the reas-
surance that feelings from the other stages will not reappear–—a sort of “happy ending.”
Rather, acceptance is a reconciling with reality, and does not mean that the mourner must
feel good or positive about the loss. This stage of grief engages the mourner’s ability to
tolerate and integrate reality with a depth and range of emotions. Acceptance is about
healing. This means continuing to gain awareness about the individual self in the absence
of the loved one, moving forward, and reidentifying and/or reevaluating what can provide
strength and support. Acceptance is a move towards the life force; it’s life-affirming. And
it does not mean that a person forgets about the death or the loss; it simply means there
has been time and space to grieve. As a grieving child once said to me, “People come, and
people go—but we don’t forget.”
Worden’s Tasks of Mourning

Worden (2008) prefers to make a distinction between grief (the individual experience of
loss) and mourning (the process that occurs following a loss). While Worden does not take
134 Aubrey Uresti
issue with the stages or phases of grief proposed by other theorists, he elects to frame the
process of mourning through four distinct tasks. Although the tasks are not specifically
ordered, an order is implied by their explanations.
Accepting the Reality of the Loss. The first task of mourning is to accept the reality of
the situation—that permanent, unchanging loss has occurred. This includes both intellec-
tual (acknowledging the fact of the loss) as well as emotional (psychic integration of the
loss) acceptance of the loss. The challenge in this task is grappling with denial, which pres-
ents in different ways for different people. Denial may involve minimizing the significance
of the loss or even of the relationship itself. It may mean leaving belongings of the deceased
untouched or unchanged, creating a type of shrine. On the other hand, some people very
quickly get rid of clothing and belongings of the deceased in an effort to clear any evidence
of the person, which functions as a way to avoid reality as well.
Another complicating factor in this first task is accepting the permanence of the loss.
This task cannot be complete until the mourner accepts that the loss is a fixed state and
that the deceased will never return. While there is no set timeline for this task, it is clear
that this piece of mourning requires time. Rituals like funerals, memorials, and religious
services can concretize the reality of loss and assist with fulfillment of this task. When tra-
ditional rituals are absent, or if the survivor cannot be present, denial of reality can persist
and the healthy resolution of this task can be delayed.
Processing the Pain of Grief. The second task of mourning is characterized by the
mourner’s ability to acknowledge and experience feelings connected to the loss. This
aspect of mourning will most likely be different for everyone in that how we experience
and process grief is not identical; while there are common themes, each person’s experience
is unique. Even for the same person, mourning losses could vary based on relationship,
significance of the loss, and developmental issues. Other authors share this sentiment (e.g.,
Dopp & Cain, 2012; Freud, 1917; Jarratt, 1994; Kübler-Ross, 1969, 2008; Kübler-Ross
& Kessler, 2005; Rando, 1991; Tatelbaum, 2008). One factor that can interfere with the
second task is the mourner’s rejection of feelings that are undesirable, unpleasant, or dif-
ficult to tolerate, such as anger, hurt, guilt, depression, or loneliness. Worden calls this the
“pain of grief” (2008, p. 45).
Adjusting to a World Without the Deceased. In the third task, Worden discusses three
areas of adjustment: external, internal, and spiritual. External adjustments relate to how
the loss affects interpersonal and day-to-day life activities of the mourner. The breadth of
necessary external adjustments is not typically immediately clear to the survivor. What-
ever responsibilities or roles had been carried out by the deceased must be assumed by the
survivor(s), who may or may not have known the extent of these activities prior to the loss.
Resentment can surface during this task, because the survivor’s world still has needs that
must be filled. This is another level of being confronted with the reality of loss.
Internal adjustments concern the intrapersonal domains, including identity and self-
perception. Because death has such strong existential implications, this aspect of the third
task is not only connected to the individual’s identity with regard to the deceased, but to
the core of identity altogether and one’s sense of agency in the world. It can be an espe-
cially damaging time if the survivor internalizes feelings or insecurities about successfully
fulfilling the roles and responsibilities once held by the deceased. This aspect of adjustment
is incredibly introspective and painful until a person has the capacity to hold a new defini-
tion of self after the loss.
Spiritual adjustments reflect the mourner’s ethics, values, and worldview after the
death. A loss can impact the spiritual wellness of the survivor. This is also connected to
the existential perspective in that it is about making meaning. Some deaths are easier to
make sense of than others (e.g., the death of an elderly grandparent may seem to be more
in the natural of course of events than the death of a young child), and have a different
potential impact on the spiritual perspective of the individual. A death that is especially
tragic or unexpected may result in more work in this area for the survivor, who faces the
challenge of reorganizing, reinterpreting, and reintegrating values and beliefs in the midst
of spiritual crisis.
Finding an Enduring Connection with the Deceased in the Midst of Embarking on a
New Life. Worden’s fourth task has been revised significantly since his first publications
regarding the tasks of mourning. He had previously supported classic thought in this area
and had been especially influenced by Freud’s work on mourning (1917). Initially, the task
involved detaching from the relationship in order to move forward in life without the lost
loved one. The most current version of this fourth task implies that the goal is not to take
away the emotional bond but to redefine it. This task is about maintaining connection
with the person who died in a way that also supports life without the deceased. When
faced with this task, some survivors become stuck because they realize that, in some ways,
their lives also “stopped” when the death occurred. The fourth task requires coming to
terms with the loss, maintaining an emotional connection to the deceased, moving forward
in life, and creating new relationships and connections. Eventually, mourning will not
prevent the person from having a healthy life.
How Can the School-Based Practitioner Conceptualize Working with Grief?

Professional preparation programs help to build the foundational skills for mental health
practitioners to work effectively with children, adolescents, and their families on a wide
range of issues. Grief work, however, tends to carry an increased sense of importance and
responsibility. Often, school-based mental health specialists feel underprepared or inad-
equate, or they may lack training in grief and loss, which can provoke feelings of anxiety,
fear, and avoidance. This may lead some to underestimate, dismiss, or subconsciously
ignore the needs of grieving children. By revisiting basic theoretical principles and manag-
ing their own countertransference, school counselors and school psychologists can gain
confidence and skills in addressing grief and loss.
Cognitive Behavioral Theory (CBT)

The CBT approaches can help mourners to identify, sort through, and redefine thought
patterns that are inhibiting the grieving process. However, it is essential that the school-
based practitioner have a clear understanding of cognitive development in children, so
that unrealistic demands are not placed upon grieving youngsters. CBT in conjunction
with play and art therapy techniques is most helpful in resolving trauma symptoms based
on extreme situations that result in complicated grief and pathological responses (e.g.,
posttraumatic stress disorder [PTSD] and childhood traumatic grief [CTG]), as opposed
to assisting children and adolescents with normal progression through the stages of grief
(Edgar-Bailey & Kress, 2010; Mannarino & Cohen, 2011).
Rogerian Theory
What can often be most challenging for practitioners is creating a space that is truly client-
led, extremely present, and capable of containing the “unknownness” of grief work. Wolfelt
(2009) proposes, “We need soul-based models of caring that demonstrate the sensitivity
of the heart. We need models that allow mourners to stay open to the mystery as they
encounter the wilderness of their grief” (p. 31). Through the core conditions of providing
136 Aubrey Uresti
Unconditional Positive Regard, Genuineness, and Empathy, the mourner has agency to move
at whatever pace feels right, making nondirective approaches to counseling both gentle and
appropriate for containing powerlessness, blame, guilt, shame, isolation, and other common
but seldom expressed grief responses. Because the helper believes in the client’s potential for
healing and is willing to be present throughout the journey, the client can begin to internalize
and move towards the promise of self-actualization (Corey, 2008).
Gestalt Theory
Well-known Gestalt therapists Oaklander (1988) and Tatelbaum (2008) acknowledge the
seriousness and importance of directly addressing grief in counseling. Grieving requires the
courage to face, express, and release difficult feelings, a task that is very challenging in and
of itself, and even more so because society, on the whole, does not support outward, open
grief (Holland, 2008; Jarratt, 1994; Kübler-Ross, 1997; Tatelbaum, 2008; Young & Papa-
datou, 1997). Gestalt therapy grants children the opportunity to reexperience and process
their loss through storytelling, play, art, and dream-work. Classic Gestalt techniques like
“finishing” and “empty chair” also help mourners gain a different perspective on the situ-
ation, and work through unfinished business (Tatelbaum, 2008).
Oaklander (1988) discusses the need for therapeutic intervention for children who have
experienced trauma or loss. This therapeutic support can help children access their feelings,
gain awareness and insight, make meaning about the loss, and position that meaning in
their lives. Unsupported children experience additional difficulties like intense, unmanage-
able feelings, complicated grief, and difficulty processing future grief and loss. Ironically,
the presenting problem that brings children to counseling commonly appears unconnected
to a loss. Yet grief is often under the surface.
Existential Theory
Existentialism is a recurring theme for grieving students and their families. Existentialism
provides a philosophical perspective for understanding and confronting the universality
and inevitability of death, along with our natural tendency to fear and resist the reality
that each of us will die (James et al., 2001; Kessler, 2007; Tatelbaum, 2008; Yalom, 2009).
Some children and adolescents may seem unduly burdened with existential awareness
(i.e., realities about the finite nature of life, one’s purpose, the meaning of suffering), while
others may enter into an “existential crisis” upon experiencing the death of a loved one.
Yalom’s writings on death focus on themes such as “death anxiety” and the “pain of
mortality.” The fear of death is a pervasive and persistent force that surfaces sometimes
in response to a specific trigger or simply because we are conscious and self-aware. Grief
itself may awaken the fear of death in an individual. Death is a lonely, solitary experience,
and so connection with others throughout our lives is essential. Yalom highlights empa-
thy, being present, and reaching out to connect with others as qualities and tools that are
especially useful when working with someone who is dealing with death and/or existential
issues regarding mortality (Yalom, 2009).
Managing Countertransference
Students’ sources of grief may carry personal or social meaning for the school mental
health practitioner. Because death is a universal theme for all living creatures, identifying
with the stories of another is normal—however, it can develop into countertransference
in the counselor who is inexperienced with matters of grief. It is imperative that school
counselors and school psychologists engage in their own grief work and confront their
own existential fears in order to be more effective working with students and their fami-
lies. Examining grief in your own life is a prevention strategy that reduces the potential
for countertransference, which can surface and interfere with counseling if it remains
unconscious or is mismanaged.
Grieving in Various Circumstances

The following sections consider grief due to death in the family system, be it the death of
a child or a key figure in the child’s life, followed by deaths within the extended family
system. The differences between sudden versus prolonged death are also described, along
with the topic of stigmatized or disenfranchised grief.
Death in the Family System

The death of a child is often considered the hardest to face, because it seems so out of
order in the natural course of life (Duffy, 2005; Lichtenthal et al., 2010; Rando, 1991;
Tatelbaum, 2008; Worden, 1996; Young & Papadatou, 1997). The murder of a child is
exceptionally devastating to the entire family system, which is particularly relevant in the
case of missing children and is more likely to lead to higher substance abuse among family
members (Kübler-Ross, 1997). Parents who lose a child may feel like failures as parents,
regardless of the reason for their child’s death. Because of Western social expectations, par-
ents are pressured to hide their grief and return to being productive within a short period
of time following the loss (Kübler-Ross, 1997; Young & Papadatou, 1997). A longitudinal
study comparing the impact of different sources of grief indicated that the loss of a child
had the strongest impact on an individual (Middleton, Raphael, Burnett, & Martinek,
1998). Lichtenthal, Currier, Neimeyer, and Keesee’s (2010) study of bereaved parents
emphasizes the difficulty they had in making sense or meaning out of their loss; some of
the participants were eventually able to achieve greater compassion for and a desire to help
others who were suffering, although the loss represented a major existential crisis.
When a death occurs within a family, the entire family system must reorganize itself
(Bowen, 2004). The success with which the family reorganization takes place after a
loss will also affect the developmental progress of the grieving child (Rando, 1991). The
way the family functioned before the loss will shape how the family processes it, and so
it can be helpful to understand the family dynamics, including family rules about com-
munication and the expression of feelings (Jarratt, 1994; Kübler-Ross, 2008; McGoldrick
& Walsh, 2005; Packman et al., 2006). If the family system changes in such a way that
prevents healthy expression of feelings and responses, this will hinder grief. If key rela-
tionships change after the loss, as they inevitably will, this, too, can have an impact on the
child in her or his grief. Children will attempt to find and identify their own roles within
the family system after a loss, and may adopt the role of caregiver, rebel, protector, and
so on. These adopted roles may be an attempt to carry on the role of the deceased, or to
fill whatever void is left in the family system after the loss (McGoldrick & Walsh, 2005;
Rando, 1991).
Death of a Parent/Caregiver. The loss of a parent is understandably one of the most
traumatic events, because it threatens the child’s basic sense of survival (Dopp & Cain,
2012; Duffy, 2005; Holland, 2008; Rando, 1991). A parent’s death may also affect chil-
dren’s ability to form or maintain emotional bonds or attachments with others, and create
an urgent need to know that they will be taken care of (Jarratt, 1994; Tatelbaum, 2008).
When a parent dies, fear can develop in the child about losing the other parent to death
138 Aubrey Uresti
or abandonment (Bowlby, 1980). Another consideration in this case is that the surviving
parent (if the family constellation includes two or more primary caregivers) is also grieving,
which may mean fewer resources available to the child (Kübler-Ross, 2008). A child or
adolescent is capable of sharing difficult feelings openly about a parent’s death when a
sympathetic listener is present (Bowlby, 1980; Kübler-Ross, 2008). If a parent is dying, it
is best practice that someone tell the child the truth in simple language, and prepare ritu-
als such as videos or photos for the child to have after the parent is gone (Kessler, 2007).
Young children will likely experience a sense of guilt and blame themselves when a par-
ent dies, because their understanding of death is not completely developed and because
they experience the world more through physical senses than through logical reasoning
(Bowlby, 1980; Holland, 2008; Packman et al., 2006; Paris et al., 2009). When a child
has lost a parent, the child will miss the parent most when life’s circumstances are stressful
(Bowlby, 1980). Holidays and anniversaries can be particularly difficult times when one
is grieving (Holland, 2008; Jarratt, 1994; Mannarino & Cohen, 2011; Packman et al.,
2006). It is important for counselors and psychologists to remember this fact when work-
ing with students who have experienced a loss, especially during times of transition. Even
positive transitions, such as graduation or entering college, will be times during which a
child who has lost a parent—even if the loss has been grieved well—will miss the parent
and wish he or she were present.
Sibling Death. For a child who has lost a sibling, having the support, comfort, and
strength of a parent is crucial. Parental support, however, is not always available to surviv-
ing children. Parents who are overwhelmed and consumed with their own process of grief
cannot provide support to their surviving children (Davies, 2000; Mannarino & Cohen,
2011; Packman et al., 2006). Researchers seem to agree that parental grief over the loss of
a child has a longer duration than any other type of grief (Duffy, 2005; Lichtenthal et al.,
2010; Middleton et al., 1998; Rando, 1991; Tatelbaum, 2008; Worden, 1996; Young &
Papadatou, 1997). When a child dies, the surviving children begin to see the humanness of
their parents. The grieving child turns to the parent, often only to discover a person who
is in need of comforting too. This absence of support can have a lasting and potentially
damaging impact on a child’s ability to move through grief (Davies, 2000; Jarratt, 1994;
Packman et al., 2006; Rando, 1991; Sarnoff Schiff, 1978; Tatelbaum, 2008).
Sibling death carries with it some unique features compared to other types of losses.
Research shows that sibling death results in high levels of grief and trauma among surviv-
ing siblings, regardless of whether the death was sudden or expected (Paris et al., 2009).
Children who lose a sibling are less likely to be treated by others as legitimate “mourners,”
because the focus is often on the parents who have lost a child (Rando, 1991). They may
feel higher levels of guilt after the death, because it is so normal for siblings to have feelings
of anger, jealousy, and resentment towards one another in life. The surviving child may
be at greater risk of developing anxiety and/or mood disorders. He or she may feel com-
pelled—or unfortunately in some cases, encouraged by the parent(s)—to take on the role
of the deceased brother or sister. Sometimes the parents may blame the surviving child for
the death of the sibling, or the surviving child may internalize a guilty fear that the death
was her or his fault (Davies, 2000; Packman et al., 2006; Paris et al., 2009; Worden, 1996).
Finally, sibling death can have a profound existential effect on survivors in that it may be
the first time when they become aware of the possibility of death for themselves (Jarratt,
1994; Rando, 1991). Studies indicate that an ironic benefit of experiencing sibling death
for adolescents is an increased sense of maturity and awareness of the fragility of life that
may not be shared by peers of a similar age (Packman et al., 2006).
“Survivor guilt” is a dynamic that may surface for individuals who have lost a sibling.
While the bereaved parent experiences a feeling of powerlessness after experiencing the
loss of a child, the surviving sibling often experiences an immense feeling of guilt (Di
Ciacco, 2008; Sarnoff Schiff, 1978). Survivors are left wondering why they were spared
and feeling remorseful about not being able to save the deceased, or angry at their par-
ents for not protecting their sibling (Worden, 1996). Sibling death marks a trauma to the
family system, and surviving siblings often experience the death of a sibling as a void (Di
Ciacco, 2008; McGoldrick & Walsh, 2005; Packman et al., 2006; Sarnoff Schiff, 1978;
Worden, 1996). Herman (1997) discusses the guilt endured by the survivor, highlighting
that the severity is at its greatest when the individual has witnessed the suffering and death
of another. While it was previously thought that an indicator of healing was letting go of
the attachment to the deceased, current research indicates that maintaining a bond or con-
nection with the loved one is a natural part of integrating the loss (Worden, 2008); these
ongoing connections may be especially pronounced for surviving siblings, since sibling
bonds tend to be among the strongest in families (McGoldrick, Watson, & Benton, 2005;
Packman et al., 2006).
Death of a Grandparent. The death of a grandparent may be the first experience a child
has with death, because it occurs in what we might call the “natural sequence of time” for
an elderly person to die. Just because it may be “natural” for a grandparent to die does
not mean it is an easier loss to bear, especially if the child was very close to the grandpar-
ent. In some cases, the grandparent may have been one of the primary people raising the
child; this tends to be most common in communities with a lower socioeconomic status,
high rates of teenage pregnancy, or in African American families (Edwards & Daire, 2006;
Kliman & Madsen, 2005; Walsh, 2005).
Children tend to have unique relationships with their grandparents that are very differ-
ent from the relationships they have with their parents (Corr, 2004; Dyregrov, 2008; James
et al., 2001). This special relationship is mutually beneficial: for the grandparents, it repre-
sents the opportunity to be a parental figure without all of the day-to-day responsibilities
of parenting; and for the child, the relationship can provide support in times of conflict
or disagreement with parents (Walsh, 2005). The loss of a grandparent may be more dis-
tressing to children than many adults realize. Parents, who have their own relationships
with their parents, will be experiencing grief, too. Corr (2004) suggests bibliotherapy as a
way to deal specifically with a grandparent’s death, or to have grandparents help children
prepare for death, and presents a host of relevant readings on all dimensions of death
related to grandparents.
Death of a Pet. The death of a pet can bring up overwhelming sadness for all family
members, although it may also help the child learn about the nature of death and grief as
applied to people (Jarratt, 1994). Research indicates that pet loss results in grief, because
people are attached to pets and consider them family members (Luiz Adrian, Deliramich,
& Frueh, 2009). Kaufman and Kaufman (2006) studied the effects of pet loss on children
in a case study format, which revealed not only the impact of the loss of a pet, but also
societal failure to recognize pet death as a legitimate source of grief. Sometimes parents
may think it is possible to replace a deceased pet without the child’s knowledge; however,
direct, open communication about death and allowing the opportunity to grieve the loss
is a more appropriate response (Di Ciacco, 2008).
Since children, and many adults, form intense and unconditional bonds with animals, it
is essential not to overlook the effect that the loss of a pet may have on a child. If it is the
first loss, this may be the moment when the child realizes that death is irreversible and that
all living creatures die. This is a tremendous reality for a child to absorb. General princi-
ples about healthy bereavement apply to those grieving the death of a pet, such as creating
a safe space for feelings to emerge, and understanding the specific nature and importance
of that relationship. Helping the child tell the story of how the pet came to be part of the
140 Aubrey Uresti
family and share specific memories of times spent together can be an important avenue for
the release of grief-related emotions; family support is an essential component of healing
and making meaning of the loss (James et al., 2001; Kaufman & Kaufman, 2006).
The Dying Child. Kübler-Ross (2008) interviewed many children who were in the pro-
cess of dying, and reported that their greatest fear was being alone in the moment of death.
After countless interviews and sessions with dying individuals, she came to the conclusion
that we are not, in fact, alone when we face death. Dying children will often share mysti-
cal or spiritual stories about near-death experiences (Kübler-Ross, 1997, 2008). While it is
common for dying people of all ages to share these types of stories, it can be unsettling to
school-based practitioners to hear students talk about seeing “ghosts,” traveling “to the
other side,” and so on if they are not prepared for this aspect of the dying process.
Doka (2009) describes a number of obstacles involved in working with dying children
and adolescents. Triangulation is of increased concern in these situations, because parents
may be inclined to give information to the practitioner that they do not want the child
to have; on the other hand, the dying child may tell the practitioner things he or she is
not ready to share with parents. The practitioner must be willing to be an advocate for
the child. Consequently, the development of a trusting relationship and the assurance of
confidentiality—two cornerstones of counseling—may be more difficult to establish when
working with dying children. Still, clearly outlining the role of trust and confidentiality
with the entire family system is of paramount importance (Doka, 2009).
Death in the Extended Family System: Teachers

Students spend a large portion of their week with their teachers, who serve as the school
version of caretaker, parent, disciplinarian, and advisor, as well as educator. Because teach-
ers play a pivotal role in student development, the loss of a teacher can have a dramatic
effect on the individual student and entire class, as well as the school community (Boyd
Webb, 2011). This is particularly relevant in elementary schools, where students tend to
have one teacher for the entire year. In elementary school, children often form very strong
attachment bonds to their teachers. These bonds are often the first additional attachments
with adults outside the family.
In middle and high school, students have many teachers and, if a teacher dies, it will
be important to determine the meaning of that relationship for the student. Any loss,
regardless of the significance of the specific relationship, can trigger former loss in that
child’s life. Thus, it is imperative for school counselors and school psychologists to rec-
ognize that a student’s symptoms of grief may be related to the teacher’s death, and/or
some other loss.
Death in the Extended Family System: Friends

Although friends have an important role in the lives of children and adolescents, research
on the impact of the death of a friend is lacking when compared to the death of a parent
or sibling (Balk, Zaengle, & Corr, 2011; Dyregrov, 2008). Beginning in childhood, friends
serve as playmates and companions. Friendships assist in socialization, language develop-
ment, and cognitive processing, and help children learn how to manage conflict and nego-
tiate roles in play and other settings (McGoldrick & Carter, 2005). Friendships in middle
school help children identify their own values and continue to work on identity develop-
ment; in high school, friends serve as intimate confidants, and friendships often mean as
much to them as their relationships with family members (Balk et al., 2011; Dyregrov,
2008; McGoldrick & Carter, 2005). In this way, friends take on the significance of family,
making the death of a friend uniquely and deeply painful. Adults may not immediately
recognize the potential impact of the loss of a friend; friends themselves can play a signifi-
cant part in helping children cope with the loss of a loved one or another friend (Dopp &
Cain, 2012).
At any age, the death of a peer signifies the child’s own mortality. It can be very fright-
ening for children because they may wonder if they will suffer the same fate. If it is an
accidental or unexpected death, accompanying feelings could include shock and disbelief.
If the death is the result of a prolonged illness, there is the chance that adults may have
been able to prepare the child for the possibility of death. If the child has not been readied
to anticipate death as a possibility, the grief process might become complicated and the
child might display more pathological symptoms of distress.
Sudden Versus Prolonged Death

Loss for any reason can have a dramatic impact on the life of a child. Many bereavement
experts contend that there are some important differences, however, in the experience, if
the death occurs suddenly as opposed to the result of a prolonged illness (McGoldrick &
Walsh, 2005; Rando, 1991; Tatelbaum, 2008). Sudden deaths seem to be unnatural, and
they provoke many questions and “what ifs,” while prolonged deaths are difficult because
it is painful to watch a loved one die. However, prolonged deaths may allow for the chance
to offer support and to say good-bye, as well as to engage in grieving prior to the actual
death. With a sudden death, an individual may experience a sense of unfinished business,
with feelings, thoughts, or actions that are left incomplete.
If the relationship was problematic or strained before the death, grief may involve more
than the common themes experienced by mourners (Edgar-Bailey & Kress, 2010; James
et al., 2001; Lichtenthal et al., 2010; Mannarino & Cohen, 2011; Packman et al., 2006;
Paris et al., 2009; Tatelbaum, 2008; Worden, 2008). It can also include layers of guilt,
regret, remorse, and resentment—and these feelings can be especially confusing for chil-
dren. Some of these issues may also be true in the case of a prolonged death, wherein grief
parallels the progress of the illness and each new experience—trips to the emergency room,
surgeries, new medications, changes to physical ability and appearance—represents a loss.
When death occurs, it may feel like a relief to the survivors, who have been caring for the
dying person for an extended period of time; although a normal reaction, this feeling of
relief is often accompanied by extreme guilt, especially for children.
Disenfranchised Grief
In addition to the grief that occurs from natural, sudden, or prolonged death, grief can be
the result of a traumatic or socially stigmatized death (Balk et al., 2011; Boyd Webb, 2011;
Kübler-Ross, 1997; Doka; 2009; Duffy, 2005; Edgar-Bailey & Kress, 2010; Mannarino
& Cohen, 2011). This could include deaths that are connected to suicide, AIDS, alcohol
and/or substance abuse, gangs, or domestic violence. In these instances, children who
witness the traumatic death are also at risk for childhood traumatic grief (Edgar-Bailey
& Kress, 2010; Mannarino & Cohen, 2011). Beyond death-related grieving, mourning
can emerge for children who have experienced loss due to incarceration, deportation, or
abandonment, among other socially stigmatized issues. While these types of situations do
not always involve death, they can be experienced as a serious loss and spur a grieving
process for children and adolescents. In spite of that, socially dictated norms about these
types of issues often mean that the child is not able to honestly reveal information about
the loss, grieve openly, or receive much needed social support. School-based mental health
142 Aubrey Uresti
specialists can help meet the needs of children whose grief is marginalized or disenfran-
chised by recognizing the signs of grief and offering counseling.
How to Support the Grieving Child

Most adults who experience the death of a loved one already have some history with loss;
however, for many children, the loss is their first such experience, and therefore they need
additional support in making sense of it (Rando, 1991; Young & Papadatou, 1997). How
we grieve will be affected by our relationship with the person who died, that person’s age
and stage of life, and how the death occurred (Kübler-Ross, 2008; Tatelbaum, 2008).
If at all possible, children should be prepared for death and included in the conversa-
tions and activities, especially if death is imminent. Kessler (2007) states, “If children are
old enough to love, they are old enough to grieve” (p. 125). Many of the experts on grief
in children and adolescents stress the importance of communicating clearly the details of a
loss or death in age appropriate language (Jarratt, 1994; Kübler-Ross, 2008; Rando, 1991;
Tatelbaum, 2008). The topic of death can be presented in an existential way—that is, one
can explain to the child that everything dies and that death is part of life.
Rituals provide important opportunities to talk about death and educate children about
death—whether it be rituals related to the death itself, such as the funeral, or rituals aimed
at facilitating the grief process (examples of which are provided later in the chapter) (Doka,
2000; Jarratt, 1994; Kessler, 2007). Research strongly supports the active participation of
children in funerals—including seeing and even touching the body or contributing to the
ceremony—as a concrete way to promote their understanding of the finality and perma-
nence of death (Doka, 2000; Holland, 2008; Packman et al., 2006). When children are
denied the opportunity to attend the funeral, they later report regret about their exclusion
from the process. It is more common in non-Western cultures for children to be present
and involved in death-related rituals, and to experience tangible benefits from being shep-
herded through this process by adults (Doka, 2000; McGoldrick & Walsh, 2005; Young
& Papadatou, 1997).
Children, especially, need connections with others to grieve, although they may also need
time alone (James et al., 2001; Kübler-Ross, 2008; Kübler-Ross & Kessler, 2005; Rando,
1991; Tatelbaum, 2008). Unaware of the impact of the loss, or attempting to protect the
child, adults may be unable to provide a safe space for children to discuss death. Children
may then perceive the subject as taboo, develop a need to “protect” the adult from their
feelings, and resist saying their feelings out loud (Duffy, 2005; Oaklander, 1988; Packman
et al., 2006; Rando, 1991). It is important to allow children to grieve at their own pace, to
make choices about when and how they talk about the loss, and to neither avoid conversa-
tions about grief nor force them (James et al., 2001). If supportive adults are unavailable,
children and adolescents may conclude that there is not enough time or space for them to
experience grief; they may postpone grieving until the appropriate conditions arise, until
they feel secure enough, or find the right person with whom to share their loss and process
their grief. Children also need different information at different ages, and will need to have
adults continue to explain the loss to them in new ways as they mature and are able to
integrate more knowledge (Paris et al., 2009; Rando, 1991).
Children may ask a lot of questions when a death has occurred. Rather than reflecting a
need for factual details, sometimes their questions correspond more to a need for stability
in the “story” of what happened, so that they can concretize it and allow it to enter their
field of reality. They may also be seeking reassurance that they will be loved and taken
care of, more than needing to cognitively grasp the nature of the event (Doka, 2009; James
et al., 2001; Kübler-Ross, 2008; Rando, 1991). It is important to allow children the space
to ask questions, and to answer these questions honestly, even if the answer is, “I don’t
know.” Also, children may not know how to identify or express their feelings; or they may
fear that others will not be able to hear the truth. In these cases, modeling common feel-
ings and responses and giving language to children are helpful, as is the use of pictures or
drawings of feelings to supplement words (Jarratt, 1994; Packman et al., 2006).
James, Friedman, and Landon Matthews (2001) examine common messages or myths
about grief, like “Don’t feel bad,” or “Time heals all wounds,” which, though well-
intentioned, may prevent or inhibit the mourner from uninhibited expression of productive
grief. While these messages may be unhelpful to adults, they can be even more confusing and
damaging to children, who are learning how to grieve for the first time. Caring and listening
are always more important than trying to find the “right” words to say (Tatelbaum, 2008).
Crisis Counseling Interventions

School-based practitioners must be aware of the ways in which students grieve and the
differences between adult grief and childhood grief as outlined earlier. Although schools
are in a unique position to respond when children are bereaved, it is common for school
personnel to be uncertain as to how to respond or to even recognize the signs of grief
(Holland, 2008; Openshaw, 2011). School counselors and school psychologists can be
key players in difficult times for families, because of their training in human develop-
ment, communication skills, and crisis response. Practitioners can offer a wide range of
services to the child and the family, as discussed next. In their role as consultants, they
can encourage teachers to be flexible in their academic expectations of children and ado-
lescents who are grieving, educate them about the developmental processes and needs of
bereaved students, and offer suggestions for including themes of loss and death in cur-
ricula (Holland, 2008).
Parents may have strong objections to other adults explaining death to their children,
especially if the explanation includes religious, spiritual, or cultural beliefs that differ from
their own. Including phrases like “heaven” or “life after death” in discussions with chil-
dren may conflict with the values of families. Therefore, school personnel need to be
familiar with what the parents have told their children about death (Holland, 2008). On
the other hand, some adults refuse to talk with children at all after a death occurs, refer-
ring them back to their parents; this serves only to isolate the child and prevent support
during a difficult time.
A primary role of the school-based mental health practitioner working with grieving
students involves providing individual, group, and school-wide support. The next sections
offer a range of interventions for bereaved students, including rituals and commemorative
activities, and creative and expressive art therapy techniques to foster healthy movement
through grief. All of the interventions discussed are in and of themselves prevention strate-
gies as well, in that they support the productive expression of grief and deter the develop-
ment of complicated or disenfranchised grief.
Rituals
The value of rituals in the grieving process has been written about extensively (Doka,
2000; Kessler, 2007; Kübler-Ross, 2008; Kübler-Ross & Kessler, 2005; Wolfelt, 2009;
Young & Papadatou, 1997). As part of a larger social, cultural, or spiritual framework
for grieving, rituals may complete a compulsory or obligatory duty. In spite of these sys-
temic expectations, rituals actually serve an important role in helping grieving children
and adolescents. Rituals can also be an integral part of school-based grief work. The use
144 Aubrey Uresti
of rituals in counseling can benefit grieving students by allowing them to address issues
connected to unfinished business, memorialize and honor the deceased, and facilitate read-
iness to move forward.
Unfinished Business. When a loved one dies, the survivor is often left without a sense
of closure. Even in the case of chronic or terminal illness, where death is an expected,
imminent, and sometimes welcome occurrence, the person who lost a loved one can expe-
rience unfinished business, or unexpressed, curtailed feelings. When unfinished business
is part of a loss, it will impede the grieving process and should be attended to (Kessler,
2007; Kübler-Ross, 1997). School-based mental health specialists can create a safe space
for grieving children to discover blocks to awareness and be present with unfinished busi-
ness. It is not uncommon for this process to be painful, distressing, or prolonged, as the
mourner may have built up protective defenses to mask these difficult, alienated feelings.
For example, a grieving student may struggle with forgiveness after the loss of someone
with whom there was a conflicted relationship (James et al., 2001). If unfinished business
is dealt with successfully, the mourner can experience the freedom of pushing through the
impasse and entering grief.
One intervention that can be used to address unfinished business is a letter-writing ritual
(James et al., 2001). The child can be provided with stationery, nice writing pens, and art
materials for the activity. An open-ended prompt is useful in introducing the activity to
the students, as it does not limit their potential expression. This ritual can be framed as
an opportunity to express feelings or thoughts to their lost loved one. As with any grief-
related ritual, sufficient time should be allowed for the letter to emerge. The purpose of
this activity is not for the student to share all of the content included in the letter—rather
it is to provide a safe space for the student to explore and enhance awareness around any
potential areas of unfinished business. The letter should be placed in the envelope by the
student and sealed. Again, the content of the letter can remain private, and students can
choose what, if anything, they would like to share or simply talk about the experience of
writing the letter and process the feelings connected to the activity.
Building an Altar. Used for sacred rites and spiritual offerings, altars have long been part
of grieving rituals. For students facing grief, the creation of an altar can provide them with
the chance to remember and celebrate the loved one who died. A small box can easily serve
as an altar. I like to offer students a variety of choices in size, shape, color, and material.
Also, I provide options in the type of box—something that remains open versus some-
thing that slides open or has a lid. A variety of art media (e.g., magazines, paint, papier-
mâché, markers, feathers) can be available for students to decorate their altars. Students’
memories of the deceased can include handwritten poems or notes, drawn images, or
photographs. Grieving children honor the deceased through the creation of the altar itself,
and may also choose to add an object that belonged to the loved one or use clay to create
a representation of such an object. Even when students have attended a funeral or other
ritual, they benefit from making an altar because of the time that has passed since that
initial event when they may have been in a state of shock, disbelief, or been overwhelmed.
Building an altar to commemorate the first anniversary of the death, for example, may
mean that the mourning student is in a different phase of the grieving process, one that
allows for reflection and celebration.
The Family Dinner. The initial year after a loved one dies presents a series of “firsts”
for the mourner—birthdays, holidays, celebrations—without the deceased. Reminded of
past traditions and faced with the absence of the deceased, the grieving student is often
presented with a challenge by these important life events. School counselors and school
psychologists can address the inescapable flood of memories that accompany these occa-
sions by inviting the memories into counseling and planning a “family dinner.” While
this intervention works particularly well in a group, it can also be effective one-to-one.
Students are invited to prepare and serve a favorite dish of the loved one. Along with the
dish, students are asked to share the significance of the food or any feelings that surface.
The family dinner can be made more ceremonious by taking the time to transform the
regular counseling space into a special gathering place for the occasion—covering desks
with tablecloths and using special dishes and place settings. Student-generated ideas for the
“table setting” help to embrace the rituals and traditions of each family.
Time Capsule. A time capsule represents a message about a moment in time planned for
future opening. Time capsules are commonly used as part of historic or commemorative ritu-
als, buried in the cornerstone of a building or containing artifacts. A colleague shared with
me a ritual his students designed that involved writing messages about what to expect from
the grieving process and grief group; these were contained in one time capsule and sealed,
with the intention that the following year’s grief group members would open the capsule and
read the messages. This intervention illustrates the shift in energy and reinvestment in oth-
ers that accompany effective grief work. Moreover, having multiple peer perspectives about
grief experiences, without the use of advice or minimization, highlights the individuality and
uniqueness of the grieving process while normalizing themes common to grieving students.
Transitional Objects. Transitional objects are inanimate objects that symbolize meaning
connected to the bonds people form with each other. Used in counseling, transitional objects
can transfer the connection that a student may have to a school-based practitioner, group
members, or the counseling experience itself into a tangible object that can be retained by
the student. It is customary for transitional objects in counseling to represent the work
done by students—a key to symbolize unlocking awareness, a map to represent discovering
new emotional territories, a scale to signify finding balance. A transitional object might be
the result of a final creative activity like making a video diary, storybook, or board game.
Expressive Arts and Play Therapy

Paralleling Rogerian nondirective tenets, the use of expressive arts and play therapy with griev-
ing children allows for counseling to advance at the client’s pace (Axline, 2002). Researchers
and experts on bereavement agree that these modalities are priceless in permitting the release
of grief in children and adolescents (Boyd Webb, 2011; Corr, 2004; Edgar-Bailey & Kress,
2010; Holland, 2008; Kaufman & Kaufman, 2006; James et al., 2001; Oaklander, 1988;
Openshaw, 2011; Packman et al., 2006; Tatelbaum, 2008). Simple, inexpensive toys and
materials can be manipulated through the grieving child’s imagination to represent anything
from a hospital room to a reexperiencing of a dream involving the deceased.
Children of any age can benefit from the open expression that is generated from play.
From elementary children to high school adolescents, the counseling space can be trans-
formed into a place where grief masks, shadowboxes, and reenactment of last moments
with the loved one can come to light. Through my work with grieving students, I have
developed several interventions for grief counseling at different levels—helping elementary
age children to identify grief somatically, middle schoolers to gain access to memories
about the loved one, and high school students to redefine self-identity and connection to
the deceased. A tip sheet for school-based practitioners with core concepts for grief work
can be found in Appendix A (Uresti, 2010). The following sections describe the applica-
tions of sandtray, music therapy, and bibliotherapy in school-based grief work.
Sandtray. School-based practitioners using sandtray with grieving students release the
potential for the profound meaning of the child’s metaphor to emerge. Sandtray work allows
for feelings to surface that may not be at a conscious level or that are difficult for the child
to express directly. Sufficient time, a nondirective counseling space, and access to a variety
146 Aubrey Uresti
of miniatures and figures are central to an inviting sandtray experience. While extravagant
stationary sandtray tables and shelves are available, school-based practitioners who meet the
needs of multiple schools may enjoy the flexibility and practicality of portable sandtrays. A
comprehensive collection of figures includes people of various ages and races, toy soldiers
and warriors, animals, insects, mythical and fantasy creatures, cars and planes, rocks, shells,
buildings, fences and gates, and trees. Images of death (e.g., skeletons, coffins, headstones,
religious or spiritual symbols) can augment a standard sandtray collection for grief work.
Music Therapy. An individual’s music collection can parallel the wide array of emotion
that is also present in the grieving process. Incorporating music into grief work can draw
on the intrinsic capacity that songs have to resonate with feelings. Whether children and
adolescents select songs that help them to stay present (even if only briefly) with their grief
or songs that help them to reminisce and continue to position the meaning of loss in their
life, music can have surprising, sometimes cathartic, outcomes in counseling. Songs could
make literal reference to death and dying from the mourner’s perspective, like the Paul
McCartney song “Here Today,” that was written about his friendship with John Lennon
after Lennon’s death. Furthermore, songs could come from a variety of genres, and need
not be explicitly linked to death. Music about heartbreak or sadness could appeal to stu-
dents and provide inspiration and a foundation for discussion. School-based practitioners
should remain open and nonjudgmental with grieving students, encouraging them to select
music that resonates with their grieving process.
Bibliotherapy. From classic children’s literature like Charlotte’s Web and Bridge to Tera-
bithia, to more modern stories like Tears of a Tiger and Green Angel, books can help griev-
ing children and adolescents discover and sort through their feelings. The use of books and
literature in counseling allows mourners to take in a story, identify with its characters, and
interact with the messages and meaning of the book. This type of intervention can directly
connect students with issues relevant to grieving while allowing for breaks from traditional
talk therapy. School-based practitioners may consider consulting with teachers about exist-
ing curriculum, working with students to choose a contemporary book with grief and loss
motifs like The Catcher in the Rye, Romeo and Juliet, or the Harry Potter series, or referring
to a resource such as The Dougy Center (The National Center for Grieving Children and
Families), which publishes psychoeducational books in English and Spanish.
Grief Group Work

A bereavement group facilitated by a school counselor or school psychologist is an invalu-
able intervention for grieving students (Openshaw, 2011). Grief groups can be designed
in various ways: targeting a traditional type of loss (e.g., death of a parent, suicide of a
friend), addressing a nontraditional or disenfranchised source of grief (e.g., community
or gang violence, incarceration, deportation), or focusing on a relevant issue for a par-
ticular subcommunity of students within the school (e.g., new students, children from
military families). Grief work is often more effective in groups, which provide normal-
izing, comforting, and meaningful experiences to assist students in making sense of loss
and learning valuable coping skills. In addition, group work can help to promote a sense
of connectedness for grieving students in a time when it is not uncommon to experience
loneliness. Groups provide students with a twofold benefit: the space to move through
their individual process of grief, while also allowing them to heal in relation to others
instead of suffering in isolation.
Like the process of grief, an effective group must also progress through a series of stages.
The first task for a group is to build trust (Corey, 2008). The members of a grief group will
not automatically bond or coalesce simply because they have experienced a loss. Members
need a chance to get to know each other; this can be accomplished through a team-building
activity or game in which the members work towards a collective goal. Once trust has been
established, group members can take a risk. Risk-taking marks the group’s entry into the
working phase and may involve member-to-member contact, increased or more meaning-
ful self-disclosure, and/or more active participation (Corey, 2008). In a school-based grief
group, an ongoing ritual or art project can cultivate the conditions necessary for working
by channeling focus enough to allow for vulnerability and authenticity to emerge. What
often begins as a short project becomes the work of the group. Moved by the artistic inspi-
rations of my students, I have spent weeks and sometimes months nurturing grief work
through the construction of elaborate hats, creation of memory books, and composition
of original music and lyrics. In addition to these creative interventions, classic techniques
like genograms, empty chair, and mandalas are also recommended for grief group work.
When the energy of grief group members begins to transfer from the all-consuming aspects
of loss to allow for the curiosity, awareness, investment in life, and the world that comes with
recovering from grief, the group is ready for termination. Proper termination, an essential
part of any group, is especially vital for grief groups. Symbolizing another “loss” for group
members, termination may trigger strong responses or regression behaviors in members. Ter-
mination must be planned well in advance and directly discussed with group members (Corey,
2008). Practitioners can support members in being present with good-byes and should be
aware of the potential impact that termination may have for them as well, conscious of their
feelings, and open to consultation or supervision for areas of question or concern.
School-Wide Interventions
As previously referenced in the chapter, grieving is often restricted to private spaces, with-
out the support of social networks. School-wide grief-related interventions deviate from
the norm, making grief approachable and open to the community. By raising awareness,
school-wide interventions also serve as a prevention strategy. Members of a terminating
grief group, for instance, may further the understanding of grief and loss by visiting class-
rooms and giving a presentation about school-based support for grieving students. While
it is possible for the school-based practitioner to provide this information directly to stu-
dents, the opportunity for student leadership and peer mentoring should not be ignored.
Students have conceived of some of the most rewarding projects I have facilitated.
Reflecting on the insight and support gained from grief counseling, members of a bereave-
ment group considered other students who might be grieving but were not part of the
group. In a lovely gesture intended to promote healing and awareness on campus, the
students and group leaders designed a “Memorial Wall” (see Appendix B). This art project
was a graffiti art mural spray painted on canvas. Upon completion, the mural was avail-
able at lunch for students and staff to sign the name of a lost loved one. From pet birds, to
military parents, to elderly grandparents, and trusted friends, the mural was soon covered
with memories and expressions of love from school community members. As with any
intervention that has a potentially triggering impact, follow-up support was available to
all members of the school community. The completed mural remained in the school, as an
observance of grief and a salute to the grieving process.
Prevention
Pioneered by the work of Herman Feifel and continued by other humanists, death educa-
tion remains a rare aspect of K–12 curriculum. Commonly associated with the training
of adults, primarily in the medical profession, death education aims to prepare specialists
148 Aubrey Uresti
for the personal, professional, and existential aspects of working with end-of-life issues,
dying individuals, and death. With regard to counselors and psychologists, it seems that
little or ineffective attention is given to these issues in professional preparation programs.
Perhaps death anxiety thwarts open discussion; indeed, research regarding the efficacy of
death education reflects mixed results. Therefore, training in this area typically falls into
the category of crisis response rather than prevention (Harrawood, Doughty, & Wilde,
2011; Wass, 2004).
In K–12 schools, comprehensive death education would include integration of the cul-
tural aspects of death, exploration of suicide and violent behavior, and assessment of the
desensitizing effects of media exposure to violence (Wass, 2004). In addition to the strate-
gies presented in this chapter that support these goals, other suggestions include wearing
blue in observance of “Children’s Grief Awareness Day” (sponsored by Highmark Car-
ing Place on the Thursday before Thanksgiving each year), referring a grieving student
to Camp Erin (a nationwide free grief camp supported by the Moyer Foundation), or
providing the school librarian with the National Bereavement Resource Guide book list
(published by New York Life Foundation and the Moyer Foundation) so that books about
grief and death are available to students and adults. Comprehensive prevention would also
include raising awareness about grief, promoting healthy expressions of grief, and prevent-
ing complicated grief. Certainly, the prevention of loss is impossible, and the prevention
of grief itself is not desirable. Grief is a natural response to loss that will heal with time,
space, and support.
REFERENCES
Axline, V. M. (2002). Play therapy. Edinburgh: Churchill Livingstone.

Balk, D. E., Zaengle, D., & Corr, C. A. (2011). Strengthening grief support for adolescents coping with a
peer’s death. School Psychology International, 32(2), 144–162. doi:10.1177/0143034311400826
Bowen, M. (2004). Family reaction to death. In F. Walsh & M. McGoldrick, Living beyond loss:
Death in the family (2nd ed., pp. 47–60). New York: W.W. Norton.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation, anxiety, and anger. New York: Basic Books.
——— (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. New York: Basic Books.
Boyd Webb, N. (2011). Play therapy for bereaved children: Adapting strategies to community,
school, and home settings. School Psychology International, 32(2), 132–143. doi:10.1177/
0143034311400832
Corey, G. (2008). Theory & practice of group counseling (7th ed.). Belmont, CA: Thomson/Brooks
Cole.
Corr, C. A. (2004). Grandparents in death-related literature for children. Omega, 48(4), 383–397.
doi:10.2190/UHT5-KYTM-ANWF-VBD5
Davies, B. (2000). Sibling bereavement: We are grieving too. In K. J. Doka (Ed.), Living with grief:
Children, adolescents, and loss (pp. 231–241). Florence, KY: Hospice Foundation of America.
Di Ciacco, J. A. (2008). The colors of grief: Understanding a child’s journey through loss from birth
to adulthood. London: Jessica Kingsley.
Doka, K. J. (2000). Using ritual with children and adolescents. In K. J. Doka (Ed.), Living with grief:
Children, adolescents, and loss (pp. 153–159). Florence, KY: Hospice Foundation of America.
——— (2009). Counseling individuals with life-threatening illness. New York: Springer.
Dopp, A. R., & Cain, A. C. (2012). The role of peer relationships in parental bereavement during
childhood and adolescence. Death Studies, 36, 41–60. doi:10.1080/07481187.2011.573175
Duffy, T. (2005). Grief, loss, and death. In D. Comstock (Ed.), Diversity and development: Critical
contexts that shape our lives and relationships (pp. 253–268). Belmont, CA: Thomson/Brooks Cole.
Dyregrov, A. (2008). Grief in children: A handbook for adults (2nd ed.). London: Jessica Kingsley.
Dyregrov, K., & Dyregrov, A. (2008). Effective grief and bereavement support: The role of family,
friends, colleagues, schools and support professionals. London: Jessica Kingsley.
Edgar-Bailey, M., & Kress, V. E. (2010). Resolving child and adolescent traumatic grief: Creative
techniques and interventions. Journal of Creativity in Mental Health, 5, 158–176. doi:10.1080/1
5401383.2010.485090
Edwards, O. E., & Daire, A. P. (2006). School-age children raised by their grandparents: Problems
and solutions. Journal of Instructional Psychology, 33(2), 113–119.
Freud, S. (1917). Mourning and melancholia. In S. Freud (Ed.), The standard edition of the complete
psychological works of Sigmund Freud: Vol. 14 (1914–1916). On the history of the psycho-
analytic movement, papers on metapsychology and other works (pp. 237–258).
Harrawood, L. K., Doughty, E. A., & Wilde, B. (2011). Death education and attitudes of counselors-
in-training toward death: An exploratory study. Counseling and Values, 56, 83–95.
Herman, J. (1997). Trauma and recovery: The aftermath of violence—from domestic abuse to politi-
cal terror. New York: Basic Books.
——— (2008). How schools can support children who experience loss and death. British Journal of
Guidance & Counseling, 36(4), 411–424. doi:10.1080/03069880802364569
Holland, J. (2008). How schools can support children who experience loss and death. British Journal
of Guidance & Counselling, 36, 411–424. doi:10.1080/03069880802364569
James, J. J., Friedman, R., & Landon Matthews, L. (2001). When children grieve. New York: Harper-
Collins.
Jarratt, C. J. (1994). Helping children cope with separation and loss (Rev. sub. ed.). Harvard, MA:
Harvard Common Press.
Kaufman, K. R., & Kaufman, N. D. (2006). And then the dog died. Death Studies, 30, 61–76.
doi:10.1080/07481180500348811
Kessler, D. (2007). The needs of the dying: A guide for bringing hope, comfort, and love to life’s final
chapter. New York: HarperCollins.
Kliman, J., & Madsen, W. (2005). Social class and the family life cycle. In B. Carter & M. McGold-
rick (Eds.), The expanded family life cycle: Individual, family, and social perspectives (3rd ed., pp.
88–105). New York: Allyn & Bacon.
Kübler-Ross, E. (1969). On death and dying. New York: Scribner.
——— (1997). On children and death: How children and their parents can and do cope with death.
New York: Simon & Schuster.
Kübler-Ross, E. (2008). On life after death. Berkeley, CA: Celestial Arts.
Kübler-Ross, E., & Kessler, D. (2005). On grief and grieving: Finding the meaning of grief through
the five stages of loss. New York: Scribner.
Lichtenthal, W. G., Currier, J. M., Neimeyer, R. A., & Keesee, N. J. (2010). Sense and significance:
A mixed methods examination of meaning making after the loss of one’s child. Journal of Clinical
Psychology, 66(7), 791–812. doi:10.1002/jclp.20700
Luiz Adrian, J. A., Deliramich, A. N., & Frueh, C. (2009). Complicated grief and posttraumatic
stress disorder in humans’ response to the death of pets/animals. Bulletin of the Menninger Clinic,
73(3), 176–187.
Mannarino, A. P., & Cohen, J. A. (2011). Traumatic loss in children and adolescents. Journal of
Child and Adolescent Trauma, 4, 22–33. doi:10.1080/19361521.2011.545048
McGoldrick, M., & Carter, B. (2005). Self in context: The individual life cycle in systemic perspec-
tive. In B. Carter & M. McGoldrick (Eds.), The expanded family life cycle: Individual, family, and
social perspectives (3rd ed., pp. 27–46). New York: Allyn & Bacon.
McGoldrick, M., & Walsh, F. (2005). Death and the family life cycle. In B. Carter & M. McGold-
rick (Eds.), The expanded family life cycle: Individual, family, and social perspectives (3rd ed.,
pp. 185–201). New York: Allyn & Bacon.
McGoldrick, M., Watson, M., & Benton, W. (2005). Siblings through the life cycle. In B. Carter &
M. McGoldrick (Eds.), The expanded family life cycle: Individual, family, and social perspectives
(3rd ed., pp. 153–168). New York: Allyn & Bacon.
Middleton, W., Raphael, B., Burnett, P., & Martinek, N. (1998). A longitudinal study comparing
bereavement in recently bereaved spouses, adult children and parents. Australian and New Zea-
land Journal of Psychiatry, 32, 235–241.
Oaklander, V. (1988). Windows to our children: A Gestalt therapy approach to children and adoles-
cents. Highland, NY: Gestalt Journal Press.
150 Aubrey Uresti
Openshaw, L. L. (2011). School-based support groups for traumatized students. School Psychology
International, 32(2), 163–178. doi:10.1177/0143034311400830
Packman, W., Horsley, H., Davies, B., & Kramer, R. (2006). Sibling bereavement and continuing
bonds. Death Studies, 30, 817–841. doi:10.1080/07481180600886603
Paris, M. M., Carter, B. L., Day, S. D., & Armsworth, M. W. (2009). Grief and trauma in
children after the death of a sibling. Journal of Child & Adolescent Trauma, 2, 71–80.
doi:10.1080/19361520902861913
Piaget, J. (1967). Six psychological studies. New York: Random House.
Piaget, J., & Inhelder, B. (2000). The psychology of the child. New York: Basic Books.
Rando, T. A. (1991). How to go on living when someone you love dies. New York: Bantam Books.
Sarnoff Schiff, H. (1978). The bereaved parent. New York: Penguin.
Tatelbaum, J. (2008). The courage to grieve: The classic guide to creative living, recovery, and
growth through grief. New York: HarperCollins.
Uresti, A. (2010). Creative strategies for school counselors to normalize grief and loss. Presentation at
the annual meeting of the California Association of School Counselors (CASC), Montebello, CA.
Walsh, F. (2005). Families in later life: Challenges and opportunities. In B. Carter & M. McGold-
rick (Eds.), The expanded family life cycle: Individual, family, and social perspectives (3rd ed.,
pp. 307–326). New York: Allyn & Bacon.
Wass, H. (2004). A perspective on the current state of death education. Death Studies, 28, 289–308.
doi:10.1080/07481180490432315
Wolfelt, A. (2009). Handbook for companioning the mourner: Eleven essential principles. Fort Col-
lins, CO: Companion Press.
Worden, J. W. (1996). Children and grief: When a parent dies. New York: Guilford Press.
——— (2008). Grief counseling and grief therapy: A handbook for the mental health practitioner
(4th ed.). New York: Springer.
Yalom, I. D. (2009). Staring at the sun: Overcoming the terror of death. San Francisco: Jossey-Bass.
Young, B., & Papadatou, D. (1997). Childhood, death and bereavement across cultures. In C. M.
Parkes, P. Laungani, & B. Young (Eds.), Death and bereavement across cultures (pp. 191–205).
New York: Routledge.
Appendix A
Working with Grief in Schools: A DABDA Approach
Do honor your clients’ experience without trying to be an expert—let them tell the story.
Draw on your strengths and intuition to build a therapeutic alliance. Rely on theory to
D
guide you.
Discover your own ability to be brave by tolerating silence and intense emotions.
Ask direct questions, even when you’re afraid.

Allow genuine expressions of feelings to emerge—including, but not limited to, laughter,
A yelling, silence, and crying.
Anticipate a journey that will unfold unlike any other. Support the client through each
step, and move slowly.
Breathe! It will help you to stay grounded for your client.

B Bring your most authentic self to this work.
Believe that the work that you do matters.
Do your own grief work. It will help you to recognize and manage countertransference.
Design creative activities and interventions—music, movement, art, storytelling—for and
D with your client.
Develop a list of resources and referrals for students who may need ongoing therapeutic
support.
Accept every stage of the grief process, and help to normalize all of the thoughts and feel-
ings that occur in it.
A Advocate for your client with caretakers and teachers for potential modifications at home
and school.
Acknowledge the termination process. “Good-bye” can be intentional, planned, and healing.
Note. “DABDA” stands for Denial, Anger, Bargaining, Depression, Acceptance, which are the stages of grief as
described by Elisabeth Kübler-Ross in On Death and Dying and other works. From Uresti, 2010.
Appendix B
Memorial Wall
Figure 8.1 Student spray paints on canvas for school-wide tribute to grief and loss.
9 Illness: A Crisis for Children
Dianne Castillano & Amy N. Scott
Everyone succumbs to illness at some point in life, be it a simple cold or a life-threatening

disease. Illness affects young and old, rich and poor, and male and female. However, each
type of illness affects individuals differently, both physically and emotionally. This chap-
ter discusses the prevalence of childhood illness, the risks associated with illness, and the
intervention and prevention techniques one can use in a school setting with children who
are physically ill.
Magnitude of the Problem

In the past, schooling for children with chronic or life-threatening illness was seen as rela-
tively unimportant and irrelevant. In fact, more than 3 out of 100 children died between
their first and 20th birthdays in 1900, whereas today, less than 2 out of 1,000 children
die. In 1900 the leading cause of childhood death was infectious disease (diarrheal dis-
eases, diphtheria, measles, pneumonia/influenza, scarlet fever, tuberculosis, typhoid and
paratyphoid fever, and whooping cough), and today the leading cause of childhood death
is unintentional injuries (accidents). During the 20th century, overall American health has
improved and the leading causes of death have shifted from infectious to chronic diseases
(Guyer, Freedman, Strobino, & Sondik, 2000).
Chronic illnesses are typically defined as long-term conditions or diseases that do not
spontaneously resolve or get cured (McKinney, James, Murray, & Ashwill, 2009). Exam-
ples of chronic illnesses include asthma, cancer, cardiac disorders, sickle cell disease, and
cerebral palsy. It should be noted that chronic illness is a broad category, and therefore
the severity and needs of each child vary among the chronic conditions and within each
individual child. For example, children with chronic illness may fluctuate from being rela-
tively stable to critically ill and these changes may impact their functioning temporarily
or permanently. Additionally, the child’s developmental level, support system, and coping
skills may further affect his or her functioning.
Today, more children with both acute and chronic illnesses are attending, returning,
and transitioning back to school (Lotstein, McPherson, Strickland, & Newacheck, 2005).
Schools in turn are increasingly expected to support not only the academic needs of chil-
dren, but also the social, emotional, medical, and other needs of students with chronic
illness through effective transition plans (Armstrong, Blumberg, & Toledano, 1999). The
changes in expectations can be attributed to enactment of Public Law 94–142 and its sub-
sequent reauthorizations that guarantee all children a place in the public classroom (Kaf-
fenberger, 2006). Additionally, medical care and technology have improved and there has
been an increased emphasis from the medical community on outpatient care (29% increase
from 1992 to 2000; Kaffenberger, 2006). Because more students with chronic illness are
receiving outpatient care, they are more likely to be attending school. Unfortunately,
154 Dianne Castillano & Amy N. Scott
schools currently lack the resources to properly cater to the needs of these children. Edu-
cators and other school professionals, including administrators, school psychologists, and
school counselors, often have limited training, support, and knowledge to properly meet
the needs of children who have a physical illness.
Absence Rates and Prevalence Rates of Diseases

Even though improved medical technology and an increased emphasis on medical research
have allowed individuals to better prepare for and prevent the occurrence of illnesses,
these medical advances have not completely eliminated sicknesses. According to the Cen-
ters for Disease Control and Prevention, in 2004 10.9% of school-age children missed
6–10 days of school due to illness or injury. An additional 5.1% of school-age children
missed 11 days or more due to illness or injury. Minor respiratory diseases such as cold
and flu, injuries, and chronic illnesses are among the most common reasons children are
absent from school (Borrego, Cesar, Leiria-Pinto, & Rosada-Pinto, 2005; Thompson &
Gustafson, 1996). In fact, children with chronic illnesses are absent from school for an
average of 16 days a year compared to approximately 3 days a year for healthier children
(McDougall et al., 2004).
Although there are differences in the prevalence rates across studies, it has been esti-
mated that approximately 18% of all children in the United States have a chronic illness,
with 6.5% of children suffering a more severe illness that interferes with their normal
school activities (American Academy of Pediatrics, Council on Children with Disabilities,
2005; Graff & Ault, 1993; Newacheck & Halfon, 1998; Thompson & Gustafson, 1996).
The top three chronic illnesses among children are respiratory allergies, ear infections,
and asthma (Newacheck & Taylor, 1992). Among school-age children, asthma is the most
common illness (Grant et al., 1999). The prevalence of childhood asthma in the United
States ranges from 4.3% to 6.7% (Gergen, Mullally, & Evans, 1988; Weitzman, Gort-
maker, Sobol, & Perrin, 1992). Although some children acquire acute asthma, more severe
forms of asthma are typically defined and categorized as chronic.
Whereas asthma is the leading cause of childhood illness, cancer is the leading child-
hood illness that causes death (Kochanek, Kirmeyer, Martin, Strobino, & Guyer, 2012).
Furthermore, childhood cancer is the fourth leading cause of death among children aged
1 to 19 years old and it is preceded only by unintentional injury, suicide, and homicide
(Kochanek et al., 2012; Pollack, Stewart, Thompson, & Li, 2007). Childhood cancers
include leukemia, lymphoma, and brain and spinal tumors. Many childhood cancers that
are diagnosed early are curable; however, the treatment typically lasts for many months.
Therefore, there may be times that the child is in the hospital, certain periods that the child
is receiving outpatient treatment, and times when no medical procedures are taking place.
Depending on the treatment regimen, a child diagnosed with cancer may face difficulties
with school attendance in all stages of the cancer treatment, with the most absences within
the year after diagnosis (Vance & Eiser, 2002). According to the American Cancer Society
(2012), about 12,060 new cases will be reported in children from birth to 14 years of age
in 2012. Additionally, childhood cancer incidence rates increased slightly (0.5% per year)
from 2004 to 2008, which is a consistent trend since 1975.
Although this chapter focuses on illness, it is important to note that children also miss
school due to injuries caused by accidents. In fact, the leading cause of death in children
has been attributed to unintentional injuries (Kochanek et al., 2012; McKinney et al.,
2009). Prevalence rates vary, but it has been estimated that one in every four children
experience a physical injury each year (Scheidt et al., 1995). The effects of a physical injury
on a child vary based on the accident or injury. Some children suffer temporary physical
Illness: A Crisis for Children 155
limitations caused by a broken bone or a sprain. Other children suffer more major injuries
that can cause permanent brain damage and even death. Regardless of the illness or injury,
children are often at risk for other negative factors associated with an illness or injury and
some children are more at risk than others for illness.
Children at Risk for Illness

There are demographic differences in the reported incident rates for children with illnesses.
For some conditions, racial background appears to be a factor in the susceptibility to
chronic illness. Cystic fibrosis and leukemia, for example, are more common in Caucasians
and sickle cell disease is more common in African Americans than other ethnic groups
(Kliewer, 1997; Wang, 2007). Several studies have indicated that individuals from minor-
ity groups have a higher risk for chronic illnesses. Specifically, research has suggested that
Latino youth face greater risks for adverse health outcomes when compared to youth of
other ethnic groups (Public Health Service, 1991). Wickrama, Elder, and Abraham (2007)
emphasize that increased health risk among rural Latinos potentially stems from health
service problems and limitations in rural areas.
Other risk factors include poverty, gender, health status, and age. Newacheck et al.
(1998) found that the prevalence rate for illness was higher for children from low-income
and single-parent households. Gender may also be a risk factor. For instance, asthma and
leukemia have been found to be more common in boys (American Cancer Society, 2012).
Similarly, boys are more prone to unintentional injuries than girls (Newacheck et al.,
1998). Children with existing special health needs are often at greater risk for developing
other illnesses (Newacheck et al., 1998). For example, children with genetic diseases such
as Down syndrome, Bloom syndrome, or Fanconi anemia are at greater risk for develop-
ing acute lympoblastic leukemia (ALL), the most common childhood cancer (Herrmann,
Thurber, Miles, & Gilbert, 2011). Newacheck et al. (1998) also found that the prevalence
for illness was higher in older children, whereas ALL is usually diagnosed between the
ages of 2 and 7 years.
Illness as a Stressor
For many families and children, childhood is a dynamic time that is filled with activities
connected to school and community. When an illness in the family disrupts these activities,
it introduces a level of stress that is not typical in most families.
Parental Stress. For parents, the stress stems from several factors that include but are not
limited to: new and increased responsibility, financial burdens caused by the illness, strains
on time due to caregiving responsibilities, and the constant fear for the welfare of the child
(Shudy et al., 2006). Parents also have reported increased levels of depression, anxiety,
and clinical burnout after their child has been diagnosed with a serious physical condition
(Lindstrom, Aman, & Norberg, 2009; Steele, Dreyer, & Phipps, 2004). In some studies,
marital satisfaction among the parents also suffered. More specifically, sexual intimacy
was reported to be affected negatively after the child’s diagnosis (Hughes & Lieberman,
1990; Lavee & May-Dan, 2003).
Some families experience greater stress due to being uninsured or underinsured. This
lack increases out-of-pocket expenses and can lead to bankruptcy (Newacheck, Park, Brin-
dis, Biehl, & Irwin, 2004). Besides paying for medical treatments, parents are expected to
be with their child physically during treatments. This expectation requires parents to take
time off from work, which can lead to possible employment loss and further increases the
financial stress of the parents (Winthrop et al., 2005). Although it is rarely addressed or
studied, the overall stress is likely greater for single parents who have to deal with circum-
stances by themselves, both financially and emotionally (Brown et al., 2008).
Parental stress, however understandable, adds to the stress of the child who is ill and the
rest of the family. Parental stress is correlated to parental neglect of their other children
and has been found to affect the quality of caregiving, increase symptom expression in the
child who is sick, and decrease the quality of life for the child who is ill (Anthony, Brom-
berg, Gil, & Schanberg; 2011; Li, Ji, Qin, & Zhang, 2008; Onatsu-Arvilommi, Nurmi, &
Aunola, 1998). Simply put, an illness in a child can cause a cycle of stressors that eventu-
ally affects the entire family.
Stress for Ill Children. For children who are ill, stress is not a surprising comorbidity.
Many children experience stress and anxiety from constantly being in the hospital, fear of
pain from injections and checkups, and uncertainty about their condition (Hommel et al.,
2003; Reissland, 1983). In addition, children who are ill have also reported concerns
related to death and their illness returning after treatment (Gibson, Aldiss, Horstman,
Kumpunen, & Richardson, 2010). Older children worry about how their treatment may
affect them in the future, with some children worrying about being able to have children
of their own (Gibson et al., 2010). Some children experience extended distress and have
reported clinically significant symptoms of posttraumatic stress disorder (PTSD), even
after they have survived the illness (Stuber et al., 2010). Higher rates of posttraumatic
stress symptoms have been found to be associated with poorer quality of life and further
depressive symptoms (Schwartz & Drotar, 2006).
Stress for Siblings. Similarly, siblings of children with chronic illnesses have been shown
to experience negative effects and stress due to their sibling’s condition (Sharpe & Ros-
siter, 2002). When parents become preoccupied with a child who is sick, siblings are the
ones who experience the lack of attention (Williams et al., 2009). In a study examining
siblings of children with epilepsy, 11% indicated that they wanted to get sick in order
to receive more attention (Tsuchie, Guerreiro, Chuang, Baccin, & Montenegro, 2006).
Similar to the effects of a sibling dying, as stated in Chapter 8, siblings may experience
jealousy and anger towards the sibling with chronic illness (Tsuchie et al., 2006). During
hospitalization, it is common for the child who is ill to receive gifts and toys from family
and friends, which can further foster jealousy (Williams et al., 2009). Research has found
that some siblings act out in order to receive attention. Siblings may report similar physical
symptoms as their sibling who is ill and they often display higher levels of externalizing
behaviors in school (Gyulay, 1975; Taylor, 1980). These behaviors can become dangerous
when siblings decide to hurt themselves in order to be ill as well. Siblings also report feel-
ings of guilt for a variety of reasons, including, for possibly causing, through their words
or actions, the illness in their sibling (Fleitas, 2000); for being fortunate and having good
health (Fleitas, 2000; Gyulay, 1975); and for having negative feelings towards their sibling
and for being angry about the attention the sibling who is ill is receiving (Azarnoff, 1984;
Fleitas, 2000). Apart from guilt, siblings of children with chronic illness have reported
experiencing psychosocial and emotional problems, such as low self-esteem and loneliness
(Lobato & Kao, 2002; Quittner & Opipari, 1994). Thus, not only the child who is ill but
also their siblings and parents may have a reduced quality of life.
Quality of Life Outcomes of Childhood Illness

Quality of life (QoL) measures are objective or subjective indicators of physical and psy-
chosocial well-being that take into consideration the multiple domains that are important
in one’s life (Nabors, Hoffman, & Ritchy, 2011). QoL can be global or specific aspects of
life and should be a concern from initial diagnosis to reentry into school to future outcomes.
Social Domain
One area that can be affected in a child’s life is his or her social environment. The illness
may powerfully influence peer relationships at school and in the neighborhood (Hamiwka
et al., 2009; Sentenac et al., 2010), and later in life, relationships at work and with friends.
Bullying. Children with chronic diseases have been reported to experience a higher
level of peer victimization and bullying than their healthy peers (Sentenac et al., 2010).
Peer victimization and bullying vary depending on the particular chronic illness and the
restrictions experienced from the illness. For example, children with asthma did not report
significantly higher peer victimization compared to their peers without a chronic disease
(Blackman & Gurka, 2007). However, children who are not able to participate in certain
school activities, such as physical education, have been found to report higher risk of being
bullied compared to counterparts who had chronic illnesses that did not restrict their par-
ticipation in school activities (Sentenac et al., 2010). Thus, it appears that students with an
illness are the targets of aggressive behavior by other children when their chronic illness is
obvious and symptoms can be observed by other students.
Peer Alienation. In addition to bullying, children with chronic illness also experience
alienation from their peers. Children with illness have reported feeling different from peers
and have reported experiencing peer rejection (Sandstorm & Schanberg, 2004). Students
with illness appear to be at greater risk for social isolation related to peers misunder-
standing their condition and their needs. It is not hard to imagine that other students
may acquire misinformation about illness that causes them to avoid children with illness
for fear of “catching” the illness. Unfortunately, this neglect does not help children with
chronic illness, as it comes at a time in their lives when they need optimal support from
friends and family. Besides experiencing victimization through their peers, children with
chronic illness also have to deal with the comorbid disorders or side effects that are associ-
ated with their illness or their medications. Some of these side effects in turn affect the way
a child functions in the classroom, both academically and behaviorally.
The social impact of childhood illness has also been found to extend beyond child-
hood. Across two studies, adults who had or were diagnosed with a childhood chronic
illness reported lower rates of employment and lower mean income when compared to
their counterparts who had no previous chronic illness (Gortmaker, Perrin, Weitzman,
Horner, & Sobol, 1993; Maslow, Haydon, McRee, Ford, & Halpern, 2010). These stud-
ies further portray the importance of early intervention in order to prevent these negative
social effects.
Psychological Domain
Internalizing disorders are also associated with illness. Both children and adolescents diag-
nosed with a chronic illness report higher levels of depression and anxiety compared to
their healthier peers (Bennett, 1994; Jorngarden, Mattsson, & Essen, 2007; Pinquart &
Shen, 2011; Stallard, 1993). The high levels of depression and anxiety may stem from
the initial shock of being diagnosed with an illness or the negative self-image resulting
from physical changes during treatment (Stallard, 1993). In addition, diagnostic and treat-
ment procedures can be very intimidating and painful, especially for children. Children
who have been recently diagnosed and experience chronic pain symptoms report higher
levels of depression and anxiety, even when compared to other children with chronic ill-
ness (Jorngarden, et al., 2007; Pinquart & Shen, 2011). These risk factors may also have
a bidirectional effect. Students who experience long periods of illness, for example, are
more likely to have internalizing problems such as depression, somatic complaints, social
withdrawal, and high anxiety (Boekaerts & Röder, 1998). These symptoms of depression
can, in turn, develop into more serious risk factors and may lead to suicide. There is a
vast amount of research showing an increase in suicide risk among individuals diagnosed
with chronic and acute illness. These findings have been found in both adults and adoles-
cents, and have been associated with individuals who are diagnosed with cancer, diabetes,
epilepsy, and asthma (Goodwin, Marusic, & Hoven, 2003; Hughes & Kleespies, 2001;
Pompili, Girardi, Tatarelli, Angeletti, & Tatarelli, 2006).
Academic Domain
School life is often drastically impacted for children with illness. More specifically, chil-
dren with illness experience more absences directly related to their illness or due to treat-
ment of their illness. Repeated absences eventually translate to missed instruction, which
in turn contributes to poor academic performance. In addition, prolonged absences may
contribute to a sense of learned helplessness and despair, and have also been found to inter-
fere with coping and the rehabilitative process (Houlahan, 1991). Children with a chronic
illness may also fall behind in their school work due to the symptoms related to their ill-
ness. For example, children with asthma have reported a lack of sleep and concentration
in school due to constant wheezing (Grant et al., 1999). Students with asthma have also
reported lower performance in math, likely due to the sequential nature of the math cur-
riculum, and less participation in school activities (Krenitsky-Korn, 2011). Falling behind
in school and behind fellow classmates can further contribute to negative feelings towards
school (Thies, 1999).
Children with long-term or chronic illness may also experience neuro-cognitive defi-
cits that are associated with the treatment they are receiving. Brown and Madan-Swain
(1993), for example, reviewed the literature concerning the impact of leukemia, and found
a high incidence of neuro-cognitive deficits associated with radiation treatment. Short-
term memory impairment, distractibility, motor speed, and perception were some of the
deficits. The deficits resulted in more special education placements and lower achievement
and performance scores on math and reading tests (Peckham, Meadows, Bartel, & Mar-
rero, 1988; Taylor, Albo, Phelbus, Sachs, & Bierl, 1987). These neuro-cognitive deficits
can affect many aspects of a child’s life, including social relationships, psychological well-
being, behavior, and school performance.
Steward’s Matrix of a Child’s Appraisal of the Experience of Illness

In a previous edition of this book, Steward (2002) separates the effects of illness based on
the severity and visibility of symptoms (see Figure 9.1). Her matrix includes two intersect-
ing dimensions: (a) duration of illness (chronic to acute) and (b) visibility of the symptoms
of the illness or treatment process (invisible to clearly visible). Although she states that
the diseases represented in each quadrant may appear very different from each other, she
highlights that the illnesses have very similar characteristics on these two dimensions.
Children in quadrant #1 experience an illness that is brief but visible. Some examples
of these illnesses include measles, chicken pox, and less severe physical illnesses. Steward
claims that because the symptoms of these children are acute and visible, their recovery
will also be fairly visible to others and therefore these children will have the easiest time
monitoring their healing.
In contrast, children in quadrant #4 have chronic illnesses that have invisible symptoms.
Steward indicates that because these children are not able to see their illness, they often
find their illness confusing and are often faced with more questions from peers about their
ACUTE
Measles Flu
Broken Bone Cold
VISIBLE #1 #2 INVISIBLE
#3 #4
Diabetes
Neuromuscular
Sickle Cell
Cerebral Palsy
Asthma
Spinal Bifida
Cancer
CHRONIC
Figure 9.1 Steward’s Matrix of a child’s appraisal of the experience of illness.
illness. Similarly, because of the invisible symptoms, there is often a decrease in treatment
compliance. Children often cannot tell whether they are getting better and may experi-
ence frustration due to the lack of control of the invisible symptoms. It is also not hard
to imagine the impact “invisible” symptoms may have on other people’s perception. For
example, other children may not be able to understand why a child cannot participate in
an activity or play with others when the child who is ill appears to be completely healthy.
Similarly, parents and school staff may experience difficulty in gauging a child’s health
improvement or medical needs.
Quadrant #2 contains children that have invisible but acute illnesses that last for only
a short period of time. Although Steward states that the effect of invisible symptoms may
be the same as for those in quadrant #4, the fact that the duration of the illness is short
allows a child to easily reintegrate back to his or her “normal” routine.
Steward identified children with visible and chronic conditions as being in quadrant #3.
Children in this quadrant are faced with the task of accepting their condition while also
having to deal with awkward looks and criticisms about their symptoms. They have to
learn to live with their condition and, as their minds and bodies grow and change, they
also have to adapt to these changes and the subsequent changes of the symptoms of their
illness or medication needs.
Illness and Coping

Although an unexpected illness changes the course of a child’s life and his or her family’s
life, successful coping with the illness has been found to bring about resiliency and can be
a learning experience for both the child and family. For example, Jorngarden et al. (2007)
found that although children diagnosed with cancer reported higher levels of depression
symptoms initially, these children reported having lower levels of depression symptoms
at an 18-month follow-up. The results of the study suggest that most children cope with
their illness and are eventually able to overcome their negative feelings about their illness.
Similarly, siblings of children with chronic illness report a greater appreciation for life,
such as being healthy, and have reported better quality of life when compared to their
peers (Havermans et al., 2011). The authors attributed the positive outcomes to the sib-
ling’s already existing personal and social strengths and to the vicarious observation of the
illness by the siblings. Additionally, a recent meta-analysis also revealed that the siblings’
experience of having a sibling who is ill can foster positive outcomes, such as increased
sensitivity and increased personal growth and maturation (Williams et al., 2009).
Positive outcomes have similarly been found for parents of children with illness and
include increased communication, trust, and closeness (Brody & Simmons, 2007; Lavee
& May-Dan, 2003). Parents have reported a strengthened relationship due to the joint
responsibility and mutual support that is required to go through the ordeal of having a
child who is sick. During the illness, parents often depend on each other to take up addi-
tional responsibilities and also rely on each other for encouragement. However, just as for
the child who is ill and the siblings, it is important to note that these positive effects were
reported after successful coping, which is typically a year after the diagnosis.
Crisis Counseling Interventions

Although there have been positive results for those who are able to successfully cope with
illness, crisis counseling may be an important aspect for restoring the child’s ability to
effectively cope with the situation and assisting those around the child to better under-
stand and cope with the reality of the illness. Many children and their peers, teachers, and
parents may benefit from psychoeducation and counseling at a variety of stages during the
course of the illness. But crisis counseling is more likely to be needed during any transi-
tion time, from initial diagnosis, to change in treatment regimen, to change in school (i.e.,
elementary to junior high). As previously indicated, more children than ever before are
attending school with chronic illnesses; therefore the potential need for school personnel,
such as counselors and school psychologists, to provide these services is also greater than
ever. Wodrich and Cunningham (2008) argue that school counselors and school psycholo-
gists, due to their unique responsibilities, are appropriately suited to lead interventions for
children with illness. Therefore they need to be equipped with skills to address the varied
needs of children with illness. School mental health providers also need to recognize that
the services provided to the student with an illness, their peers, teachers, or parents may
vary depending on the illness, the severity, the child’s age or developmental level, and the
resources available. Because each illness is different and each child’s response to an illness
may be different, the role of school psychologists and school counselors is more complex.
School psychologists and counselors need to critically analyze the needs of each individual
student and be aware of the interventions available for an individual with specific health
needs. They may need to be able to offer optimal services in collaboration with nurses,
doctors, or health practitioners and can serve as a liaison between families, the school
system, and health care providers (Wodrich & Cunningham, 2008).
Guidelines for Counseling

Currently little is known about children’s perception of the need for counseling. Most
school-based practitioners rely on a parent’s or teacher’s account regarding the child’s
reactions to the illness and need for counseling (Chesson, Chrisholm, & Zaw, 2004). We
encourage practitioners to exercise caution with this approach and make sure that they
meet the needs of the child. Two other general cautions are offered as they relate to the
overreliance on verbal communication and confidentiality.
Communication Modes. Chesson, Chisholm, and Zaw (2004) highlight the overreliance
of verbal communication in counseling children with chronic illness. According to the
authors, “play and drawing are more natural modes of communication” for children and
should therefore be integrated into the counseling sessions. Drawing and play allow for
open expression of emotions in children who are not able to put their expressions in words
due to their conditions or their maturity. Relying solely on verbal communication may
make a counseling session unappealing and may make a child a less willing participant in
future counseling sessions. In addition to encouraging participation, play and drawing can
also be used to establish good rapport prior to and during counseling sessions.
Confidentiality. Chesson et al. also stress that it is essential that counselors address the
limits of confidentiality often. Although this would be routinely done for any counseling
situation, it is especially important when counseling children with illness. The discus-
sion of confidentiality should not be limited to the first counseling session. It should be
a necessary first step in all counseling sessions. Reiterating this information is important
so that the child fully understands his or her boundaries and limits; it can also prevent
feelings of betrayal in cases where practitioners need to engage in mandated reporting.
While explaining the limits of confidentiality, it is also helpful for practitioners to intro-
duce their role and purpose to prevent any misconceptions about the actual role of the
counselor or therapist.
Behavioral and Cognitive-Behavioral Techniques

Although a variety of theoretical orientations and techniques may be appropriate for use
with children with illness, we highlight a few successful evidence-based interventions based
on theoretical orientation in this section. As with all mental health services, the needs of
the child should dictate the type of service that is provided and the counselor should be
appropriately trained in the evidence-based interventions that he or she provides.
Behavioral and cognitive-behavioral techniques are often used to address problems
experienced by children with illness. Cognitive-behavioral therapy (CBT) has been used
to manage stress, address psychosocial adjustment problems, and teach coping strategies
to children experiencing chronic illness. Studies have shown promising results by using a
CBT approach called self-management. In self-management children are taught how to
seek information about their illness, how to reform their perception about their illness,
and how to monitor their illness and medication (Chiang, Ma, Huang, Tseng, & Hsueh,
2009; Guevara, Wolf, Grum, & Clark, 2003; Last, Stam, Onland-van Nieuwenhuizen, &
Grootenhuis, 2007). By allowing children to take charge and responsibility over matters
related to their illness, children regain more self-control and thereby increase their self-
worth. This technique has been found to decrease physiological symptoms in children,
including signs and symptoms of the disease, and decrease their reliance on medications.
Self-management techniques have also been found to reduce school absenteeism in chil-
dren with asthma (Chiang et al., 2009). During times of illness, feeling helpless about the
condition is a normal experience. Self-management techniques are a great way to boost
self-esteem while also teaching children how to be independent.
Teaching children to use coping strategies is another CBT approach that can be effec-
tively used with children with illness. Coping strategies include relaxation and breath-
ing techniques and positive thinking approaches (Chiang et al., 2009; Last et al., 2007).
Patients who have been taught these techniques reported feeling significantly more relaxed
and reported engaging in positive thinking a few weeks after the intervention. Further-
more, children also reported a higher quality of daily functioning and a higher global
self-worth. In addition, patients also exhibited less behavioral-emotional and internalizing
problems as reported by their parents.
As mentioned early in the chapter, children with illness experience problems with social
functioning as well. Both behavioral and cognitive-behavioral approaches have been used
to address social functioning problems in children diagnosed with varying illness. These
interventions teach children social skills in order for them to be able to adapt to daily liv-
ing and reintegrate back to school more smoothly (Barakat et al., 2003; Die-Trill et al.,
1996; Varni, Katz, Colegrove, & Dolgin, 1993). Social skills interventions for children
with illness focus on teaching skills (such as assertiveness), coping with peer rejection, cop-
ing with bullying, and responding to questions about the illness. Modeling, role playing
with feedback, and reinforcing successful behaviors are typically incorporated with social
skills interventions. Social skills training can be used as an intervention or as a preventive
approach, has been shown to improve social competence, and reduce internalizing and
externalizing behaviors in children with cancer and brain tumors (Barakat et al., 2003;
Varni et al., 1993).
Solution-Focused Therapy
Solution-focused therapy (SFT) has also been used effectively for counseling children with
illness or children with an ill family member. SFT helps children deal with their illness
using techniques that focus on the future (Lethem, 2002). Solution-focused therapy is
successful when used with school-age children to help them increase their self-esteem and
have more positive attitudes and better coping skills (LaFountain & Garner, 1996; New-
some, 2004). These are all characteristics that can help children with illness integrate back
into school faster and more effectively. Additionally, SFT has been linked to increased
grade performance and improved behavior problems in students (Franklin, Moore &
Hopson, 2008; Newsome, 2004), both characteristics that children with illness might
need assistance with.
Art and Play Therapy

Children with illness may also benefit from art and play therapy. Art therapy is a form
of therapy that uses creativity and play as a medium for young children to express their
feelings and experience. In regards to illness, the main goal of art and play therapy is to
reduce anxiety and fear in children. In a pilot study, Favara-Scacco, Smirnee, Schiliro, and
Cataldo (2001) used art therapy to help children develop coping skills to deal with the
painful procedures that are associated with leukemia treatment. In their study, they used
visual imagination, structured drawing, and free drawing. These techniques were used to
help activate alternative thought processes prior to and after a painful procedure. Addi-
tionally, the techniques reduced anxiety by providing a structured activity and reduced
confusion and fears by allowing children to externalize their emotions. In their pilot study,
children who were provided with art therapy exhibited more collaborative behavior and
less anxiety, compared to children who were not provided art therapy. Furthermore, art
therapy was shown to prevent permanent trauma. As mentioned in Chapters 8 and 10, art
therapy can also be used with siblings and parents who have experienced the death of a
loved one due to illness or accident.
Play therapy is similar to art therapy, as it allows children to use a recreational activity
to express their emotions. In regards to childhood illness, puppets and dolls have been used
as materials during play therapy (Li, Lopez, & Lee, 2007; Pelicand, Gagnayre, Sandrin-
Berthon, & Aujoulat, 2006). Particularly, these toys have been used to allow children
to express how they feel about their illness, being hospitalized, and their fears and dif-
ficulties. Therapeutic play uses a cognitive-behavioral approach to engage young children
in activities and play, thereby improving their understanding of their current situation.
Because children with illness often feel a lack of control in their situation, the primary
goal of therapeutic play is to help children regain control, thereby decreasing the level of
stress (Lazarus & Folkman, 1984). Li, Lopez, and Lee (2007) examined these effects with
children undergoing surgery. By using dolls, the authors demonstrated medical procedures
to children so that children would become desensitized to the stressful surgery ahead.
Children who went through the intervention reported fewer negative emotions and lower
levels of anxiety and stress.
Steward’s Model and Intervention

Let us return now to Steward’s model of illness that is based on the severity and visibility
of symptoms (see Figure 9.1; Steward, 2002). Steward states that children from all four
quadrants may benefit from similar interventions; however, she also highlights specific
interventions that may be appropriate in each quadrant.
Because their healing will be fairly visible to others and themselves, children in quad-
rant #1 often do not seek or require a counseling intervention. Similarly, children in
quadrant #2 have invisible symptoms that last for only a short period of time. Due to
the short duration of these illnesses and lack of perceived need for counseling, there is a
lack of research focusing on interventions for children with acute illnesses. Steward sug-
gests that a possible counseling intervention could be to reassure the child of the body’s
ability to heal, which may prevent any long-term anxiety regarding the reoccurrence of
the illness or injury. In addition, children with illnesses or injuries in these quadrants can
also be taught preventive measures. Children in these quadrants are usually able to easily
reintegrate back into their “normal” routine.
Steward identifies children with visible and chronic conditions as being in quadrant #3.
Recall that children in this quadrant are faced with the task of accepting their condition
while also having to deal with awkward looks and criticisms about their symptoms. Chil-
dren in this quadrant are likely to find it difficult to transition back to the school. Cop-
ing interventions may be needed to help children accept and deal with their conditions
appropriately. Individuals in this quadrant may also benefit from peer group intervention
because it creates an opportunity for their peers to learn about their condition and to
learn how to give support.
Children in quadrant #4 have chronic illnesses that have invisible symptoms. Because
there is a decrease of treatment compliance, often in adolescence, children in this quadrant
may benefit from receiving interventions to enhance treatment adherence. Behavioral inter-
ventions to increase treatment adherence typically focus on problem solving, role playing,
and parent training (Bernard & Cohen, 2004; Kahana, Drotar, & Frazier, 2008). Multicom-
ponent interventions, on the other hand, incorporate social support, social skills training,
and educational and behavioral components. One multicomponent intervention includes
the use of an asthma education video game to promote asthma self-management behaviors.
Researchers found that, along with an educational and behavioral approach, the use of
technology showed statistically significant improvement in asthma knowledge and qual-
ity of life (Shames et al., 2004). Additionally, students in quadrant #3 and #4 may benefit
from anticipatory guidance, in which the therapist prepares the student for an anticipated
event or crisis. These events could include changes in medications or treatment regimens,
developmental transitions, or transitions related to schooling (new class, new teacher, new
school, etc.). Anticipatory guidance has been advised by many authors for students and their
parents with many health conditions, including diabetes and epilepsy (Scaramuzza et al.,
2010; Smaldone & Ritholz, 2011; Yu, Lee, Wirrell, Sherman, & Hamiwka, 2008). Teachers
also may benefit from anticipatory guidance in order to prepare for changes in the child.
Peer Group Intervention

Peer interaction plays a large role in a child’s life, especially during adolescence, when there
is less dependence on parents. For this reason, it is also important to include peers, when-
ever possible, in the intervention. Peers may also benefit from psychoeducation and antici-
patory guidance. For example, educating parents and peers about diabetes and teaching
them problem-solving skills, such as conflict resolution and stress management, increased
the overall quality of life for adolescents with diabetes. The intervention improved peers’
knowledge about diabetes and their knowledge about ways to offer support to their friend
who was ill. In addition, the problem-solving skills and education reduced family conflict
(Greco, Pendley, McDonell, & Reeves, 2001).
Transitioning to School
As mentioned before, children with chronic illnesses often return to school. Madan-Swain,
Katz, and LaGory (2004) describe a three-phase model to help children with chronic ill-
ness transition back to school. Phase one involves identifying community supports and
educating peers. Educating peers about the chronic illness prevents fears from students and
potentially prevents peer victimization and bullying from occurring in the school. As part
of phase one, the school, the parents, and/or the child may decide whether school counsel-
ing is necessary for the child. Because each child can react and adjust differently depending
on several other factors, it is important for parents and school staff to offer services based
on individual needs. Phase two is a time to develop instructional support plans, anticipate
psychosocial adjustment issues, and address absenteeism, as necessary. Some students may
continue with a medical treatment plan and have to be absent from school for days and
weeks; it is essential that the school has a plan for how students can potentially make up
missed instruction and assignments. Phase three involves continual hospital-school-family
collaboration and communication.
Referral Options
School-based providers are well aware that children with illness, specifically long-term ill-
ness, are often eligible for special education services under the Individuals with Disabilities
Education Improvement Act of 2004 (IDEA). While not every student with illness will
qualify for special education services, students with illness may qualify for educational
accommodations under Section 504 of the Rehabilitation Act of 1973. Regardless of how
the student with illness qualifies for school-based services, a very specific plan should be
developed before the child returns to school. Students may be eligible to receive individu-
alized educational services to aid them in their academic studies or with needed social,
psychological, physical, or medical support. For some students, this may mean designating
someone to monitor their medication; for others it may mean receiving ongoing counsel-
ing. School-based providers should also be aware of community services that may be
appropriate for the family or student and refer to those agencies, as needed. These may
include illness-specific or general support groups to agencies that offer respite care.
Summer Camps
Counselors may also want to acquaint themselves with the ever-increasing variety of summer
camps to refer children with illness. These camps often serve as an intervention or preventive
measure. At these camps, often for a specific disease, children with illness gather in a place
where they will not be ridiculed for their illness. Furthermore, children can learn about their
illness and the procedures that they may have to go through, which can further prevent long-
term anxiety or stress related to treatments. Wu, Prout, Roberts, Parikshak, and Amylon
(2010) assessed the children who attended a camp for children with cancer as well as their
siblings. Campers reported enjoying the camp and receiving a lot of support from their fel-
low campers. In addition, parents reported improvements in their child’s behaviors and level
of independence. Campers also reported learning new skills to assist them during treatment
and dealing with their cancer. Hunter, Rosnov, Koontz, and Roberts (2006) found similar
results for young children who attended a camp for children diagnosed with diabetes. They
found that the camp improved self-management skills and enhanced self-esteem in the young
campers. They did not find these results with the older campers, suggesting the importance
of early entry to summer camps. Summer camps also offer parents a temporary “break” or
relief from caregiving, which may help prevent psychosocial problems and other problems
associated with caregiving burnout (Meltzer & Johnson, 2004).
Prevention
Psychological/Psychosocial Prevention
Psychological Screening. Given the effect of illness on the psychological well-being of a
child, it is important to conduct screenings at school. Schools offer the opportunity for
large-scale screening of psychological and psychosocial symptoms. Students who are at
risk can be identified and it may help prevent the occurrence of mental health problems,
such as suicide and depression. Although researchers have recommended routine psycho-
logical screening for children with illness (Taylor, Absolom, Snowden, & Eiser, 2011),
there is a very limited body of literature that empirically supports the effectiveness of this
recommendation. One study successfully integrated routine psychological screening at a
cancer survivor clinic and found that one third of the participants reported significant
psychological distress. These survivors’ mental health needs would have gone undetected
without the screening and they would not have received additional mental health services
(Recklitis, O’Leary, & Diller, 2003). Gall, Pagano, Desmond, Perrin, and Murphy (2000)
also examined the utility of psychosocial screening at a school health center. They found
that 12% of their participants qualified for mental health services for emotional or behav-
ioral problems. Two months after screening and appropriate referral for services, the same
adolescents attended and were on time for school more often than they were before the
intervention (Gall, Pagano, Desmond, Perrin, & Murphy, 2000).
Bullying Prevention. Students who are chronically ill or have siblings who are ill are
susceptible to being bullied and teased by their peers in school (Sentenac et. al., 2010). It
is important that students are taught how to handle bullying and teasing appropriately, as
Vreeman and Carroll (2007) report that when children are able to overcome teasing they
become more resilient and report a better quality of life. Antibullying curriculums typically
include role playing and games to expose children to different scenarios related to bully-
ing. Vessey and O’Neil (2010) added additional antibullying supports, such as distributing
information sheets about bullying to parents and school staff to ensure key messages were
reinforced to students and extending the intervention across the entire school year. They
found that students reported being less bothered by teasing and had increased self-concept
as a result of their study. Thus, involving the entire school community is important in
antibullying interventions. Chapter 6 also covers bullying prevention in detail.
Disease Prevention
Disease prevention measures are a matter of public health. Many prevention techniques
have been introduced in the schools to interrupt or reduce the spread of illness. For exam-
ple, many schools have hand sanitizer readily available and there are many signs reminding
students to use soap and water to wash hands in the restrooms. These simple practices
were shown to reduce absenteeism by 49.1% and reduce the occurrence of respiratory
illnesses by 49.7% (Dyer, Shinder, & Shinder, 2000). The use of hand sanitizer has been
found to be the most effective way to prevent infection and increase attendance in school
(Vessey, Sherwood, Warner, & Clark, 2007). Other methods to prevent the spread of respi-
ratory infections include physical barriers such as wearing protective masks and isolating
infected individuals (Jefferson et al., 2007).
Since many chronic illnesses are hereditary, it may be important to conduct prenatal and
other medical screenings to increase early detection (Schrag et al., 2002). For example,
screening for asthma in children from a rural setting revealed that one fourth of the chil-
dren met the diagnosis criteria and these children would not have been diagnosed and
treated had it not been for the screening. The screening reduced the likelihood of a more
severe and harder to treat condition developing in the future (Rodehorst, Wilhelm, &
Stepans, 2006).
Injury Prevention
It has been noted that the leading cause of death in children is injuries caused by accidents.
Many of these accidents can leave permanent scars both physically and psychologically.
These accidents can be prevented by taking extra measures to ensure safety in children.
Injuries can be separated into two types: acute and overuse. Acute injuries are typically
the result of one event. Prevention strategies for acute injuries can range from wearing
proper protective apparel such as helmets and guards, or simply having the proper shoes
for physical activities, thereby preventing falls or sprains. Helmets that meet legislation
standards have been shown to reduce childhood bicycle-related head injuries (MacPherson
& MacArthur, 2002). Although research is limited, helmets can also help prevent sei-
zure-related injury in special populations, such as children with severe epilepsy. Deekollu,
Besag, and Aylett (2005) found that although head injuries were prevented by wearing a
helmet, injuries to the face and scalp continued to occur in children, suggesting the need
for more research in helmet design. Injuries at home can be prevented by increasing the
ability of adult caregivers and parents to anticipate injury and prevent it. Gaines and
Schwebel (2009) found that parenting classes improved the ability of parents to recognize
hazards better than professionals working in day-care or pediatric settings.
Overuse injuries are injuries caused over a period of time. For children who participate in
sports, overuse injuries are the most common (McLeod et al., 2011). McLeod et al. (2011)
conducted a study to examine risk factors for overuse injuries and conclude that sports
rules for children in the schools need modification (Brenner, 2007; McLeod et al., 2011).
Modifications to rules can include playing for a shorter time period or even shortening the
playing distance for sports played on a field or court. The authors also recommend neces-
sary proper conditioning and training before and during a sports season, as it is important
to prepare children’s bodies for physical activity so that they are not overexerted.
Summary
Today more children than ever before are attending, returning, and transitioning back to
school after being diagnosed with an acute or chronic illness or injury. Being diagnosed
with an illness, especially one that is chronic, during childhood can be a stressful time for
students and their families. Children who are ill often experience poorer quality of life as
compared to their healthy peers. However, there are positive outcomes for children who
successfully cope with their illness. Therefore, crisis counseling may be necessary to assist
the child who is ill, as well as his or her family, with coping throughout the course of the
illness, especially at times of transition. Although a variety of counseling approaches may
be appropriate, evidence-based techniques include cognitive-behavioral therapy, solution-
focused therapy, and art and play therapy. Practitioners should also be aware of the need
for transition plans or special education services, or the need to make referrals to providers
outside the school system. Although many illnesses may not be preventable, school-based
psychological service providers may be involved in school-wide screenings for psychologi-
cal well-being and other initiatives related mental or physical health, such as antibullying
campaigns. School-based mental health providers are encouraged to expand their skill set
to include working with children who are ill.
REFERENCES
American Academy of Pediatrics Council on Children with Disabilities. (2005). Care coordination in
the medical home: Integrating health and related systems of care for children with special health
care needs. Pediatrics, 116, 1238–1244.
American Cancer Society. (2012). Cancer facts & figures 2012. Atlanta: American Cancer Society.
Anthony, K. K., Bromberg, M. H., Gil, K. M., & Schanberg, L. E. (2011). Parental perceptions of
child vulnerability and parent stress as predictors of pain and adjustment in children with chronic
arthritis. Children’s Health Care, 40, 53–69.
Armstrong, F., Blumberg, M., & Toledano, S. (1999). Neurobehavioral issues in childhood cancer.
School Psychology Review, 28, 194–203.
Azarnoff, P. (1984). Parents and siblings of pediatric patients. Current Problems in Pediatrics, 14, 1–40.
Barakat, L. P., Hetzke, J. D., Foley, B., Carey, M. E., Gyato, K., & Phillips, P. C. (2003). Evaluation
of a social skills training group intervention with children treated for brain tumors: A pilot study.
Journal of Pediatric Psychology, 28, 299–307.
Bennett, D. S. (1994). Depression among children with chronic medical problems: A meta-analysis.
Journal of Pediatric Psychology, 19(2), 149–169.
Bernard, R. S., & Cohen, L. L. (2004). Increasing adherence to cystic fibrosis treatment: A system-
atic review of behavioral techniques. Pediatric Pulmonology, 37, 8–16.
Blackman, J. A., & Gurka, M. J. (2007). Developmental and behavioral comorbidities of asthma in
children. The Journal of Developmental and Behavioral Pediatrics, 28(2), 92–99.
Boekaerts, M., & Röder, I. (1998). Stress, coping, and adjustment in children with a chronic disease:
A review of the literature. Disability and Rehabilitation, 21, 311–337.
Borrego, L., Cesar, M., Leiria-Pinto, P., & Rosado-Pinto, J. (2005). Prevalence of asthma in a Por-
tuguese countryside town: Repercussions on absenteeism and self-concept. Allergologia et Immu-
nopathologia (Madrid), 33, 93–99.
Brenner J. S. (2007). Overuse injuries, overtraining, and burnout in child adolescent athletes. Pedi-
atrics,119, 1242–1245.
Brody, A. C., & Simmons, L. A. (2007). Family resiliency during childhood cancer: The father’s
perspective. Journal of Pediatric Oncology Nursing, 24, 152–165.
Brown, R. T., Wiener, L., Kupst, M. J., Brennan, T., Behrman, R., Compas, R., . . . Zeltzer, L. (2008).
Single parents of children with chronic illness: An understudied phenomenon. Journal of Pediatric
Psychology, 33(4), 408–421.
Brown, R. T., & Madan-Swain, A. (1993). Cognitive, neuropsychological, and academic sequelae in
children with leukemia. Journal of Learning Disabilities, 26, 74–90.
Chesson, R. A., Chisholm, D., & Zaw, W. (2004). Counseling children with chronic physical illness.
Patient Education and Counseling, 55, 331–338.
Chiang, L. C., Ma, W. F., Huang, J. L., Tseng, L. F, & Hsueh, K. C. (2009). Effect of relaxation-
breathing training on anxiety and asthma signs/symptoms of children with moderate to severe
asthma: A randomized controlled trial. International Journal of Nursing Studies, 46, 1061–1070.
Deekollu, D., Besaga, F. M. C., & Aylett, S. E. (2005). Seizure-related injuries in a group of young
people with epilepsy wearing protective helmets: Incidence, types, and circumstances. Seizure, 14,
347–353.
Die-Trill, M., Bromberg, J., Vally, B., Portales, L. A., San-Feliz, A., & Patenaude, A. F. (1996). Devel-
opment of social skills in boys with brain tumors: A group approach. Journal of Psychosocial
Oncology, 14, 23–41.
Dyer, D. L., Shinder, A., & Shinder, F. (2000). Alcohol-free instant hand sanitizer reduces elementary
school illness absenteeism. Family Medicine Journal, 32, 633–638.
Favara-Scacco, C., Smirnee, G., Schiliro, G., & Cataldo, A. D. (2001). Art therapy as support for
children with leukemia during painful procedures. Medical and Pediatric Oncology, 36, 474–480.
Fleitas, J. (2000). When Jack fell down . . . Jill came tumbling after: Siblings in the web of illness and
disability. The American Journal of Maternal and Child Nursing, 25, 267–273.
Franklin, C., Moore, K., & Hopson, L. (2008). Effectiveness of solution-focused brief therapy in a
school setting. National Association of Social Workers, 30, 15–26.
Gaines, J., & Schwebel, D. (2009). Recognition of home injury risks by novice parents of toddlers.
Accident Analysis and Prevention, 41(5), 1070–1074. doi:10.1016/j.aap.2009.06.010.
Gall, G., Pagano, M. E., Desmond, M. S., Perrin, J. M., & Murphy, J. M. (2000). Utility of psycho-
social screening at a school-based health center. Journal of School Health, 70, 292–298.
Gergen, P. J., Mullally, D. I., & Evans, R. (1988). National survey of prevalence of asthma among
children in the United States, 1976 to 1980. Pediatrics, 81, 1–7.
Gibson, F., Aldiss, S., Horstman, M., Kumpunen, S., & Richardson, A. (2010). Children and young
people’s experiences of cancer care: A qualitative research study using participatory methods.
International Journal of Nursing Studies, 47, 1397–1407.
Goodwin, R. D., Marusic, A., & Hoven, C. W. (2003). Suicide attempts in the United States: The
role of physical illness. Social Science and Medicine, 56, 1783–1788.
Gortmaker, S. L., Perrin, J. M., Weitzman, M., Horner, C. J., Sobol, A. M. (1993). An unexpected
success story: Transition to adulthood in youth with chronic physical health conditions. Journal
of Research on Adolescence, 3, 317–36.
Graff, J. K., & Ault, M. M. (1993). Guidelines for working with students having special health care
needs. Journal of School Health, 68, 335–338.
Grant, E. G., Daugherty, S. R., Moy, J. N., Nelson, S. G., Piorkowski, J. M., & Weiss, K. (1999).
Prevalence and burden of illness for asthma and related symptoms among kindergartners in Chi-
cago public schools. Annals of Allergy, Asthma & Immunology, 83, 113–120.
Greco, P., Pendley, J. S., McDonell, K., & Reeves, G. (2001). A peer group intervention for adoles-
cents with type 1 diabetes and their best friends. Journal of Pediatric Psychology, 26, 485–490.
Guevara, J. P., Wolf, F. M., Grum, C. M., & Clark, N. M. (2003). Effects of educational intervention
for self-management of asthma in children and adolescents: Systematic review and meta-analysis.
British Medical Journal, 326, 1308–1309.
Guyer, B., Freedman, M. A., Strobino, D. M., Sondik, E. J. (2000). Annual summary of vital sta-
tistics: Trends in the health of Americans during the 20th century. Pediatrics, 106, 1307–1317.
Gyulay, J. E. (1975). The forgotten grievers. American Journal of Nursing, 75, 1476–1479.
Hamiwka, L. D., Yu, C. G., Hamiwka, L. A., Sherman, E. M., Anderson, B., & Wirrel, E. (2009).
Are children with epilepsy at greater risk for bullying than their peers? Epilepsy Behavior, 15,
500–505.
Havermans, T., Wuytack, L., Deboel, J., Tijtgat, A., Malfroot, A., Boeck, D., & Proesmans, M.
(2011). Siblings of children with cystic fibrosis: Quality of life and the impact of illness. Child:
Care, Health and Development, 37, 252–260.
Herrmann, D. S., Thurber, J. R., Miles, K., & Gilbert, G. (2011). Childhood leukemia survivors and
their return to school: A literature review, case study, and recommendations. Journal of Applied
School Psychology, 27, 252–275.
Hommel, K. A., Chaney, J. M., Wagner, J. L., White, M. M., Hoff, A. L., & Mullins, L. L. (2003).
Anxiety and depression in older adolescents with long-standing asthma: The role of illness uncer-
tainty. Child Health Care, 32, 51–63.
Houlahan, K. (1991). School reentry program. Journal o Pediatric Oncology Nursing: Official Journal
of the Association of Pediatric Oncology Nurses, 8, 70–71.
Hughes, D., & Kleespies, P. (2001). Suicide in the medically ill. Suicide and Life Threatening Behav-
ior, 31, 48–59.
Hughes, P. M., & Lieberman, S. (1990). Troubled parents: Vulnerability and stress in childhood
cancer. British Journal of Medical Psychology, 63, 53–64.
Hunter, H. L., Rosnov, D. L., Koontz, D., & Roberts, M. C. (2006). Camping programs for chil-
dren with chronic illness as a modality for recreation, treatment, and evaluation: An example of a
mission-based program evaluation of a diabetes camp. Journal of Clinical Psychology in Medical
Settings, 12, 67–80. doi:10.1007/s10880–005–9006–3
Jefferson, T., Foxlee, R., Del Mar, C., Dooley, L., Ferroni, E., Hewak, B., . . . Rivetti, A. (2007).
Physical interventions to interrupt or reduce the spread of respiratory viruses: Systematic review.
British Medical Journal, 336, 77–80.
Jorngarden, A., Mattsson, E., & Essen, L. V. (2007). Health-related quality of life, anxiety and
depression among adolescents and young adults with cancer: A prospective longitudinal study.
European Journal of Cancer, 43, 1952–1958.
Kaffenberger, C. J. (2006). School reentry for students with a chronic illness: A role for professional
school counselors. Professional School Counseling, 9, 223–230.
Kahana, S., Drotar, D., Frazier, T. (2008). Meta-analysis of psychological intervention to promote
adherence to treatment in pediatric chronic health conditions. Journal of Pediatric Psychology,
33, 590–611.
Kliewer, W. (1997). Children’s coping with chronic illness. In S. A. Wolchik & I. N. Sandler (Eds.), Hand-
book of children’s coping: Linking theory and intervention (pp. 275–300). New York: Plenum Press.
Kochanek, K. D., Kirmeyer, S. E., Martin, J. A., Strobino, D. M., & Guyer, B. (2012). Annual sum-
mary of vital statistics: 2009. Pediatrics, 129, 338–348.
Krenitsky-Korn, S. (2011). High school students with asthma: Attitudes about school health, absen-
teeism, and its impact on academic achievement. Pediatric Nursing, 37, 61–69.
LaFountain, R. M., & Garner, N. E. (1996). Solution focused counseling groups: The results are in.
Journal for Specialists in Group Work, 21, 128–143.
Last, B. F., Stam, H., Onland-van Nieuwenhuizen, A., & Grootenhuis, M. A. (2007). Positive effects
of a psycho-educational group intervention for children with a chronic disease: First results.
Patient Education and Counseling, 65, 101–112.
Lavee, Y., & May-Dan, M. (2003). Patterns of change in marital relationships among parents of
children with cancer. Health & Social Work, 28, 255–263.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Lethem, J. (2002). Brief solution focused therapy. Child and Adolescent Mental Health, 7, 189–192.
doi:10.1111/1475–3588.00033
Li, Y., Ji, C. Y., Qin, J., & Zhang, Z. X. (2008). Parental anxiety and quality of life of epileptic
children. Biomedical and Environmental Sciences, 21, 228–232.
Li, H. C. W., Lopez, V., Lee, T. L. I. (2007). Effects of preoperative therapeutic play on outcomes of
school-age children undergoing day surgery. Research in Nursing & Health, 30, 320–332.
Lindstrom, C., Aman, J., & Norberg, A. L. (2009). Increased prevalence of burnout symptoms in
parents of chronically ill children. Acta Paediatrica, 99, 427–432.
Lobato, D., & Kao, B. (2002). Integrated sibling-parent group intervention to improve sibling knowl-
edge and adjustment to chronic illness and disability. Journal of Pediatric Psychology, 27, 711–716.
Lotstein, D. S., McPherson, M., Strickland, B., & Newacheck, P. W. (2005). Transition planning
for youth with special health care needs: Results from the national survey of children with special
health care needs. Pediatrics, 115, 1562–1568.
MacPherson, A. K., & MacArthur, C. (2002). Bicycle helmet legislation: Evidence for effectiveness.
Pediatric Research, 52, 472.
Madan-Swain, A., Katz, E. R., & LaGory, J. (2004). School and social reintegration after a serious
illness or injury. In E. R. Katz (Ed.), Handbook of pediatric psychology in school settings (pp.
637–655). Mahwah, NJ: Lawrence Erlbaum Associates.
Maslow, G. R., Haydon, A., McRee, A., Ford, C. A., & Halpern, C. (2010).Growing up with a
chronic illness: Social success, educational/vocational distress. Journal of Adolescent Health, 49,
206–212.
McDougall, J., King, G., De Wit, D. J., Miller, L. T., Hong, S., Offord, D. R., . . . Meyer, K.
(2004). Chronic physical health conditions and disability among Canadian school-aged children:
A national profile. Disability and Rehabilitation, 26, 35–45.
McKinney, E. S., James, S. R., Murray, S. S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed.).
St. Louis, MO: Saunders.
McLeod, T. C., Decoster, L. C., Loud, K. J., Micheli, L. J., Parker, T., Sandrey, M. A., & White, C.
(2011). National athletic trainer’ association position statement: Prevention of pediatric overuse
injuries. Journal of Athletic Training, 46, 206–220.
Meltzer, L. J., & Johnson, S. B. (2004). Summer camps for chronically ill children: A source of respite
care for mothers. Children’s Health Care, 33, 317–331.
Nabors, L. A., Hoffman, A. R., Ritchy, P. N. (2011). Four illnesses: Lenses for critical topics in child
quality of life research. The Journal of Pediatrics, 158, 529–531.
Newacheck, P. W., & Halfon, N. (1998). Prevalence and impact of disabling chronic conditions in
childhood. American Journal of Public Health, 88, 610–617.
Newacheck, P. W., Park, J., Brindis, C., Biehl, M., & Irwin, J. C. (2004). Trends in private and
public health insurance for adolescents. The Journal of the American Medical Association, 291,
1231–1237.
Newacheck, P. W., Strickland, B., Shonkoff, J. P., Perrin, J. M., McPherson, M., McManus, M., . . .
Arrango, P. (1998). An epidemiologic profile of children with special health care needs. Pediatrics,
102, 117–123.
Newacheck, P. W., & Taylor, W. R. (1992). Childhood chronic illness: prevalence, severity, and
impact. American Journal of Public Health, 82, 364–371.
Newsome, W. S. (2004). Solution-focused brief therapy groupwork with at-risk junior high school
students: Enhancing the bottom line. Research on Social Work Practice, 14, 336–343.
Onatsu-Arvilommi, T., Nurmi, J., & Aunola, K. (1998). Mothers’ and fathers’ wellbeing, parenting
styles, and their children’s cognitive and behavioral strategies at primary school. European Journal
of Psychology in Education, 13, 543–556
Peckham, V. C., Meadows, A. T., Bartel, N., & Marrero, O. (1988). Educational late effects in long-
term survivors of childhood acute lymphocytic leukemia. Pediatrics, 81, 127–133.
Pelicand, J., Gagnayre, R., Sandrin-Berthon, B., & Aujoulat, I. (2006). A therapeutic education
programme for diabetic children: Recreational, creative methods, and use of puppets. Patient
Education and Counseling, 60, 152–163.
Pinquart, M., & Shen, Y. (2011). Depressive symptoms in children and adolescents with chronic
physical illness: An updated meta-analysis. Journal of Pediatric Psychology, 36, 375–384.
Pollack, L. A., Stewart, S. L., Thompson, T. D., & Li, J. (2007). Trends in childhood cancer mortal-
ity—United States, 1990–2004. Morbidity and Mortality Weekly Report, 56, 1257–1261.
Pompili, M., Girardi, P., Tatarelli, G., Angeletti, G., & Tatarelli, R. (2006). Suicide after surgical
treatment in patients with epilepsy: A meta-analytic investigation. Psychological Reports, 98,
323–38.
Public Health Service. (1991). Healthy people 2000: National health promotion and disease preven-
tion objectives. Washington, DC: Department of Human and Health Services, Public Health Service.
Quittner, A. L., & Opipari, L. C. (1994). Differential treatment of siblings: Interview and diary
analyses comparing two family contexts. Child Development, 65, 800–814.
Recklitis C., O’Leary T., & Diller L. (2003). Utility of routine psychological screening in the child-
hood cancer survivor clinic. Journal of Clinical Oncology, 21, 787–792.
Reissland, N. (1983). Cognitive maturity and the experience of fear and pain in the hospital. Social
Science and Medicine, 17, 1389–1395.
Rodehorst, T. K., Wilhelm, S. L., & Stepans, M. B. (2006). Screening for asthma: Results from a rural
cohort. Issues in Comprehensive Pediatric Nursing, 29, 205–224. doi:10.1080/01460860601098575
Sandstorm, M. J., & Schanberg, L. E. (2004). Peer rejection, social behavior, and psychological
adjustment in children with juvenile rheumatic disease. Journal of Pediatric Psychology, 29, 29–34.
Scaramuzza, A. E., De Palma, A., Mameli, C., Spiri, D., Santoro, L., Zuccotti, G. V. (2010). Adoles-
cents with type 1 diabetes and risky behavior. Acta Paediatrica, 99, 1237–1241.
Scheidt, P. C., Harel, Y., Trumble, A. C., Jones, D. H., Overpeck, M. D., & Bijur, P. E. (1995). The
epidemiology of nonfatal injuries among US children and youth. American Journal of Public
Health, 85, 932–938.
Schrag, S. J., Phil, D., Zell, E., Stat, M., Lynfield, R., Roome, A., . . . Schuchat, A. (2002). A
population-based comparison of strategies to prevent early-onset group B streptococcal disease in
neonates. The New England Journal of Medicine, 347(4), 233–239.
Schwartz, L., & Drotar, D. (2006). Posttraumatic stress and related impairment in survivors of
childhood cancer in early adulthood compared to healthy peers. Journal of Pediatric Psychology,
31, 356–366.
Sentenac, M., Gavin, A., Arnaud, C., Molcho, M., Godeau, E., & Gabhainn, S. N. (2010). Victims
of bullying among students with a disability or chronic illness and their peers: A cross-national
study between Ireland and France. Journal of Adolescent Health, 48(5), 461–466. doi:10.1016/j.
jadohealth.2010.07.031
Shames, R. S., Sharek, P., Mayer, M., Robinson, T. N., Hoyte, E. G., Gonzalez-Hensley, F., . . .
Umetsu, D. T. (2004). Effectiveness of a multicomponent self-management program in at-risk,
school-aged children with asthma. Annals of Allergy, Asthma, and Immunology, 92, 611–618.
Sharpe, D., & Rossiter, L. (2002) Siblings of children with a chronic illness: A meta-analysis. Journal
of Pediatric Psychology, 27, 699–710.
Shudy, M., de Almeida, M. L., Ly, S., Landon, C., Groft, S., Jenkins, T. L., & Nicholson, C. E.
(2006). Impact of pediatric critical illness and injury on families: A systematic literature review.
Pediatrics, 118, S203–S218.
Smaldone, A., & Ritholz, M. D. (2011). Perceptions of parenting children with type 1 diabetes
diagnosed in early childhood. Journal of Pediatric Health Care, 25, 87–95.
Stallard, P. (1993). The behavior of 3-year-old children: Prevalence and parental perception of prob-
lem behavior: A research note. Journal of Child Psychology and Psychiatry, 34, 413–421.
Steele, R. G., Dreyer, M. L., & Phipps, S. (2004). Patterns of maternal distress among children with
cancer and their association with child emotional and somatic distress. Journal of Pediatric Psy-
chology, 29, 507–517.
Steward, M. (2002). Illness: A crisis for children. In J. Sandoval (Ed.), Handbook of crisis counsel-
ing, intervention, and prevention in the schools (2nd ed., pp. 183–211). Mahwah, NJ: Erlbaum.
Stuber, M. L., Meeske, K. A., Krull, K. K., Leisenring, W., Stratton, K., Kazak, A. E., . . . Zeltzer, L.
K. (2010). Prevalence and predictors of posttraumatic stress disorder in adult survivors of child-
hood cancer. Pediatrics, 125(5), 1124–1134.
Taylor, H. G., Albo, V. C., Phelbus, C. K., Sachs, B. R., & Bierl, P. G. (1987). Post-irradiation treat-
ment outcomes for children with acute lymphocytic leukemia: Clarification of risks. Journal of
Pediatric Psychology, 12, 395–411.
Taylor, N., Absolom, K., Snowden, J., & Eiser, C. (2011). Need for psychological follow-up among
young adult survivors of childhood cancer. European Journal of Cancer Care, 21, 52–58.
Taylor, S. C. (1980). Siblings need a plan of care too. Pediatric Nursing, 6, 9–13.
Thies, K. (1999). Identifying the educational implications of chronic illness in school children. Jour-
nal of School Health, 69, 392–397.
Thompson, R. J., & Gustafson, K. E. (1996). Adaptation to chronic childhood illness. Washington,
DC: American Psychological Association.
Tsuchie, S. Y., Guerreiro, M. M., Chuang, E., Baccin, C. E., & Montenegro, M. A. (2006). What about
us? Siblings of children with epilepsy. Seizure, 15, 610–614. doi:10.1016/j.seizure.2006.08.007
Vance, Y. H., & Eiser, C. (2002). The school experience of the child with cancer. Health and Devel-
opment, 28, 5–19.
Varni, J. W., Katz, E. R., Colegrove R., & Dolgin, M. (1993). The impact of social skills training
on the adjustment of children with newly diagnosed cancer. Journal of Pediatric Psychology, 18,
751–767.
Vessey, J. A., & O’Neil, K. M. (2010). Helping students with disabilities better address teasing and
bullying situations: A MASNRN study. The Journal of School Nursing, 27, 139–148.
Vessey, J. A., Sherwood, J. J., Warner, D., & Clark, D. (2007). Comparing hand washing to hand
sanitizers in reducing elementary school students’ absenteeism. Pediatric Nursing, 33, 368–372.
Vreeman, R. C., & Carroll, A. E. (2007). A systemic review of school-based interventions to prevent
bullying. Archives of Pediatric and Adolescent Medicine, 161, 78–88.
Wang, W. (2007). Central nervous system complications of sickle cell disease in children: An over-
view. Child Neuropsychology, 13, 103–119.
Weitzman, M., Gortmaker, S. L., Sobol, A. M., & Perrin, J. M. (1992). Recent trends in the prev-
alence and severity of childhood asthma. The Journal of American Medical Association, 268,
2673–2677.
Wickrama, K. A. S., Elder, G. H., & Abraham, W. T. (2007). Rurality and ethnicity in adoles-
cent physical illness: Are children of the growing rural Latino population at excess health risk?
National Rural Health Association, 23(3), 229–237.
Williams, P. D., Ridder, E. L., Setter, R. K., Liebergen, A., Curry, H., Piamjariyakul, U., & Williams,
A. R. (2009). Pediatric chronic illness (cancer, cystic fibrosis) effects on well siblings: Parents’
voices. Issues in Comprehensive Pediatric Nursing, 32, 94–113.
Winthrop, A. L., Brasel, K. J., Stahovic, L., Paulson, J., Schneeberger, B., & Kuhn, E. M. (2005).
Quality of life and functional outcome after pediatric trauma. Journal of Trauma, 58, 468–473.
Wodrich, D. L., & Cunningham, M. M. (2008). School-based tertiary and targeted interventions for
students with chronic medical conditions: examples from type 1 diabetes mellitus and epilepsy.
Psychology in the Schools, 45, 52–62. doi:10.1002/pits.20278
Wu, Y. P., Prout, K., Roberts, M. C., Parikshak, S., & Amylon, M. D. (2010). Assessing experiences
of children who attended a camp for children with cancer and their siblings: A preliminary study.
Child Youth Care Forum, 40, 121–133. doi:10.1007/s10566–010–9123–5.
Yu, C. G., Lee, A., Wirrell, E., Sherman, E. M. S., & Hamiwka, L. (2008). Health behavior in teens
with epilepsy: How do they compare with controls? Epilepsy and Behavior, 13, 90–95.
10 Children of the Disabled, Incarcerated,
or Deployed
Mari Griffiths Irvin, Melissa Keane,
& Jonathan Sandoval
Many children face changes in their family constellation as they grow up. Some of these
changes occur as a result of divorce or separation, as discussed in Chapter 5, and some
from the death of a parent, as discussed in Chapter 8. This chapter examines other cir-
cumstances in which family changes do not result in the permanent loss of a parent, but
nevertheless bring additional stressors into a child’s life. First we will discuss the special
needs of children in families with a disabled parent. Next we will examine the impact of
having a parent incarcerated, and finally we will review the reaction of children of military
or other personnel who are deployed abroad for long periods of time. Although these are
very different circumstances, they have a number of similar hazards in common.
THE DISABLED PARENT

With the passage of the Americans with Disabilities Act, more attention has been given to
the rights of the disabled. Over the past quarter-century discussions of the various needs
of members of the “family with disability” have increasingly been found at professional
conferences and in the literature. School personnel now often take the lead in providing
interventions designed to attend to the specific needs of children adversely affected by a
particular disability in the family.
The needs of many such children remain more hidden, however, as some disabilities
within the family are less visible to school personnel. These children, the children of par-
ents with disabilities, are not a homogeneous group, as the disabilities incurred by their
parents and their family situations are varied. But in each instance the child lives a life in
relationship to a parent who has or parents who have incurred significant impairment. Who
among these children needs supportive intervention?
The purpose of this section is to (a) help the school pupil personnel services practitioner
develop an awareness of this particular population of children; (b) provide preliminary
information about the critical variables that must be considered in the determination of the
needs of these children; and (c) suggest ways in which the school pupil personnel services
staff might better serve these children and their parents.
Who Are Parents with Disabilities?
Types of Disabling Conditions

We most readily associate the term disability with individuals who have a physical anom-
aly or sensory deficit. It is within the life experience of most adults to have had personal
interaction with an individual with significant physical, visual, or hearing deficit. Men-
tal retardation and mental illness are also commonly perceived as disabling conditions,
174 Mari Griffiths Irvin, Melissa Keane, & Jonathan Sandoval
especially when the degree of impairment is sufficient to be readily observable behavior-
ally. Less immediately observable may be those individuals who experience disability as a
result of substance abuse. Individuals whose lives are seriously affected by the use of alco-
hol or drugs may often appear normal to the casual observer, although members of their
immediate families or close work associates are likely to experience the negative effects
of their addiction. Perhaps most invisible to the life experience of the majority of persons
are those individuals whose physical health is seriously impaired through chronic illness.
The invisibility of the illness may be related to one of two conditions. Either the individual
with a chronic illness may be in the early state of a debilitative disease process in which
the individual appears relatively normal, or the chronically ill person may be so impaired
as to be in social contact only with members of the immediate family.
Prevalence
It is probable that every public school serves children who have parents with a variety of
disabling conditions. According to the 2006 American Community Survey, 12% of the 16
to 64 age group is disabled (Brault, 2008). The prevalence is 4.3% for a sensory disabil-
ity, 9.4% for a physical disability, 5.6% for a mental disability, and 2.9% for a self-care
disability (Brault, 2008). It is likely that school instructional, administrative, and support
personnel are not aware of the total number of children attending any given school who
have parents with disabilities. It may be argued that it is not necessary, or perhaps even
desirable, to identify those children who have parents with disabilities unless the behavior
of the children commands the attention of school personnel. However, it is reasonable to
hypothesize that some unidentified children who have parents with disabilities are at-risk
children who will have difficulty learning to their potential in school. Preventive interven-
tions for such children cannot be made unless these children can be identified prior to
“problem referral” for school special services.
Who Are At-Risk Children of Parents with Disabilities?

The professional literature is sparse regarding children of parents with disabilities. The
effects of physical disability and chronic illness upon the individual have had a longer
history of study (Garrett & Levine, 1973; Marinelli & Dell Orto, 1977; Schonz, 1975;
Wright, 1960), and these studies have provided some insight into the variables that must
be considered if the needs of children of parents with disabilities are to be well recognized.
In addition, the study of the ability of the family to cope with the experience of major ill-
ness has been recognized (Eisenberg, Sutkin, & Jansen, 1984; Gallagher & Vietze, 1986;
Hill & Hansen, 1964). Four categories of specific factors related to the family’s ability to
cope are identified by Hill and Hansen (1964): (a) characteristics of the disabling event; (b)
the perceived threat of the disability to family relationships, status, and goals; (c) resources
available to the family; and (d) the past experience of the family in dealing with the same
or similar situation.
The publication of S. Kenneth Thurman’s (1985) Children of Handicapped Parents:
Research and Clinical Perspectives represents a significant contribution to both the prac-
titioner and the researcher in that it explicitly sets forth the complexity of the potential
impact of parental disability in the lives of children. In the Thurman book, Coates,
Vietze, and Gray (1985) discuss the methodological issues specifically involved in the
study of children of disabled parents. The authors present a systematic discussion of the
variables that must be considered in determining the impact of parental condition upon a
given child. This chapter has heuristic value for the school practitioner who is concerned
Children of the Disabled, Incarcerated, or Deployed 175
about children of parents with disabilities both at the problem prevention and problem
resolution levels.
Coates et al. (1985) identify the onset of the disabling condition of the parent (i.e.,
whether the condition is congenital or “adventitious”) as the first question that must be
answered. If the parental disability is not congenital, the time relationship of the disability
and the arrival of the child must then be considered a critical question. Other variables of
importance—type of disability, family status, child status, and family process—assume dif-
fering relationships to each other, dependent on the time of onset of the disabling condition
in the life of the child under consideration.
Significance of Time of Onset of Parental Disability

It may seem obvious that the time of the onset of a disability in the life of an individual
would play a large role in the determination of the personal self-awareness and the manner
in which the person with a disability is able to relate to others and to fulfill social roles.
Individuals who have congenital disabilities develop self-awareness with the impairment
or disability as a “given” in their lives. That is not to say that there may not be grieving
for what might have been. But such individuals have experienced themselves in no other
way and the process of self-development in some way includes the reality of the disability.
Similarly, the significant others in the lives of persons with congenital disabilities have
known the individual in no other way.
The developmental process of persons with congenital disabilities proceeds with the dis-
ability woven into the fabric of the lives of both the person with the disability and persons
of significance. However, the stigma referred to by Goffman (1963) and English (1971)
may serve to transform the impairment or disability into handicap to a greater or lesser
degree. The point here, however, is that the capacity of the person with the disability to
take on the social roles of spouse and parent is “negotiated” with the perceived handicap-
ping condition already present as a part of the “life space” of the involved parties. For per-
sons with congenital disabilities who become parents, the disability and how all involved
parties perceive it operate as independent variables that directly affect both family process
and child outcomes.
In contrast, in the case of noncongenital disabilities, regardless of the time of onset, the
self and significant others experience the disability as an assault, an intrusion to which
there must be coping and adaptation. The loss of function, or continuing loss in the case
of individuals with a degenerative disease, brought about by the disabling condition rep-
resents a type of “death” that needs to be acknowledged and truly grieved if subsequent
optimal living is to occur (Keleman, 1974; Kübler-Ross, 1969; Matson & Brooks, 1974).
The person who has incurred the impairment or disability is not the only individual who
is experiencing loss and needs to grieve. Family members who have strong emotional ties
to the person with the disability, especially when dependency or interdependency of some
type is involved, are likely also to experience traumatic loss (Cole, 1978; Feldman, 1974).
Family members go through a period of emotional turbulence subsequent to the disabling
event as each seeks to accommodate the reality of the personal loss experienced (Shellhase
& Shellhase, 1972). The five-stage developmental sequence (denial, bargaining, anger,
depression, and acceptance) introduced by Kübler-Ross (1969) to characterize personal
reactions of the individual to dying is also applicable to the process each parent must
undergo in dealing with the reality that (s)he is the parent of a child with a disability. This
model may also have utility in understanding the behavior and needs of the child who has
a parent with a disability. Behavior of family members can easily be misinterpreted during
this indefinite period of “coping” (Duncan as cited in Seligman, 1979). Unfortunately, the
needs of family members are often overlooked or ignored as energy is directed towards the
person who is impaired or disabled. This exclusive focus on the person with the disability
is sometimes true even when members of the family unit are involved in the rehabilitative
process (Lindenberg, 1977).
Regretfully, there can be no hard and fast rules to guide school personnel in the determi-
nation of whether a specific parental disability necessarily results in a negative outcome for
a given child. Physical impairment and disability may result from a variety of causes and
always are interactive with the personality dynamics of the individual with the disability
and each member of the affected family. Thus, great care should be taken to avoid stereo-
typed descriptions or prognostic statements about either persons with disabilities or the
significant others in their lives. Nonetheless, the precipitous onset of parental disability is
more likely to have a negative impact upon the child, at least temporarily, until the family
has the opportunity to reorganize itself with the parental disability as a component of the
family’s reality. This is surely a time when school personnel need to demonstrate sensitivity
to the varied and multiple needs of the child and the family.
Significance of Parental Disability Variables

Do specific parental disabilities result in specific outcomes for children, or are children
likely to be affected simply by the fact that they have a disabled parent? This issue was
raised by Campion (1995) in her book entitled Who’s Fit to Be a Parent? Written primar-
ily for a British audience, Campion suggested that inadequate parenting may result from
parental illness and/or disability. The passage of the Children Act 1989 into British law
focused attention on the rights of children as individuals and stressed the responsibilities
that parents have in raising children. Ironically, at about the same time, the Americans
with Disabilities Act was passed in the United States, which underscored the rights of all
individuals regardless of impairment or disability. Earlier, the 1977 White House Confer-
ence on the Handicapped had affirmed the rights of persons with disabilities to assume the
responsibilities of marriage and child-rearing (Proceedings, 1977).
In her analysis of the fitness of parents, Campion differentiated between ideal and actual
conditions regarding parenting fitness and approached the questions she raised with a
social policy focus. Social policy questions about the fitness of parents have also been
addressed through several court decisions in recent years despite the assertion of Coates
et al. (1985) that the research has not adequately dealt with the critical questions regard-
ing child outcomes and parental disability. The professional literature now contains an
increasing number of studies that point to certain outcomes for children based upon a spe-
cific parental disability variable. Bornstein’s (1995) four-volume “handbook” represents a
major contribution to the diversity of issues affecting parenting. His fourth volume includes
extensive chapters on three conditions of parental disability: sensory and physical disability
(Meadow-Orlans, 1995), depression (Field, 1995) and substance abuse (Mayes, 1995).
The growing body of literature on children of parents who abuse alcohol and other drugs
is particularly important because of the large number of children affected by substance
abuse of various kinds and the social policy directed towards substance abuse offenders
including parents (e.g., incarceration). Much of the earlier literature on the topic was pri-
marily descriptive and self-reported with strong and predictable, primarily negative, child
outcome effects. However, more empirical studies have been published in recent years that
acknowledge the complexity of the interaction of the number of variables involved in pre-
dicting outcome effects on children whose parents are substance abusers (Mayes, 1995).
Although the empirical research base is growing on the relationship of parental dis-
ability to child outcome effects (Aldridge, 2006; Buck & Hohmann, 1983; Coates et al.,
1985; Downey & Coyne, 1990; Duvdevany, Moin, & Yahav, 2007; Greer, 1985; New-
man, 2002; Perkins, Holburn, Deaux, Flory, & Vietze, 2002), there continues to be a need
for research that methodologically addresses specific critical parental disability factors.
This need is particularly important because positive outcomes have often been found in
many contexts.
Severity. The severity of the parental disability, the degree to which the parent has inde-
pendent living skills, is likely to affect the child. How the parent with the disability is cared
for and the amount of family energy, both financial and emotional, that must go towards
providing direct care for that family member may have decided implications for the needs
of other family members, particularly children. The severity of the parental disability is
also likely to be related directly to the amount and kind of nurturance that the child is able
to receive from the parent.
Stability. Certain disabling conditions, regardless of the severity of the condition, are
relatively stable throughout the lifetime of the person. That is not to say that the disability
may not have different significance for the person at various times throughout the indi-
vidual’s lifetime; rather, the condition does not itself result in deterioration of function over
time. For example, the individual who loses a leg as the result of an automobile accident
can be contrasted with an individual who has multiple sclerosis (MS). Although both dis-
abilities are for the lifetime of the persons involved, the person with the amputated leg
has incurred a one-time “assault,” whereas the person with MS is likely to experience an
unpredictable disease pattern with episodic loss of various types of physical function and
the possibility of gradual physical deterioration resulting in total or near-total physical
dependency. The person who has lost a leg has incurred a sudden loss for which there has
not been an opportunity to prepare. However, the rehabilitative task is usually one with
good prognosis as the disability is not degenerative. In contrast, the person with MS is
likely to experience continual adjustment and readjustment to the physical losses result-
ing from a characteristically erratic disease process. It seems likely that children growing
up in families with a parent whose disability results in the experience of periodic, major
negative changes or gradual deterioration of function might be living in a more stressful
home environment than children who grow up in families wherein the parental disability
is the result of a onetime event.
Such children will need support in school, particularly during times of disruption, but
school personnel need also to be aware that the child who is experiencing the slow death
of a parent may be undergoing a continuous grieving process over a period of months or
even years. In such a situation, the child is likely to experience many “little deaths” as the
disease process continues and the limitations of the parent with their attendant implica-
tions for child-parent interaction become more global. The actual death of such a parent
may at last provide closure for the child, so that the grieving can be completed.
Similarly, the spouse of a person with a debilitating disease will be experiencing a series
of losses as well as increases in family responsibilities that may also involve negative eco-
nomic changes. It is possible that some of the priorities of school personnel may become
less urgent in such a family situation given this increase in parental responsibility and the
very real limitations of parental time and energy. What may appear to be lack of parental
concern in response to a given perceived need of the child by school personnel may be, in
reality, a reflection of the cumulative effects of parental stress. Sensitivity to the less appar-
ent, more subtle variables operating upon the family experiencing a parental debilitative
disease process may be a major contribution to the ability of a family to cope with its
various problems and stresses.
Chronicity. Related to the stability variable in conditions involving parental disabil-
ity is chronicity—that is, how long has the parent been disabled and for how long is it
anticipated that the parent will be disabled. Some conditions involving disability are “for-
ever,” but some “forevers” are longer than others. For example, the life expectancy for
individuals with major diseases may vary from a few weeks to several decades. Support
may be more available for individuals in “acute” rather than “chronic” situations because
of the ability and willingness of many individuals to respond to “emergencies” that require
an immediate and focused response.
Less energy may be available for the sustained support both of the family member with
the disability and other members of the family if there is no immediate resolution of the
problem. Thus, it is probable that the effects of parental disability in the lives of children
may vary based upon the length of time the parent is afflicted with the disability. School
personnel should not, however, make any assumptions about the specific effects of this
time variable upon a given child or family; rather, each instance needs to be reviewed
carefully with attention given both to the child’s various needs and to sources of ongoing
support available to the child and the family.
Involved Processes. What functions of the individual are affected by the disability? Is
the person primarily restricted in physical movement but mental processing remains unim-
paired? Is cognitive processing affected? Is the primary condition a mental illness or are
emotional responses such as depression secondary to a physical disease or disability? Does
the disability result in mood changes or volatile behavior on the part of the affected indi-
vidual? Answers to these questions may have definite implications for the risk status of
children whose parents experience disabling conditions.
Visibility. How visible, literally, is the disability? The degree of impairment resulting
from some disabilities is signaled by a commonly understood aid (e.g., white cane or
wheelchair). In contrast, some individuals with disabilities use supports that alert the
observer to a problem but provide much less information about the extent of the person’s
condition (e.g., a hearing aid). It is difficult to state globally whether the visibility of a
person’s disability serves to help or hinder interpersonal relationships. The visibility of the
disability, on one hand, may serve as a stigma in that it alerts observers to the differences
between such individuals and so-called normal persons. As such, the individual with the
disability may experience stereotypic behavior as relational responses from persons. On
the other hand, the visibility of the disability may prevent misinterpretation of certain
behaviors. As an example, a person with MS who is experiencing problems with balance
while walking might be perceived as intoxicated or on drugs by unaware observers.
Societal Acceptance. Because of the stigma that may be assigned to disability and impair-
ment (Goffman, 1963), it is probable that the person with a disability will experience ques-
tioning of self-worth subsequent to the awareness of the disabling condition. “Depression,
self-blame and self-hatred, blocked motivation, slowed behavior or pathological compen-
satory activity, and difficulties progressing on the rehabilitation program and in commu-
nity adjustment—these are all concomitants of feelings of low worth” (Geis, 1977, p. 131).
Thus, it is possible that the primary variable for children whose parents have disabilities, at
least for those with adventitious disabilities, relates to living in a family that is struggling
with the emotional sequella of the experience of the disability.
In addition, some disabling conditions are more readily acceptable societally. For example,
an individual impaired by heart disease is usually afforded more understanding and accep-
tance than an individual who is battling AIDS or recovering from an accidental overdose
of an illegal addictive substance. It is possible that the type of disability experienced by the
parent will have implications for the sensitivity of the school community to the child’s needs,
but it is difficult to predict whether more or less support will be afforded the child depen-
dent on the values placed on the parental disability. The existing perception of the child by
the teacher may be a critical variable in determining the degree of support given the child.
Particularly vulnerable, then, may be the child whose behavior is already disturbing to the
teacher. Conversely, knowledge of the parental condition may be useful to the teacher in
understanding the problematic behavior of a child. Clearly, in each instance of a child whose
parent experiences disability, school personnel should accept the child’s needs for in-school
support independent of their evaluation of the condition of the parent with the disability.
Family Status Variables

Family status variables, background information about the family, are assumed to contrib-
ute to child outcome behavior. The answers to specific contextual family questions can be
helpful in ascertaining the diverse needs of family members, especially children. Does the
child have two parents or is the parent with the disability a “single parent”? If the child
lives within an extended family unit, does this family pattern represent internal family sup-
port or is it an additional source of stress? Does the family have external support through
close friends or religious affiliation? Does the community in which the family lives provide
support to the family through the provision of needed medical or social services? Is the
economic status of the family stable? Have roles within the family changed as the result of
parental disability; are roles presently stable, or does the nature of the disability result in
ongoing change in role function that must continuously be assimilated by family members?
Child Status Variables

The assumption should not be made that all children in a family with a parent who has
a disability will experience similar effects. In such families, the age and birth order of
children may be critical variables in assessing the impact of the effect of the disabling
condition upon a given child. The gender of the parent with the disability, particularly
in combination with the gender and age of the child, may also have a differential effect.
Child status variables may be particularly important when the onset of the disabling condi-
tion is adventitious, when the disability serves as an unwelcome intrusion in the family’s
developmental pattern.
Family Process Variables

Coates et al. (1985) summarized family process or interaction variables as falling into three
general categories: (a) power-decision-making style, (b) communication, and (c) problem-
solving effectiveness. Again, the time of disability onset, congenital or adventitious, tends
to determine whether independent or dependent variable status is assigned to the parental
disabling condition in relation to these processes and the effects of the disabling condition
on the child.
Role of School Pupil Personnel Services Staff

Specifically, what can and should be done in schools for at-risk children of parents with
disabilities? Who should provide those services?
Use of a Team Model

Perhaps the best vehicle for potential use in identifying at-risk children of parents with
disabilities is the multidisciplinary team (MDT). Since the passage of Public Law 94–142
and its mandate of the team approach to the identification of children with disabilities,
MDTs have assumed a primary coordinational responsibility in schools for the identifica-
tion of children with special needs. Although the literature points to limitations in team
effectiveness (Abelson & Woodman, 1983; Yosida, 1983), it can be argued that some of
the difficulties experienced in using the team model are a function of the relative skill of
team members in using a collaborative process for problem identification and resolution.
The model offers considerable potential for usage beyond that of decision making for
children with disabilities.
Pfeiffer and Tittler (1983) have presented a model of team functioning based on a family
systems orientation. This model appears to have particular utility in serving children of
parents with disabilities in that it assumes that school and family are “intimately inter-
related and reciprocally influential” (p. 168). The determination of risk status of any
given child whose parents have disabling conditions cannot be done by relying on existing
research outcomes, but there is ample evidence of critical variables that need to be con-
sidered. This exploration can be done only if school personnel and family members are
able to share information systematically. A school-family systems orientation is needed to
provide for the generation of the kind of data needed to make appropriate child-specific
recommendations for children of parents with disabilities.
Identification of At-Risk Children

A twofold approach is recommended for the determination of at-risk children of parents
with disabilities—specific child referral and school screening.
Specific Child Referral. Follow-up to each child problem referral to the MDT should
include sufficient family and health information to determine whether either of the child’s
parents or immediate caregivers does, in fact, experience impairment or disability. This
task may not be as easy as it may appear, given the variety of conditions, some more invis-
ible than others, that may constitute a parental disability. School personnel who have had
contact with the family over time should be interviewed, and the contact with the family
subsequent to the referral of the child should be made by personnel who are sensitive to
the presence of disabling conditions in families. Pfeiffer and Tittler (1983) recommend
that the focus of any formal assessment should extend beyond the child and include data
regarding the family. Ideally the involvement with the family should begin before the time
of a “problem referral” on a child.
School Screening. When screening occurs in a school, for whatever purpose, the inten-
tion is to identify those students for whom preventive intervention may be appropriate.
Thus, it is hoped that the number of problem referrals can be reduced or, more ideally,
eliminated. The objective is to prevent times of school crisis by anticipating need rather
than reacting to it. In such a model, data are gathered on all children so that a determi-
nation might be made as to which children are in need of more extensive follow-up and
services. A “family interview” would be one means by which such screening could occur to
identify children of parents with disabilities. The child’s first teacher within a given school
system could be a primary person in arranging for such a home or school contact. The
logistics of an every-child family interview are significant, given contemporary working
patterns both of parents and school professionals. It is unrealistic to expect that such an
opportunity for interaction between family and school representatives will occur without
the use of released time specifically designated for such a purpose. Only those administra-
tors who regard the use of time for this purpose as a long-term investment in successful
child outcomes are likely to implement such an approach.
A second, less ideal approach to screening for the purposes of identifying children of
parents with disabilities would be to include some critical questions about the family in the
data-gathering done by the school for other purposes, such as vision and hearing screen-
ing. The disadvantage to this approach is that it relies heavily on “hearsay” information
and does not necessarily include the interviewer as an observer. However, even limited data
gathered in such a way, if reliable, would afford the opportunity to determine whether
additional involvement with the family is warranted for the purposes of identifying at-risk
children of parents with disabilities.
What Next? Gathering data on families about the possible presence of a parent with a
disability in the family unit should not be seen as an end unto itself. The mere fact that a
child has a parent with a disabling condition does not necessarily warrant atypical services
by the school district to that family or to the child. Rather, it is one “bit” of data that must
be integrated with other known information about the child and then used for decision
making in determining “appropriate” educational services for that child.
Intervention Strategies
Prevention of Crisis Situations

Sandoval (Chapter 1, this volume) identifies several strategies that can be used in schools
to prevent crises. One of them, anticipatory guidance, has much possibility for use with
children of parents with disabilities. Such guidance provides the opportunity for chil-
dren to prepare for events that are likely to occur in their future. School personnel,
especially if working together with family members, can help a given child, on a child-
specific basis, prepare for events and situations that have the potential for disruption
for the child. Similarly, teachers who work regularly with the child can be provided
information so that they might also prepare for specific changes in the child’s life. If,
for example, school personnel can be alerted to the absence of a parent from the home
for an extended period of rehabilitation, school personnel can help the child deal with
this event both factually and emotionally. The focus in such guidance is to provide the
child with the emotional resources needed to cope well with the necessary life changes
that are occurring for the large part outside of the child’s control. Such guidance can be
more easily provided when there is a collaborative school-home relationship. However,
some parental disabling conditions do not as easily lend themselves to such collabora-
tion. If both parents are addicted to alcohol, for example, the child cannot depend on the
parents to work collaboratively with school personnel, as denial may be a component
of their disease process. In such instances, school personnel may need to work directly
and only with the child, to the degree that the parents will support such involvement.
Similarly, when the parental disabling condition involves the possibility of child abuse
and child protective services need to be involved, school personnel will be limited in their
choices. However, in most situations throughout the period of the child’s public school
enrollment, parents have the right to be advised, even if they need not consent, before
supportive services can be provided to the child.
The Developmental Variable

Generally speaking, the younger the child the more probable that significant others will
be needed to provide support. The provider of support services to the child needs to
attend carefully to the child’s level of understanding of the parental disability. What feel-
ings are elicited by this experience? How are they different, if they are, from the feelings
expressed by other children of comparable chronological age in regard to their parents? Is
the child developmentally ready to relate to other children in a group situation designed to
strengthen coping skills? How much “information” can the child handle about the paren-
tal disability? Persons who work with the children of persons with disabilities need to be
sensitive to the ways in which the child receives information about the disability. It is quite
possible that the individual child is experiencing difficulty in decoding parental behavior.
One cannot assume that the child has specific information about the parent’s impairment.
Often children in the family are “protected” from knowledge about the parental disability.
Even when the condition is signaled in some visible manner, the child may not have the life
experiences to enable appropriate interpretation. When the behavior of a child of a par-
ent with a disability suggests that the child is receiving mixed messages about the parental
disability or when the child gives evidence of confusion or concern about the parental
condition, school personnel may find it helpful to discuss this matter explicitly with one or
both of the parents. It is possible that the parents may not be aware of the child’s particular
understanding of the situation.
It is also possible that the parents may need help in deciding what the child should be
told or how to discuss with the child what may be a particularly painful topic for them.
Again, no assumptions that are not checked out carefully should be made about the feel-
ings or the needs of the parents in this matter. Rather, school personnel should attempt to
work as supportive partners with the parents in the process of helping the child acquire
the information, as emotionally loaded as it is, about the parental disability appropriate
for the child’s developmental level. In addition, school personnel may be able to serve as
resources to the child as the child makes decisions about what or how to share information
about the parental condition with friends.
Support for the Supporters

A parental disabling condition is usually a long-term experience in the lives of children. The
passage of time does result in changes within the family unit, many of which may reflect the
adaptation and adjustment that alleviate certain types of stress. But it is possible that family
helpers may need their own support resources to enable them to continue to work well with
persons undergoing a chronic type of stressful condition. When energy is put into helping
people deal with crisis, there may be an expectation, recognized or not, that change will
occur in a relatively short period of time. The problems affecting many families with parents
who experience disabling conditions tend to be slow to resolve in a satisfactory manner.
Teachers who work for a limited period of time, usually one academic year, with a given
child may be able to receive adequate support from the school pupil personnel services
staff, support that will enable them to work productively with a child and parents who are
experiencing significant difficulty related to parental disability. But school pupil person-
nel services staff may find themselves working for several years with a given family that
is experiencing chronic stress related to parental disability. It may indeed be a frustrating
and painful experience to “watch” a family struggle with the ongoing effects of disability
over time. Such school staff need to be particularly aware of the possibility of “blaming
the victim” for lack of satisfactory resolution of difficult problems. Staff support groups
may be one vehicle for the “working through” of issues related to serving as providers of
services to families experiencing chronic and difficult problems related to parental ability.
Summary
As society has recognized the number of children affected by similar adverse conditions, it
has designed interventions to attend to the needs of these children. The needs of other chil-
dren, however, remain more hidden because the source of their stress is not as apparent.
One such group of children are those who have parents with disabilities. Although not a
homogeneous group, many of these children experience significant loss or distortion of
parenting care as the result of the disability incurred by one or both of their parents. School
pupil personnel services staff are encouraged to work with teachers and administrators
in the identification of families incurring stress as the result of parental disability. Inter-
ventions should be designed for such children and families that will provide for ongoing
support. School personnel need to be sensitive to their own needs in working with families
whose problem situations continue over time.
Parents with disabilities may be less available physically or emotionally for their chil-
dren at times, but they are typically physically present when not in treatment or hospital-
ized. The next two sections discuss situations in which one or sometimes both parents are
physically absent for a period of time.
INCARCERATED PARENTS
The following is a quote from Araya, a teen girl whose father is incarcerated: “When they
do time we also do time. Just because we’re not in there doesn’t mean we don’t do time.
Because you’re not with us, we also do time” (Allard & Greene, 2011). This observation
demonstrates that parental incarceration can have extreme, detrimental effects on the chil-
dren of the absent parents. This section provides a broad overview of (a) the prevalence
of children with incarcerated parents, (b) the implications of having an incarcerated par-
ent, (c) subsequent risk factors, (d) protective factors, and (e) the recommendations and
interventions available to support affected children. The purpose of this section is to help
prepare professionals to support students effectively in times of crisis related to parental
incarceration.
Prevalence
As reported by Poehlmann, Dallaire, Loper, and Shear (2010), nearly 1.7 million children
had a parent in state or federal prison in the United States in 2007, and it is estimated that
millions of additional children have at least one parent in jail. Nearly one quarter of these
children are age four or younger, and more than a third will become adults while their
parent remains behind bars. African American children are seven times more likely and
Latino children are two-and-a-half times more likely to have a parent in prison than White
children (Allard & Greene, 2011). The estimated risk of parental imprisonment for White
children by the age of 14 is one in 25, while for Black children it is one in four by the same
age. Most of these children reside in low-income homes, with about half of incarcerated
parents reporting a monthly income of less than $1,000 prior to arrest (La Vigne, Davies,
& Brazzell, 2008).
Implications of Parental Incarceration

Children are likely to experience dramatic disruption in their lives following the incarcera-
tion of a parent. La Vigne et al. (2008) categorize the experiences that children encounter
into three groups: changes in living arrangements, changes in parent-child relationships, and
changes in financial circumstances. Though children of incarcerated fathers are typically
placed with their mothers and often will not experience a significant change in their living
situation, children of incarcerated mothers tend to have more varied and uncertain living
arrangements. Most do not live with their fathers and instead reside in the care of grandpar-
ents, other relatives, or friends. According to Katz (1998, as cited in La Vigne et al., 2008,
p. 4), new caregivers often assume responsibility for the child with little information about
how long the parent will be away and with limited resources needed to address possible trau-
mas experienced by the child due to his or her parent’s incarceration. Although the actions
of those around children of incarcerated parents reinforce the message that the situation is
temporary, research suggests that permanent change is likely (La Vigne et al., 2008).
Parental incarceration may also result in changes to the parent-child relationship. Most
incarcerated parents reside over 100 miles away from their children, making visits time-
consuming, expensive, and difficult to coordinate (La Vigne et al., 2008). According to
Hairston (1998, as cited in La Vigne et al., 2008), long-distance phone calls may be pro-
hibitive, as it is much more expensive to place calls within a prison than outside. In addi-
tion to financial barriers, many of the policies and procedures designed to promote safety
within the prison discourage visits. Visitors often feel intimidated or uncomfortable. Care-
givers may also have negative relationships with the incarcerated parent, which provides a
strong disincentive for facilitating visits for the child. Furthermore, parents may not want
their child to visit them in prison out of shame or fear that seeing them behind bars would
be upsetting to the child. Ultimately, over half of incarcerated parents do not receive any
visits from their children during their sentence. Parents incarcerated before or soon after
the birth of their child may not see their child until after the critical period for attachment
has already ended (as cited in La Vigne et al., 2008, p. 5).
Finally, children with an incarcerated parent will likely experience greater financial
hardship than other children (La Vigne et al., 2008). Incarcerated parents cannot provide
the level of financial support they offered prior to their arrest. As a result, nonresident
fathers who paid child support before their arrest cannot afford child care payments while
in prison. Children may also lose the support of welfare funds from parents who were
unemployed prior to incarceration, as welfare funds are often difficult to transfer to a new
caregiver (Hairston, 1998, as cited in La Vigne et al., 2008, p. 6).
Risks
Related to the implications discussed earlier, children of incarcerated parents are subject
to many risks, including, but not limited to: internalizing and externalizing behavior prob-
lems, substance abuse, truancy, school failure, adult offending and incarceration, increased
likelihood of unemployment, and serious mental health problems (Aaron & Dallaire,
2010). In fact, children with at least one incarcerated parent are two times more likely to
develop mental health problems than the general population. They are at particular risk
of antisocial behavior (Murray, Farrington, & Sekol, 2012). Affected children also often
experience additional risks in their environments such as parental substance abuse, family
victimization, and family conflict.
It is currently unclear whether parental incarceration is the cause of children’s problematic
outcomes or solely a risk marker (Johnson & Easterling, 2012). The existing large-scale
longitudinal studies focusing on children of incarcerated parents have relied on secondary
analyses of data that were not collected for the purpose of assessing the potential effects
of parental incarceration on children (Aaron & Dallaire, 2010). Therefore, they convey
little about developmental, familial, or contextual processes linking parental incarceration
with children’s outcomes. Many smaller-scale studies have begun to shed light on such
processes. However, many of the studies have methodological limitations such as small
sample sizes, cross-sectional designs, and lack of comparison groups (Aaron & Dallaire,
2010; Johnson & Easterling, 2012).
Aaron and Dallaire (2010) examined an archival dataset, in which children aged 10–14
years and their parents/guardians reported children’s risk experiences (e.g., exposure to
poverty, parental substance use), family processes (e.g., level of family victimization,
family conflict), and children’s delinquent behaviors at two time points. Parents also
reported their recent and past incarceration history. Their study examined the effects
of having a family history of parental incarceration on family processes and children’s
delinquency, over and above the effects of other factors, and the effects of recent paren-
tal incarceration on family processes and children’s delinquency after accounting for
previous parental incarceration. They found that a history of parental incarceration
predicted children’s delinquent behavior, family victimization, and sibling delinquency.
However, once family victimization and sibling delinquency were added to the predic-
tion equation, a history of parental incarceration no longer predicted children’s delin-
quent behaviors. They also found that children who had experienced the incarceration
of a parent in the last 2 years were more likely than their peers to report family conflict,
and their parents were more likely to report experiences of family victimization. This
association remained significant after taking into account the effects of demographic
characteristics, children’s cumulative risk experience, and previous parental incarcera-
tion. In addition, they found that recently incarcerated parents reported their children
as more delinquent, even after accounting for effects of exposure to risk and previous
parental incarceration. However, once family conflict and victimization were added to
the prediction equation, recent parental incarceration no longer predicted children’s
delinquency. The implications of these findings are discussed later in this section under
the “Interventions” subheading.
Murray and Farrington (2008) also reviewed the effects of parental incarceration on
children. They drew from qualitative research to identify specific “mediating factors” that
might cause adverse outcomes in later years for the children of incarcerated parents. They
point to a number of theories that might help to explain how parental imprisonment can
increase the likelihood of antisocial or criminal behavior in children. The following is a list
of these theories along with brief summaries:
• Trauma Theories. The trauma of parent-child separation could disrupt a child’s ability
to form attachment relationships, producing feelings of insecurity and sadness. If chil-
dren are lied to or misled about the source of separation, they may blame themselves.
• Modeling and Social Learning Theories. Children may tend to imitate their parents’
antisocial behaviors by engaging in delinquent acts, or by developing hostile attitudes
towards police and other authority figures.
• Strain Theories. Loss of economic and social capital, lowered family income, and
expenses for visitation, phone calls, and money sent to the imprisoned parent could
produce poverty, a factor strongly associated with criminal behavior.
• Stigma and Labeling Theories. Social stigma, bullying, and teasing, as well as biased
treatment by others, could lead to a higher risk of being arrested or convicted for
criminal behavior.
Murray and Farrington (2008) argue that there is little high-quality evidence as to why
parental incarceration might cause adverse outcomes for children. They believe that future
studies should investigate whether mechanisms that are theoretically plausible, such as the
ones just listed and summarized, mediate the effects.
Allard and Greene (2011), researchers for Justice Strategies, a nonpartisan, nonprofit
research organization, compiled a report titled “Children on the Outside,” based on 18
structured interviews from approximately 80 people. Participants included children of
incarcerated parents, parents currently behind bars, caregivers, and caseworkers and
counselors who work in programs to assist parents reentering society after prison terms.
They were recruited from eight, 2-hour focus groups in New York and Alabama. Qualita-
tive analysis concluded the following:
• The sudden removal of a parent from daily life fundamentally undermines a child’s
sense of stability and safety.
• Parental incarceration impacts the economic circumstances of children and the ex-
tended family.
• Parental incarceration presents significant obstacles to a child’s experience of the kind
of unconditional bond with parents needed to lay the foundation for a stable adult
life.
• Once the parental presence is removed, many young people have trouble trusting oth-
ers and letting caring adults into their lives.
• Children typically experience parental incarceration as a form of rejection; they see
the parent’s reckless behavior as having taken precedence over their family.
In view of their findings, Allard and Greene (2011) compiled a set of recommendations for
those working with or caring for children of incarcerated parents. These recommendations
are summarized later in this section under the “Recommendations” subheading.
Protective Factors
Although children with incarcerated parents are subject to many risks, there are individu-
als who, despite these risks, thrive; they grow up to live happy and productive lives. The
closeness of the parent-child relationship before incarceration will likely determine how
well a child copes with the loss once the parent is arrested (La Vigne et al., 2008). Losing
a parent to whom one is closely attached will likely produce more disruption and sadness
than losing an absentee parent. A positive parent-child relationship also increases the like-
lihood of communication during the period of incarceration (Bloom & Steinhart, 1993,
as cited by La Vigne et al., 2008, p. 10). Research suggests that maintaining contact with
one’s incarcerated parent is one of the most effective ways to improve a child’s emotional
response to the incarceration and reduce the incidence of problematic behavior (La Vigne
et al., 2008). Children who maintain contact with their parent during incarceration exhibit
fewer disruptive and anxious behaviors (Sack & Seidler, 1978, as cited in La Vigne et al.,
2008, p. 10). Contact has also been linked to lowered recidivism rates and more positive
interactions between children and their parents once the parent has left prison (Edin et al.,
2004; Sampson & Laub, 1993; Uggen, Manza, & Behrens, 2004, as cited in La Vigne
et al., 2008, p. 10).
Strong relationships with primary caregivers, family members, friends, and other mem-
bers of the community can also support children as they try to process and cope with their
parent’s incarceration (La Vigne et al., 2008). These relationships are especially impor-
tant for children who are unable to maintain a relationship with the incarcerated parent.
Research suggests that close relationships with extended family members may ease the
trauma of incarceration and mitigate the associated negative effects, particularly if the
children lived with those family members before their parent’s incarceration (Bloom &
Steinhart, 1993, as cited in La Vigne et al., 2008, p. 11).
Children of incarcerated parents may also get support through mentoring programs (La
Vigne et al., 2008). Although no studies have specifically examined the impact of mentor-
ing programs on children with incarcerated parents, research has found that mentoring
in general leads to significant improvements in the academic performance, social behav-
ior, relationships, and decision-making skills of a range of at-risk children (Grossman
& Garry, 1997, as cited in La Vigne et al., 2008, p. 12). For example, one study found
that when compared to controls, children who participated in the Big Brothers/Big Sisters
mentoring program were significantly less likely to initiate drug use or consume alcohol or
skip school. These children also reported more feelings of competence about schoolwork.
Intervention
Allard and Greene (2011) suggest nurturing children’s sense of stability and safety by (a)
providing educational workshops to student bodies about the impact of incarceration
on children, families, and communities within the school system; (b) training child care
workers, elementary and high school teachers, and counselors to recognize and address the
far-reaching implications of parental incarceration on their pupils when it manifests within
the school setting; and (c) keeping siblings together, whenever possible, or maintaining
regular contacts when parents are imprisoned. In addition, they recommended supporting
children’s sense of connectedness and worthiness by (a) launching public education cam-
paigns in schools, churches, and community centers across the country to combat stigma-
tization, and (b) providing specialized support groups and therapists to aid children and
youth, caregivers, and parents in tackling the emotional and psychological trauma arising
from parental incarceration. Also recommended was facilitating children’s attachment and
ability to trust by offering workshops and handouts to relative and nonrelative caregivers,
and adults who work with youth, on how to give honest, age-appropriate information to
children about where their parents are, why they are there, and what to expect when they
return home. Finally, Allard and Greene (2011) recommend fostering children’s sense of
having a place in the world by providing supportive counseling for children of incarcerated
parents to help them cope with the psychological and emotional impact of experiencing
the separation from the parent, adapting to new living conditions, and adjusting to the
parent’s return home.
In light of their findings (as discussed earlier), Aaron and Dallaire (2010) suggest that
programs aimed at preventing or lessening the delinquency of children affected by paren-
tal incarceration should attempt to involve other members of the family. They specifically
recommended Families and Schools Together (FAST), a program in which families attend
weekly support groups, participate in structured activities, and meet regularly with their
children’s teachers. FAST programs are available for purchase at familiesandschools.org
and include:
• Complete on-site team training and team/site certification

• Site visits and support by trainer
• All manuals and forms
• Activity components
• Pre- and postsurveys for first cycle
• Evaluation report for proof of effectiveness
• Initial and ongoing technical support
• Recruitment and PR collateral
• Customer satisfaction guarantee
• FASTWORKS membership
FAST is considered a universal prevention program that targets the family and school
domains. It uses developmentally sound approaches to help bolster family functioning and
reduce risk factors such as school failure, violence, delinquency, substance abuse, and fam-
ily stress (as cited in Crozier, Rokutani, Russett, Godwin, & Banks, 2010). FAST has been
credited with meeting the needs of all socioeconomic, racial, and geographical groups,
making it a successful universal program. In addition, different FAST curricula have been
developed to meet the needs of specific target populations, including: Baby FAST, Pre-K
FAST, Kids FAST, Middle School FAST, and Teen FAST. Literature detailing the program
structure, operational framework, and real-world implications for the FAST program is
widely available. In addition, a number of empirical studies have investigated outcomes
for the implementation of FAST programs within individual schools and have evidenced
its effectiveness (as cited in Crozier et al., 2010).
Summary
There are millions of children experiencing dramatic disruptions in their lives due to their
parent(s) incarceration. Although it has been established that these children are subject to
negative outcomes, such as internalizing and externalizing behavior problems, substance
abuse, truancy, school failure, adult offending and incarceration, increased likelihood of
unemployment, and serious mental health problems, it is unclear whether parental incar-
ceration is the cause of such outcomes or solely a risk marker. Something that is very clear,
however, is that despite the risks, some children with incarcerated parents thrive. The
closeness of the parent-child relationship before incarceration and strong relationships
with primary caregivers, family members, friends, and other members of the community
appear to mitigate the risks. Future research should study the effectiveness of interven-
tions, such as FAST, used with this very specific population of children in need. Future
research should also further explore the relationships between parental incarceration, risk
factors, protective factors, and outcomes. A more in-depth understanding of the interac-
tions between these variables is needed if we hope to effectively support students in times
of crisis related to parental incarceration.
CHILDREN OF DEPLOYED PARENTS

More than 2 million troops have deployed to Iraq and Afghanistan, since the terrorist
attacks of 9/11. Of these service members, more than 6,000 have been killed and nearly
50,000 wounded. One in six of those deployed has been afflicted by posttraumatic stress
disorder (PTSD) and traumatic brain injury (TBI). In the first 6 months of 2012, deaths
by suicide among soldiers exceeded fatalities in Afghanistan, and the military is struggling
with major increases in domestic violence, child abuse, and sex crimes (Stars and Stripes,
2012). As traumatic as war has been for soldiers, trauma has also been brought home to
their families.
Prevalence
Three out of five service members deployed around the world leave families at home
(American Psychological Association Presidential Task Force on Military Deployment Ser-
vices for Youth, Families and Service Members, 2007). An estimated 42% of those soldiers
serving in Iraq and Afghanistan are parents of dependent children (DeVoe & Ross, 2012).
Of the children left behind, one third are at “high risk” for psychosocial morbidity,
regardless of parental military rank, child age or gender, or ethnic background. (Flake,
Davis, Johnson, & Middleton, 2009). Families are disrupted by the separation, the
absence of a spouse, and the ever-present possibility of death or injury to a loved one
(Chawla & Solinas-Saunders, 2011). Intact families suddenly become, in effect, single-
parent families. Stressors are associated with family members adjusting and readjusting to
new roles and responsibilities (Mmari, Roche, Sudhinaraset, & Blum, 2009). Because of
legitimate worry as well as other factors such as interrupted attachment (Posada, Longo-
ria, Cocker, & Lu, 2011; Riggs & Riggs, 2011), internalizing symptoms in children may
be more common than externalizing symptoms. Children with attachment issues are par-
ticularly vulnerable. In addition, there is an established link between the level of parental
distress and child distress. Parental depression and PTSD are related to child depression
and child internalizing and externalizing behaviors (Lester et al., 2010), and are common
in both spouses and returning troops. Child anxiety symptoms may persist even after a
parent has returned home.
Another reason for high levels of child maladjustment is a high rate of child maltreat-
ment, particularly neglect, during times of deployment (Gibbs, Martin, Clinton-Sherrod,
Walters, & Johnson, 2011). For National Guard and Reserve troops, being called up
and deployed often means a loss of family income with the resulting stress of economic
hardship.
The length of deployment is another factor influencing adjustment. Families are bet-
ter able to cope emotionally with shorter deployments (e.g., 6 months) than with longer
ones (11+ months). The longer the time between deployments the better, since this allows
families to adjust (Riggs, 2012).
If a parent is disabled while serving in the military and the acquired disability causes
negative life events, parental disability is associated with depression and low self-esteem
(Mazur, 2011). The parent might continue to be unavailable emotionally because of the
need for lengthy rehabilitation.
Adolescents may be at particular risk of social and emotional problems. Because of
their capacity for abstract thought and greater exposure to news media, they are better
able to understand the dangers of deployment. They may also be aware of negative views
of war among the general public. Because they have more self-care skills, they may be
called upon to assume adult roles and at the same time be left without adult supervision
(Mmari et al., 2009).
Resilience and Protective Factors

Of course the majority of children and families do not experience this hazard as a crisis.
Most adjust well to deployment and can become stronger as a result of learning new skills
(Jensen, Martin, & Watanabe, 1996). In the first month or so, families have to adjust to
new responsibilities for members, taking the roles previously filled by the service mem-
ber. Families have to reestablish disrupted daily living routines and cope with anxieties
about the loved-one’s well-being. Over the subsequent months, the family might experi-
ence increased feelings of independence and self-confidence as coping is successful and
they find some new sources of support (Riggs, 2012).
Prevention
The military does have some structures in place, and recognizes the need to intervene with
the family prior to the deployment, during the deployment, and after the deployment
(Wilson et al., 2011). A number of web-based resources are also available (e.g., http://
www.military.com/spouse/military-deployment/dealing-with-deployment; http://www.
beyondtheyellowribbon.org/deployment-cycle-support). The Military Child Education
Coalition works with different branches of the military and school districts to offer training
to school counselors and teachers (Military Child Education Coalition, 2001). Resources
may be available on base and on the web to help children and families, but mental health
professionals working in schools serving military dependents should be prepared to take
over some of this work. Many active military families return to their families of origin and
hometowns to ease financial burdens and to access social and emotional support systems.
National Guard and Reservists are also deployed. As a result, school personnel may serve
military children in any community, and may not have easy access to military resources.
Prior to Deployment
General Strategies. Prevention prior to deployment involves anticipatory guidance about
the temporary loss of a family member and what to expect in his or her absence. Informa-
tion should be presented in developmentally appropriate terms, and children should be
encouraged to ask questions. Questions often reveal the child’s greatest concerns and his
or her level of cognitive and affective development. Prepare to deal calmly and rationally
with misconceptions. Older children can be helped to anticipate altered family roles and
responsibilities, as family dynamics will change. Some discussion of ways to cope with the
unknown and available sources of support will be important. It will be helpful if children
and adolescents understand the purpose or mission of the deployment. Older children
and adolescents will need to discuss possible threats or risks to the parent. Threats should
be placed in a realistic context without false reassurance but with accurate information.
Younger children particularly will need some reassurance to protect them from excess
worry. Because of the demands of military movement, children should be prepared for
the fact that there may be times when no information about their parent will be available.
Emotional inoculation is also important. Children and spouses should understand that
a variety of feelings and emotions are bound to come up during the deployment and that
strong feelings are natural, common, and legitimate. Loneliness and worry about the miss-
ing family member’s well-being are usual. Concern about how the family will function
without the deployed member is also common. The family should be warned about the
problem of unsubstantiated rumors during times when little information is available, and
how to seek verification of unofficial information, and otherwise cope when feelings get
overwhelming.
The entire family needs to do joint planning prior to deployment. Most important is
a discussion about how the family will communicate during deployment. The plan may
include a schedule and preparation around the means of communication (telephone,
e-mail, video conferencing) and trial runs to be sure the technology will work. The family
should spend as much quality time together prior to deployment as possible. Each child
should enjoy some time alone with the departing parent to preserve positive memories
(Riggs, 2012).
School-Based Prevention. Most teachers and administrators are not very knowledgeable
about military practices and procedures or how they can be of assistance during times of
deployment. One helpful resource, Educator’s Guide to the Military Child During Deploy-
ment, has been prepared by the Educational Opportunities Directorate of the Department
of Defense (n.d.). This booklet, which may be downloaded, gives relevant background
information about deployment and intervention strategies that will help teachers under-
stand their possible roles in addressing military children’s needs.
Prevention During Deployment

General Strategies. During deployment, prevention consists of helping the child maintain
contact with the parent but being realistic about the limits of availability. There may be
times when duty will interfere with scheduled communications. Helping the child develop
social support through friendships with peers and sympathetic adults will also be impor-
tant. Families, teachers, and school staff should be made aware of the child’s situation, so
they may offer extra mentoring. If the child can be busy and active, in school and in the
community, the time may pass more quickly. Breaking up the time is also important—for
example, through vacation trips, summer camps, visits to grandparents, and extracur-
ricular activities. These kinds of activities have the advantage of offering “single” parents
time without children.
Operation Military Kids (www.operationmilitarykids.org), organized by the U.S. Army
in collaboration with other groups, has developed a number of programs to support
children during deployment. The aims include connecting youth who are experiencing
deployment, offering a range of recreational, social, and educational programs, and gain-
ing leadership, organizational, and technical skills through participating in outreach to
the community.
Children may wish to have their own collection of pictures and keepsakes to remind
them concretely of their missing parent. They can assist with tracking the time of the
deployment so they will have a realistic sense of when the parent will return. Again, oppor-
tunities to ask questions will be important along with the provision of developmentally
appropriate answers.
In general it is important to limit and supervise a child’s exposure to the media. With
adolescents it will not be possible, but younger children do not need to be exposed to
news programs with graphic depictions of combat operations. Such images may stimulate
anxiety in younger children particularly.
Towards the end of the deployment, children will likely become excited and distractible,
thinking about the reunion. They may have high and nostalgic expectations for a return to
previous relationships in the family. However, there may be conflicting emotions, particu-
larly in older children, because they may wonder if they will need to give up some auton-
omy and independence when the parent returns. Often there is a rush to complete “to do”
lists, in preparation for the homecoming, which can cause additional stress (Riggs, 2012).
School-Based Prevention. The Educator’s Guide to the Military Child During Deploy-
ment has several suggestions for classroom teachers. The authors suggest it is important
maintain a focus on students and the learning environment. It is important that children
continue to make academic progress and participate in classroom routines. Teachers can
provide structure through setting classroom rules and enforcing them consistently. Class-
room regularities are reassuring to children going through changes elsewhere in their lives.
On the other hand, the teacher must be understanding of the stresses the student is under
and reduce student work load as needed. By maintaining contact with both the deployed
and remaining parents, the teacher may be better able to monitor the child’s adjustment
to the new situation.
Teachers can also provide time for children to share feelings in a safe way. This sharing
must be done sensitively, attending to the comfort level and developmental status of the
student. Art activities, letter writing, and classroom discussions can be avenues to express
feelings and thoughts about military issues. “After any classroom discussion of a deploy-
ment related event, end the discussion with a focus on the child’s safety and the safety mea-
sures being taken on behalf of their loved one. In the event of a deployment due to crisis or
war, protect students from unnecessary exposure to frightening situations and reminders.
Limit adult-to-adult conversations about frightening details in front of your students. It is
best not to have television news as a backdrop when students are in class” (Educational
Opportunities Directorate of the Department of Defense, n.d., p. 7).
The Educator’s Guide makes the point that teachers, despite personal opinions about war,
must remain neutral in the classroom and express no negativity about military practices or
the parent’s participation. They must listen carefully and acknowledge and validate feelings.
Teachers may also have an opportunity to reinforce anger management and other coping
strategies the child may employ during the parent’s deployment.
Educators need to be aware of symptoms of a crisis response in children with a deployed
parent. They should watch for signs of stress, such as angry outbursts, weight gain or loss,
lowered school performance, distractibility, depression, or withdrawal. If changes persist
for some time after deployment, teachers should know who is available to take a referral
and how to contact them.
The military branches and bases typically have school liaison officers. They can be of
assistance by bringing resources to the school and facilitating communication between
the school and parents. These resources may be found on military installation web sites.
Prevention Postdeployment
Reunion is usually a time of great joy and relief from anxiety about the physical well-being
of the parent. On the other hand, there is a need to readjust roles and responsibilities and
deal with the expectation that the family dynamics will go back to the way they were prior
to deployment. Most families will be able to adjust to the “new normal.” They will be
able to incorporate changes in relationships without major disruption in family function-
ing (Riggs, 2012).
It is important for the child and family to have realistic expectations. In working with
children one should not reinforce the idea that everything will be all right when the par-
ent returns. Large numbers of returning troops will suffer from physical and emotional
disorders, particularly traumatic brain injury and posttraumatic stress disorder. They may
appear normal physically, but have symptoms of trauma (Herzog, 2011). Even those unaf-
fected will need to move from the culture and simplicity of deployment to the complexity
of family life at home. This reintegration will take time.
The “SOFAR” Guide for Helping Children and Youth Cope with the Deployment and
Return of a Parent in the National Guard and Other Reserve Components suggests that
parents or others talk to children about the return and help them anticipate what will
occur. They may plan what they want to do or say to the returning parent. It also suggests,
“Prepare them for changes and anticipate unanticipated stressors. Create time for them to
express feeling of guilt at the difficulty they might have looking at or dealing with a severely
wounded or cognitively impaired parent” (Levin, Daynard, & Dexter, 2008, p. 26).
The guide offers the following advice to parents and helpers: “Help children under-
stand the unanticipated changes, especially in terms of how they are affecting the children
themselves. Let them know that what is happening is not their fault and that it is the job
of grown-ups, not theirs, to make it better. If changes in behavior occur in the children—
such as sleep disturbance, acting like a younger child, making extra demands, heightened
anger—recognize that this may be a consequence of changes in the returning parent and
the family. Provide extra support. And let other members of children’s support network—
grandparents, other relatives and friends, teachers—know the children may need special
help and support too” (p. 27).
A parent education program, ADAPT, has been developed for military families and cul-
ture. It targets common postdeployment adjustment reactions that can disrupt family rela-
tions, and focuses on emotion regulation for parents. The program content covers contingent
skill encouragement, limit-setting, positive involvement, monitoring children’s activities, and
effective family problem solving (Gewirtz, Erbes, Polusny, Forgatch, & DeGarmo, 2011).
Because children may have not had as much supervision during deployment, returning
service members may expect children to test limits set by parents. The children will need
time to adjust, and it will be important to listen to and accept children’s feeling of relief
and, perhaps, anger at being abandoned. As aforementioned, school personnel can also
be helpful. They can be alert to crisis responses in children following reunions and make
referrals. They can provide opportunities for the expression of feelings and ideas, and
individualize instruction so that the child maintains academic progress.
Crisis Intervention
Nevertheless, children must adjust to the separation and loss of a primary caretaker, and
this loss may precipitate a crisis. When a crisis reaction does manifest itself, many of
the counseling strategies outlined earlier in this chapter and in related chapters will be
applicable (Hardaway, 2004; Herzog & Haigler, 2011). Since the crisis often involves the
entire family, family therapy is clearly justified. Play therapy has been used successfully in
this context (James & Countryman, 2012; Smith, 2011). Filial therapy, helping parents
play therapeutically with their children, has shown promise with this population (Chawla
& Solinas-Saunders, 2011).
As in other crisis situations, counselors can help children deal with fears and anger
issues. Developmentally appropriate counseling strategies can examine unrealistic con-
cerns about a parent’s safety, concerns about the future, feelings of neglect, guilt about
forgetting about the missing parent, and anger at the parent for missing family milestones
or restricting new freedoms upon return.
Disability and Injury. Special counseling intervention will be necessary if a parent is
injured or disabled while away. Injury will add to stresses of homecoming. Levin, Day-
nard, and Dexter (2008) recommend that other adults in the child’s life “shield the child as
much as possible from any disturbing emotions the veteran may be experiencing [regard-
ing the injury]. Children will not benefit from hearing a parent say they wish they had died
instead, or that they should have stayed with their buddies” (p. 31).
At the same time, children will need to visit with their injured parent. Preparation for
these visits will include anticipatory guidance about what the child will experience and
emotional inoculation about feelings the visit will engender. The content of this prepara-
tion should be optimistic and hopeful, although realistic. Visits will help the emotional
reconnection between the parent and child.
Counseling may be necessary after the visit since children may be distressed by seeing
a prosthesis or disfigurement. They may also grieve for the loss of activities they can no
longer enjoy with the parent because of the injury, as well as other stresses in the family
springing from the injury, such as parental conflict.
Levin et al. (2008) point out that serious injury from “friendly fire” or accident creates
additional special issues for veterans and their families. Many individuals who are injured
in this manner and their families will develop considerable anger and adolescents may
experience additional alienation from the military. Additional counseling may be necessary
to cope with these emotions.
Parental Death. The occasion of a parental death likely will create a need for grief
counseling (Lamberg, 2004). Grief will be exacerbated by the relatively young age of the
diseased and the unanticipated circumstances of the death. Levin et al. suggest that “What-
ever the manner of the parent’s death, it is not helpful for children to be told details about
how they died. Children should be reassured that the parent did not suffer (brutal truth
is often more brutal than true) and reassured in loving ways consistent with the family’s
faith or beliefs” (2008, p. 30). Ideas of a foreshortened future without the parent, anger,
and other thoughts and emotions will need to be explored with the child, as discussed in
Chapter 8 of this volume.
Conclusion
Each of the hazardous situations reviewed involving the temporary absence of a parent has
different dynamics. Nevertheless they do present challenges with some common elements
to children and families. First, there is a need for the family to reorganize. Children will be
experiencing a loss and need to take on new roles and responsibilities that may be relin-
quished at a later time. They will be forced to grow up faster than peers and may not be
ready. Second, there is a need to facilitate communication between the absent or disabled
parent and the family to maintain emotional connections. Third, there is a continuing
need for objective information and a realistic appraisal of the future. Mistaken ideas and
fears must be addressed to alleviate anxiety. Anxiety and depression stimulated by paren-
tal absence will be common. Fourth, there may be a problem connecting with peers and
other forms of social support because of a social stigma attached to the parent’s situation.
Finally there will be a need to renegotiate a relationship to a parent who has been changed
by an experience. Children can be helped with all of these challenges through school-based
prevention and awareness and through responsive crisis intervention.
REFERENCES
Aaron, L., & Dallaire, D. H. (2010). Parental incarceration and multiple risk experiences: Effects
on family dynamics and children’s delinquency. Journal of Youth Adolescence, 39, 1471–1484.
Abelson, M. A., & Woodman, R. W. (1983). Review of research on team effectiveness: Implications
for teams in schools. School Psychology Review, 12, 125–136.
Aldridge, J. (2006). The experiences of children living with and caring for parents with mental ill-
ness. Child Abuse Review, 15(2), 79–88. doi:10.1002/car.904
Allard, P., & Greene, J. (2011). Children on the outside: Voicing the pain and human costs of paren-
tal incarceration. Retrieved from http://www.justicestrategies.org/sites/default/files/publications/
JS-COIP-1–13–11.pdf
American Psychological Association Presidential Task Force on Military Deployment Services for
Youth Families and Service Members. (2007). The psychological needs of U.S. military service mem-
bers and their families: A preliminary report. Washington, DC: American Psychological Association.
Available at http://www.ptsd.ne.gov/ publications /military -deployment-task -force-report.pdf
Bornstein, M. H. (Ed.). (1995). Handbook of parenting: Vol. 4. Applied and practical parenting.
Mahwah, NJ: Lawrence Erlbaum Associates.
Brault, M. (2008). Disability status and the characteristics of people in group quarters: A brief analysis
of disability prevalence among the civilian noninstitutionalized and total populations in the Ameri-
can Community Survey. Retrieved from http://www.census.gov/hhes/www/disability/whatsnew.html
Buck, F. M., & Hohmann, G. W. (1983). Parental disability and children’s adjustment. In E. L. Pan, T.
E. Backer, & C. L. Vash (Eds.), Annual review of rehabilitation: Vol. 2 (pp. 203–241). New York:
Springer.
Campion, M. J. (1995). Who’s fit to be a parent? New York: Routledge.
Chawla, N., & Solinas-Saunders, M. (2011). Supporting military parent and child adjustment to
deployments and separations with filial therapy. American Journal of Family Therapy, 39(3),
179–192. doi:10.1080/01926187.2010.531647
Coates, D. L., Vietze, P. M., & Gray, D. B. (1985). Methodological issues in studying children of
disabled parents. In S. K. Thurman (Ed.), Children of handicapped parents: Research and clinical
perspectives (pp. 155–180). Orlando, FL: Academic Press.
Cole, C. M. (1978). The role of brief family therapy in medical rehabilitation. Journal of Rehabilita-
tion, 44, 29–42.
Crozier, M., Rokutani, L., Russett, J. L., Godwin, E., & Banks, G. E. (2010). A multisite program
evaluation of families and schools together (FAST): Continued evidence of a successful multifam-
ily community-based prevention program. The School Community Journal, 20(1), 187–207.
DeVoe, E. R., & Ross, A. (2012). The parenting cycle of deployment. Military Medicine, 177, 184–
190. Retrieved from www.csa.com
Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An integrative review. Psycho-
logical Bulletin, 108, 1–27.
Duvdevany, I., Moin, V., & Yahav, R. (2007). The bipolarity of adolescents’ feelings toward their
parents with various illnesses and disabilities. Illness, 15, 315–332. doi:10.2190/IL.15.4.c
Educational Opportunities Directorate, Department of Defense. (n.d.). Educator’s guide to the mili-
tary child during deployment. Retrieved from www.ed.gov/about/offices/list/os/homefront/home-
front.doc
Eisenberg, M. G., Sutkin, L. C., & Jansen, M. A. (Eds.). (1984). Chronic illness and disability
through the life span, effects on self and family. New York: Springer.
English, R. W. (1971). Correlates of stigma toward physically disabled persons. Rehabilitation
Research and Practice Review, 2, 1–17.
Feldman, D. J. (1974). Chronic disabling illness: A holistic view. Journal of Chronic Diseases, 27,
287–291.
Field, T. (1995). Psychologically depressed parents. In M. H. Bornstein (Ed.), Handbook of par-
enting: Vol. 4. Applied and practical parenting (pp. 85–100). Mahwah, NJ: Lawrence Erlbaum
Associates.
Flake, E. M., Davis, B. E., Johnson, P. L., & Middleton, L. S. (2009). The psychosocial effects of
deployment on military children. Journal of Developmental and Behavioral Pediatrics, 30, 271–
278. doi:10.1097/DBP.0d013e3181aac6e4.
Gallagher, J. J., & Vietze, P. (Eds.). (1986). Families of handicapped persons: Current research, treat-
ment, and policy issues. Baltimore, MD: Paul Brookes.
Garrett, J., & Levine, E. (Eds.). (1973). Rehabilitation practices with the physically disabled. New
York: Columbia University Press.
Geis, H. J. (1977). The problem of personal worth in the physically disabled patient. In R. P. Mari-
nelli & A. E. Dell Orto (Eds.), The psychological and social impact of physical disability (pp.
130–140). New York: Springer.
Gewirtz, A. H., Erbes, C. R., Polusny, M. A., Forgatch, M. S., & DeGarmo, D. S. (2011). Help-
ing military families through the deployment process: Strategies to support parenting. Professional
Psychology: Research and Practice. Special Issue: Psychological Services for Veterans and Military
Service Members and Their Families, 42(1), 56–62. doi:10.1037/a0022345
Gibbs, D. A., Martin, S. L., Clinton-Sherrod, M., Walters, J. L. H., & Johnson, R. E. (2011). Child
maltreatment within military families. In S. M. Wadsworth, D. Riggs, S. M. Wadsworth, & D.
Riggs (Eds.), Risk and resilience in U.S. military families (pp. 111–130). New York: Springer Sci-
ence + Business Media. doi:10.1007/978–1-4419–7064–0_6
Goffman, E. (1963). Stigma. Englewood Cliffs, NJ: Prentice-Hall.
Greer, B. G. (1985). Children of physically disabled parents: Some thoughts, facts, and hypotheses.
In S. K. Thurman (Ed.), Children of handicapped parents: Research and clinical perspectives (pp.
131–143). Orlando, FL: Academic Press.
Hardaway, T. (2004). Treatment of psychological trauma in children of military families. In N. B.
Webb (Ed.), Mass trauma and violence: Helping families and children cope (pp. 259–282). New
Herzog, J. R. (2011). Secondary traumatic stress, deployment phase, and military families: Systemic
approaches to treatment. In R. B. Everson & C. R. Figley (Eds.), Families under fire: Systemic
therapy with military families (pp. 191–212). New York: Routledge/Taylor & Francis.
Herzog, J. R., & Haigler, L. A. (2011). Systemic therapy with adolescents in Army families. In R. B.
Everson & C. R. Figley (Eds.), Families under fire: Systemic therapy with military families (pp. 79–97).
New York: Routledge/Taylor & Francis.
Hill, R., & Hansen, D. A. (1964). Families under stress. In H. T. Christensen (Ed.), Handbook of
marriage and the family (pp. 782–819). Chicago: Rand McNally.
James, T., & Countryman, J. (2012). Psychiatric effects of military deployment on children and
families: The use of play therapy for assessment and treatment. Innovations in Clinical Neurosci-
ence, 9(2), 16–20.
Jensen, P. S., Martin, D., & Watanabe, H. (1996). Children’s response to parental separation during
Operation Desert Storm. Journal of the American Academy of Child & Adolescent Psychiatry,
34, 433–441. doi:10.1097/00004583–199604000–00009
Johnson, E. I., & Easterling, B. (2012). Understanding unique effects of parental incarceration on
children: Challenges, progress, and recommendations. Journal of Marriage and Family, 74(2),
342–356. doi:10.1111/j.1741–3737.2012.00957.x
Keleman, S. (1974). Living your dying. New York: Free Press.
Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.
La Vigne, N. G., Davies, E., & Brazzell, D. (2008). Broken bonds: Understanding and addressing
the needs of children with incarcerated parents. Washington, DC: Urban Institute. Retrieved from
http://www.urban.org/publications/411616.html
Lamberg, L. (2004). When military parents are sent to war children left behind need ample sup-
port. JAMA: Journal of the American Medical Association, 292(13), 1541–1542. doi:10.1001/
jama.292.13.1541
Lester, P., Peterson, K., Reeves, J., Knauss, L., Glover, D., Mogil, C., . . . Beardslee, W. (2010). The
long war and parental combat deployment: Effects on military children and at-home spouses. Jour-
nal of the American Academy of Child and Adolescent Psychiatry, 49, 310–320. doi:10.1016/j.
jaac.2010.01.003
Levin, D. E., Daynard, C. I., & Dexter, B. A. (2008). The “SOFAR” guide for helping children
and youth cope with the deployment and return of a parent in the National Guard and other
reserve components. Retrieved from http://www.sofarusa.org/download_brochures_flyers_mul-
timedia_links.html
Lindenberg, R. (1977). Work with families in rehabilitation. Rehabilitation Counseling Bulletin,
21, 67–76.
Marinelli, R. P., & Dell Orto, A. E. (1977). The psychological and social impact of physical dis-
ability. New York: Springer.
Matson, R. R., & Brooks, N. A. (1974). Adjusting to multiple sclerosis: An exploratory study. Social
Science and Medicine, 11, 245–250.
Mazur, E. (2011). Parent and adolescent positive and negative disability-related events and their rela-
tion to adjustment. In S. M. Wadsworth, D. Riggs, S. M. Wadsworth, & D. Riggs (Eds.), Risk and
resilience in U.S. military families (pp. 235–257). New York: Springer Science + Business Media.
doi:10.1007/978–1-4419–7064–0_12
Mayes, L. C. (1995). Substance abuse and parenting. In M. H. Bornstein (Ed.), Handbook of par-
enting: Vol. 4. Applied and practical parenting (pp. 101–126). Mahwah, NJ: Lawrence Erlbaum
Associates.
Meadow-Orlans, K. P. (1995). Parenting with a sensory or physical disability. In M. H. Bornstein
(Ed.), Handbook of parenting: Vol. 4. Applied and practical parenting (pp. 57–84). Mahwah, NJ:
Lawrence Erlbaum Associates.
Military Child Education Coalition. (2001). United States Army secondary education transition
study. Arlington, VA: Military Family Resources Center.
Mmari, K., Roche, K. M., Sudhinaraset, M., & Blum, R. (2009). When a parent goes off to war:
Exploring the issues faced by adolescents and their families. Youth & Society, 40(4), 455–475.
doi:10.1177/0044118X08327873
Murray, J., & Farrington, D. P. (2008). The effects of parental imprisonment on children. In M.
Tonry (Ed.), Crime and justice: A review of research (Vol. 37, pp. 133–206). Chicago, IL: Univer-
sity of Chicago Press.
Murray, J., Farrington, D. P., & Sekol, I. (2012). Children’s antisocial behavior, mental health, drug
use, and educational performance after parental incarceration: A systematic review and meta-
analysis. Psychological Bulletin, 138, 175–210. doi:10.1037/a0026407
Newman, T. (2002). “Young careers” and disabled parents: Time for a change of direction? Dis-
ability & Society, 17(6), 613–625. doi:10.1080/0968759022000010407
Perkins, T. S., Holburn, S., Deaux, K., Flory, M. J., & Vietze, P. M. (2002). Children of mothers
with intellectual disability: Stigma, mother-child relationship and self-esteem. Journal of Applied
Research in Intellectual Disabilities, 15(4), 297–313. doi:10.1046/j.1468–3148.2002.00140.x
Pfeiffer, S.I., & Tittler, B. I. (1983). Utilizing the multidisciplinary team to facilitate a school-family
systems orientation. School Psychology Review, 12, 168–173.
Poehlmann, J., Dallaire, D., Loper, A. B., & Shear, L. D. (2010). Children’s contact with their
incarcerated parents: Research findings and recommendations. American Psychologist, 65(6),
575–598. doi: 10.1037/a0020279
Posada, G., Longoria, N., Cocker, C., & Lu, T. (2011). Attachment ties in military families: Mothers’
perception of interactions with their children, stress, and social competence. In S. M. Wadsworth,
D. Riggs, S. M. Wadsworth, & D. Riggs (Eds.), Risk and resilience in U.S. military families (pp.
131–147). New York: Springer Science + Business Media. doi:10.1007/978–1-4419–7064–0_7
Proceedings from the White House Conference on the Handicapped. (1977). Washington, DC.
Riggs, S. A. (2012). Caring for the military family: What we all should know about military culture
and the stress of deployment—On-demand recording WEBCAST. Washington, DC: American
Psychological Association. Available at http://apa.bizvision.com/members
Riggs, S. A., & Riggs, D. S. (2011). Risk and resilience in military families experiencing deploy-
ment: The role of the family attachment network. Journal of Family Psychology, 25, 675–687.
doi:10.1037/a0025286
Schonz, F. C. (1975). The psychological aspects of physical illness and disability. New York: Mac-
millan.
Seligman, M. (1979). Strategies for helping parents of exceptional children: A guide for teachers.
New York: Free Press.
Shellhase, L., & Shellhase, F. (1972). Role of the family in rehabilitation. Social Casework, 53,
544–550.
Smith, G. W. (2011). Attachment as a consideration in family play therapy with military families. In
R. B. Everson & C. R. Figley (Eds.), Families under fire: Systemic therapy with military families
(pp. 79–97). New York: Routledge/Taylor & Francis.
Stars and Stripes. (2012). Special report on suicide in the military. Retrieved from http://www.
stripes.com/news/special-reports/suicide-in-the-military
Thurman, S. K. (Ed.). (1985). Children of handicapped parents: Research and clinical perspectives.
Orlando, FL: Academic Press.
Wilson, S. R., Wilkum, K., Chernichky, S. M., MacDermid Wadsworth, S. M., & Broniarczyk, K.
M. (2011). Passport toward success: Description and evaluation of a program designed to help
children and families reconnect after a military deployment. Journal of Applied Communication
Research, 39(3), 223–249. doi:10.1080/00909882.2011.585399
Wright, B. A. (1960). Physical disability—A psychological approach. New York: Harper & Row.
Yosida, R. K. (1983). Are multidisciplinary teams worth the investment? School Psychology Review,
12, 139–143.
11 The Stress of Moving
Jonathan Sandoval
Who among us enjoys moving? The process of giving up an established home and friends
and relocating to another neighborhood, city, or geographical region is often accom-
panied by fatigue, feelings of loss and alienation, and fear of the unknown. For adults,
moving may be made more pleasant by the anticipation of a more challenging or reward-
ing occupation, or by the intellectual stimulation of relocating to a new environment.
And, in fact, for many individuals, moving is a normal part of adult life, as with the
civilian and military employees of the Department of Defense, who routinely relocate
every 2 to 5 years.
Unfortunately, most moves are not made to improve one’s life. Many relocations are
dictated by other life events such as deaths, divorces, and homelessness, and come as an
added burden to children and adults experiencing life’s catastrophes. Although there is a
connection between adult attitudes and children’s reactions, as will be discussed later, we
cannot assume children will experience a move the same way parents do.
“I don’t want to move, Dad, all my friends are here!” “What will it be like in my new
neighborhood?” “I’m going to get my own room in our new house when we move, aren’t
I, Mom?” “Boy, I’ll be glad to get out of this school!”
These are some of the reactions of children to the announcement of a family move.
On balance, children do not like to move any more than do adults. Under the right cir-
cumstances, however, moving can lead to growth in intellectual, social, and emotional
development.
For children, moving means separation. In many cases children will be giving up friends,
a neighborhood, and a school environment with which they have become familiar. Accord-
ing to Bowlby (1960, 1961), separation and the emotions attached to it are the most dif-
ficult events with which children must deal. Relations with significant others form the core
of emotional development, and disruptions in the separation and individuation process
can lead to lifelong personality problems. Children who have already experienced separa-
tion difficulties will find moving much more traumatic than others. Moving may also be
a problem for the friends of a child who is relocating. Rubin (1980) found that friends
of moving children suffered increases in loneliness, irritability, and anger following their
companion’s departure.
There are studies of stress in humans that attempt to quantify various life events as to
their stress value. On Holmes and Rahe’s (1967) scale, for example, changes in residence
and a change in school each receive a value of 20 on a scale of 100. (The death of a spouse
received a full 100 points.) Almost always a move will add to a person’s stress when it
accompanies events such as family disintegration, loss of job, or death. All things being
equal, a move in the absence of other negative situations would appear to have less of a neg-
ative impact on individuals than moves accompanied by events such as illness or divorce.
The Stress of Moving 199
Extent of the Problem
Moving has become a fact of life for modern Americans. According to the U.S. Census
Bureau, in 2010, 37.5 million people 1 year and older changed residences, a rate of
12.5% of the population. Those moving cited family concerns (30.3%) (e.g., a change in
marital status); housing-related reasons (43.7%) (e.g., the desire to live in a new or better
home or apartment); employment needs (16.4%); and other factors (9.5%). The mobility
rate for people with incomes below the poverty level was 23.6% compared with a rate
of 16.5% of those living just above the poverty level (incomes between 100 and 149%
of the poverty line). African Americans had the highest mover rate (16.7%), followed
by Hispanics (15.6%), Asians (13.9%), and Caucasians (10.8%). Twenty-four percent
of those moving were between 1 and 17 years of age (U.S. Department of Commerce,
Census Bureau, 2010).
A reasonable estimate would be that almost 50% of the population in an elementary
school have moved at least once during their lifetimes. Students who change schools four
or more times represent about 13% of all kindergarten through eighth grade (K–8) stu-
dents, and are disproportionately poor, African American, and from families who do not
own their homes. These students who change schools more frequently have lower scores
on standardized reading and math tests and drop out of school at higher rates than their
less mobile peers (U.S. General Accounting Office, 2010).
We do not know for what percentage of these children moving turns into a crisis. Cer-
tainly it does not negatively impact all children and youth, as indicated by the next section.
Nevertheless, depending on the reason for the move and the individual child’s makeup,
moves may be quite traumatic and require intervention from school mental health person-
nel such as a counselor or school psychologist. Children who move will be at some risk for
developing severe learning and behavior problems in the schools.
Is Moving Always Detrimental to Children?

There is some evidence that children are not uniformly opposed to moving (Bekins, 1976;
Lehr & Hendrickson, 1968). More than half of the children in a survey sponsored by
Bekins, for example, did wish to move. This upper-middle-class sample perceived making
new friends, going to a new school, traveling, and learning about new localities to be excit-
ing prospects. The minority, however, did not look forward to moving, citing the loss of
friends as the major problem.
A number of studies have been done attempting to discover whether moving has a negative
effect on children’s academic, social, or emotional development. Before examining these out-
comes, we must consider that the effects of moving are very different for different populations.
Military Dependents. A sizable amount of this research has focused on children of
military dependents. Research has particularly focused on whether the stereotype of the
“military brat” has any validity. Very little research has contradicted the early findings
of Sackett (1935), who discovered that the children of military officers in Panama were
performing better or equal to their stateside civilian counterparts. When the proper con-
trol base rates are considered, military children seem to have fewer intellectual and social
emotional problems than other children (Bradshaw, Sudhinaraset, Mmari, & Blum, 2010;
Gerner, Perry, Moselle, & Archbold, 1992; Gordon & Gordon, 1958; Greene & Daugh-
try, 1961; Kenny, 1967; Marchant & Medway, 1987; Pedersen & Sullivan, 1964). On the
other hand, military dependent children and others living abroad have to cope with geo-
graphic mobility, transcultural experiences, a parent’s episodic absence for deployment,
and other stressful factors that place some of them at risk for adjustment problems (Shaw,
1987). In a study of Air Force adolescents, Pittman and Bowen (1994) examine the role of
various predictors in three kinds of adjustments following a move: personal adjustment,
adjustment to the new environment, and parental relations. Important features contribut-
ing to adjustment were the adolescents’ perceptions (attitudes toward the move) and level
of social support. Bradshaw, Sudhinaraset, Mmari, & Blum (2010) point out that many
of the findings about military dependents were obtained during peacetime, and that addi-
tional stressors brought on by wartime deployment may alter the picture (see Chapter 10
in this volume).
One problem in the research of military children, besides the lack of suitable control
groups, is in distinguishing between the children of officers and enlisted men. Pittman and
Bowen (1994) found that father’s rank was correlated with positive outcomes for adoles-
cents. For officers, a move may be perceived as a positive part of a career and leading to
advancement, whereas for enlisted personnel a move may simply be an inconvenience.
In a study of primarily officers’ children, Pedersen and Sullivan (1964) found that nor-
mal children had mothers who were more accepting of frequent relocation and parents
who were strongly identified with the military than did children who were diagnosed as
emotionally disturbed (see also Marchant & Medway, 1987).
However, the children of enlisted personnel, in spite of coming from low-income homes
and ethnic groups traditionally underperforming in schools, and having parents with high
school educations, still perform better than their civilian counterparts (Popp, Stronge, &
Hindman, 2003). Weber and Weber (2005) argue that the authority, control, structure,
continuity, and expectations common in military communities may decrease the rates of
disruptive behavior and increase the emphasis on academics among military dependents.
It may be unfair to generalize from military to civilian children because military moves
are scheduled and supported economically and with various planned interventions for
those who have moved. The military has a corporate culture that supports strong partner-
ships across schools and families, which includes facilitating moves (Popp et al., 2003).
Personnel who move are given time and careful orientations to their new assignments. In
addition, it is sometimes the case that military children move with a cohort and do not
necessarily lose all of their friends in a move. They simply find themselves in a different
part of the world with some of the same classmates, and relationships are maintained.
Civilian Children. Research on nonmilitary children has more often shown that children
suffer ill effects from moving, although the findings are not unanimous in detailing nega-
tive outcomes. Much of the research has examined academic outcomes. Although frequent
moves are clearly correlated with low achievement (Benson, Haycraft, Steyaert, & Weigel,
1979), when previous achievement and socioeconomic status are controlled, the effect of
moving on achievement is often reduced or eliminated (Heinlein & Shinn, 2000; Temple &
Reynolds, 1999), particularly in children from low-socioeconomic-status homes. In addi-
tion, Wright (1999) found that low achievement outcomes from a move were associated
with children moving within the school district rather than with children moving outside
of the district. Many poor children move within a school district as a result of evictions
and other changes in life circumstance.
Children for whom moving is a result of another life crisis are probably at greater risk
for developing a crisis around the event. An example of moving associated with a disas-
ter comes from Hurricane Katrina. The displaced K–12 students who moved out of the
impacted area into neighboring counties lost the ability to concentrate in school and mani-
fested a number of symptoms of depression (Picou & Marshall, 2007). Moving seemed
to exacerbate the usual impact of disasters on children (see Chapter 14 on disaster). In
another example, South, Crowder, and Trent (1998) argue that parental divorce sharply
increases the likelihood that children will move out of their neighborhoods to significantly
poorer neighborhoods (see also Tucker, Marx, & Long, 1998).
A number of studies have focused on self-concept, depression, and emotional well-being
as outcomes of moves (Brown & Orthner, 1990; Calabrese, 1989; Hendershott, 1989;
Kroger, 1980; Oishi & Schimmack, 2010). These studies have generally suggested moving
is related to adjustment problems, at least in the short run. In a study of older adults (mean
age = 46), the number of residential moves as children was related to self-reported life
satisfaction, psychological well-being, positive affect, and negative affect. The study was
able to take into account respondent age, gender, educational level, personality, and social
relations in confirming the detrimental effects of moves (Oishi & Schimmack, 2010).
The researchers found the expected negative relationship between childhood moves and
well-being, but that moving was more detrimental to introverts than extroverts, and for
neurotics than nonneurotics. They explain the effect for introverts by the relative lack of
close social relations across the lifespan.
In their 1995 review of the literature, Humke and Schaefer (1995) identify additional
factors contributing to postmove emotional adjustment, such as poor premove adjust-
ment, number of moves, distance of move, and multiple stressors. They suggest that one
of the most influential factors was parental attitude toward the move, since children are
often sensitive to their parents’ attitudes. In addition, however, moving may have different
consequences depending on the age or developmental level of the child.
Again, researchers on civilian children have not always distinguished between children’s
moves that are supported and planned (presumably leading to positive outcomes for the
family) and those moves that are a result of negative economic or social conditions. The
emotional effect of moving on children of a high-level executive is obviously going to be
different (and likely more positive) than the effect of moving on the children of a seasonal
worker or unskilled laborer who must travel from job to job. In this latter group, par-
ticularly, moving may be a result of life problems rather than a cause of them. In general,
researchers have had difficulty in distinguishing cause and effect in the study of moving.
Attention to interactions may facilitate the understanding of moving research findings.
For example, Blane and Spicer (1978) found that mobility had little or no effect on chil-
dren from high-socioeconomic-status (SES) homes but was detrimental for children from
most low-socioeconomic homes. Norford and Medway (2002) compared frequent mov-
ers, moderate movers, and nonmovers in high school on measures of depression, social
support, and participation in extracurricular activities, controlling for reason for reloca-
tion, timing, shyness, SES, and family cohesion. They found few differences. However,
relocation as a function of divorce or at an early age did lead to lower levels of high school
participation in extracurricular activities.
Examining another individual variable, Whalen and Fried (1973) found that mobility
improved test scores of intelligent children but depressed scores of children with lower
IQs. Perhaps the exposure to new environments, the pride that comes from mastering the
challenges of moving to a new place, and the introduction to different values and ways
of living that travel brings have positive effects on children. This beneficial effect is no
doubt magnified for bright children in families who perceive the move to be in their best
interests, and who are optimistic and enthusiastic about the changes (Fassler, 1978; Stroh
& Brett, 1990).
Children at High Risk of Academic, Emotional, or Social Problems

One might hypothesize that those children with a sense of separation anxiety would have
the most difficult time with a move and be more prone to exhibit the features of a crisis.
Psychiatric researchers estimate that a large number of the childhood population have
some vestiges of separation and related anxiety. Introverted children would also seem to
be at risk because of difficulty making new friends.
Poverty. Who else is at risk for developing a crisis? As already mentioned, children for
whom a move is not a planned or economically favorable situation are probably at risk
of having negative outcomes from moving. These conditions are closely linked to poverty.
Foster children also are at risk of moving frequently during their placement and this makes
them a population at risk for academic problems (Allen & Vacca, 2010). The type of
move, whether to a more or less affluent community, is also important. Among the poor,
moving to a high-crime neighborhood leads to an increase in aggression for boys in middle
childhood (Parente & Mahoney, 2009).
Migration. Migrant workers and seasonal farm workers are indispensable to the agri-
cultural industry and often move from place to place with their children. One way to
estimate the number of children of migrant workers is to examine the number of partici-
pants in the Migrant Education Program. In 2007, a half a million children in 49 states
were served by Migrant Education (National Association of State Directors of Migrant
Education, 2012). Of these migrant children, approximately 80% are Latino in origin and
10% are Caucasian. Two thirds of the children are U.S.-born (Popp et al., 2003). In addi-
tion to educational issues, these children often do not have access to health care and are
more likely to suffer from untreated illness than other children. Complicating the problem
of working with them are language barriers, uncertain legal status, and lack of physical
resources to support education, such as books and computers.
Homeless. Clearly homeless children are at risk. They move with parents from shelter
to shelter, from relative and friend to relative and friend, or live in automobiles. The 1.6
million children without homes are twice as likely to experience hunger, to have moder-
ate to severe acute and chronic health problems, and to do poorly in school as their peers
(National Center on Family Homelessness, 2010). They may or may not move schools
often, but obviously suffer from a number of emotional hazards.
Developmental Considerations
Moving will have different consequences for children depending on their level of cognitive,
emotional, and social development. To some extent risk of a crisis response to this hazard
increases with age.
Preschool. Generally speaking, most researchers have observed very little ill effects
occurring from moves in the preschool population (Inbar, 1976; Tooley, 1970). Because
the major effect of a move on preschoolers is a change of environment and usually not a
loss of significant others, moves may be easy for infants and toddlers. Because preschoolers
have formed attachments mainly to family members, and only secondarily to places and
peers, they may be protected from stress. To the extent that important family members stay
with the child during the move, there are perhaps superficial impacts of a move on young
children. Placing the child out of the home with relatives and baby-sitter while settling in
is probably not a good idea (Stubblefield, 1955). Nevertheless, one might speculate that
because a major life crisis centers around separation at the preschool age, to the extent that
the move causes parents to become preoccupied with the details of the move and to ignore
the child’s needs for comfort and emotional support, a move will create additional prob-
lems for the very young child. A move coupled with the loss of a parent through divorce
or death will be especially difficult. There is no doubt that moves can cause great stress for
one or another parent, although one might speculate that mothers bear the brunt of the
problems of packing, finding new housing, and so on. Depending on the child’s closeness
to the mother and the stress-induced changes in her reactions to the child, problems might
be anticipated for preschoolers because this is the age when children are most attuned to
their parents’ mental state.
Middle Childhood. Others have argued that middle childhood represents a time of great
vulnerability (Inbar, 1976; Matter & Matter, 1988; Tooley, 1970). Inbar (1976) suggests
that because children in elementary school are transferring their close relations from the
family to friends, moving may be a severe handicap for the socialization process. The
American Academy of Child and Adolescent Psychiatry (2011) states, “Children in kin-
dergarten or first grade may be particularly vulnerable to a family move because develop-
mentally they are just in the process of separating from their parents and adjusting to new
authority figures and social relationships. The relocation can interfere with that normal
process of separation by causing them to return to a more dependent relationship with
their parents.”
In addition, according to Erikson (1962), young elementary school children are involved
in establishing a sense of industry that occurs primarily in mastering tasks in school, such
as learning to read and write. Consequently, the disruption in school progress brought
about by a move may cause considerable emotional difficulties as well as learning prob-
lems. Adolescent residential and school mobility has been consistently linked to dropping
out of school (South, Haynie, & Bose, 2007). It may be argued that the curriculum across
the United States is more uniform than it is different, and that children can easily make
the transition to related curriculum materials or even find the same reading series, for
example, that they left behind them. Nevertheless, disruption in the curriculum is a hazard.
The problem may be much easier for higher achievers, in this regard, than for learning
disabled or other children who have difficulty learning and who depend on the interper-
sonal relationship with the teacher to facilitate learning. Although individual educational
plans (IEPs) may have been developed for exceptional children, these plans may not be as
easy to transfer from one locale to another as IEP proponents hope. Also, the problem of
requalifying for special education may crop up to the extent that different standards for
special education exist in different regions of the country. As a result, a child with learning
handicaps may not encounter a sympathetic environment when he or she moves.
Adolescence. Other researchers believe that adolescents experience the most trauma
during moves (Hendershott, 1989; Pinder, 1989; Tooley, 1970). The task of adolescents,
according to Erikson (1962), is to establish an identity through the use of interpersonal
relations with peer groups. To have the continuity of such relations with peers disrupted
by a move will obviously lead to difficulties. There is evidence that following relocation,
many adolescents go through a period of reduced contact and intimacy with close friends
(Vernberg, Greenhoot, & Biggs, 2006). Adolescents most fear the loss of a social group as
an ego support system. Because the group facilitates role playing and experimentation that
lead to identity, the loss of close friends brought about by a move is particularly destruc-
tive. In addition, adolescents often are in conflict with parents as they seek to reject family
values and parental authority in the process of creating their own values as individuals.
The move may provide a focal point for conflict and rebellion, leading the adolescent to
attempt to use the move as a way of achieving independence (by, for example, asking to
remain behind, or by simply refusing to cooperate in any way with the moving plans).
Cause and effect are not always clear in moves with adolescents. Some moves may be
occasioned by school problems. Rumberger and Larson (1998) believe that school mobil-
ity may represent a less severe form of educational disengagement, similar to dropping out.
Adolescents in their study who made even one nonpromotional school change between
grades 8 and 12 were twice as likely to not complete high school as were adolescents who
did not change schools.
Other adolescents may welcome a move as an opportunity to start over again in a sec-
ondary school with a new group of peers. They see the move as facilitating role experimen-
tation by providing a new audience and setting for them to try different ways of acting.
Those adolescents who wish a fresh start following problems in previous schools may view
moves positively. Kroger (1980), examining 11 intact middle-class homes, found little or
no negative impact of moving on self-concept.
Prevention Activities
When one knows that a move is in the offing it is possible to prepare the child for the
move in a way that will facilitate adjustment. There are a number of anticipatory guidance
activities that can be planned for a child that will help him or her think through in advance
changes that will occur and prepare for the accompanying strong feelings.
Anticipatory Guidance
To remove the fear of the unknown, children should preview the new house, actively
participate in its selection, and tour the new neighborhood, school, and community. The
moving trade organizations have worked with educational and psychological consultants
to produce excellent sets of suggestions on web sites designed for parents to help them
prepare their child for moving. Many of their suggestions are very relevant. Currently the
best set may be found at http://www.moversdirectory.com/moving_with_kids.html.
First, experts encourage parents to talk about the move with their children. Children
should not learn about the move from another source (Switzer et al., 1961). They advise
the parent to explain to each child at his or her own level of understanding the reason for
the move and to anticipate what the new home and community will be like. They should
welcome questions to open communication. They also suggest that parents inform their
children about how they can make the move a successful one and assign them a role in
the move. Additionally, they recommend that parents be accepting of children’s feelings,
even their particularly negative ones about the move. They believe that parents should be
truthful and share their misgivings as well as hopes for the new move, although attempting
to remain positive. Obviously, the further in advance of the move the conversations take
place, up to a point, the more successful they will be (Stubblefield, 1955). A child who has
moved before may have some residue of feelings about the previous move and past experi-
ences that should also be explored openly.
The web sites also offer some age-appropriate suggestions. For infants, they emphasize
the importance of disrupting the infant and toddler’s normal routine as little as possible.
Preschoolers may be helped by directly addressing any fears that the child may be left
behind, and reassuring the child that favorite toys and special objects such as teddy bears
or beds and chairs, although they will be packed and out of sight, will be restored to an
appropriate place in the new house. The movers warn against leaving preschoolers with
babysitters for a long period of time during the moving period. To do so might cause them
to experience more separation than usual. They also suggest the preschooler be allowed to
pack and carry along some of their own special possessions during the move. They suggest
that a move is not a good opportunity to discard a number of battered and broken toys
that a child has become attached to. As inconvenient as this may seem, it is probably better
to wait until the child is settled to throw things away.
Children of elementary school age can be reasoned with more effectively. Parents should
allow them to express their concerns and to talk about the challenges of fitting in with a
new group of friends and schoolmates. Frank discussions with teenagers may allow them
to express their potential anger at the move but also to consider the advantages, such as
the opportunity of meeting new people and new activities. When the teenager finds orga-
nizations and groups in the new area that are involved in interesting activities, encourage
the teenager to bring friends into the new home, even though the new house may not be
as settled and presentable as the parents may wish. These ideas embody a number of good
preventive principles, such as anticipatory guidance and emotional inoculation.
Prevention in the School Setting

One of the prevailing notions that parents have is that it will be easier on their child if they
move their school-aged children during the summer rather than interrupting their school
career. This notion is based on the idea that children will not be easily able to maintain
continuity in learning if they shift from one set of curriculum materials to another in the
middle of the year. Although there is a certain amount of truth that missing school and
changing teacher’s curriculum materials will interrupt learning, a move during the summer
may bring about a number of more serious problems. Children moving during the sum-
mer will find themselves in a new neighborhood without friends and without activities to
occupy their time. They are isolated and bored until school opens in September, allowing
time for anger and frustration to build. In addition, when school does open, most teachers
are faced with a new classroom and will not be able to identify children who have moved.
As a result, the teacher will not be able to give the newly arrived children the special atten-
tion they may require.
If the child moves during the school year, he or she will move from one social setting
to another. The teacher and the classmates will recognize that the child is new to the
school and make some allowances for the fact. Sensitive teachers will be able to engage
the new child in a number of activities to assist in the establishment of a peer group and
in an appropriate curriculum that is challenging but not overwhelming or repetitive. For
military dependents, Bradshaw et al. (2010) found that participation in extracurricular
activities and connecting with other military students and families, with sensitive teachers,
and with peers were particularly helpful in facilitating adjustment to a new school.
Helping the Child Who Is Leaving. When it is known that a child will be leaving the
school there are a number of activities teachers or others can engage in that will assist
in the transition. Ceremonies are very important in marking passages. Making sure that
children have an opportunity to say good-bye is very important. Allowing the child time
to say good-bye to former teachers and others in the school besides immediate classmates
may allow the child to make the separation easier.
Encouraging the child to write to former classmates may be a useful activity, not only
for the creative writing involved, but also for helping the child realize that friendships
can endure time and distance. Departing children can also be encouraged to take with
them a folder of previous work and work in progress. Taking a record of past and present
accomplishments helps the child maintain a sense of continuity with the old classroom
but also has the advantage of providing the new teacher with an idea of the child’s level of
academic functioning. A note to the new teacher along with an evening telephone number
and encouragement to call can also help the moving child find appropriate placement in
the new school.
As always, giving a child an opportunity to express both positive and negative feelings
about the move in the classroom can be a useful exercise for the entire class. Such class-
room meeting discussions should be planned for a period when there is time for a complete
discussion because other children in the group, and not just the departing child, may have
feelings they wish to explore about moving. No doubt there will be a number of moves
each year in a classroom and these occasions present excellent opportunities for social
studies lessons ranging from geography to anthropology.
Bibliotherapy is another activity that may be very helpful for the child leaving a school
(Smardo, 1981a). With the help of the librarian, teachers and school psychologists can
identify reading materials that focus on the experience of moving and the adjustments
to a new environment. A number of children’s books have been written on this topic
(Bernstein, 1977; Fassler, 1978; Smardo, 1981b). When doing bibliotherapy it is impor-
tant to identify materials that are relevant, are at an interest level that will engage the
child, and are at an appropriate level of reading difficulty so that the child may read the
materials on his or her own. Once the child has had an opportunity to read the materials,
some discussion should follow. The point of bibliotherapy is to provide the child with
models for effective coping and problem solving. Besides books on moving per se, stories
concerning making friends and adapting to new customs and circumstances may also be
particularly relevant.
Splete and Rasmussen (1977) suggest that school guidance personnel routinely hold
“exit interviews” of departing students to discuss their fears and apprehensions about a
move. Part of this interview might be providing factual information about the new school
and community if it is available.
Work with parents is also possible. Splete and Rasmussen recommend consulting with
parents and other family members to resolve conflicts connected to the move, based on the
notion that parent attitude toward moving is an important variable in child adjustment.
Counselors can also give parents strategies and advice for how to be proactive in working
with the new schools their children may enter. Parents can set up meetings with the new
school, accompany their child on a tour of the school, and meet school personnel prior to
enrollment (Holland-Jacobsen, Holland, & Cook, 1984).
Helping the New Child in the Classroom. The first necessity for helping a new child
become integrated in the classroom both socially and academically is to find out as much
information about him or her as possible. A phone call to a previous teacher coupled with
a close inspection of academic records will offer an excellent opportunity to prepare for
educational planning for a new child. Often, educational records take months to arrive if
they ever do. Therefore, a phone call may prove a particularly good investment. Previous
teachers may be asked about interests and preferred activities, information that can be
used to help the child establish friendships with similarly inclined peers in the classroom,
as well as to motivate academic performance. Of course, academic strengths and weak-
nesses as well as successful pedagogic technique should be inquired about.
Research on friendships suggests that those of like ability are inclined to associate
together and form lasting friendships (Rubin, 1980). If possible, the teacher might seat
the new child with like-minded peers or include them in the same work or play groups.
In secondary schools, various interest groups such as music, art, hobbies, and the like, can
form the basis for forming friendships. Because the curriculum in the secondary school
often includes elective courses, it is in these subjects that adolescents are likely to meet
potential friends.
Teachers receiving new pupils in the new classroom must be educated (by school men-
tal health professionals) about possible signs of maladaptation to the move. They should
look for symptoms of depression, withdrawal, fatigue, and even loss of appetite, and bring
students who are suffering some form of depression to the attention of school psycholo-
gists and counselors. Teachers seem to appreciate that moving is a crisis for children so
they will be open to assistance in this regard. In the next section, I discuss crisis counseling
interventions on the part of guidance personnel should teachers identify children in need
of extra assistance.
Switzer et al. (1961) note that often school personnel harbor hostility for new children
in general. New children are perceived to be threats to the accomplishment of important
goals such as building cohesive classroom groups, keeping student-teacher ratios low, and
high levels of classroom achievement. To the extent that this hostility interferes with work-
ing with an individual, consultation with the teacher directed at eliminating this theme will
be necessary.
It is an open question as to whether new children should be singled out and introduced
to classmates. Verbal and extroverted children probably can handle this situation well and
will be comfortable in front of groups and able to tell new classmates about their previ-
ous location and the circumstances of their move. Other children will be far too shy to
engage in open classroom discussions in spite of the positive outcomes that might occur
in making themselves known to potential friends and integrating themselves in the class-
room. Orientation programs in which new children may simply watch the classroom and
familiarize themselves with procedures and practices may be best for some (Levine, 1966).
Levine reports a program in which upper-grade children are recruited and trained to serve
as guides to children entering school. The guides show the new pupils the building, inform
them of school rules, and discuss age-appropriate resources in the school and community.
Holland-Jacobsen, Holland, and Cook (1984) recommend five ways a counselor can
be helpful: (a) providing in-service sessions for teachers on how to facilitate adaptation of
students to the new school; (b) arranging “get-to-know-the-school” night for new students
and parents; (c) arranging special tutoring “catch-up” sessions at the beginning of the year
and throughout the year as necessary; (d) setting up a buddy system by assigning a peer to
each new student and; (e) setting up periodic meetings with new students. These sugges-
tions seem easy to implement and are likely to be of help.
Crisis Counseling Children Who Have Moved or Are About to Move

At some point, the school psychologist will encounter a child who is in a state of crisis as a
result of a move. A first step, of course, is to determine what has brought about the move
and whether it represents a radical change in the child’s home environment or parental
relations. If the move was occasioned by another hazardous life event, perhaps the coun-
seling should be directed primarily at this circumstance, and secondarily at the issues asso-
ciated with the move. On the other hand, the impact of the move should not be ignored in
helping, for example, the child adjust to a parental divorce.
Individual Interventions
Assuming the major issue is the move and the change from one school and neighborhood
to another, the focus of counseling for younger children should be on the expression
of feelings of loss and the experience of apprehension at establishing new routines and
friendships. The child can be led to examine the old situation and encouraged to enumer-
ate both positive and negative aspects of his or her relationships. If the child attempts
to idealize the old, it will be important to question the child carefully to create a more
balanced view.
Next, the child may explore the new situation. If the child is in crisis before the move,
the counselor may ask about what ideas the child has of the new environment. By being on
the lookout for mistaken ideas and by inquiring about new opportunities and advantages
of the move, the helper may assist the child to establish a more favorable outlook.
Many times, the crisis will arise after the move when the child finds him- or herself alone
and isolated. Because the loss of friendship is so devastating at middle childhood, it may
prove effective in counseling to help the child maintain or reestablish the old friendships
through telephone calls, letter writing, and visits.
If the child is having trouble making new friends, it may be important to determine if
the child has the social skills necessary for establishing friendships or if he or she is failing
to use them. If the problem is lack of skill, a number of social skills programs have been
developed that may prove useful (Gresham, 2010). If the child has the skills but fails to
use them, a different tactic is called for. Pointing out to the counselee how he or she has
not used opportunities when they have presented themselves may facilitate action. An
interested adult who reinforces prosocial behavior may help the child establish important
social networks.
Counseling adolescents will call for many of the same approaches, modified to fit their
higher level of cognitive functioning and their unique type of egocentrism (Elkind, 1974).
As mentioned previously, adolescents, with help, can come to see a move as a new chance
to try out different styles of behaving and to play new roles. A counselor can point out this
relevant notion, and help the student consider what the premove social status has been and
what it might be in a new setting.
The adolescent’s egocentrism creates a condition of extreme self-consciousness and sense
that he or she is constantly being observed and judged by others (imaginary audience;
Elkind, 1974). Another aspect of counseling will be to help the adolescent test how realistic
it is to be afraid and inhibited in the new social situations he or she is encountering at the
new school. The client must learn to distinguish between his or her preoccupations and
sensitive points and what is of interest and of concern to others. Role playing may be a
useful technique to get the adolescent aware of another’s frame of reference.
Group Intervention
Mutual support groups have been used successfully to help individuals with common
problems explore feelings and discuss ways of overcoming them and coping. They are a
way to supply information from credible sources about an unusual situation. Interaction
with peers experiencing the same hazardous situation can reduce a sense that reactions
are unique and abnormal. Such feelings lead to alienation, isolation, and poor adaptation.
A support group may be an ideal mechanism for helping adolescents with the stress of
relocation.
Strother and Harvill (1986) describe a six-session (once a week) model support group
they have used successfully. They recommend 90-minute groups for 8 to 20 voluntary
participants. The first session is designed to help the students feel comfortable with the
group and to become acquainted. Participants are asked to describe their move and their
initial reactions. Most of the discussion is focused on answering questions about the new
school and providing information. Following the first session, students meet for a group
lunch to encourage cohesion of the group.
The second session focuses on providing members with skills to build a new support
system. Students share thoughts and feelings about their recent loss, discuss fears about
forming new social supports, and explore how they have made friends in the past. In
dyads, they discuss feelings of sadness at losing old friends as a result of the move. The ses-
sion closes with brainstorming about how to make new friends and a request to maintain
a journal of their experiences in meeting new people at school.
The next three sessions are devoted to sharing again feelings of loss, discussing common
family concerns, and encouraging mutual support among group members. Increasingly
the group shifts from providing information to providing emotional support. A number of
exercises are used to achieve these ends, as well as shared homework assignments.
The final session summarizes the previous weeks, and promotes the exchange of strate-
gies for coping with the move. The group evaluates itself and is encouraged to continue
supporting each other after the group concludes. Any group members who require further
counseling are also identified for individual follow-up.
Group work offers the advantage of working with several individuals at once, but also
has the advantage of restoring a sense of belonging that may be lost in a move. Students
can become more easily assimilated into the new school environment if they are given
knowledge and emotional support along the way.
Conclusion
In summary, moving is a hazardous time for children. Moving presents a number of oppor-
tunities to build new skills and competencies, however. With the right preparation on the
part of parents, and with sensitive school personnel, a child may experience a move as
a natural part of growing up. If the move is a part of another crisis, careful attention to
helping the child resolve the issues of moving can leave the child with more resources to
cope with other life events.
REFERENCES
Adam, E. K. (2004). Beyond quality: Parental and residential stability and children’s adjustment.
Current Directions in Psychological Science, 13, 210–213.
Allen, B., & Vacca, J. S. (2010). Frequent moving has a negative effect on the school achievement
of foster children makes the case for reform. Children and Youth Services Review, 32, 829–832.
doi: 10.1016/j.childyouth.2010.02.001
American Academy of Child and Adolescent Psychiatry. (2011). Children and family moves. Facts
for Families No. 14. Retrieved from http://www.aacap.org/cs/root/facts_for_families/children_
and_family_moves
Bekins Co. (1976). Youth consumer survey. Glendale, CA: Author.
Bernstein, J. E. (1977). Books to help children cope with separation and loss. New York: Bowker.
Benson, G. P., Haycraft, J. L., Steyaert, J. P., & Weigel, D. J. (1979). Mobility in sixth graders as
related to achievement, adjustment, and socioeconomic status. Psychology in the Schools, 16,
444–447.
Blane D., & Spicer, B. (1978). Geographic mobility, educational attainment and adjustment—Which
children are at risk? Education Australia, 3, 51–64.
Bowlby, J. (1960). Separation anxiety. The International Journal of Psychoanalysis, 41, 89–113.
——— (1961). Separation anxiety: A critical review of the literature. Journal of Child Psychology
and Psychiatry, 1, 251–269.
Bradshaw, C. P., Sudhinaraset, M., Mmari, K., & Blum, R. W. (2010). School transitions among mil-
itary adolescents: A qualitative study of stress and coping. School Psychology Review, 39, 84–105.
Brown, A. C., & Orthner, D. K. (1990). Relocation and personal well-being among early adoles-
cents. Journal of Early Adolescence, 10, 366–381.
Calabrese, R. L. (1989). The effects of mobility on adolescents’ alienation. High School Journal,
73, 41–46.
Dong, M., Anda, R. F., Felitti, V. J., Williamson, D. F., Dube, S. R., Brown, D. W., & Giles, W. H.
(2005). Childhood residential mobility and multiple health risks during adolescence and adult-
hood. Archives of Pediatrics and Adolescent Medicine, 159, 1104–1110.
Elkind, D. (1974). Children and adolescents (2nd ed.). New York: Oxford University Press.
Erikson, E. (1962). Childhood and society (2nd ed.). New York: W. W. Norton.
Fassler, J. (1978). Helping children cope: Mastering stress through books and stories. New York:
Macmillan.
Gerner, M., Perry, F., Moselle, M. A., & Archbold, M. (1992). Characteristics of internationally
mobile adolescents. Journal of School Psychology, 30, 197–214.
Gordon, R. E., & Gordon, K. K. (1958). Emotional disorders of children in a rapidly growing sub-
urb. International Journal of Social Psychiatry, 4, 85–97.
Greene, J. E., & Daughtry, S. L. (1961). Factors associated with school mobility. The Journal of
Educational Sociology, 35, 36–40.
Gresham, F. M. (2010). Evidence-based social skills interventions: Empirical foundations for instruc-
tional approaches. In M. R. Shinn & H. M. Walker (Eds.), Interventions for achievement and
behavior problems in a three-tier model including RTI (pp. 327–362). Bethesda, MD: National
Heinlein, L. M., & Shinn, M. (2000). School mobility and student achievement in an urban setting.
Psychology in the Schools, 37, 349–357.
Hendershott, A. B. (1989). Residential mobility, social support and adolescent self-concept. Adoles-
cence, 24, 217–232.
Holland-Jacobsen, S., Holland, R. P., & Cook, A. S. (1984). Mobility: Easing the transition for
students. The School Counselor, 32, 49–53.
Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychoso-
matic research, 11, 213–218.
Humke, C., & Schaefer, C. (1995). A review of the effects of residential mobility on children and
adolescents. Psychology: A Journal of Human Behavior, 32, 16–24.
Inbar, M. (1976). Social science frontiers: The vulnerable age phenomenon. New York: Russell
Sage.
Jelleyman, T., & Spencer, N. (2008). Residential mobility in childhood and health outcomes: A sys-
tematic review. Journal of Epidemiology and Community Health, 62, 584–592.
Kenny, I. A. (1967). The child in the military community. Journal of the American Academy of Child
Kroger, J. E. (1980). Residential mobility and self concept in adolescence. Adolescence, 15, 967–977.
Lehr, C. J., & Hendrickson, N. (1968). Children’s attitudes toward a family move. Mental Hygiene,
52, 381–384.
Levine, M. (1966). Residential change and school adjustment. Community Mental Health Journal,
2, 61–69.
Marchant, K. H., & Medway, F. J. (1987). Adjustment and achievement associated with mobility in
military families. Psychology in the Schools, 24, 289–294.
Matter, D. E., & Matter, R. M. (1988). Helping young children cope with the stress of relocation:
Action steps for the counselor. Elementary School Guidance & Counseling, 23, 23–29.
National Association of State Directors of Migrant Education. (2012). Migrant Education. Retrieved
from http://www.nasdme.org/migranted.html
National Center on Family Homelessness. (2010). America’s youngest outcasts, 2010. Retrieved
from http://www.familyhomelessness.org/
Norford, B. C., & Medway, F. J. (2002). Adolescents’ mobility histories and present social adjust-
ment. Psychology in the Schools, 39, 51–62. doi: 10.1002/pits.10005
Oishi, S., & Schimmack, U. (2010). Residential mobility, well-being, and mortality. Journal of Per-
sonality and Social Psychology, 98, 980–994. doi:10.1037/a0019389
Parente, M. E., & Mahoney, J. L. (2009). Residential mobility and exposure to neighborhood
crime: Risks for young children’s aggression. Journal of Community Psychology, 37, 559–578.
doi:10.1002/jcop.20314
Pedersen, F. A., & Sullivan, E. J. (1964). Relationships among geographical mobility, parental atti-
tudes and emotional disturbances in children. American Journal of Orthopsychiatry, 34, 575–580.
Picou, J. S., & Marshall, B. K. (2007). Social impacts of Hurricane Katrina on displaced K-12 stu-
dents and educational institutions in coastal Alabama counties: Some preliminary observations.
Sociological Spectrum, 27, 767–780. doi:10.1080/02732170701534267/
Pinder, C. C. (1989). The dark side of executive relocation. Organizational Dynamics, 17, 48–58.
Pittman, J. F., & Bowen, G. L. (1994). Adolescents on the move: Adjustment to family relocation.
Youth & Society, 26, 69–91.
Popp, P. A., Stronge, J. H., & Hindman, J. L. (2003). Students on the move: Reaching and teaching
highly mobile children and youth. Greensboro, NC: National Center for Homeless Education;
New York: ERIC Clearinghouse on Urban Education. ED 482 661.
Rubin, Z. (1980). Children’s friendships. Cambridge, MA: Harvard University Press.
Rumberger, R. W., & Larson, K. A. (1998). Student mobility and the increased risk of high school
dropout. American Journal of Education, 107, 1–35.
Sackett, E. B. (1935). The effect of moving on educational status of children. The Elementary School
Journal, 35, 517–526.
Shaw, J. A. (1987). Children in the military. Pediatric Annals, 17, 539, 543–544.
Smardo, F. A. (1981a). Books about moving. Childhood Education, 58, 37–39.
——— (1981b). Geographic mobility: How do we help children cope? Childhood Education, 58,
40–45.
South, S. J., Crowder, K. D., & Trent, K. (1998). Children’s residential mobility and neighborhood
environment following parental divorce and remarriage. Social Forces, 77, 667–693.
South, S. J., Haynie, D. L., & Bose, S. (2007). Student mobility and school dropout. Social Science
Research, 36, 68–94. doi:/10.1016/j.ssresearch.2005.10.001
Splete, H., & Rasmussen, J. (1977). Aiding the mobile child. Elementary School Guidance and
Counseling, 11, 225–228.
Stroh, L. K., & Brett, J. M. (1990). Corporate mobility: After the move, what do children think?
Children’s Environments Quarterly, 7, 7–14.
Strother, J., & Harvill, R. (1986). Support groups for relocated adolescent students: A model for
school counselors. Journal for Specialists in Group Work, 11, 114–120.
Stubblefield, R. L. (1955). Children’s emotional problems aggravated by family moves. American
Journal of Orthopsychiatry, 25, 120–126.
Switzer, R. E., Hirschberg, J. C., Myers, L., Gray E., Evers, N. H., & Forman, R. (1961). The effect
of family moves on children. Mental Hygiene, 45, 528–536.
Temple, J. A., & Reynolds, A. J. (1999). School mobility and achievement: Longitudinal findings
from an urban cohort. Journal of School Psychology, 37, 355–377.
Tooley, K. (1970). The role of geographic mobility in some adjustment problems of children and
families. Journal of the American Academy of Child Psychiatry, 9, 366–378.
Tucker, C. J., Marx, J., & Long, L. (1998). “Moving on”: Residential mobility and children’s school
lives. Sociology of Education, 71, 111–129.
U.S. Department of Commerce, Census Bureau. (2010). PPL-132 Geographical mobility: 2009–
2010. Retrieved from http://www.census.gov/hhes/migration/data/cps/cps2010.html
U.S. General Accounting Office. (2010). Many challenges arise in educating students who change
schools frequently (GAO-11–40). Washington, DC: Health, Education, and Human Services Divi-
sion.
Vernberg, E. M., Greenhoot, A. F., & Biggs, B. K. (2006). Intercommunity relocation and adolescent
friendships: Who struggles and why? Journal of Consulting and Clinical Psychology, 74, 511–523.
doi:10.1037/0022–006X.74.3.511
Weber, E. G., & Weber, D. K. (2005). Geographic relocation frequency, resilience, and military ado-
lescent behavior. Military Medicine, 170, 638–642.
Whalen, T. E., & Fried, M. A. (1973). Geographic mobility and its effect on student achievement.
Journal of Educational Research, 67, 163–165.
Wright, D. (1999). Student mobility: A negligible and confounded influence on student achievement.
Journal of Educational Research, 92, 347–353.
12 Acts of Violence
Jonathan Sandoval, Stephen E. Brock,
& Katie Knifton
This chapter will discuss a category of hazardous events that often comes to mind when
we think of crises in the school: acts of violence. Among these terrorist events are drive-by
shootings, on-campus shootings, sniper attacks, and bombings. This category of hazard-
ous event is the one of the most likely to cause traumatic stress, resulting in posttraumatic
stress disorder (Brock et al., 2009). One feature that acts of violence share with others is
that they are typically sudden and unanticipated (an exception is impending war). How-
ever, even with warnings, those involved often do not anticipate the severity of the event.
Another similarity with many other crises is the fact that the adults in the school as well as
the children are affected by violence. For example, a schoolyard shooting or gang killing
has the potential to traumatize the teachers, administrators, and guidance staff, as well as
students. Thus, these staff members will also need assistance in coping with the aftermath
of the crisis, and consequently, it is much more likely that outside crisis response assistance
will be needed. The emotions and fears resulting from the mayhem are often more extreme
than many other traumatic events.
Fortunately, as illustrated in Figure 12.1, acts of school violence (especially those asso-
ciated with student fatalities) are very rare (Robers, Zhang, Truman, & Snyder, 2010).
Although there is an impression that these acts are increasing, in fact, the incidence of
violent crime among youth is dropping. For example, Robers, Zhang, Truman, and Snyder
report a consistent decrease since 1992 in the rate of nonfatal, school-associated violent
crimes against students ages 12 to 18. What has increased is the amount of press coverage
that is given to these events when they do occur. Instant access to social networking sites
and Internet news reports can also contribute to misconceptions regarding the frequency
of these occurrences. The public perception is that violent crime in schools occurs fre-
quently and is severe; however, this notion is contradicted by actual occurrences reported
by school administrators (Algozzine & McGee, 2011).
Increased publicity about school violence may lead to societal reforms, such as gun
control laws, but there is also a downside to increased attention. Acts of violence that are
highly publicized increase the chance that other disturbed and impressionable individu-
als will attempt a copycat reenactment of the crime to gain the same attention (Lazarus,
Brock, & Feinberg, 1999). Additionally, prolonged mass media presence in communities
following an act of violence may increase trauma exposure and by doing so increase the
rates of psychological traumatization (Brock et al., 2009; Muschert, 2007).
The rarity of these events also leads to problems in prevention. Prevention usually is
based on understanding the dynamics and causes of the crisis event. Because these events
are unusual, it may not be cost effective to address preventing the specific event. This is not
so say that there are not things to be done with respect to primary prevention; rather the
focus of prevention is aimed at generic preparation to prevent and respond to crises in gen-
eral, rather than at preventing specific events. For a detailed review of the current status
Acts of Violence 213
26
At School
Away From School
2911
Figure 12.1 Location and Number of Violent Deaths among Youth 5 to 18 from Robers, et al.,
2010
of crisis prevention, preparedness, and response research the reader is referred to Larson
and Beckman (in press), Nickerson and Gurdineer (in press), and Nickerson, Pagliocca,
and Palladino (in press).
Chapter 2 reviewed the process of establishing crisis response teams in schools, and we
will not review that material here. Instead, drawing heavily from earlier accounts of crisis
response planning (Brock et al., 2009; Brock, Sandoval, & Lewis, 2001) we will discuss
several related topics in this chapter. First, we explore what can be done to prevent acts
of violence (including identifying and responding to potentially violent youth). Next, we
discuss how to prepare for the crisis response to acts of violence. Finally, we examine the
actual crisis intervention response to acts of violence (including the processes of identifying
and responding to psychological trauma victims).
Preventing Acts of Violence

Research demonstrates that prevention efforts can be beneficial in improving the overall
school environment and reducing acts of violence (Center for Disease Control and Preven-
tion [CDC], 2011). These efforts need to include both physical and psychological safety
efforts (Reeves et al., 2011).
Student Discipline
School climate is clearly influenced by whether norms for conduct are fair, clearly articu-
lated, and consistently enforced. The School Safety Check Book (National School Safety
Center, 1990) advocates that schools establish written discipline rules that clearly dif-
ferentiate between an infraction (unacceptable behavior such as lying and inappropriate
language) and a crime (behavior that violates the law such as assault and vandalism). Rules
must be reasonable, and should allow for due process and appeal. School disciplinary
codes must cover school fights as these events may be interpreted as assault and battery.1
School policies can mandate the use of positive behavior supports (Sugai & Horner, 2006)
and list positive expectations for student behavior (instead of simply focusing on what
student are not to do; Brock et al., 2009).
Campus Visitors
As public institutions, schools are open to visitors. However, the school can require that
visitors identify themselves and can set guidelines for access (and in fact 97% of schools
require visitors to sign in; National Center for Education Statistics, 2004). Signs should
214 Jonathan Sandoval, Stephen E. Brock, & Katie Knifton
be posted at all school entry points directing visitors to check in at the school office. It is
important to establish policies that ask all staff members to approach and identify unfamil-
iar campus visitors (Stephens, 1994; Trump, 1998) and ask them to sign in, if they have not
already done so. After having signed in, all campus visitors should be issued identification
badges. Staff should be trained in, and comfortable with, challenging visitors not wearing
a badge.
Employee and Student Identification

To further assist in the identification of campus visitors, it is also helpful if students and
employees are issued their own personal identification cards. A system of photo identifi-
cation badges increases security. This is an especially important procedure within today’s
larger school populations (Brock et al., 2001).
School Climate
Positive school climates are the result of, and contribute to, secure and safe schools. Stu-
dent discipline efforts (discussed earlier) are an important element of improving school
climate. In addition, Stephens (1994) advocates for creating a positive school climate by
building pride and ownership in the school, making the campus welcoming (by having
staff greet students as they arrive and being present during class changes), and having high
administrator visibility (including class visitations and attendance at special events).
Resiliency research and school climate research provide important data regarding fac-
tors influencing the climate of the school. Resiliency and school climate improve as chil-
dren are able to form positive relationships with caring adults (Masten, 1994; Werner &
Table 12.1 Characteristics of Effective Schools and Safe/Secure Classrooms
1. Focus on academic achievement and foster enthusiasm for learning.

2. Involve families in meaningful ways.
3. Develop links to the community.
4. Emphasize positive relationships among students and staff. Teachers and students learn and
use each other’s names.
5. Treat students with equal respect.
6. Discuss safety issues openly.
7. Create ways for students to share their concerns and help students feel safe expressing their
feelings.
8. Have in place a system for referring children who are suspected of being abused or neglected.
9. Offer extended day programs for children.
10. Promote good citizenship and character, and build a community of learners (using collabora-
tion between students and teachers, school and home).
11. Identify problems and assess progress toward solutions. Classroom meetings are held to dis-
cuss issues and solve problems.
12. Support students in making the transition to adult life and the workplace.
13. Develop and consistently enforce school-wide rules that are clear, broad-based, and fair.
14. Classroom management includes firm, fair, and consistent rules and procedures.
15. Use of learning centers and the opportunity for cooperative group work.
16. Leisure areas exist for discussions, downtime, and reading.
17. Books and magazines readily available.
18. Displays of students’ in-progress and completed work.
19. Plants and objects that assist students in developing an identity of the classroom space as
“ours.”
Note. From Dwyer, Osher, & Wagner (1998) and Strepling (1997).
Smith, 1982). Many vehicles are available for making this kind of adult-student interac-
tion possible, including schools within schools, use of community mentors, and suffi-
cient numbers of school psychologists, social workers, and counselors. Dwyer, Osher, and
Warger (1998) and Strepling (1997) have reviewed the school climate literature. Their
findings on the characteristics of effective schools and safe and secure classrooms are sum-
marized in Table 12.1.
School Environmental Design

Often a relationship exists between student and staff behavior and their surroundings.
Crowe (1990) describes crime prevention through environmental design (CPTED), that
asserts that the appropriate physical “design” and effective use of the “built environ-
ment” decrease the incidence of crime and prevalence of fear. Natural surveillance, natu-
ral access control, and territoriality are CPTED’s three guiding principles for securing a
school (Sprague & Walker, 2005). Surveillance efforts include ensuring adequate school-
wide supervision. Access control involves exercising control over who and what enters
the school building. Territoriality refers to efforts designed to increase a sense of shared
ownership of the school (which in turn increases the likelihood that students will challenge
inappropriate behavior when it is observed). The notion of territoriality is supported by
the CDC (2011); when youth serve as active bystanders, students are more likely to inter-
vene to stop school violence episodes.
The National Association of School Psychologists (NASP, n.d.) offers a checklist to
help schools create a safe school building. For example, the NASP checklist recommends
schools keep hallways well lit at all times, combine faculty and student parking, and keep
lockers in an open, visible location. Crowe (1990) identifies significant problem areas on
school campuses, including parking lots and lockers, and also suggests potential remedies.
It is important for school personnel to be vigilant for possible signs of developing trouble.
Signs include shifts in clusters of students congregating together; rival groups binding
together; students attending events they normally do not attend; sudden appearance of
underground publications, web sites, or blogs; and parents withdrawing their children
from school due to a fear that something might happen (Brooks, 1993).
School Security
Many schools have their own security personnel or have become “beats” for local police.
Models of campus security, described by Grant (1993), include “officer friendly” and
“campus cop.” In the former, the police officer has a public relations role; educates chil-
dren on safety, gangs, and substance abuse; and is viewed as a positive role model. In the
latter model, the officer’s role is to enforce laws. Combining both models, Grant also
describes the development of the School Liaison Officer Program in Richmond, British
Columbia. In this program police officers attend sporting events, dances, field trips; have
casual conversations with students; investigate school crimes; follow up on disclosures;
and provide enforcement. In today’s schools, only 35% have safety resource officers (or
SROs; Weiler & Cray, 2011). This statistic is likely a reflection of the current economy and
minimal funding schools are receiving. Fortunately, the Cops in Schools Grant Program
continues to place SROs in schools when possible, placing 6,400 SROs nationwide in 2008
(Mayer, 2008).
Schools have also utilized modern technological security measures to increase physical
safety. Video cameras, closed circuit television systems, metal detectors, and electronic key
cards can be useful (Jennings, Khey, Maskaly, & Donner, 2011). A U.S. Department of
Justice grant program that provides innovative security to ensure school safety is offered
by the Office of Community Oriented Policing Services (the COPS Office). The COPS
Office works with law enforcement agencies and assists schools in obtaining metal detec-
tors, locks, lighting, and other deterrent measures. Security training for personnel and stu-
dents is also available. For more information, go to www.cops.usdoj.gov. A balance must
be struck between adequate monitoring for safety and the establishment of a friendly,
caring school climate. To help maintain a positive atmosphere, employing student resource
officers (or SROs) can also be useful (Jennings et al., 2011).
Identifying and Responding to Potentially Violent Students

The school environment can be made as safe as possible, and still an act of violence can
occur. Consequently, an important additional step in the prevention of acts of violence is
to recognize the warning signs of students who may be prone to violence.
Identifying Warning Signs of Violence

School staff members, students, and parents should be helped to recognize the early warn-
ing signs of potentially violent students. Fortunately, several resources are available to
help. One of the first resources published was Early Warning, Timely Response: A Guide
to Safe Schools (Dwyer, Osher, & Wagner, 1998). Developed at the request of President
Clinton and mailed to every school in the nation, this document reflects the views of
experts in the fields of education, psychology, mental health, criminal justice, and law
enforcement. Threat Assessment in School: A Guide to Managing Threatening Situations
and to Creating Safe School Climates (Fein et al., 2004) is another helpful violence preven-
tion resource. This document was developed through a collaboration between the Depart-
ment of Homeland Security and the U.S. Department of Education, and followed a study
that examined school shootings as far back as 1974, researching 37 school attacks and
41 attackers. Interviews with attackers were also conducted. The goal was to provide
schools with tools and information to prevent future attacks. The results revealed that inci-
dences of targeted violence tend to be premeditated and often other children are aware of
the impending attack. These results provide hope that prevention can be achieved through
the identification, assessment, and managing of students. For a summary of warning
signs that includes a checklist of youth who have caused school-associated violent deaths,
see the document provided by the National School Safety Center (Stephens, 1998, 2011).
Most of these signs or indicators suggest problems with anger control, but unfortunately,
they are often dismissed as normal adolescent behaviors, especially in males. A history of
displaying several signs should be taken more seriously than a single behavior in isolation.
In addition, discussions and/or rumors from other children regarding possible violence
should also be investigated.
We strongly recommend that when publicizing these warning signs to attend to them
with great caution, which professionals and training programs also recommend. Students
who display these warning signs might, or might not, commit a violent act. Warning signs
should be used only to identify students who may require further assessment to evaluate
risk and to guide interventions. They should not be viewed as predictors of violent behav-
ior, nor should they be used to exclude students from school (Brock, 1999). Dwyer et al.
(1998, pp. 6–7) provide several principles designed to help schools avoid the misuse or
misinterpretation of warning signs. These principles include the following.
Do No Harm. The intention of early warning sign checklists should be to facilitate the
identification of students who are troubled and in need of supportive interventions. They
should not be used to label, exclude, punish, or isolate. In addition, information about
early warning signs must be kept confidential and disclosed only on a need-to-know basis.
Avoid Stereotypes. It is essential not to use stereotypes (e.g., race, socioeconomic status,
learning ability, or appearance) to identify students. Even if the purpose of the identifi-
cation is to provide “helpful” interventions, such labeling can do harm. Another area
of potential misuse is invasion of privacy and discrimination by overidentifying certain
groups of children (Nelson, Roberts, Smith, & Irwin, 2000). Biased school staff may
consciously or unconsciously target individuals from a particular group. Nelson, Roberts,
Smith, and Irwin (2000) also express concern over the possibility that students labeled as
dangerous might be denied access to after-school programs.
View Warning Signs Within a Developmental Context. It is important to place the student’s
behavior within the appropriate developmental context. Developmentally typical behavior
should not be interpreted as a warning sign. If necessary provide all staff with informa-
tion describing developmentally typical behavior for the age group they are working with.
Always remember that troubled students typically display many warning signs, repeatedly,
and with increasing intensity over time. Thus, it is important not to overreact to a single sign.
Responding to Warning Signs

It is critical that referral procedures to assist in the assessment of potentially violent stu-
dents be developed. We recommend that these procedures be sensitive to the level and
intensity of the warning signs being observed. Specifically, at least two levels of referrals
need to be in place: one for “at-risk,” and another for “high-risk” students.
At-Risk Referral Procedures. The first level of referral procedures should be designed to
facilitate the assessment of students who display relatively low-intensity and short-duration
early warning signs. Vehicles for these referrals may include traditional school resources,
such as student study teams or student assistance programs. Through these resources, the
appropriate school staff members (e.g., administration, school mental health staff, other
support staff, and/or teachers) can be informed about the status and progress of the at-risk
students, and recommend appropriate interventions.
High-Risk Referral Procedures. The second level of referral procedures should be
designed to facilitate the assessment of students who display several imminent warning
signs of violence (see Table 12.2). Obviously, a school’s response to these signs must be
immediate. School procedures must specify that when any of these behaviors are noted,
the observer should make an immediate referral to a school administrator, to a school
mental health professional, or both. An initial assessment procedure should determine the
nature of the suspected violence and determine if the means for such behavior are available
(e.g., whether the student has a weapon). If the means are at hand, responsible and trusted
adults should remove them as soon as possible. If the student refuses to relinquish the
means of threatened violence, school staff will need to discretely call for assistance from
Table 12.2 Imminent Warning Signs of Violence
1. Serious physical fighting with peers or family members.

2. Severe destruction of property.
3. Severe rage for seemingly minor reasons.
4. Detailed threats of lethal violence.
5. Possession and/or use of firearms and other weapons.
6. Other self-injurious behaviors or threats of suicide.
Note. From Dwyer, K., Osher, D., & Warger, C. (1998, p. 11).
law enforcement. Next, once immediate safety is assured, a mental health professional
should conduct a careful risk assessment. While waiting for this evaluation, a responsible
and trained adult should keep the student under close supervision. Under no circumstances
should a high-risk student be left alone.
Intervening with Potentially Violent Students

There are a variety of strategies that may help the student at risk for violence. Among them
are individual counseling, social skills and anger management training, and behavioral
programming.
Counseling. One of the most important interventions for troubled children is individual
counseling. A school psychologist, counselor, or social worker typically provides this sup-
port. As with all counseling interventions, a plan should be developed that is unique to the
individual. With the student at risk for violence, however, this plan will need to include
provision for immediate assistance. For example, there may need to be provisions for
responding to and calming the student who is on the verge of losing control and, if neces-
sary, an action plan to ensure the safety of others.
Social Skills and Anger Management Training. With potentially violent youth, counsel-
ing may focus on teaching skills such as anger management (e.g., Goldstein & Glick, 2002)
and social skills (e.g., Elliot, Frey, & DiPerna, in press), rather than traditional psycho-
therapy. Counseling curriculum for students of all ages is being widely used—for instance,
children from preschool age to middle school can benefit from programs such as Second-
Step: A Violence Prevention Program, which is considered an early intervention program.
Second-Step aims to reduce impulsive and aggressive behaviors and has been empirically
supported (Frey, Nolen, Edstrom, & Hirschstein, 2005). Examples for teens and adoles-
cents include Too Good For Drugs and Violence High School (Bacon, 2001), Seeing Red:
An Anger Management and Peacemaking Curriculum for Kids (Simmonds, 2003), and
Aggression Replacement Training, developed by A. P. Goldstein (Goldstein & Glick, 2002;
Goldstein, Glick, Reiner, Simmerman, & Coultry, 1985), as well as the Student Created
Aggression Replacement Education or SCARE program (Herrmann & McWhirter, 2003).
Anger management counseling is becoming more attainable as many schools now offer
group counseling that focuses on these skills. Other options such as online anger manage-
ment classes are also available. In our experience we feel more research needs to be done
before assuming the effectiveness of such programs.
Functional Assessment and Positive Behavioral Programming. A second individual
intervention is functional assessment and the development of positive behavior plans,
which identify an undesirable behavior and then determine its function or purpose. Once
the purpose and antecedents of the behavior have been identified, the next step is to iden-
tify a replacement behavior and make environmental adjustments that set the student up
for success. Ideally, this replacement behavior not only is more socially adaptive, but also
provides an alternative way for the student to achieve his or her behavioral goal or goals
(Quinn, Gable, Rutherford, Nelson, & Howell, 1998; Gable, Quinn, Rutherford, Howell,
& Hoffman, 1998a, 1998b).
Preparing for Acts of Violence

Schools have a history of preparing for disasters, with the most obvious example being
drills (e.g., fire, tornado, earthquake drills). Recently, schools have also begun to develop
similar procedures for responding to acts of violence. Elements of such drills and other
preparedness considerations are discussed in this section.
Crisis Response Box
An essential crisis preparedness activity is the development of a crisis response box, which
can quickly be accessed and provides relevant information to the right people in an emer-
gency situation (Lockyer & Eastin, 2000). These boxes contain medical information, keys
to all classrooms, as well as student and faculty lists and contacts. Procedures for the
school building, such as how to turn off electricity or sprinklers, are also included along
with a blueprint for the school. A crisis response box can save emergency personnel valu-
able time and bring order to a chaotic situation.
Emergency Communications
A growing number of students, faculty, and parents now carry cell phones, which can be an
undeniable asset when a crisis occurs. School administration can notify parents and teachers
of an emergency simultaneously. For example, the National Incident Management System
(NIMS; U.S. Department of Homeland Security, 2008) recommends that crisis teams imple-
ment a plan that makes use of an emergency communication system in which one call is
made and all necessary parties are texted or e-mailed specific information regarding a critical
incident. Many alert systems have been developed, such as the School System Alert, which
sends messages to hundreds and even thousands of people instantly (http://ssalert.com).
Brock et al. (2009) provide a detailed discussion of emergency communication options.
Emergency Procedures
Complementary to the emergency communication preparedness just described, school
staff members need to be trained regarding exactly what to do when they are informed
of (or observe) an act of violence. One essential procedure, often referred to as a “lock-
down” (an unfortunate borrowing of a term from the prison system), contains students in
one location. Variations include lockdown within the classroom itself, or in a larger space
together, such as the gym. Typically, in any lockdown situation, no one is allowed to enter
or exit the school grounds until an “all clear” is announced. During a lockdown, staff
must know that students are to be directed to a secure room, doors locked, cover taken
underneath tables or desks, windows closed, and curtains drawn. Drills are an important
part of this emergency response procedure.
The Port Huron schools in Michigan developed an SOS system to be used in life-threat-
ening emergency situations while in lockdown. Each classroom has three posters in red,
yellow, and blue, which can be posted on the window or slid under the door in an emer-
gency. Red indicates someone in the room needs immediate medical attention, yellow
indicates there are injuries but they are not life-threatening, and blue indicates there are
no injuries in the classroom (Lockyer & Eastin, 2000). The SOS system is especially useful
when phones and Internet are down or in locations where there is no service or power.
Clearly, it is essential that all school staff members be frequently trained regarding the
procedure and practices implemented at each individual school.
Emergency Evacuations
Some acts of school violence may necessitate the evacuation of students from one location
to another (e.g., terrorist attacks, bombings, bomb threats). The first step in developing
an evacuation plan is to identify potential safe areas that students could be moved to in
the event that their school and/or their classrooms are no longer safe. Ideally, the area
chosen would be large enough to accommodate the entire student body. Examples of such
locations include shopping centers, community recreation facilities, business offices, and
churches. In most cases, existing fire drill evacuation routes can be adapted to other poten-
tial emergencies requiring evacuation. However, the evacuation procedure should contain
alternative evacuation routes, in the event that the primary evacuation routes or safe areas
are affected by the crisis event (Brock et al., 2001).
Accounting for Students and Staff

It is also important to develop plans and procedures that will allow the school to quickly
and efficiently account for students and staff members following acts of violence. Report-
ing methods will include the use of alphabetical listings of all students and staff or class
lists. Information such as this would be located in the aforementioned crisis response box
(Brock et al., 2001).
Reuniting Students with Parents

Facilitating the development of procedures for reuniting students with their families fol-
lowing acts of violence is another essential preparedness task. Our experience with literally
hundreds of parents arriving simultaneously to locate their children following a school
shooting has emphasized the importance of having these procedures in place. The plan
should designate a trained staff member to the pickup area to oversee reunification and
avoid potential chaos. Brock et al. (2009) provide an accounting and reunification protocol.
Crowd Control
Crowd control procedures complement student and parent reunion procedures. In advance
of a crisis, areas need to be designated where parents can wait until they can be reunited
with their children. Possible locations may include school cafeterias, multipurpose rooms,
playground areas, and libraries.
Additionally, these procedures will also need to include strategies to manage the media.
Another part of crowd control procedures is ensuring that the crisis response team is able
to communicate with large groups of people at one time. This will mean making sure
that bullhorns or public address systems are available. According to Lockyer and Eastin
(2000), police chiefs involved in several recent school shootings have recommended that
schools and law enforcement plan for three distinct staging areas. Separate areas will pre-
vent the press from overwhelming and/or interfering with the police or parents reuniting
with their children. In addition to the parent center and media areas, they also suggest the
establishment of a staging area for law enforcement and emergency personnel.
Involving Law Enforcement

An important part of planning is to obtain a prior written agreement regarding coordina-
tion between the school and local law enforcement in response to acts of school violence.
This document should detail the point at which the responsibility for a situation would
be assumed by law enforcement. When preparing for the involvement of law enforcement
in school crisis events (e.g., school shootings), police will often want a detailed floor plan
of the school showing entrances, windows, roof latches, ventilation systems, and so on;
and current estimates of the number and identities of staff and students in each class area
(Petersen & Staub, 1992; Trump, 1998). Often school yearbooks or class pictures become
handy tools for helping law enforcement to identify current students. Police should also
have a master key to the school and know if there are parking permits used to identify
student and staff cars (Neal, 1999). The crisis response box would contain all of the infor-
mation just listed and be easily accessible.
Referral Planning Procedures

Preparing for the crisis intervention response to psychological trauma victims is yet another
critical crisis preparedness procedure. To meet the needs of those who have been psycho-
logically traumatized, we must first consider crisis intervention referral options.
Referral planning procedures typically involve staff in-service and training. Given that
an effective crisis intervention provides such support immediately, it is ideal to have as
many staff members as possible receive in-service instruction. We suggest that preparation
in psychological first aid be made a part of annual school crisis intervention in-services.
The National Association of School Psychologists (NASP) developed a program specifi-
cally for this purpose; the PREPaRE School Crisis Intervention Curriculum has been used
nationally (Brock et al., 2009). A comprehensive intervention and training program can be
difficult to implement; however, it is important that every member of the school’s guidance
staff have a clear understanding of the principles, goals, and limitations of psychological
first aid. In addition, professional mental health counseling resources need to be identi-
fied. The identification of community resources will involve the survey of both commu-
nity mental health agencies and private practitioners. Community agencies are typically
well known to most school psychologists, social workers, and counselors. School district
personnel should have little difficulty developing a comprehensive list of these local com-
munity agencies, but it will be important to verify expertise in crisis intervention. Private
mental health practitioner referrals can be more difficult to identify, especially in urban
communities where there are large numbers of private practitioners. Always be sure prac-
titioners are competent, well trained, and confident in crisis situations.
Referral planning must acknowledge that not all individuals exposed to acts of violence
will require immediate individual assistance or eventually require a professional mental
health referral. Depending on circumstances and resources, many students and staff mem-
bers may be able to independently integrate the trauma into their lives. Individuals who
are not currently in crisis or at high risk will not need to be an intervention priority, but
can still benefit from other methods of crisis resolution. For example, large numbers of
students can effectively be intervened with through the activation of naturally occurring
social support systems (Brock et al., 2009). With preparation, and if comfortable in the
role, the classroom teacher can be an effective provider of this type of crisis intervention.
Responding to Acts of Violence

Following acts of extreme violence, the medical workers who first arrive and find wide-
spread injury will first perform medical triage. Triage, derived from the French for “sort-
ing,” is defined as follows:
The screening and classification of sick, wounded, or injured persons during war or
other disasters to determine priority needs for efficient use of medical and nursing
manpower, equipment, and facilities. . . . Use of triage is essential if the maximum
number of lives is to be saved during an emergency situation that produces many more
sick and wounded than the available medical care facilities and personnel can possibly
handle. (Thomas, 1993, p. 1767)
This concept is also applicable to the identification of psychological trauma victims. The
purpose of triage in crisis intervention is not only to identify who is in the greatest need of
crisis intervention, but also to facilitate early intervention to prevent further injury.
Initial Psychological Triage Following Acts of Violence

The process of psychological triage involves deciding who is at risk for psychological trau-
matization following the hazard of an act of violence. Based upon the work of Brock et al.
(2001, 2009), the following are our guidelines for psychological triage decision making.
Physical Proximity. All individuals directly experiencing or witnessing an act of violence
should be considered at high risk of being significantly affected by the event. The physi-
cally closer the individual is, the greater the likelihood of becoming a psychological trauma
victim. Conversely, the greater the physical distance between the individual and the place
in which the crisis event occurred, the less the likelihood of psychological traumatization.
This fact has been documented in several studies (Bloch, Silber, & Perry, 1956; Green,
Grace, & Lindy, 1983; Green et al., 1991; Nader, Pynoos, Fairbanks, & Frederick, 1990;
Pynoos et al., 1987; Shore, Tatum, & Vollmer, 1986). See Brock et al. (2009) for a current
review of this literature.
Emotional Proximity. In addition to physical proximity, emotional proximity is also a
consideration when attempting to identify the psychological victims of violence. Individu-
als who have an emotional attachment to someone who was injured or killed are at risk
for psychological traumatization. The stronger the attachment, the more likely it is that
the individual will be traumatized. An individual can be exposed to an event indirectly
through family members or loved ones and still be at risk for PTSD, especially if the person
is killed (Brock & Cowen, 2004). The importance of attachment has been demonstrated
by Nader, Pynoos, Fairbanks, and Frederick (1990), who found that greater acquaintance
with the victim of a schoolyard shooting was significantly related to higher scores on a
measure of posttraumatic stress.
Perception of danger or threat may also increase emotional proximity to acts of vio-
lence. Following such acts, those who have developed a concern for the well-being and
safety of themselves, a family member, or other emotionally significant person may also be
at risk for psychological trauma. Concern for family and friends can be extremely stressful
and can lower one’s resistance (Brock et al., 2001).
Previous Trauma. Particular attention needs to be directed toward students who have
experienced other traumas within the past year and/or those who have experienced prior
acts of violence. How an individual perceives the act of violence will have a lot to do with
his or her frame of reference at the time of the event. If the individual had experienced
numerous, recent significant traumas and losses, a relatively minor or remote act of vio-
lence might be sufficient to cause psychological trauma. For example, Nader et al. (1990)
report that children who had experienced previous traumas had renewed posttraumatic
stress disorder symptoms related to the previous experience following a sniper attack at
their school. A preexisting mental illness may also exacerbate trauma, leading to PTSD
(Brock & Cowen, 2004; Brock et al., 2009).
Acute Stress Reactions. Any individual whose response to the event is out of proportion to
the degree of exposure to the event should be evaluated next. These individuals may not have
the intellectual or emotional problem-solving skills necessary to cope with the experience.
Those conducting psychological triage must determine whether the psychological victims are
either over- or underreacting to the event based upon their degree of exposure. Denial, block-
ing, and/or emotional numbing of the unpleasant reality of an act of violence are often part
of the early reactions to a crisis event. For example, individuals who were directly exposed to
a shooting and are not reacting to it should be monitored closely. We should also be aware
that delayed stress reactions are possible following a trauma (Brock et al., 2001).
Psychopathology. Although the acute stress associated with psychological trauma is not
a sign of mental illness, a history of emotional disturbance or special needs can lower one’s
capacity to cope with an unforeseen crisis (NASP, 2002). A preexisting psychopathology
can also make it more difficult to process information during crisis intervention. Brock et al.
(2009) also recommend that the family’s mental health should be considered. For example,
following a school bus kidnapping, Terr (1983) found “. . . relationships between the clini-
cal severity of the children’s posttraumatic conditions and their preexisting family pathol-
ogy” (p. 1550). If family members are not functioning well enough to support the child’s
coping, it will obviously be more difficult for the child to surmount a traumatic event.
Lack of Resources. A lack of resources can make it much more difficult for children and
adults to cope with violence. For example, a lack of material resources such as money,
food, housing, and transportation can turn a moderately stressful event into a crisis. Inter-
nal resources include intelligence, skill in problem solving, personality, and temperament.
Individuals with disabilities may use up these resources in coping with their disability and
not have extra resources available to deal with violence. These internal personal resources
must also be evaluated in the attempt to identify children and adults at risk for psychologi-
cal trauma (Brock et al., 2009).
Initial Interventions and Secondary Screening

All individuals classified as being at risk for psychological trauma should be closely moni-
tored to assess their need for mental health referrals. Crisis intervention will be provided
by school and community mental health professionals, unless the disaster is so widespread
that state or national assistance is forthcoming. It may or may not be provided at the
school site. The goals of triage include identification of students and staff members most
significantly affected by crisis and then providing these individuals with immediate psy-
chological first aid assistance. Secondary triage goals include identification of individuals
mildly to moderately affected by the crisis, and the collection of data used in making pro-
fessional mental health referral decisions.
Screening
After psychological triage has identified all individuals judged to be at risk due to either
proximity or other risk factors, the next step is to survey the entire school population for
signs of traumatic stress. Mass screening is especially important following acts of violence
that affect large numbers of students. During these situations, it is unlikely that the crisis
interveners will be able to independently identify all students significantly affected by the
event. Thus, teachers and parents should be enlisted in the process. Parents and teachers
are the most likely to see and be affected by a student’s crisis reactions. In his discussion
of mass screening, Klingman (1988) suggests using “. . . observation of signs of behavior
maladaption, child paper-and-pencil products (e.g., free writing, drawing), anxiety scales
administered to children, and the identification of absentees” (pp. 210–211).
Referral
An effective referral system needs to educate care providers about reactions to look for
among youth following a crisis. It would tell them what signs suggest the need for a crisis
intervention. Staff in-service, both during and before an event, would be important for
teachers. School newsletter articles both before and during an event would serve a similar
purpose for parents. Finally, it is important to note that the media can be very helpful.
Newspapers and broadcast media can quickly and efficiently alert parents and the commu-
nity in general to signs, symptoms, and reactions suggesting the need for crisis intervention
and where assistance can be obtained.
Self-Referral
All students need to be informed about the availability of assistance in coping with acts of
violence. Especially following crises affecting large numbers of students, it is possible that
crisis workers, teachers, and parents may overlook or fail to recognize signs suggesting the
need for a crisis intervention. Other students may not display behavioral signs of distress.
Thus, students need to know where to go for assistance on their own. This information
can be disseminated in a variety of ways, such as public address announcements, school
assemblies, and teacher-led discussions.
Parent Involvement
Because of the sudden and unexpected nature of acts of violence, it is not always possible
to contact a student’s family right away. Some students will need to be seen immediately
and in a crisis situation this is an appropriate action. However, we recommend that as
soon as possible crisis interveners obtain parent permission for referral or continuing crisis
intervention. Parents also need to know about distress their children are experiencing so
that they may participate in lending their child emotional and physical support.
Treating Psychological Victims of Violence

Crisis intervention and counseling for children and youth subject to the traumatic stress
of acts of violence are not greatly different from the generic principles of counseling and
intervention outlined in the first chapter of this book. The impact of violence is typically a
loss for the affected individual. The loss may be of human life or of a sense of safety and
security. Grieving and morning these losses will be among the objectives of the counseling
intervention (see Chapter 8).
It is important to acknowledge that the combination of traumatic stress and grief gener-
ated by a sudden traumatic loss creates unique problems for crisis interveners. Associated
with traumatic stress are emotional numbing and avoidance of trauma reminders. These
symptoms can greatly interfere with the process of grieving. Given this reality it is typically
recommended that trauma work take precedence over grief work.
Another feature of acts of violence is a lowered sense of control over one’s destiny and
heightened fear of the unknown. Thus, a focus on returning a sense of empowerment will
be important. Finally, there may be issues of survivor guilt, if there is widespread loss of
life or property. Those spared, but witnessing the devastation of others, may have extreme
feelings of guilt that will need to be dealt with. They will need to explore their magical
thinking about why they escaped injury or loss, and be encouraged to be proactive and
look toward the future.
Conclusion
Although stressful, traumatic events such as acts of violence typically come without warn-
ing, schools can be prepared to respond to them. Schools can protect themselves from pos-
sible attacks from outsiders by implementing security measures and increasing strategies to
identify and treat potentially violent terrorists among the student body. In addition, follow-
ing a traumatic event, a psychological triage can facilitate the delivery of crisis intervention
and counseling; and in doing so facilitate the adaptive coping of trauma victims. We will
never be free of violence, but we can do much to ameliorate its psychological impact.
NOTE
1. Poland (1997) reports that the Houston schools experienced a dramatic decrease in the number of
fights after implementing a policy requiring students involved in fights to make a court appearance
and pay a $200 fine.
REFERENCES
Algozzine, B., & McGee, J. (2011). Reported occurrence and perceptions of violence in middle and
high schools. Clearing House, A Journal of Educational Strategies, Issues and Ideas, 84, 91–97.
Bacon, T. P. (2001, November). Impact on high school students’ behaviors and protective factors: A
pilot study of the “Too Good for Drugs and Violence” prevention program. Sanibel, FL: Florida
Educational Research Council. Retrieved from https://www.mendezfoundation.org/resources/
evaluation/documents/TGFDV_High_School_Study_2001.pdf
Bloch, D. A., Silber, E., & Perry, S. E. (1956). Some factors in the emotional reactions of children to
disaster. The American Journal of Psychiatry, 113, 416–422.
Brock, S. E. (1999, Summer). The crisis of youth violence: Dangers and opportunities. CASP Today:
A Quarterly Magazine of the California Association of School Psychologists, 48, 18–20.
Brock, S. E., & Cowen, K. (2004, January). Coping after a crisis: Counseling 101. Principal Lead-
ership: High School Edition, 4(5), 9–13. Retrieved from http://www.nasponline.org/resources/
principals/PTSD%20NASSP%20January%2004.pdf
Brock, S. E., Nickerson, A. B., Reeves, M. A., Jimerson, S. R., Liberman, R., & Feinberg, T. A.
(2009). School crisis prevention and intervention: The PREPaRE model. Bethesda, MD: National
Brock, S. E., Sandoval, J., & Lewis, S. (2001). Preparing for crises in the schools: A manual for
building school crisis response teams. New York: Wiley.
Brooks, R. D. (1993, Winter). Signs of the times. School Safety, 4–7.
Center for Disease Control and Prevention. (2011). School violence: Prevention. Retrieved from
http://www.cdc.gov/violenceprevention/youthviolence/schoolviolence/prevention.html
Crowe, T. D. (1990, Fall). Designing safer schools. School Safety, 9–13.
Dwyer, K., Osher, D., Warger, C. (1998). Early warning, timely response: A guide to safe schools.
Washington, DC: U.S. Department of Education. Retrieved from http://cecp.air.org/guide/anno-
tated.asp
Elliott, S. N., Frey, J. R., & DiPerna, J. C. (in press). Promoting social skills: Enabling academic
and interpersonal success. In S. E. Brock & S. R. Jimerson (Eds.), Best practices in school
crisis prevention and intervention (2nd ed.). Bethesda, MD: National Association of School
Psychologists.
Fein, R. A., Vossekuil, B., Pllack, W. S., Borum, R., Modzeleski, W., & Reddy, M. (2004, July).
Threat assessment in schools: A guide to managing threatening situations and to creating safe
school climates. Washington, DC: United States Secret Service & U.S. Department of Education.
Retrieved from http://www2.ed.gov/admins/lead/safety/threatassessmentguide.pdf
Frey, K. S., Nolen, S. B., Edstrom, L. V. S., & Hirschstein, M. K. (2005). Effects of a school-based
social-emotional competence program: Linking children’s goals, attributions, and behavior. Jour-
nal of Applied Developmental Psychology, 26, 171–200. doi:10.1016/j.appdev.2004.12.002
Gable, R. A., Quinn, M. M., Rutherford, R. B., Howell, K. W., & Hoffman, C. C. (1998a). Address-
ing student problem behavior—Part II: Conducting a functional behavioral assessment (3rd ed.).
Washington, DC: Center for Effective Collaboration and Practice. Retrieved from http://cecp.air.
org/fba/problembehavior2/Functional%20Analysis.PDF
——— (1998b). Addressing student problem behavior—Part III: Creating positive behavioral inter-
vention plans and supports. Washington, DC: Center for Effective Collaboration and Practice.
Retrieved from http://cecp.air.org/fba/problembehavior3/part3.pdf
Goldstein, A. P., & Glick, B. (2002). Aggression replacement training. In S. E. Brock, P. J. Lazarus,
& S. R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp. 225–248).
Goldstein, A. P., Glick, B., Reiner, S., Simmerman, D., & Coultry, T. M. (1985). Aggression replace-
ment training: A comprehensive intervention for aggressive youth. Champaign, IL: Research Press.
Grant, S. A. (1993, Winter). Students respond to “campus cops.” School Safety, 15–17.
Green, B. L., Grace, M., & Lindy, J. D. (1983). Levels of functional impairment following a civil-
ian disaster: The Beverly Hills Supper Club Fire. Journal of Consulting Clinical Psychology, 51,
573–586. doi:10.1037//0022–006X.51.4.573
Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C., & Smitson-Cohen,
S. (1991). Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of
the American Academy of Child and Adolescent Psychiatry, 30, 945–951. doi:10.1097/00004583–
199111000–00012
Herrmann, D., & McWhirter, J. (2003). Anger and aggression management in young adolescents:
An experimental validation of the SCARE program. Education and Treatment of Children, 26,
273–302.
Jennings, W., Khey, D., Maskaly, J., & Donner, C. (2011). Evaluating the relationship between law
enforcement and school security measures and violent crime in schools. Journal of Police negotia-
tions, 11, 109–124. doi:10.1080/15332586.2011.581511
Klingman, A. (1988). School community in disaster: Planning for intervention. Journal of Community
Psychology, 16, 205–216. doi:10.1002/1520–6629(198804)16:2<205::AID-JCOP2290160210>
3.0.CO;2–0
Larson, J., & Beckman, S. (in press). Preventing student violence. In S. E. Brock & S. R. Jimer-
son (Eds.), Best practices in school crisis prevention and intervention (2nd ed.). Bethesda, MD:
Lazarus, P. J., Brock, S. E., & Feinberg, T. (1999, September). Dealing with the media in the after-
math of school shootings. Communiqué: National Association of School Psychologists, 28(1),
7–6, 10.
Lockyer, B., & Eastin, D. (2000). Crisis response box. A guide to help every school assemble the
tools and resources needed for a critical incident response. Sacramento, CA: California Depart-
ment of Education. Retrieved from http://www.cde.ca.gov/ls/ss/cp/documents/crisisrespbox.pdf
Masten, A. S. (1994). Resilience in individual development: Successful adaptation despite risk and
adversity. In M. C. Wang & E. W. Gordon (Eds.), Educational resilience in inner-city America:
Challenges and prospects (pp. 3–25). Hillsdale, NJ: Erlbaum.
Mayer, S. (2008, November). Fact sheet #5: School resource officers. Muncie, IN: Consortium to
Prevent School Violence. Retrieved from http://www.ncsvprp.org/resources_assets/CPSV%20
Fact%20Sheet-5-School%20Resource%20Officers.pdf
Muschert, G. (2007). Research in school shootings. Sociology Compass, 1, 60–80. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1111/j.1751–9020.2007.00008.x/pdf
Nader, K., Pynoos, R., Fairbanks, L., & Frederick, C. (1990). Children’s post-traumatic stress disor-
der reactions one year after a sniper attack at their school. American Journal of Psychiatry, 147,
1526–1530.
National Association of School Psychologists. (n.d.). Creating a safe school building. Retrieved from
http://www.nasponline.org/resources/crisis_safety/neat_buildings.aspx
National Association of School Psychologists. (2002, September). Coping with crisis—Helping
children with special needs. Retrieved from http://www.nasponline.org/resources/crisis_safety/
specpop_general.aspx
National Center for Education Statistics. (2004). Crime and safety in America’s public schools:
Selected findings from the school survey on crime and safety. Washington, DC: Author. Retrieved
from http://nces.ed.gov/pubs2004/2004370.pdf
National School Safety Center. (1990). School safety check book. Westlake Village, CA: Author.
——— (1998, 2011). Checklist of characteristics of youth who have caused school-associated vio-
lent deaths. Malibu, CA: Author. Retrieved from http://www.schoolsafety.us/
Neal, C. (1999, September). Keynote speaker: First responding officer, Columbine High School.
Keynote speech presented at the Western Regional Hate Crimes Symposium, Sacramento, CA.
Nelson, R., Roberts, M., Smith, D., & Irwin, G. (2000, February). The trouble with profiling youth
at-risk for violence. Communiqué, 28, 10.
Nickerson, A. B., & Gurdineer, E. E. (in press). Research needs for crisis prevention. In S. E. Brock
& S. R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (2nd ed.).
Nickerson, A. B., Pagliocca, P. M., & Palladino, S. (in press). Research and evaluation needs for crisis
intervention. In S. E. Brock & S. R. Jimerson (Eds.), Best practices in school crisis prevention and
intervention (2nd ed.). Bethesda, MD: National Association of School Psychologists.
Petersen, S., & Staub, R. L. (1992). School crisis survival guide: Management techniques and materi-
als for counselors and administrators. West Nyack, NY: Center for Applied Research in Education.
Poland, S. (1997). School crisis teams. In A. P. Goldstein & J. C. Conoly (Eds.), School violence
intervention: A practical handbook (pp. 127–159). New York: Guilford Press.
Pynoos, R. S., Frederick, C., Nader, K., Steinberg, A., Eth, S., Nune, F., & Fairbanks, L. (1987).
Life threat and post traumatic stress in school-age children. Archives of General Psychiatry, 44,
1057–1063. doi:10.1001/archpsyc.1987.01800240031005
Quinn, M. M., Gable, R. A., Rutherford, R. B., Nelson, C. M., & Howell, K. W. (1998). Addressing
student problem behavior: An IEP team’s introduction to functional behavioral assessment and
behavior intervention plans. Washington, DC: Center for Effective Collaboration and Practice.
Retrieved from http://cecp.air.org/fba/problembehavior/funcanal.pdf
Reeves, M. A., Nickerson A. B., Conolly-Wilson, C. N., Susan, M. K., Lazzaro, B. R., Jimerson,
S. R., & Pesce, R. C. (2011). Crisis prevention and preparedness: Comprehensive school safety
planning (2nd ed.). (Available from National Association of School Psychologists, 4340 East West
Highway, Suite 402, Bethesda, MD 20814).
Robers, S., Zhang, J., Truman, J., & Snyder, T. D. (2010, November). Indicators of school crime and
safety: 2010. Washington, DC: National Center for Educational Statistics and Bureau of Justice
Statistics. Retrieved from http://nces.ed.gov/pubs2011/2011002.pdf
Shore, J. H., Tatum, E. L., & Vollmer, W. M. (1986). Psychiatric reactions to disaster: The Mount
St. Helens experience. American Journal of Psychiatry, 143, 590–595. doi:10.2105/AJPH.76.
Suppl.76
Simmonds, J. (2003). Seeing red: An anger management and peacemaking curriculum for kids.
Gabriola Island, Canada: New Society.
Sprague, J., & Walker H. (2005). Safe and healthy schools: Practical prevention strategies. New
Stephens, R. D. (1994). Planning for safer and better schools: School violence prevention and inter-
vention strategies. School Psychology Review, 23, 204–215.
——— (1998, 2011). Checklist of characteristics of youth who have caused school-associated vio-
lent deaths. Westlake Village, CA: National School Safety Center. Retrieved from http://www.
schoolsafety.us/media-resources/checklist-of-characteristics-of-youth-who-have-caused-school-
associated-violent-deaths
Strepling, S. H. (1997). The low-aggression classroom: A teacher’s view. In A. P. Goldstein & J.
C. Conoly (Eds.), School violence intervention: A practical handbook (pp. 23–45). New York:
Guilford Press.
Sugai, G., & Horner, R. (2006). A promising approach for expanding and sustaining the implemen-
tation of school-wide positive behavior support. School Psychology Review, 35, 245–259.
Terr, L. C. (1983). Chowchilla revisited: The effects of psychic trauma four years after a school-bus
kidnapping. American Journal of Psychiatry, 140, 1543–1555.
Thomas, C. L. (Ed.). (1993). Taber’s cyclopedic medical dictionary (17th ed.). Philadelphia, PA: F.
A. Davis.
Trump, K. S. (1998). Practical school security: Basic guidelines for safe and secure schools. Thou-
sand Oaks, CA: Corwin.
U.S. Department of Homeland Security (DHS). (2008, December). National incident management
system. Washington, DC: Author. Retrieved from http://www.fema.gov/pdf/emergency/nims/
NIMS_core.pdf
Weiler, S., & Cray, M. (2011). Police at school: A brief history and current status of school resource
officers. Clearing House, A Journal of Educational Strategies, Issues and Ideas, 84, 160–163.
Werner, E. E., & Smith, R. S. (1982). Vulnerable but invincible: A study of resilient children. New
York: McGraw-Hill.
13 Preparing for and Responding to
Disasters
Stephen E. Brock, Quinn Ballard,
& Christina Saad
Schools require specific, specialized protocols to safeguard students in the event of disas-
ters. While the need for protocols to address physical safety has been recognized for some
time, only recently has it been acknowledged that an effective school crisis response must
also account for psychological trauma (Laraque et al., 2004; Silove, Steel, & Psychol,
2006). As with medical first aid for physical injuries, immediate psychological first aid
helps to mitigate the severity of psychological injuries (Hu, Yang, Liu, & Liu, 2010). This
chapter will discuss how the PREPaRE model of school crisis prevention and interven-
tion (Brock et al., 2009) can be used to address the psychological injuries generated by
disasters. It begins by defining what the term “disaster” means, and then provides a brief
overview of the PREPaRE model. Finally, it provides a detailed discussion of how this model
can be used to prepare for and respond to disasters.
There are two broad disaster categories schools must be prepared to address: natural
and industrial. A third type of disaster occurs when these disasters combine. Natural disas-
ters are extreme, naturally occurring phenomenon that affect infrastructure and human
lives. Industrial disasters involve large-scale accidents caused by human error that threaten
lives. Weak oversight of procedural rules and regulations regarding the care of potentially
harmful substances is often a cause of industrial disasters.
Combined disasters usually involve the malfunction of poorly made infrastructure after
being exposed to a natural disaster. Another cause for combined disasters may be weak
oversight of procedural rules and regulations regarding the care of potentially harmful
substances. The Fukushima Daiichi nuclear disaster Japan experienced in 2011 is an exam-
ple of a combined disaster. The original disaster, an earthquake and resulting tsunami
wave, directly caused the industrial crisis at the nuclear plant and served to amplify the
destruction of the event (Wood, 2011). Another example of a combined disaster is the
flooding of New Orleans as the result of levy breaks following Hurricane Katrina in 2005
(Brunner, 2007).
The Centers for Disease Control and Prevention (CDC; 2012) identifies earthquakes,
tornadoes, hurricanes, tsunamis, avalanches, floods, volcano eruptions, wildfires, land-
slides, and mudslides as natural disasters. Industrial disasters are man-made and can
have severe, catastrophic consequences due to unforeseen complications or ill-planned
responses. According to the Body (2010) and the Environmental Protection Agency
(EPA; 2012) industrial disasters include, but are not limited to, oil spills, nuclear blasts,
hazardous materials incidents, and terrorist hazards (e.g., biological, chemical threats).
Disaster preparedness begins by accurately identifying the potential disasters to which a
given school may be exposed (e.g., addressing the fact that a particular school is physi-
cally proximal to a chemical plant or train tracks that are used to transport potentially
hazardous substances).
230 Stephen E. Brock, Quinn Ballard, & Christina Saad
One strategy for preparing for and responding to disasters (both natural and industrial) is
the PREPaRE model of Crisis Prevention and Intervention (Brock et al., 2009). The reader
is also directed to Chapter 2 in this volume. Designed by and for school professionals, this
model has five hierarchical and sequential elements. Specifically, PREPaRE is an acronym for
(a) Prevent/Prepare, (b) Reaffirm, (c) Evaluate, (d) Provide and Respond, and (e) Examine.
It includes best practice recommendations for preparing for and responding to disasters.
Preparing for Disasters

The first letter of the PREPaRE acronym (“P”) stands for Prevention/Preparedness. While
there is little that schools can do to prevent natural and industrial disasters, there is much
that can be done to become better prepared to respond to such (Watson, Brymer, &
Bonanno, 2011). In fact, preparedness is the cornerstone of schools’ disaster management
planning. Critically assessing possible crisis situations and the resources a school has avail-
able mitigates the physical and psychological damage generated by disasters (Brock et al.,
2009). Preparedness activities discussed in this section include using the National Incident
Management System’s (NIMS) Incident Command System (ICS) to form a crisis team,
procedures for ensuring both physical and psychological safety, the development of a hier-
archical set of mental health crisis interventions, and fostering student and staff resiliency.
National Incident Management System and the Incident Command System

According to Brock et al. (2009), the PREPaRE model’s effectiveness when it comes to
disaster response depends on the level of organizational readiness of a school’s staff, as
well as a school’s integration with other community resources and responders (e.g., police
and fire departments). This integration with community resources is facilitated by use
of the National Incident Management System (NIMS; U.S. Department of Homeland
Security, 2008). When a school uses the NIMS to structure its disaster preparedness and
response plans, it employs the same procedures and language as federal, state, and local
first-responders and adopts a common organizational hierarchy referred to as the Incident
Command System (ICS). This integration between school and community resources allows
students’ needs to be addressed more quickly and effectively, and in a coordinated and
comprehensive manner.
A competent multidisciplinary disaster response (or crisis) team is drawn from a school’s
personnel. This is done by evaluating school personnel’s unique talents and traditional
job functions, and then assigning to them corresponding crisis preparedness responsibili-
ties (Brock et al., 2009). The roles and responsibilities articulated in the PREPaRE model
are taken directly from the ICS, as articulated by the U.S. Department of Homeland
Security (2008).
The ICS prescribes five essential roles for disaster preparedness and response. The PRE-
PaRE model describes how these roles may function in the school environment. Each of
the five roles are designated as specific disaster preparedness and response activities. The
five roles are (a) Command, (b) Planning, (c) Operations, (d) Logistics, and (e) Finance/
Administration (Brock, Nickerson, Reeves, & Jimerson, 2008).
Command. The Command section has the overarching responsibility of ensuring that
all essential disaster preparedness and response activities are completed. During a disaster,
the incident commander for a school will usually be a school or district administrator. In
an extreme event with multiple agencies responding to a disaster, the ICS provides a struc-
ture for combined agency leadership (referred to as a “unified command”) to combine
and effectively use the various skill sets and resources of school and community agencies.
Preparing for and Responding to Disasters 231
Planning. Perhaps the most important preparedness activity of the Planning section is to
carefully assess the community within which a school is located and identify the potential
sources of industrial disasters (e.g., nuclear power plants) and types of natural disasters
(e.g., tidal waves are a concern for schools located on a coastline). Working with other sec-
tions of the ICS, the Planning section ensures that disaster-specific plans are documented
and determines the appropriate methods of disseminating such plans. During a disaster
response, this section collects all disaster-related updates and ensures that the appropriate
individuals have all necessary disaster facts. Because communication is an essential task of
this section, it is also in charge of recorders, logs, radios, and campus maps.
Operations. From the specific disaster threats identified by the Planning section, the
Operations section would then be responsible for developing disaster-specific plans. For
example, for schools located close to nuclear power plants the Operation section will need
to have plans in place that address radiation emergencies. Similarly, for schools located
on a coastline, this section will ensure that the school has plans in place for responding to
tidal waves. During a disaster response, the Operations section of the team provides onsite
response, matching resources (obtained by the Logistics section, which will be discussed
next) with those who need it. Further, they are involved in search and rescue, student and
parent reunion, medical and psychological first aid, security, and fire suppression. The
Operations section also provides translation, interpretation, and cultural services.
Logistics. The Logistics section obtains all essential supplies identified by the Planning
and Operation sections as being necessary to responding to disasters. The specific types
of supplies obtained will vary depending on the specific types of disaster risks identi-
fied by the Planning section. However, typically such supplies include those that address
basic needs such as food, water, and blankets, as well as more difficult procurements like
transportation.
Finance/Administration. The Finance and Administration section authorizes, tracks and
records all monetary transactions that support a school’s crisis preparedness and response
efforts. This is an especially important section when responding to disasters as the docu-
mentation of expenses is essential to receiving reimbursements or grants from state or federal
agencies after the disaster, or during rebuilding.
Physical and Psychological Safety

Developing a cohesive disaster plan requires a focus on both physical and psychologi-
cal safety (Brock et al., 2008). Attention must be given to developing procedures that
address the needs of a student’s family and community following specific types of disas-
ters. This includes addressing key issues that may arise in the aftermath of a disaster, such
as accounting for students, a student-parent reunification procedure, methods for crowd
and traffic control, as well as devising systems to provide emergency medical attention,
and conducting mental health crisis intervention (Brock et al., 2008). Disaster prepared-
ness also involves establishing relationships with other community-based agencies (e.g.,
American Red Cross). The school and district need to maintain a direct and ongoing rela-
tionship with local police and fire departments (Brock et al., 2009).
Securing school buildings is important at every phase of disaster response. Before a
disaster, the architectural design should be assessed for its strengths, weaknesses, and
ability to withstand disaster threats. Following disaster, assessing the structural integrity
or safety of particular sites where students will be sheltered is essential. In the longer
term, the physical structure of the school will have to be evaluated for classes to resume.
Consequently, as a part of disaster preparedness, resources that can conduct such safety
evaluations (e.g., structural engineers) need to be identified.
appropriately to this specific type of disaster, but also will reduce traumatic stress. It does
so by facilitating student perceptions of the disaster event as being more controllable (i.e.,
students had the ability to take direct action that increased their physical safety). Inter-
nal resiliency building efforts should also include providing school-wide recognition and
support for the development of emotional regulation and problem-solving skills, as well
as promoting self-confidence, self-esteem, and positive attitudes (Brock et al., 2008). Stu-
dent resiliency can also be supported by the promotion of external support systems. For
example, schools should support family engagement and communication with the school,
as well as an environment to develop positive peer relationships, connectedness to positive
adult role models in combination with a caring, supportive learning environment that has
connections with other prosocial institutions in the community (Brock et al., 2009).
Responding to Disasters
The remaining letters of the PREPaRE acronym (“R,” “E,” “PaR,” and “E”) stand for
Reaffirm, Evaluate, Provide and Respond, and Examine. This section discusses these ele-
ments of a school’s response to disaster.
Reaffirming Physical Health and Perceptions of Safety

Meeting basic needs should be the primary focus following disaster. This includes account-
ing for the location and condition of all students, while providing food, water, and adequate
shelter (Watson et al., 2011). Such activities are important to stabilizing students physically
and psychologically. Reaffirming students’ perceptions of safety is also vital after disaster. Not
only must students be safe, they must also believe that disaster-related dangers have passed
before psychological recovery can begin (Brock et al., 2009; Hobfoll et al., 2007). During this
initial crisis intervention, caregivers can help students by responding as quickly as possible to
distress; creating a calm environment; and remaining calm, emotionally available and within
an appropriate physical proximity to students (Brymer et al., 2006; Watson et al., 2011).
Sharing carefully selected crisis facts has the potential to reassure students that the crisis
has ended, and that adults understand and are able to manage the situation. Since students’
threat perceptions are often based on adult reactions to the disaster, crisis responders must
project an appropriate demeanor to stabilize student reactions. This dependence on adult
reactions is more pronounced among young children, who often look toward adult behav-
iors to understand the level of threat presented by a given situation (Brock et al., 2008).
Reestablishing normal routines and empowering students with tasks such as distributing
food and water are also recommended, assuming it is safe to do so and will not involve
unnecessary exposure to disturbing disaster-related images. Getting students to do some-
thing to support disaster recovery efforts will help them to view their situation as “control-
lable” and has the potential to reduce threat perceptions (Brock et al., 2008).
Evaluating Students’ Psychological Traumatization

In addition to ensuring physical health and perceptions of safety, evaluation of psycho-
logical trauma risk is also prerequisite to the actual provision of mental health crisis
intervention (Watson et al., 2011). In the school environment, this requires determining
the psychological effect of the disaster on students (as well as those responsible for their
well-being, including school staff and onsite personnel). To ensure a competent, efficient
delivery of limited mental health crisis intervention resources, a school disaster response
must include assessing exposure to trauma-inducing risk factors (i.e., disaster exposure,
personal vulnerabilities, threat perceptions) and identifying warning signs of psychological
trauma. Since recovery from disaster exposure is expected for individuals without preex-
isting mental health challenges (National Institute of Mental Health, 2002), being able to
sort (or triage) students who are at high risk for psychological traumatization from those
who are at low risk is best practice (Brock et al., 2009; 2008).
Disaster Exposure. Physical proximity (or degree and amount of exposure) to a disaster
is the single most powerful predictor of psychological trauma. The probability of trauma
increases the closer a student was to the source of the disaster (Pynoos et al., 1987). Fur-
thermore, the duration of disaster exposure may have a direct impact on psychological
well-being (Kruczek & Salsman, 2006). The actual level of physical danger experienced
by survivors is an especially powerful predictor. Those most exposed and suffering physi-
cal injury will be at greatest risk, especially when there is extended crisis exposure. For
example, any physical injury, regardless of severity, increases the likelihood of posttrau-
matic stress disorder (PTSD; Kassam-Adams, Marsac, & Cirilli, 2010).
After physical injury, other exposure variables include having been physically threatened
in some way by the disaster (this includes believing that one’s life was in danger), being
an eye witness to the aftermath of disaster (this may include exposure generated by view-
ing media reports), being in the vicinity of the disaster (for example, this would include
living in an area that was just missed by a tornado), and being absent by chance from the
disaster area (for example, being on vacation away from home during a disaster; Brock,
Sandoval, & Lewis, 2001).
Although not as powerful a predictor of traumatic stress as physical proximity, emo-
tional proximity also needs to be considered when evaluating exposure to the disaster.
Emotional proximity to the disaster primarily involves having close personal relationships
with crisis victims and is associated with an elevated risk of psychological trauma. Having
had a family member who was killed in the disaster is an especially powerful predictor of
traumatic stress (Applied Research and Consulting, Columbia University Mailman School
of Public Health, & New York Psychiatric Institutes, 2002).
Personal Vulnerability. The flipside of the resiliency factors discussed earlier in this
chapter is vulnerability, which also increases the likelihood of the need for mental health
crisis interventions. Internal vulnerability risk factors include poor or prolonged avoidance
coping, preexisting mental illness, poor emotional regulation, low developmental level,
and previous psychological trauma. External vulnerability risk factors are a lack of family
resources, social support, and/or perceived social support that results in a student feeling
“alone” (Brock et al., 2009). A student with more personal vulnerabilities may require
more direct, individually focused, intensive, and specific intervention (Brock et al., 2008).
Threat Perceptions. Finally, a student’s subjective impression of the disaster (which is
directly shaped by both the student’s exposure to the disaster and his or her personal vul-
nerabilities) may be more psychologically relevant to that student than his or her actual
exposure. These subjective impressions are arguably the most important risk factor (Ehlers
& Clark, 2000; Weaver & Clum, 1995). The student’s belief about the disaster’s ability to
cause him or her harm is clearly associated with psychological trauma (Brock et al., 2009).
Warning Signs of Traumatic Stress. Warning signs are the specific indicators that the risk
for psychological trauma (generated by the risk factors discussed earlier) has been realized.
Those that have the greatest disaster exposure, have the most personal vulnerabilities, and
displayed acute symptoms of stress during the event are likely to be individuals who will
require mental health crisis intervention (Brock et al., 2009). Warning signs include emo-
tional, cognitive, physical, and interpersonal/behavioral symptoms, such as irritability,
impaired concentration, insomnia, and/or social withdrawal (Speier, 2000; Young, Ford,
Ruzek, Friedman, & Gusman, 1998).
Ongoing monitoring of these warning signs is a key element of the evaluation of psycho-
logical trauma (such evaluation is a process, not an event). Not only is evaluation a part
of the process wherein the school makes an initial determination regarding which disaster
survivors need which types of crisis interventions (which are discussed next), but also such
evaluation continues throughout the life of the crisis intervention (Brock et al., 2009).
Providing Mental Health Crisis Interventions and Responding to Psychological Needs

From the initial evaluation of psychological trauma, initial decisions are made regarding
which students will need which crisis intervention. As initial interventions are provided,
these crisis intervention treatment decisions are further refined. This ongoing evaluation
of psychological trauma continues until all students either have developed the ability to
cope with disaster stressors independently (or with the assistance of naturally occurring
caregiving resources such as parents and teachers), or have been referred for intensive
psychotherapeutic intervention. Ranging from least to most intensive, the mental health
crisis interventions included in the PREPaRE model are: (a) reestablishing social support,
(b) psychological education, (c) immediate psychological first aid, and (d) providing or
referring students for long-term mental health services (Brock et al., 2009; 2008). The
PREPaRE model uses a three-tiered model of service delivery for students, ranging from
broad, universal interventions, to group and individual selected interventions, to indi-
vidual and intensive psychotherapeutic indicated interventions (Watson et al., 2011).
Reestablishing Social Support Systems. The reestablishment of social support after a
disaster is vital because it decreases the risk of psychological trauma (Ma et al., 2010). Gen-
erally, the chances of psychological trauma are decreased if a student has access to social
support or perceives social support to be available if required (Robinaugh et al., 2011).
The primary sources of social support are parents (Alisic, Boeije, Jongmans, & Kleber,
2012; Bernardon & Pernice-Duca, 2010). However, teachers (Klingman, 2001) and peers
(especially with adolescents; Nickerson & Nagle, 2005) are also important social support
providers. Given that the majority of students will recover from traumatic events without
intervention (National Institute of Mental Health, 2002), facilitating the reunification of
students with their natural support networks and returning them to regular and stable
routines in school should be the primary action (Brock et al., 2009; Hobfoll et al., 2007).
The PREPaRE model outlines several considerations for schools to facilitate beneficial
social support. First, students should be reunited with their caregivers as soon as possible
following a crisis. The younger the student, the more critical this becomes. The reestab-
lishment of normal routines whereby students rejoin friends, teachers, and classmates
also facilitates psychological recovery by contributing to consistency and predictability
(Barenbaum, Ruchkin, & Schwab-Stone, 2004).
An essential component of student psychological health is their relationships with care-
givers. Students look to caregivers to gauge the severity of the situation and also for the
caregivers’ crisis reactions (Green et al., 1991). Psychoeducational information should be
made available to caregivers to maximize the effectiveness of their influence on students
Attention to cultural differences should also be given in regards to social support. Chil-
dren from different cultures perceive different levels of social support. Furthermore, chil-
dren of different cultures and ethnicities also have different preferences for social support.
Therefore, depending on the student, the level of social support and the source of social
support may be important factors to include in guiding interventions (Brock et al., 2009).
Psychological Education. Psychological education provides functional information that
encourages students to return to normal routines and social support systems as quickly as
possible (Carr, 2004). Relevant, appropriate, and adaptive information is made available
to students and caregivers to stabilize crisis reactions and increase resiliency. The infor-
mation is delivered creating an atmosphere of awareness and support with informational
bulletins, flyers, or handouts, through caregiver trainings, and classroom-based psycho-
educational lessons (Brock et al., 2008).
Informational documents should be used as soon as possible following a disaster. Hand-
outs, flyers, bulletins, and the school’s electronic resources should be employed to inform
students, parents, and other caregivers about relevant information and available resources
(Brock et al, 2008). For example, social media has been found to provide a powerful sense
of community, information, and help after crises (Dabner, 2012) and can be an important
way to share these documents. The PREPaRE model stipulates that translations be made
available so that a school’s entire community has access to, and knowledge of, psychologi-
cal interventions.
The goals of caregiver training are almost identical to student-focused sessions (dis-
cussed next), including relating disaster facts to dispel rumors, describing common disaster
reactions, and disseminating information on how to make referrals for both school and
community mental health services (Brock et al., 2009). At these trainings, caregivers who
may be struggling with their own disaster reactions are identified and offered additional
assistance. This is important since caregivers are an influential factor in lessening the
traumatic effects of a disaster on children (Trickey, Siddaway, Meiser-Stedman, Serpell,
& Field, 2012). Consequently, caregivers are taught intervention strategies for helping
themselves as well as their children. This is especially critical given that a caregiver’s reac-
tion also has the potential to negatively influence and perpetuate a child’s crisis reaction
(Brymer et al., 2006).
Student psychological educational lessons complement the caregiver trainings. The main
difference is that caregivers are being provided information to look after others first instead
of themselves, while the primary focus of these student lessons is self-care (Brock et al.,
2009). Psychoeducational groups for students may be accomplished in as little as one hour.
Students learn interventions to help themselves as well as help each other (Brock et al., 2009).
The PREPaRE model specifies four major goals for student psychoeducational sessions.
First, processing the disaster experience may proactively lessen the impact of a traumatic
event (Fullerton, Ursano, Vance, & Wang, 2000; Kindt, 2005). Dispelling rumors will be
essential to allow students to build an authentic narrative. Taking 20 minutes to clarify
disaster facts will establish structure and direction for students. Second, after dispelling
any rumors, it is important to both explain and give examples of common reactions to
disaster. Students should be told that these reactions are typical responses. It is also impor-
tant to highlight that psychological recovery from a crisis is the norm. Third, students
should be taught to identify more severe signs of psychological injury and be directed as
to how to make self-referrals (Brock et al., 2009).
Finally, students need to be taught to identify and self-administer interventions for man-
aging possible crisis reactions. It is important to note that interventions discussed up to this
point are primarily indirect services and that they do have their limitations. More direct
crisis intervention services may also be necessary for some students. A major limitation
of these psychoeducational approaches is the extent to which psychological trauma may
be entwined with factors such as preexisting psychological disorders (Mueser, Rosenburg,
Goodman, & Trumbetta, 2002) or the length of the crisis exposure. In these rare cases, in
which the natural recovery mechanisms are ineffective, the school must have more inten-
sive, direct, and focused mental health crisis interventions (Brock et al., 2008).
Identifying more traumatized students and providing immediate psychological first aid
is an essential function of school-based mental health professionals. The delivery of more
intensive psychological first aid should be continuous and complement all of the other
crisis interventions specified by the PREPaRE model. The transition is from more universal
psychological interventions towards concentration on students who may need additional,
more direct and intensive interventions (Brock et al., 2009). In a three-stage interven-
tion model, the school-based mental health professional needs to provide second-tier, or
selected, crisis interventions (Brock et al., 2008). However, these interventions are still
proactive and focused on helping students before they develop trauma reactions such as
posttraumatic stress disorder (PTSD). The two delivery methods are classroom-based and
individual crisis interventions.
In the PREPaRE model, the classroom-based crisis intervention (CCI) has a similar
structure to the student psychoeducational lesson. A CCI session begins with a review of
the crisis event to dispel any rumors since any misperceptions may increase psychological
trauma. What is different is that the CCI will identify group participants’ crisis reactions
after sharing their stories to normalize their crisis reactions. This sharing is acceptable
only in a homogeneous group because of the sameness of the members’ experiences. In
a homogenous group, this may build community and decrease students’ social isolation.
However, this step might cause harm in a heterogeneous grouping by traumatizing less
exposed students with previously unheard crisis facts. An important distinction is that
participants in a CCI session will have a similar level of crisis exposure and response
The PREPaRE model offers clear indicators regarding students who should be included
in CCI and those students who should be excluded. Those who should be involved in a
CCI group will have crisis exposure without acute trauma or physical injury; be involved
in a comprehensive intervention program that combines the reestablishment of social sup-
port, psychological education, and individual support (including individual crisis interven-
tion and psychotherapy); and engage in longer group sessions of crisis intervention with
other individuals exposed to the same crisis event. Students with a different disaster profile
than the PREPaRE model outlines for inclusion may be harmed by CCI. There are eight
exclusion criteria. Specifically, CCI is suggested to be inappropriate if a student has suf-
fered a physical injury or acute trauma in the crisis; is offered CCI as the only intervention
or a brief crisis intervention; is part of a group exposed to different crisis events; belongs
to a group that is unsupportive or divisive; was exposed to a politicized crisis event; or is
a witness in a police investigation (Brock et al., 2009).
Individual crisis intervention (ICI) best serves students who are emotionally overwhelmed
by their disaster exposure and need immediate, intensive, and individualized coping support.
Students with acute crisis exposure or physical injuries from the crisis event are potential
recipients of ICI. For some students, this is the first step in what will become the longer-term
psychotherapeutic treatment process. However, school mental health professionals may also
use ICI for students with less severe psychological injuries that may be resolved without
psychotherapeutic treatment. The primary goal of ICI is supporting a student’s coping with
disaster-related stressors (Brock et al., 2009).
The reestablishment of immediate coping skills is done through a specific series of steps.
Broadly stated, a student’s coping is reestablished by making psychological contact by
through the provision of physical and emotional support. ICI is conducted when a stu-
dent is both ready and capable of processing the crisis event. A student who has his or
her emotions under control and who is answering questions is usually ready for ICI. If a
student is still too upset to dialogue, it is essential that he or she not be forced to do so,
and reaffirming the student’s physical safety and comfort becomes the focus. If capable,
the student will help the school-based mental health professional identify crisis-generated
problems and focus on applying the student’s own adaptive coping resources. Finally, the
student’s trauma risk is assessed and he or she is matched with the appropriate psychologi-
cal resources. Depending on the student’s state of mind, a school-based mental health pro-
fessional may facilitate the student in developing his or her own ideas, or be directive if the
student requires more intensive intervention. A directive approach is necessary whenever
the student appears unable to act on his or her own behalf and/or when student behavior
conveys any degree of lethality (Brock et al., 2009).
Individualized, direct psychotherapy is the third and final tier of mental health crisis
intervention in the PREPaRE model. School-based mental health professionals are seldom
specialists in CBT and need to be able to refer students to skilled providers. Since CBT
is the most effective psychotherapy for treating crisis-related reactions (Giannopoulou,
Dikaiakou, & Yule, 2006; Smith, Perrin, & Yule, 1999), school-based mental health pro-
fessionals need to be able to judge when a referral is necessary. Examples of CBT proven
to be effective for children suffering from traumatic stress include: imaginal and in-vivo
exposure; eye-movement desensitization and reprocessing (EMDR); anxiety management
training; and group-delivered cognitive-behavioral interventions (Brock et al., 2009).
Combining a CBT intervention with a comprehensive intervention program, including
parent training and psychological education, is highly recommended for students with
severe psychological stress (Watson et al., 2011).
When students are unresponsive to psychotherapeutic interventions, psychopharmaco-
logical treatments may be added as an intervention. The school-based mental health pro-
fessional is well placed to effectively monitor severely traumatized students in the school
setting for maladaptive coping such as depression, panic, anxiety, inattention or hyperac-
tivity, or psychosis (Brock et al., 2009). This information may be useful to medical profes-
sionals in deciding if psychopharmacological treatments are warranted.
Making a referral requires time and organization. Because of the primary mandates
of school-based mental health professionals, as well as the added stresses and duties of
responding to a crisis event, time must be budgeted carefully. However, when making a
referral, students’ parents must be consulted and sometimes directed through the referral
process. Making the decision to request that parents consider a community-based mental
health referral also requires that school-based mental health professional be aware of the
student’s developmental level and developmental manifestations of PTSD.
Examining Effectiveness of School Crisis Interventions

The Examine element of the PREPaRE model analyzes the entire crisis response for what
worked and what needs to be added or improved for future implementation. Learning
from a disaster is important for effectively deploying future resources as well as determin-
ing if a school has accurately gauged its capacity to respond. School crisis plans are sup-
posed to extend the safety and well-being of students. To work properly, crisis plans need
to account for all local safety concerns that individual schools may have to navigate (U.S.
Department of Education, 2007). Since crises are both rare and unpredictable, it is even
more important to review, revise, and practice crisis plans regularly (Brock et al., 2008).
Summary
The school’s response to industrial and natural disasters is critical to the physical and psy-
chological well-being of its students. While these events are fortunately rare, when they do
occur they have the potential to quickly overwhelm a school’s resources and its ability to
help its students cope. Consequently, disaster preparedness is essential, and the PREPaRE
model of crisis prevention and intervention offers a clear structure for such preparedness.
The essential elements of PREPaRE include the development of a multidisciplinary crisis
team and development of disaster-specific crisis plans. Following disaster, the PREPaRE
model advocates for a sequential and hierarchical response. Beginning with the reestab-
lishment of both physical and psychological safety, this model also includes a range of
crisis interventions, including the reestablishment of naturally occurring social support
systems, psychological education, immediate psychological first aid, and longer-term pro-
fessional mental health treatments.
REFERENCES
Alisic, E., Boeije, H. R., Jongmans, M. J., & Kleber, R. J. (2012). Supporting children after single-inci-
dent trauma: Parents’ views. Clinical Pediatrics, 51, 274–282. doi:10.1177/0009922811423309
Applied Research and Consulting, Columbia University Mailman School of Public Health, & New York
Psychiatric Institutes. (2002, May 6). Effects of the World Trade Center attack on NYC public school
students: Initial report to the New York City Board of Education. New York: New York City Board of
Education. Retrieved from http://www.impact-kenniscentrum.nl/doc/kennisbank/1000010739–1.pdf
Barenbaum, J., Ruchkin, V., & Schwab-Stone, M. (2004). The psychosocial aspects of children
exposed to war: Practice and policy initiatives. Journal of Child Psychology and Psychiatry, 45,
41–62. doi:10.1046/j.0021–9630.2003.00304.x
Bernardon, S., & Pernice-Duca, F. (2010). A family systems perspective to recovery from post-
traumatic stress in children. The Family Journal, 18, 349–357. doi:10.1177/1066480710376618
Body, V. O. (2010, June). Top 10 recent American industrial disasters. Washington, DC: Federal
Emergency Management Agency. Retrieved from http://listverse.com/2010/06/01/top-10-recent-
american-industrial-disasters/
Brock, S. E. (2011). Crisis intervention and recovery: The roles of school-based mental health profes-
sionals (2nd ed.). (Available from National Association of School Psychologists, 4340 East West
Highway, Suite 402, Bethesda, MD 20814).
Brock, S. E., Nickerson, A. B., Reeves, M. A., & Jimerson, S. R. (2008). Best practices for school
psychologists as members of crisis teams: The PREPaRE Model. In A. Thomas & J. Grimes (Eds.),
Best practices in school psychology V (Vol. 4, pp. 1487–1504). Bethesda, MD: National Associa-
tion of School Psychologists.
Brock, S. E., Nickerson, A. B., Reeves, M. A., Jimerson, S. R., Lieberman, R. A., & Feinberg, T. A.
(2009). School crisis prevention and intervention: The PREPaRE Model. Bethesda, MD: National
Brock, S. E., Sandoval, J., & Lewis, S. (2001). Preparing for crisis in the schools: A manual for build-
ing school crisis response teams (2nd ed.). New York: Wiley.
Brunner, B. (2007). Hurricane Katrina: A disaster and its catastrophic aftermath. Retrieved from
http://www.infoplease.com/spot/hurricanekatrina.html
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., . . . Watson, P. (2006). Psy-
chological first aid: Field operations guide (2nd ed.). Los Angeles, CA: National Child Traumatic
Stress Network and National Center for PTSD. Retrieved from www.nctsn.org/nctsn_assets/pdfs/
pfa/2/PsyFirstAid.pdf
Carr, A. (2004). Interventions for posttraumatic stress disorder in children and adolescents. Pediatric
Rehabilitation, 7, 231–244. doi:10.1080/13638490410001727464
Centers for Disease Control and Prevention. (CDC, 2012). Natural disasters and severe weather.
Retrieved from http://www.bt.cdc.gov/disasters/
Cohen, J. A., Jaycox, L. H., Walker, D. W., Mannarino, A. P., Langley, A. K., & DuClos, J. L. (2009).
Treating traumatized children after Hurricane Katrina: Project Fleur-de Lis. Clinical Child & Fam-
ily Psychology Review, 12, 55–64. doi:10.1007/s10567–009–0039–2
Dabner, N. (2012). ‘Breaking Ground’ in the use of social media: A case study of a university earth-
quake response to inform educational design with Facebook. The Internet and Higher Education,
15, 69–78. doi:10.1016/j.iheduc.2011.06.001
Davis, A. S., Kruczek, T., & McIntosh, D. E. (2006). Understanding and treating psychopathology
in schools: Introduction to the special issue. Psychology in the Schools, 43, 413–417. doi:10.1002/
pits.20155
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour
Research and Therapy, 38, 319–345. doi:10.1016/S0005–7967(99)00123–0
Environmental Protection Agency (EPA, 2012). Learn the issues. Retrieved from http://www.epa.
gov/gateway/learn/
Fairbrother, G., Stuber, J., Galea, S., Pfefferbaum, B., & Fleischman, A.R. (2004). Unmet need
for counseling services by children in New York City after the September 11th Attacks on the
World Trade Center: Implications for pediatricians. Pediatrics, 115(5), 1367–1374. doi:10.1542/
peds.113.5.1367
Fullerton, C. S., Ursano, R. J., Vance, K., & Wang, L. (2000). Debriefing following trauma. Psychi-
atric Quarterly, 71, 259–276. doi:10.1023/A:1004634227908
Giannopoulou, I., Dikaiakou, A., & Yule, W. (2006). Cognitive-behavioral group intervention for
PTSD symptoms in children following the Athens 1999 earthquake: A pilot study. Clinical Child
Psychology and Psychiatry, 11, 543–553. doi:10.1177/1359104506067876
Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C., & Smitson-Cohen,
S. (1991). Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of
the American Academy of Child and Adolescent Psychiatry, 30, 945–951. doi:10.1097/00004583–
199111000–00012
Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., . . . Ursano, R.
J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical
evidence. Psychiatry, 70, 283–315. doi:10.1521/psyc.2007.70.4.283
Hu, X., Yang, Y., Liu, L., & Liu, X. (2010). Early psychological intervention following a natural
disaster: A study with a victim buried under rubble for 124 hours. Social Behavior and Personality,
38, 71–74. doi:10.2224/sbp.2010.38.1.71
Kassam-Adams, N., Marsac, M. L., & Cirilli, C. (2010). Posttraumatic stress disorder symptom
structure in injured children: Functional impairment and depression symptoms in a confirma-
tory factor analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 49,
616–625. doi:10.1016/j.jaac.2010.02.011
Kindt, M. (2005). Trauma processing and the development of posttraumatic stress disorder. Journal
of Behavior Therapy and Experimental Psychiatry, 36, 69–76. doi:10.1016/j.jbtep.2004.11.007
Klingman, A. (2001). Stress responses and adaptation of Israeli school-age children evacu-
ated from homes during massive missile attacks. Anxiety, Stress, and Coping, 145, 149–172.
doi:10.1080/10615800108248352
Kruczek, T., & Salsman, J. (2006). Prevention and treatment of posttraumatic stress disorder in the
school setting. Psychology in the Schools, 43, 461–470. doi:10.1002/pits.20160
Laraque, D., Oscarino, J. A., Battista, A., Fleischman, A., Casalino, M., Hu, Y., . . . Chemtob, C. (2004).
Reactions and needs of Tristate-Area pediatricians after the events of September 11th: Implications
for children’s mental health services. Pediatrics, 113, 1357–1366. doi:10.1542/peds.113.5.1357
Ma, X., Liu, X., Hu, X., Qiu, C., Wang ,Y., Huang, Y., . . . Li, T. (2010). Risk indicators for post-
traumatic stress disorder in adolescents exposed to the 5.12 Wenchuan earthquake in China.
Psychiatry Research, 189, 385–391. doi:10.1016/j.psychres.2010.12.016
Mueser, K. T., Rosenburg, S. D., Goodman, L. A., & Trumbetta, S. L. (2002). Trauma, PTSD, and
the course of severe mental illness: An interactive model. Schizophrenia Research, 53, 123–143.
doi:10.1016/S0920–9964(01)00173–6
National Institute of Mental Health. (2002). Mental health and mass violence: Evidence-based early
psychological intervention for victims/survivors of mass violence. A workshop to reach consensus
on best practices. Washington, DC: U.S. Government Printing Office. Retrieved from www.nimh.
nih.gov/health/publications/massviolence.pdf
Nickerson, A. B., & Nagle, R. J. (2005). Parent and peer attachment in late childhood and early
adolescence. Journal of Early Adolescence, 25, 223–2489. doi:10.1177/0272431604274174
Osofsky, J. D. (2008). In the aftermath of Hurricane Katrina: A personal story of a psychologist from
New Orleans. Professional Psychology: Research and Practice, 39, 12–17. doi:10.1037/0735–
7028.39.1.12
Pynoos, R. S., Rederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., . . . Fairbanks, L. (1987).
Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry, 44,
1057–1063. doi:10.1001/archpsyc.1987.01800240031005
Robinaugh, D. J., Marques, L., Traeger, L. N., Marks, E. H., Sung, S. C., Beck, J. G., . . . Simon, N.
M. (2011). Understanding the relationship of perceived social support to post-trauma cognitions
and posttraumatic stress disorder. Journal of Anxiety Disorders, 25, 1072–1078. doi:10.1016/j.
janxdis.2011.07.004
Silove, D., Steel, Z., & Psychol, M. (2006). Understanding community psychosocial needs after
disaster: Implications for mental health services. Journal of Postgraduate Medicine, 52, 121–125.
Retrieved from http://www.jpgmonline.com/text.asp?2006/52/2/121/25157
Smith, P., Perrin, S., & Yule, W. (1999). Cognitive behavior therapy for post traumatic stress disor-
der. Child & Adolescent Mental Health, 4, 177–182. doi:10.1111/1475–3588.00273
Speier, A. H. (2000). Psychosocial issues for children and adolescents in disasters (2nd ed.). Wash-
ington, DC: U.S. Department of Health and Human Services. Retrieved from http://cretscmhd.
psych.ucla.edu/nola/video/MHR/Governmentreports/Psychosocial%20Issues%20for%20Chil-
dren%20and%20Adolescents%20in%20Disasters.pdf
Trickey, D., Siddaway, A. P., Meiser-Stedman, R., Serpell, L., & Field, A. P. (2012). A meta-analysis
of risk factors for post-traumatic stress disorder in children and adolescents. Clinical Psychology
Review, 32, 122–138. doi:10.1016/j.cpr.2011.12.001
U.S. Department of Education, Office of Safe and Drug-Free Schools. (2007). Practical information
on crisis planning: A guide for schools and communities. Washington, DC: Author. Retrieved from
http://www2.ed.gov/admins/lead/safety/emergencyplan/crisisplanning.pdf
U.S. Department of Homeland Security (2008, December). National incident management system.
Washington, DC: Author. Retrieved from http://www.fema.gov/pdf/emergency/nims/NIMS_core.
pdf
Watson, P. J., Brymer, M. J., & Bonanno, G. A. (2011) Postdisaster psychological intervention since
9/11. American Psychologist, 66, 482–494. doi:10.1037/a0024806
Weaver, T. L., & Clum, G. A. (1995). Psychological distress associated with interpersonal violence:
A meta-analysis. Clinical Psychology Review, 15, 115–140. doi:10.1016/0272–7358(95)00004–9
Wood, J. (2011). The 2011 nuclear crisis in Japan: Acute radiation syndrome, reactor meltdown,
and nuclear disaster are all scary terms. Learn about what the terms mean in relation to Japan’s
2011 crisis. Retrieved from http://www.infoplease.com/world/disasters/japan-nuclear-2011.html
Young, B. H., Ford, J. D., Ruzek, J. I., Friedman, M., & Gusman, F. D. (1998). Disaster mental
health services: A guide for clinicians and administrators. Palo Alto, CA: National Center for Post
Traumatic Stress Disorder. Retrieved from http://www.hsdl.org/?view&did=441325
14 Suicide
Oanh K. Tran, Alexis S. Pham,
& John M. Davis
This chapter provides an overview of youth suicide, including an underlying theory, an

analysis of risk and protective factors, and counseling approaches in schools. The first
section presents recent statistics on adolescent suicide and gender and ethnic group differ-
ences. The theory section provides definition, nomenclature, cognitive-behavioral model
of suicide, and typology for suicide and suicide-related behaviors. The risk and protec-
tive factors section discusses environmental and psychological risks in youth, medication
effects, vulnerable groups at risk for suicide, and factors that buffer suicidal behaviors. The
school counseling approaches section presents prevention and intervention for varying
levels of suicidal needs, including primary prevention (e.g., assessment and school-wide
programs), secondary intervention (e.g., crisis intervention and referral), and tertiary inter-
vention (e.g., aftercare and postvention).
Suicide in Youth
Schools experience many challenges while educating students. One of the most alarming and
urgent issue is the prospect of suicide (i.e., taking one’s own life). Sadly, suicide is a complex
problem and suicidal behavior has significantly increased in our young population; specifi-
cally the largest increase occurred during 2003–2004 (from 6.87 to 7.32 per 100,000 people;
Centers for Disease Control [CDC], 2007a). Many contributors have been hypothesized for
the rise of suicide, particularly in adolescents. School and social pressures, transitions and
new life experiences, and puberty all occur during a very sensitive and tumultuous period.
Many of these youngsters are not prepared and are ill-equipped to address these changes
or stressors. In addition, those youth who are struggling frequently go unnoticed due to the
internal nature of suicidal thought; therefore, these students do not receive the appropriate
services needed, leaving them vulnerable to maladaptive behaviors.
Prevalence
According to the Centers for Disease Control and Prevention (CDC, 2007b—most recent
data available), suicide ranks as the 10th leading cause of death for the general popula-
tion, the third leading cause of death for young people ages 15 to 24, and the fifth leading
cause of death for 5- to 14-year-olds. Approximately 4,400 lost lives each year are a result
of suicide. Alarmingly, rates increased for 10- to14-year-olds by 196% during 1983–1998
(Lieberman, Poland, & Cowan, 2006). Suicide does occur in children under the age of 10,
though very rarely. Our main concern in this chapter is adolescence because during these
years the risk of suicide increases dramatically. Of every 100,000 young people, the fol-
lowing number died by suicide: 0.9 children ages 10 to 14, 6.9 adolescents ages 15 to 19,
and 12.7 young adults ages 20 to 24. In 2007, a national survey of U.S. children in grades
Suicide 243
9–12 found that approximately 15% of adolescents considered attempting suicide, 11%
developed a suicide plan, 9% attempted suicide, and 2.5% attempted suicide requiring
serious medical treatment (CDC, 2007a). The problem of suicide is observed not only in
the high statistics of deaths, but also in failed attempts, a risk factor for future successful
attempts (Shaffer & Pfeffer, 2001).
The choice of methods by youth attempting suicide will depend upon access, opportu-
nity, and gender. Common methods used include firearms (46%), suffocation (37%), and
poisoning (8%; CDC, 2007b). However, while adolescents and young adults are more
likely to use firearms than suffocation, children are dramatically more likely to use suf-
focation. Males are more likely to use firearms and females are more likely to use poison
(Otsuki, Kim, & Peterson, 2010). Other methods include overdoses of over-the-counter
medications and cutting; these latter forms of suicide are predictive of repeat suicide
attempts (Spirito & Esposito-Smythers, 2006). For every completed suicide, an estimated
100–200 attempts are made (Otsuki et al., 2010). Along the lines of suicidal behaviors,
school practitioners should also keep in mind other forms of behaviors that are considered
disturbing—nonsuicidal self-injury (NSSI), which is intentional bodily harm (some may
consider it a means of self-mutilation; see Chapter 19, this volume).
Gender and Ethnicity

Suicide affects all youth and ethnic groups; however, certain groups are at greater risk
than others. Research suggests gender and racial group differences in suicide among young
people ages 10 to 24. More females attempt suicide than males; however, more males com-
plete suicide than females. According to CDC (2007b), nearly five times as many males as
females ages 15 to 19 die by suicide; just under six times as many males as females ages 20
to 24 die by suicide; specifically, 84% of the deaths are males and 16% are females. The
reason behind the higher rates of males’ completion of suicide is likely that males tend to
use more lethal methods than females. Although more females (roughly 10% more than
males) attempt suicide, they often use less lethal methods than their male counterparts.
Langhinrichsen-Rohling, Friend, and Powell (2009) examined gender differences in
the rate of suicidal behaviors in the four largest minority cultural groups in the United
States: African Americans, Native Americans, Asian Americans, and Latino Americans.
The authors concluded that the gender paradox exists in all four major cultural groups
(i.e., females more frequently have suicidal thoughts than males, while males complete
suicide more frequently than females). The authors warn against using direct assessment
to identify at-risk male youth, such as surveys or questionnaires, as these measures have
limited ability to detect expressions of suicidal behaviors, given that males are less likely
to express/report thoughts of suicide.
In 2004, Hispanic students were considered at most risk for suicidal ideation and behav-
ior than any other minority students. Currently, Native Americans have a higher rate of
suicide than any other cultural groups (CDC, 2007a). In this group, for those ages 15 to 34
years, suicide is the second leading cause of death. Native American males have the highest
prevalence rate (Otsuki et al., 2010). Across all cultures, males have approximately five
times higher rate of completed suicide than females (Otsuki et al., 2010).
Suicide Theory
What are “suicide” and “suicide-related” behaviors? Are all suicides the same or are there
different “types”? What is the role of “development” in the youth’s evolving understand-
ing of suicide? Knowledge of the different types of suicide provides a guide that can help
244 Oanh K. Tran, Alexis S. Pham, & John M. Davis
school practitioners to conceptualize the level of mental illness, treatment types, and prior-
ity treatment issues. Finally, an understanding of the child’s evolving understanding and
cognitive processes of suicide will help school professionals make their response to the sui-
cidal crisis developmentally appropriate. The following section will discuss those aspects.
Suicide Defined
Attempts to operationalize deaths as “suicide” are ongoing. Currently, the classification
system used by coroners’ offices to identify a death as suicide varies from one jurisdiction
to another. The definition that is most appealing to the authors has been offered by Jobes,
Berman, and Josselsen (1987). This definition has two components. First, it indicates that
there must be evidence that the death was self-inflicted. Jobes et al. (1987) suggest that
this may be determined by pathological, toxicological, investigatory, and psychological
evidence. Statements from witnesses may also be used to determine if the death was self-
inflicted. Second, this definition requires there be evidence of intent to die. In other words,
at the time of the self-inflicted injury there was explicit and/or implicit evidence that the
victim intended or wished to kill him- or herself, and that the decedent understood the
likely consequences of the behavior. Examples of implicit evidence offered by Jobes et al.
(1987) include preparations for death; expressions of farewell, hopelessness, and great
pain; efforts to obtain or learn about means of death; rehearsals of the fatal behavior; pre-
cautions to avoid rescue; evidence that the victim recognized the lethality of the means of
death; prior suicide attempts and threats; stressful events or significant losses; and serious
depression or mental disorder (p. 322).
A Nomenclature for Suicidal Behaviors

As has already been suggested, the topic of this chapter is broader than completed suicide.
It also includes a variety of suicide-related behaviors. In this section, the authors review a
nomenclature for suicidal behaviors proposed by O’Carroll et al. (1996). It attempts to define
a set of basic terms for suicidology, and is designed to “to facilitate communication and
minimize confusion among those who work to understand and prevent suicide” (p. 239). In
this nomenclature, a distinction is made between suicide-related thoughts and suicide-related
behaviors. The former includes suicidal ideation. The latter includes instrumental suicide-
related behaviors (e.g., suicide threats) and suicidal acts (i.e., suicide attempts and completed
suicide). The O’Carroll definitions for each of these behaviors are provided in Table 14.1.
Cognitive-Behavioral Model of Suicide

From a cognitive-social learning theory model, suicidal behavior is the result of maladap-
tive learning experiences resulting in distorted cognitions, behavior, and feelings. A pro-
posed cognitive-behavioral model is offered for suicidal behaviors in Figure 14.1 (Spirito
& Esposito-Smythers, 2006). In this model, youth are at risk if exposed to dysfunctional
behaviors and learning patterns from their social environment, such as from poor parent-
ing, childhood trauma, parental psychopathology, peer violence, or victimization, and they
have a genetic predisposition. These factors make them vulnerable to misinterpretations
of social situations and unhealthy psychological and emotional functioning. For example,
a youth experiences a stressor from peers or family (e.g., name-calling, rejection), which
triggers negative feelings and cognitions. The youth engages in distorted thinking errors
(e.g., I’m no good, no one likes me, personalizing the situation, self-blame) and has lim-
ited problem-solving strategies in order to overcome the problem situation. The problem
Suicide 245
Table 14.1 O’Carroll et al. (1996) Nomenclature for Suicidology
I. Suicidal Ideation: Any self-reported thoughts of engaging in suicide-related behavior.

II. Suicide-Related Behavior: Potentially self-injurious behavior for which there is explicit or
implicit evidence either that (a) the person intended at some level to kill himself/herself, or (b)
the person wished to use the appearance of intending to kill himself/herself in order to attain
some other end. Suicide-related behavior comprises instrumental suicide-related behavior and
suicidal acts.
A. Instrumental Suicide-Related Behavior: Potentially self-injurious behavior for which there is
evidence (either implicit or explicit) that (a) the person did not intend to kill himself/herself
(i.e., had zero intent to die), and (b) the person wished to use the appearance of intending to
kill himself/herself in order to attain some other end (e.g., to seek help, to punish others, to
receive attention).
1. Suicide Threat: Any interpersonal action, verbal or nonverbal, stopping short of a directly
self-harmful act, that a reasonable person would interpret as communicating or suggest-
ing that a suicidal act or other suicide-related behavior might occur in the near future.
B. Suicidal Act: A potentially self-injurious behavior for which there is evidence (either implicit
or explicit) that the person intended at some level to kill himself/herself. A suicidal act may
result in death (completed suicide), injuries, or no injuries.
1. Suicide Attempt: A potentially self-injurious behavior with a nonfatal outcome, for
which there is evidence (either explicit or implicit) that the person intended at some level
to kill himself/herself. A suicide attempt may or may not result in injury.
a. Suicide Attempt With Injuries: An action resulting in nonfatal injury, poisoning, or
suffocation where there is evidence (either explicit or implicit) that the injury was self-
inflicted and that the decedent intended at some level to kill himself/herself.
2. Suicide: Death from injury, poisoning, or suffocation where there is evidence (either
explicit or implicit) that the injury was self-inflicted and that the decedent intended to
kill himself/herself. (Note: The term completed suicide can be used interchangeably with
the term suicide.)
Note. Adapted from “Beyond the Tower of Babel: A Nomenclature for Suicidology” (pp. 246–247) by P. W.
O’Carroll, A. L. Berman, R. W. Maris, E. K. Moscicki, B. L. Tanney, and M. M. Silverman, 1996, Suicide and
Life-Threatening Behavior, 26,(3), 237–252. Copyright 1996 by Guilford Press.
worsens with dysregulation of affect and engagement of poor solutions to the problem.
Over time a pattern is developed in which distorted thinking/cognitions are reinforced
through poor and ineffective solutions. The youth is at increased risk for engaging in mal-
adaptive behaviors of suicidal ideation or attempt as a way to stop the cycle.
Types of Suicide
Clearly not all suicides are the same. In fact, it has been argued that there are probably as many
motivations for suicide as there are people who commit suicide (Ramsay, Tanney, Tierney, &
Lang, 1996). However, there have been attempts to classify the different types of suicide. For
example, Beebe (1975), Everstine and Everstine (1983), Gould (1965), and Maris (1992) have
all offered typologies of suicide. The following is the authors’ consolidation of their works.
The “types” are indicative of the underlying rationale or processes occurring within the youth
at the time of the suicide attempt. The typology serves as an informational diagnostic guide
that can help to conceptualize the level of psychopathology, the type of treatment, and the
first issues that would need to be addressed in treatment. Seven “types” are discussed ahead.
Psychosis or Personality Disintegration. This type is best represented by the youth expe-
riencing auditory hallucinations ordering him or her to kill him- or herself or to die. It is
important to acknowledge that the self-inflicted deaths of some youth who are functioning
TRIGGER
Interpersonal conflict
Other negative life events
Worsening of psychiatric symptoms
Cognitive Distortions
Suicidal Thinking
Cognitive errors
Passive Cognitive triad Affect Dysregulation
SUICIDE “I would be better off dead” Negative self-talk Physiological arousal
ATTEMPT “No one cares about me” Worsening of current mood state
Cognitive Deficiencies
Active Anger
“I want to kill myself” Inability to generate or implement
adaptive problem-solving solutions
Maladaptive Behaviors
Employ ineffective solution to problem
Self-medicate with alcohol or drugs
Self-injurious behavior
Figure 14.1 Cognitive-Behavioral Model of Suicidal Behavior in Predisposed Adolescents

Suicide 247
under an active delusional system may not be classified as suicide. For example, the child
or adolescent under the delusion of being Superman might leap off a tall building, killing
him- or herself. However, such behavior would not be classified as suicidal unless there
was an intent to die and an awareness that the behavior would result in death.
Self-Homicide. The primary causative factor in this type of suicide is intense rage at
another. However, for some reason, the rage cannot be outwardly expressed, so is turned
inwards. Self-murder, then, symbolically represents the murder of someone else.
Retaliation for Real or Imagined Abandonment. In this type, the youth hopes that the
suicide will accomplish two things when he or she is threatened by rejection or abandon-
ment. First, the youth beats the adult to the punch (e.g., “you can’t kick me out, I’m
leaving”). Second, the youth uses suicide as a demonstration of power to compensate for
feelings of helplessness and lack of control.
Blackmail and/or Manipulation. Suicide is used as the ultimate threat in this type: “If
you don’t treat me better, you’ll be sorry.” This and the previous type are most often seen
in families in which suicidal threats or gestures are used as power ploys.
Rejoining a Powerful Lost Love Object. In this type, death is thought of as a way to become
reunited with a dead significant other, most often a parent or grandparent, but any signifi-
cant other whose loss is experienced as insurmountable. This type of suicide occurs when
the youth is unable to move through the grieving process concerning the loss of a loved one.
Atonement of Unpardonable Sins. This type finds death being viewed as the only way
to be relieved of the guilt and “badness” a youth feels he or she has engendered. Although
this type of suicide is believed to be very infrequent, injury-prone youth may fit into a less
extreme version of this dynamic.
A Cry for Help. This type is probably the most familiar and most successfully treated.
Although overwhelmed, regardless of the kind of underlying problem, youth in this type
are at least aware they have a problem and that they would like to have some other means
of coping with it. They either know no other way to cope or to call for help, or other chan-
nels have been blocked from them by their guardians, so they turn to suicidal behavior.
Risk and Protective Factors

The suicide research literature (e.g., Baller & Richardson, 2009; Dave & Rashad, 2009;
Hardt et al., 2008; Swahn et al., 2009) suggests several significant factors that place youth
at risk for suicide or that buffer against suicidal behaviors. They include a history of previ-
ous suicide attempts, a family history of suicide, a history of depression and other mental
illness, drug/alcohol use, stressful life event or loss, easy access to lethal methods, exposure
to the suicidal behavior of others, parent-child conflict, and incarceration. In addition,
other internal factors such as aggressive-impulsive behavior, hopelessness, perception of
image, and pessimism can influence an adolescent’s suicidal behavior.
Environmental Risk Factors

Suicide has a contagious nature, in that if one person within a social circle commits or
attempts suicide, others within that same circle of friends may have similar thoughts,
particularly those who have characteristics of negativity and impulsivity. Baller and Rich-
ardson (2009) examined the strength of weak ties in relation to suicide and found that
adolescents’ suicidal thoughts increased when they knew of a friend of a friend who com-
mitted or attempted suicide. Weak ties are indirect links between individuals or friends of
friends. Weak ties can disseminate information about suicide, resulting in those individuals
who have preexisting vulnerable characteristics developing suicidal ideation.
Another factor that places youth at risk for suicide is having low self-esteem and poor
perceived body image. Swahn et al. (2009) examined the relationship between perceived
body weight and suicidal behavior. The study found that the perception of being overweight
is a statistically significant risk factor among youth suicide, after carefully controlling for
other factors such as drugs/alcohol use and feelings of depression. Similar findings are
noted by Dave and Rashad (2009). They found that the perception of being overweight is a
predictive factor of suicidal behaviors in females, but not in males. Both studies concluded
that the perception of being overweight does not necessarily mean that the individual is
actually overweight (based on BMI index), but rather that perceived negative physical
image increased depressive feelings and thus increased suicidal tendency.
In addition to internal factors, external events (e.g., life adversities) can also lead to sui-
cidal behaviors in youth. Hardt et al. (2008) found that adversities in childhood contribute
to suicidal behavior later in life. The study found that sexual abuse and harsh physical
punishment in childhood correlate with an increase in suicide attempts. In addition, other
factors such as financial hardship and unstable family relationships, such as divorce and
arguments, predict suicide attempts later in life.
External events, such as drug and alcohol use, are also contributing factors to suicidal behav-
iors. Swahn, Bossarte, Ashby, and Meyers (2010) found a strong correlation between preteen
alcohol use and suicidal ideation. Youth who reported that they had used alcohol in their
preteen years were more likely than nondrinkers to commit suicide during their teen years.
Also, early alcohol consumption can lead to detrimental outcomes while intoxicated,
leading to teens’ suicidal behavior. Behnken, Le, Temple, and Berenson (2010) examined
the relationship between alcohol use, forced sexual intercourse, and suicidality among
adolescent girls. One of the study’s major findings is that binge alcohol consumption can
lead victims of sexual assault to become more suicidal as compared to the nondrinkers.
The authors relate the use of alcohol to poor decision making, lack of impulse control, and
increased feelings of aggression. These behavioral factors are usually found in adolescents
who have a higher suicidal tendency.
Psychological Risk Factors

Not only is suicidal behavior linked to environmental factors, but also there are underlying
psychological disorders that can increase the likelihood for attempting suicide. Goldston
et al. (2009) found that major depressive disorder was associated with the greatest risk
for suicidal attempts after controlling for all other mental disorders. In fact, having major
depressive disorder increases the risk of suicide by five times. Female youth have a higher
prevalence of an affective disorder than male youth (Otsuki et al., 2010). Other disorders
that were found to correlate with an increase in suicidal behavior are generalized anxiety
disorder and substance abuse disorder. Substance abuse is a significant risk factor, espe-
cially for adolescent males (Shaffer et al., 1996), particularly when an affective disorder
coexists (Gould & Kramer, 2001). Similarly, Chronis-Tuscano et al. (2010) found that
adolescents with preexisting childhood ADHD had an increased risk for depression, sui-
cidal ideation, and suicide attempt. The authors also note that girls are at greater risk for
depression and suicide attempts.
Other psychological conditions, such as attention deficit hyperactivity disorder (ADHD),
are also related to an increased tendency for suicidal behavior due to impulsiveness (or
lack of restraint) presented in individuals with this disorder. In their study, conducted with
participants who had been admitted to the psychiatric emergency room due to attempted
suicide, Manor et al. (2009) found that of those who attempted suicide, 66% met the
criteria for ADHD Inattentive type and 34% met the criteria for ADHD Combined type.
Suicide 249
Although most of the participants in the study met the criteria for ADHD, only 22% per-
cent had been diagnosed and 13% had been medicated.
Another study, conducted by Galera, Bouvard, Encrenaz, Messiah, and Fombonne (2008),
found that males who were diagnosed with ADHD Inattentive type showed more suicidal
behavior in adolescence than peers, a tendency that continued into adulthood. On the other
hand, females diagnosed as ADHD Inattentive type did not show an increased risk for sui-
cide. Additionally, these authors concluded that the existence of ADHD alone, without other
comorbid psychological disorders, is still associated with an increase in suicidal ideation. The
authors suggest that other factors related to ADHD, such as social and professional struggles,
can be related to suicidal thoughts, though more research is needed to confirm this hypothesis.
Another finding is that ADHD is highly comorbid with depression (Faraone & Kunwer,
2007), linking two risk factors. Thus it is important in assessing youth to seek signs of
both in assessing risk.
Antidepressant Medication
Medication used for the treatment of certain mental disorders, particularly those used for
depression, can be linked to an increase in self-harm or suicidal behavior. Dubicka, Had-
ley, and Roberts (2006) performed a meta-analysis measuring the use of antidepressants
and its correlation to suicidal behavior in youth. The class of antidepressants used in this
sample were: fluoxetine, sertraline, citalopram, paroxetine, venlafaxine, and mirtazapine.
These drugs were compared to a placebo drug to examine the effects the drugs have on
adolescents’ suicidal thoughts, self-harm, and tendency to attempt suicide. The results
indicated that there is a statistically significant difference between the placebo group and
the antidepressants group on these measures of suicide, with the group taking antidepres-
sants more likely to display suicidal behaviors than the nonmedicated group. Additionally,
a report by Healy (2009) indicates that selective serotonin reuptake inhibitors (SSRIs)
increase suicidal tendencies. Profound negative effects were found in younger children,
which led to a recommendation that SSRIs not be prescribed to this group.
Sexual Minority Youth

Gay, lesbian, and bisexual youth (GLB) live in a society that condemns and stigmatizes
homosexuality (Herek, 2000). GLB youth describe their sexual identity formation process
as a period of alienation and confusion (Munoz-Plaza, Quinn, & Rounds, 2002) in which
they are isolated from their heterosexual peers. Although some of these youth reported
having received support from some peers, they recognize that they feel more isolated when
disclosing their sexual orientation to their heterosexual peers.
The next chapter in this volume focuses on gay youth. In brief, gay and lesbian youth are
2–6 times more likely to attempt suicide than their heterosexual peers (Munoz-Plaza et al.,
2002). Grossman and D’Augelli (2007) found that those GLB youth who reported suicide
attempts related to their sexual orientation had greater childhood parental psychological
abuse and were identifiable as gay, lesbian, or bisexual by their parents. Parents’ dis-
couragement of gender atypical behavior was associated with increased suicide attempts,
especially for male participants. Similarly, other studies have found an increase in suicidal
tendency for sexual minority youth (Radkowsky & Siegel, 1997; Saunders & Valente,
1987). Furthermore, research has found that GLB youth continue to have psychological
distress after their suicide attempts (Rosario, Schrimshaw, & Hunter, 2005).
Transgender youth are also at risk for attempting suicide. About half of transgender
youth have thoughts about suicide and a quarter have attempted suicide (Grossman &
D’Augelli, 2007). Some factors relating to increased suicidal attempts in this group include
parental abuse, low self-esteem, weight dissatisfaction, and constantly being aware of
judgment of others.
Special Education
Students placed in the special education classrooms are at risk for suicidal behaviors.
Medina and Luna (2006) examined Mexican American students who were placed in special
education classrooms and their thoughts about suicide. They found that some major factors
that contribute to the increase in special education students’ tendency for suicide are similar
to those for adolescents who are not placed in special education. These components include:
signs of depression, substance abuse, interpersonal and social conflict, family dysfunction,
and school stress. The authors postulate that the reason we see an increase in suicidal ten-
dency in special education students is because these students were already at risk before
they were placed into special education. Medina and Luna estimate that about 50% of the
students placed in special education met criteria for depression. In addition, school failure
can cause depressive feelings in these students, in which they feel unsuccessful in learning.
Moreover, the authors suggest that placing students in special education class serves as an
additional stress to students because they are now excluded or “isolated” from the rest of
their peers. Medina and Luna concluded that school personnel should receive more training
for effective suicide prevention, such as through awareness of risks and symptoms related
to suicide. Attention to screening for mental health problems when a student is referred for
special education, as well as academics and cognitive processing, is critical.
Protective Factors
In order to understand the risks and preventative strategies, it is important to examine the
protective factors that may buffer youth from committing suicide. Suicide is often referred
to as a permanent solution to a temporary problem. Practitioners often use reasons to live
as a therapy to convince suicidal youth to resist suicidal thoughts. If the youth is able to
perceive that there are multiple reasons to continue living, and that there are other meth-
ods of coping with life problems, he or she may restrain from engaging in suicidal acts.
Sharaf, Thompson, and Walsh (2009) conducted a study to examine the relationship
between self-esteem, family support, and adolescent suicide risk. Previous findings suggested
that improved self-esteem and family support lower the risk of suicide. The study concluded
that family support moderates the effects of adolescents’ self-esteem on suicide risk. The stu-
dents who reported that they have low family support rely more heavily on their self-esteem
as a buffer against attempting suicide. When little family support is available, youth will
likely be forced to rely on their internal coping mechanisms in times of need.
School Counseling Approaches

This section discusses what schools can do to address suicide using the public health
notion of three tiers of prevention, which has been adopted by school mental health work-
ers (Sugai & Horner, 2002). Primary prevention (Tier 1) consists of efforts aimed at the
total school population prior to any suicidal threats or behaviors, with the goal of reduc-
ing the incidence of suicidal behaviors. Secondary prevention (Tier 2) are those interven-
tions aimed at the suicidal individual at high risk for an attempt or the individual and the
subpopulation who have had contact with the youth who has attempted or completed
suicide. The goal of these efforts is to reduce the immediate damage caused by suicidal
Suicide 251
thoughts and behaviors. This includes suicide intervention (with the suicidal individual)
and postvention (with those who have had contact with the individual who attempted or
committed suicide). Finally, tertiary prevention (Tier 3) efforts are aimed at the individual
who has attempted suicide and/or the family and close friends of the person who has com-
mitted suicide. The goal of these efforts is to reduce the long-term impairment caused by
suicidal behavior.
Assessment and Primary Prevention (Tier 1)

There is no one method of treatment and prevention for youth suicide. However, functional
assessment can be useful to determine the purpose or “function” of each youth’s issue (i.e.,
what need the behavior is serving). Mash and Barkley (2007) propose the SORC model for
functional analysis. First, clinicians should assess the stimuli (S) that are associated with
initiating suicidal thoughts or behavior (i.e., trigger). Following the assessment of stimuli,
clinicians should pay attention to the risk and protective factors of the organism/individual
(O), which can moderate or mediate the interactional relationship of the precipitants, envi-
ronment, and behavior. Not all stimuli will result in the same outcome. For example, some
adolescents who are dealing with a romantic breakup might want to commit suicide, while
others do not. A good prevention plan should aim at determining the presence of risks and
protective factors that may mediate the risk. The third variable that should be considered
is the response (R)—particularly, whether the individual is considering suicidal behaviors
or the intended method of suicide. The last variable is the consequences (C), which is to
look at what will happen after the individual attempts suicide. All these factors should be
considered as doing so provides insight into the “function” of a youth’s behavior.
The treatment of suicidal youth is beyond school practice (Liebling, 2010), though
schools can play a significant part in preventing suicide. There are great resources within
school systems that can be advantageous in prevention efforts and supporting suicidal
youth. The following section discusses those supports that are available in schools.
Using the Support System Within School

Many students may not openly share their suicidal thoughts with adults. Prevention pro-
grams should aim at alternatives to identifying these youngsters through early warning
signs, involving family as a support, using trusted friends and peers, and school personnel
to build connections. Skill-building strategies through social and emotional learning can
be introduced to students to build coping skills in dealing with general school and life
problems.
Collaboration with Family. Educating parents on the mental health needs of the student
and referring the family to counseling are critical. Many parents are concerned and desire
the help of school professionals. Additionally, collaborating with parents in developing a
“home plan” to remove any potentially dangerous objects that the adolescent can access to
attempt suicide in their house should decrease the chances that an adolescent can complete
suicide. These objects include firearms, medicines, sharp materials, etc. School profession-
als can collaborate with law enforcement to further support educating parents on how to
keep their child safe in the home.
Peer Support. Many suicidal youth often will not share their thoughts with school pro-
fessionals or do not know where to seek mental health help, which makes the task of
identifying youth at risk more challenging. Training peers to recognize and report suicidal
youth is a good way to initiate early support. The student, as well as the friend, should be
taught that by seeking help, they are not breaking the trust in the friendship, but rather
they are showing that they care. Students should be taught that suicide is a dysfunctional,
permanent solution to a temporary problem. Being a “good” friend/peer/citizen means
letting adults know when a student is suicidal. Liebling (2010) suggests, “We should teach
youth that it is better to lose a friendship than to lose a friend.”
In the book Suicidal Youth, written by Davis and Sandoval (1991), there are excellent
suggestions for peer counseling programs, conflict resolution programs, extracurricular
activities, work experience programs, student advocates, and assessment of the peer cul-
ture. In peer-counseling programs, students can receive training to become effective peer
counselors, with supervision, to offer support to their isolated and disturbed peers. Simi-
larly, conflict resolution programs can also train students with leadership skills to serve
as conflict managers when there is a dispute on campus. Peer negotiation and conflict
management strategies aimed at decreasing misunderstandings between students are par-
ticularly important for all school-age children. Student advocates can also be available to
allow students to open up to their peers who they view as similar to them.
Extracurricular Activities. Extracurricular activities such as clubs, organizations, and
groups aimed at creating an inclusive environment for students who may be isolated should
also be considered. Work experience programs and the opportunity for trade school, such
as beauty school, for those students who may not excel academically may help them dis-
cover a sense of self-worth and give them more reason for living. Additionally, athletic
participation was found to decrease youth suicidal ideations and behaviors (Sabo, Miller,
Melnick, Farrell, & Barnes, 2005).
Social and Emotional Learning. A proactive approach that can be embedded into
the core curriculum, at any grade level, to teach youth essential skills for dealing with
stressors, while improving self-concept, interpersonal, and emotional adjustment is social
and emotional learning (SEL; Tran, 2008). Skills taught in social and emotional learn-
ing include: 1) self-awareness, 2) social awareness, 3) self-management, 4) relationship
skills, 5) responsible decision making, and 6) awareness of metacognitive skills that impact
emotional adjustment (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). SEL
takes a cognitive-behavioral approach to developing prosocial skills and addressing cogni-
tive distortions, which was previously discussed as associated with suicidal ideations and
behaviors. SEL is proven to produce positive effects in students’ social and emotional func-
tioning and academic performance. An example of an evidence-based SEL program is the
Strong Kids Social and Emotional Learning program (see Merrell, Carrizales, Feurborn,
Gueldner, & Tran, 2007).
School-Wide Screening and Suicide Programs

Many suicide education programs exist for addressing suicidal behaviors (see Doan,
Roggenbaum, & Lazear, 2003). Some examples of programs that are widely used in
schools, nationally or state funded, and empirically based include Project SOAR (see King
& Smith, 2000), the Adolescent Suicide Awareness Program (ASAP; Kalafat & Ryerson,
1999), Signs of Suicide (SOS; Screening for Mental Health, 2012), and Columbia’s Teen
Screen Program (Columbia University TeenScreen, 2004).
Project SOAR (Suicide, Options, Awareness, Relief). This is a well-recognized program
for school personnel for prevention, intervention, and postvention. Prevention consists of
suicide awareness lessons for teachers and staff. Intervention consists of training school
counselors in all secondary and elementary schools in risk assessment of potential suicides
through personal verbal interviews. A crisis team does postvention for students and teach-
ers. King and Smith (2000) evaluated Project SOAR with Dallas school counselors and
Suicide 253
found that their knowledge and confidence increased when it came to recognizing suicidal
warning signs and steps in dealing with a suicidal student.
Adolescent Suicide Awareness Program (ASAP). The ASAP program includes education
for teachers, school staff, and parents, as well as students. The focus is on raising knowl-
edge and awareness of youth suicide. A 10-year follow-up showed that all but one of the
31 survey respondents who participated had retained the student lessons that were the core
of the program (Kalafat & Ryerson, 1999).
Signs of Suicide (SOS, mentalhealthscreening.org). The SOS program, promoted by
Screening for Mental Health (2012), is recognized by the federal Substance Abuse and
Mental Health Services Administration (SAMHSA). Students learn how to ACT (Acknowl-
edge, Care, and Tell) in the face of a mental health emergency. Topics include depression
and suicide, warning signs, risk factors, how to get help, and dos and don’ts regarding
depression and/or suicidal ideation, using SOS, an evidenced-based program (see Weiss &
Cunningham, 2006). In a randomized study, SOS participants showed a 40% reduction in
self-report suicide attempts (Screening for Mental Health, 2012) and improved knowledge
and attitudes about depression and suicide (Aseltine & DeMartino, 2004).
Columbia University’s TeenScreen Program (www.teenscreen.org). This is an evidence-
based, national voluntary program that provides schools and local agencies free techni-
cal assistance and mental health screening and suicide risk screening programs for youth
aged 11 to 18. Participating agencies are provided access to materials and to suicide,
depression, and mental health screening questionnaires in Spanish and English. The pro-
gram efficiently and effectively identifies adolescents who are at risk for suicidal behaviors
(Columbia University TeenScreen, 2004).
Secondary Prevention: Suicide Identification, Intervention, and Referral (Tier 2)

Secondary prevention activities take place after suicidal behaviors and/or ideation have
occurred and target those students at risk for suicide. They are designed to minimize the
duration and harm that can result from these behaviors and thoughts. Specific activities
to be discussed include identification of the suicidal youth, intervention with those judged
to be at risk for suicidal behavior, and a review of referral options. It should be noted
that while the actual implementation of these activities is clearly secondary prevention,
preparing a school to provide these services could be classified as primary prevention. The
following section discusses the identification and assessment of youth at risk.
Identifying Suicidal Youth

Assessment of Warning Signs and Triggers. Although suicidal youth may not confide in
mental health professionals, awareness by those who come into contact with these students
is essential (i.e., teachers, counselors, secretary, nurse, yard duty personnel, custodians,
instructional aides, and principal). These personnel can be taught to recognize children
who are isolated or for whom they have observed a sudden change in affect, and then to
initiate actions that foster the inclusion of these children into their peer group. Table 14.2
provides a helpful list of warning signs that warrant further attention (Kalafat & Lazurus,
2002; Weiss & Cunningham, 2006). When warning signs are identified, staff can consult
with school mental health professionals on how to appropriately interact and engage the
youth, and if a referral is needed. It is important to keep in mind that research suggests that
isolation increases the risk of suicide; thus, supporting the need for school staff to make
connections with at-risk youth is essential.
Table 14.2 Warning Signs, Triggers, and Plans of Suicide
Warning Signs:
• Verbal and written statements about • Violent or rebellious behavior
death and dying • Running away
• Dramatic changes in behavior • Drug and alcohol use
or personality • Unusual neglect of personal appearance
• Fascination with death and dying • Distinct changes in personality
• Giving away prized possessions or • Difficulty concentrating or decline
making out a will in school performance
• Interpersonal conflicts or loss • Frequent complaints about
• Changes in eating and sleeping habits physical symptoms
• Withdrawal from friends, family, and • Loss of interest in pleasurable activities
regular activities
Triggers:
• Getting into trouble with authorities • Bullying or victimization
• Breakup with a boyfriend/girlfriend • Family conflict/dysfunction
• Death of a loved one or significant loss • Academic crisis or school failure
• Knowing someone who died by suicide • Disappointment or rejection
• Trauma exposure • Abuse
• Serious illness or injury • Forced or extended separation from
• Anniversary of the death of a loved one friend or family
Plans to Commit Suicide:
• Complaining of being a bad person
• Making comments like, “I won’t be a
problem for you much longer.”
• Giving away favorite possessions or
throws away important belongings
• Suddenly becoming cheerful after a
period of depression
Assessment and Identification. With the indicators of suicidal behavior in mind, identi-
fication and assessment of these youth are critical in order to provide the services needed.
Sandoval and Brock (1996) indicate that screening for suicidal behavior is a two-stage
process. The first stage involves the administration of a questionnaire designed to identify
suicidal ideation. Examples of questionnaires that are commonly used for assessing sui-
cide include the Suicidal Ideation Questionnaire (SIQ; Reynolds, 1988), and the Reynolds
Adolescent Depression Scale 2nd Ed. (RADS-2; Reynolds, 2002). Other questionnaires
available include the Adolescent Psychopathology Scale (APS), Beck Scale for Suicidal
Ideation (BSSI), Children’s Depression Inventory (CDI), and Reynolds’ Child Depression
Scale (RCDS). The second stage involves a thorough clinical evaluation of students identi-
fied by the screening as being suicidal. Examples of the kinds of questions found useful for
interviewing children and parents are provided in Table 14.3. It is assumed that a positive
rapport has been established before questioning. If rapport has not been established, it is
then safest to hospitalize, given the hospital staff will have more time to develop a rapport
and to ensure closer monitoring until needed information is obtained.
Suicide Intervention and Referral

The two primary questions that need to be answered by the suicide evaluation are: (a)
In your professional opinion, is the child or adolescent at risk for attempting suicide?
and (b) What interventions are necessary given the answer to the first question? Specific
Suicide 255
Table 14.3 Assessment Questions for Children, Parents, and Teachers
Child Questions Parent Questions
• It seems things haven’t been going so well • Has any serious change occurred in your
for you lately. Your parents and/or teachers child’s or your family’s life
have said ________. Most children your recently (within the past year)?
age would feel upset about that. • How did your child respond?
• Have you felt upset, maybe some sad or • Has your child had any accidents or ill-
angry feelings you’ve had trouble talking nesses
about? Maybe I could help you talk about without a recognizable physical basis?
these feelings and thoughts. • Has your child experienced a loss recently?
• Do you feel like things can get better or • Has your child experienced difficulty in
are you worried (afraid, concerned) things any areas of his/her life?
will just stay the same or get worse? • Has your child been very self-critical or
• Other children I’ve talked to have said that have you or his/her teachers been very
when they feel that sad and/or angry they critical lately?
thought for a while that things would be • Has your child make any unusual state-
better if they were dead. Have you ever ments to you or others about death or
thought that? What were your thoughts? dying? Any unusual questions or jokes
• What do you think it would feel about death or dying?
like to be dead? • Have there been any changes you’ve
• How do you think your father and mother noticed in your child’s mood or behavior
would feel? What do you think would over the last few months?
happen with them if you were dead? • Has your child ever threatened or
• Has anyone that you know of attempted to attempted suicide before?
kill themselves? Do you know why? • Have any of his friends or family, including
• Have you thought about how you might yourselves, ever threatened or attempted
make yourself die? Do you have a plan? suicide?
• Do you have (the means) at • How have these last few months been for
home (available)? you? How have you reacted to your child
• Have you ever tried to kill yourself before? (anger, despair, empathy, etc.)?
• What has made you feel so awful?
Teacher Questions
• Have you noticed any major changes in • Does the student appear depressed and/or
your student’s schoolwork recently? hostile and angry? If so, what clues does
• Have you noticed any behavioral, the student give?
emotional, or attitudinal changes? • Has the student either verbally, behavior-
• Has the student experienced any trouble in ally, or symbolically (in an essay or story)
school? What kind of trouble? threatened suicide or expressed statements
associated with self-destruction or death?
Note. Words and phrasings should be changed to better fit the child and/or interviewer. Two things need to be
accomplished during this questioning: (a) to gather more information about the child, and (b) to try to evaluate
the parents in terms of their understanding, cooperation, quality of connection with their child, energy to be
available to a child in crisis.
school-based suicide intervention procedures by Davis and Brock (2002) are presented in
Table 14.4. For youth who have engaged in suicide, it is critical to intervene and provide
the necessary support.
Suicide Contract/No-Harm Agreement. Current research shows mixed findings on the
effectiveness of a no-suicide contract (Lee & Bartlett, 2005), but this component should
also be included in suicide intervention. A no-suicide contract can serve as an agreement to
seek treatment or as a delay to sidetrack poor decision making. A good no-suicide contract
should include a phone number to a suicidal hotline and/or phone numbers to the student’s
closest social connections. The student should be advised to try to call those numbers when
Table 14.4 School Suicide Intervention Procedures
1. Stay with the student or designate another staff member to supervise the youth constantly and
without exception until help arrives.
2. Under no circumstances should you allow the student to leave the school.
3. Do not agree to keep a student’s suicidal intentions a secret.
4. If the student has the means to carry out the threatened suicide on his or her person, determine
if he or she will voluntarily relinquish it. Do not force the student to do so. Do not place your-
self in danger.
5. Take the suicidal student to the prearranged room.
6. Notify the student care coordinator immediately.
7. Notify the incident commander immediately.
8. Inform the suicidal youth that outside help has been called and describe what the next steps
will be.
Note. Adapted from Davis, J. M., & Brock, S. E. (2002). Suicide. In J. Sandoval (Ed.), Handbook of crisis
counseling, intervention and prevention in the schools (2nd ed., pp. 273–299). Hillsdale, NJ: Lawrence Erlbaum
Associates.
he or she feels overwhelmed. Berman, Jobes, and Silverman (2006) suggest that students
should be asked to sign contracts stating that they will commit to treatment in addition to
agreeing not to harm themselves. Furthermore, these no-harm contracts should be used in
conjunction with other suicide intervention programs.
Contacting the Parent(s). Contacting the parent(s) should be a top priority. Lieberman,
Poland, and Cassel (2008) suggest that when working with parents of suicidal youth, four
questions that should be addressed include: Are the parents available? Are the parents
cooperative? What information do the parents have that will assist in the prevention of
suicide? Does the family have mental health insurance? If the parents are available, school
practitioners should contact the parents and gain a written permission for a release of
information and then make referral to services. School practitioners should help the par-
ents bring the student to an outside agency, if necessary. If the parents are not available,
two members of the crisis team should escort the child to a mental health facility with a
school administrator’s approval.
When contacting the parents, keep in mind that cultural differences will influence how
the parents will respond to the situation. In some cultures, parents avoid seeking mental
health services for their child and instead seek alternative solutions, such as spiritual rituals
to help their child (Goldston et al., 2008). School professionals should remind parents about
the importance of seeking help and persuade parents to follow through with the recom-
mended services. If there are any signs of abuse and neglect from the parents, child protec-
tive services should be contacted.
In some instances, suicide assessments reveal that a student is at a low risk for suicide; nev-
ertheless, the parent should still be notified in writing. Parents should be asked to sign a form
stating that they have been notified of their child’s suicidal assessments in a timely manner.
Hospitalization. Hospitalization is necessary if the student is assessed to be in imminent
danger and needs monitoring. Other options would be referral to a halfway house, crisis
intervention, or outpatient psychotherapy. The choice depends on a combination of three
factors: (a) suicidal risk, (b) family strengths and dynamics, and (c) community resources.
If danger is imminent and legal guardians agree and are cooperative, hospitalization can
move smoothly as long as the evaluator is aware of the local resources. If the legal guard-
ians disagree or are uncooperative, the evaluator may need to initiate the state “involun-
tary hold” code. Such a procedure usually entails calling the police or sheriff’s department
and having the child or adolescent involuntarily taken to the emergency/crisis clinic or a
psychiatric clinic or hospital.
Suicide 257
When dealing with minors, especially adolescent minors, there is sometimes a gray area
when the legal guardians agree to the hospitalization, but the child or adolescent does not.
If the guardians cannot control the child or adolescent and facilitate the hospitalization,
law enforcement authorities should be summoned. Should this occur, it is very important
that the guardians be informed about what will happen (e.g., their child may be hand-
cuffed and taken away in a police vehicle).
After hospitalization, when it is deemed safe for the youth to leave the hospital, the
decision as to whether the child returns to home and school, to a halfway house, or to a
foster home needs to be made. This decision is most often made by the hospital staff after
an extended evaluation.
Outpatient Treatment. If the youth is assessed as being suicidal, but the danger is not
imminent, then immediate outpatient treatment may be appropriate. As has already been
mentioned, such options might include a halfway house, crisis intervention, or outpatient
psychotherapy. Outpatient psychotherapy should address cognitive distortions and coping
skills. Cognitive-behavior therapy has been found to be effective in dealing with depression
and suicide (Spirito & Esposito-Smythers, 2006).
The family unit requires support as well. Multisystemic therapy (MST) focuses on
family-based, home-based interventions that support home, school, and community fac-
tors related to youth difficulties. Depressed mood, hopelessness, and suicidal ideation
improved in participating youths in follow-up using MST (Huey et al., 2004).
Other Suicide
Suicide of a Parent. Each year, roughly 7,000 to 12,000 children will lose a parent to
suicide. According to Science Daily (2010), children who lose parents to suicide are more
likely to die from suicide and have a higher risk of developing a psychiatric disorder.
Nearly one out of four people who attempted suicide have a history of suicide attempts
in their family (Sorenson & Rutter, 1991). In such cases, after the death of a parent by
suicide, children will feel grief, abandonment, confusion, guilt, and depression. Some of
these feelings will occur in small increments as children are trying to continue living their
lives, but at the same time they will continue to be reminded about the loss. School pro-
fessionals can assist in having open discussions about the parent’s death. The Centre for
Addiction and Mental Health (2011) offers useful tips for explaining a suicide to a child.
Importantly, assure the child that he or she is not at fault. Any talk of suicide should be
taken seriously and professional help should be provided to the child.
Suicide of a Teacher/Other Adults. Death of a staff member is rare compared to death of
a student or parent. Oftentimes, discussions about the death of a staff member are avoided
due to uncomfortable feelings other staff members may have while they are in the bereave-
ment process. Nonetheless, it is beneficial for students and staff members to openly express
their emotions towards the death and allow for mutual support. The Crisis Management
Institute suggests that activities can also supplement life tributes to the individuals who
passed away (e.g., field day for a PE teacher, reading day for a librarian; Life Tributes,
2010). Keep in mind not to glamorize suicide, but use a tribute to educate students about
suicide, methods of preventing future occurrences, and where to seek help within the school.
Tertiary Intervention: Aftercare and Postvention (Tier 3)

This area is not generally in the domain of the school personnel. However, when a youth
death occurs, schools need to be prepared and address the aftermath of the fatality
(see Table 14.5).
Table 14.5 Recommendations for Postvention of a Completed Suicide
1. Verify that a death has occurred.

2. Mobilize the crisis response team.
3. Assess the suicide’s impact on the school and estimate the level of postvention response.
4. Notify other involved school personnel.
5. Contact the family of the suicide victim.
6. Determine what information to share about the death.
7. Determine how to share information about the death.
8. Identify students significantly affected by the suicide and initiate a referral mechanism.
9. Conduct a faculty planning session.
10. Initiate crisis intervention services.
11. Conduct daily planning sessions.
12. Provide memorials.
13. Debrief the postvention response.
One form of intervention can be therapy for the family and close friends who experi-
enced a completed suicide so they do not decompensate or become symptomatic. Another
form is working with the family and the victim of a suicide attempt who has survived but
has incurred some permanent disability (e.g., paralysis) from the attempt. In the latter
situation, the school mental health professional can help in the evaluation and planning
of a continuing educational plan for the now handicapped student. Consultation and col-
laboration with the school team are essential.
Postvention
When assisting in dealing with the aftermath of suicide, practitioners should consider
which population is likely to be at risk for the “copycat” phenomenon. Zenere (2008)
describes the contagion of suicidal behaviors as circles of vulnerability with four types of
proximity: geographical proximity, psychosocial proximity, social proximity, and popula-
tion at risk. Geographical proximity refers to how close the person is to the incident, which
could be someone who witnessed the incident or someone who discovered the person after
he/she committed suicide. Psychological proximity refers to how connected the individual
feels to the person who committed suicide. This relationship is especially strong when the
person who committed suicide is popular or is a celebrity. Social proximity is defined as
the relationship that the individual has to the deceased. This may include friends, family,
romantic partners, or acquaintances. Population at risk consists of those individuals who
have predispositional factors that make them vulnerable to the effects of suicide (e.g.,
individuals who have mental illnesses). Individuals who have the highest likelihood for
experiencing the contagion of suicide are those who have close geographical proximity,
strong psychological proximity, and social proximity, as well as those who have high vul-
nerability to the effects of suicide. Practitioners should pay close attention to those who
have a combination of these four factors and monitor their reactions after a suicide occurs.
Students. Youth are most vulnerable the first few days after the suicide. The crisis
response team should be ready to serve as counselors and listen to students’ concerns
as well as offer solutions to guide students to quickly return to their daily activities. In
this period, practitioners should emphasize that suicide is not a solution to problems and
offer methods for healthy coping. Staff should be prepared to identify students who are
especially vulnerable following a suicide and provide counseling for these youth (Tentoni
& Storm, 1990).
Staff. Following a suicide, staff should be prepared to answer questions and lead open
discussions about the incident, with guidance from mental health professionals. Staff
Suicide 259
should be given factual information and facilitate a discussion with the class after the sui-
cide (Tentoni & Storm, 1990). In addition, counseling support should be offered to staff
in the healing process.
Parents. In responding to the aftermath of a completed suicide, the crisis intervention team
should contact the parents and siblings and offer supportive services (Tentoni & Storm,
1990). Parents should be encouraged to seek counseling services for themselves and for other
children in the family.
Media/Internet. Suicide should never be glamorized. In the age of technology with tex-
ting, social media, and TV, youth spend a good amount of time following the media, with
60% of teenagers spending 20 hours weekly watching TV or using the computer (Science
Daily, 2008). Given that some of these youth will be vulnerable to the effects of suicide,
using media to discuss a suicide act might increase the “copycat” phenomenon. Although
there are some web sites that provide good suicide prevention tips, there are others that
promote suicide (e.g., suicide planning, how to write a suicide note, and safe locations for
committing suicide; Siegel & McCabe, 2009). Technology use should be monitored closely
following a suicide act.
Conclusion
Youth suicide is a major problem among our adolescent population. Sadly, suicide affects
not only troubled youth, but also all students and staff within the school. School profes-
sionals must be prepared and intervene cautiously for the appropriate care of our young
population. It is important that practitioners work collaboratively with all school staff,
parents, and community agencies in dealing with youth crisis. This chapter provides
critical information and recommendations for understanding suicidal behaviors, cogni-
tive development, risk factors, protective factors, assessment methods, prevention and
intervention programs, and postvention methods to assist when suicide occurs in schools.
Suicide, as well as most other problems that we will see in the schools, does not have one
solution. School mental health professionals should be aware of all the available methods
and choose the one that best suits at-risk students and their school. Also, school practitio-
ners cannot solely work independently in youth suicide; thus, professionals should hold
knowledge of available outside resources to make referrals when necessary. Suicide is not
just an isolated event, but rather it requires ongoing care and support for the youth.
If you know of someone in crisis and need help right away, call this toll-free number,
available 24 hours a day, every day: 1–800–273-TALK (8255). You will reach the National
Suicide Prevention Lifeline, a service available to anyone. You may call for yourself or for
someone you care about. All calls are confidential.
REFERENCES
Aseltine, R. H., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention
program. American Journal of Public Health, 94, 446–451. doi:10.2105/AJPH.94.3.446
Baller, R. D., & Richardson, K. K. (2009). The “dark side” of the strength of weak ties: The
diffusion of suicidal thoughts. Journal of Health and Social Behavior, 50(3), 261–276.
doi:10.1177/002214650905000302
Beebe, J. E. (1975). Treatment of the suicidal patient. In C. P. Rosenbaum & J. E. Beebe III (Eds.),
Psychiatric treatment: Crisis, clinic and consultation (pp. 42–62). New York: Basic Books.
Behnken, M. P., Le, Y. L., Temple, J. E., & Berenson, A. B. (2010). Sexual assault, suicidality, and
binge drinking among adolescent girls. Addictive Behaviors, 15, 507–509. doi:10.1016/j.add-
beh.2009.12.008
Berman, A. L., & Jobes, D. A. (1995). Suicide prevention in adolescents (Age 12–18). Suicide and
Life-Threatening Behavior, 25, 143–154. doi:10.1177/002214650905000302
Berman, A. L., Jobes D. A., & Silverman, M. M. (2006). Adolescent suicide: Assessment and inter-
vention. Washington, DC: American Psychological Association.
Centers for Disease Control and Prevention (CDC, 2007a). Teen suicide rate: Highest increase in 15
years. ScienceDaily. Retrieved from http://www.sciencedaily.com /releases/2007/09/070907221530.
htm
——— (CDC, 2007b). Web-Based Injury Statistics Query and Reporting System (WISQARS).
National Center for Injury Prevention and Control, CDC (producer). Retrieved from www.cdc.
gov/injury/wisqars/index.html
Centre for Addiction and Mental Health. (2011). When a parent dies by suicide . . . what kids
want to know. Retrieved from http://www.camh.net/About_Addiction_Mental_Health/Mental_
Health_Information/when_parent_suicide.html
Chronis-Tuscano, A., Molina, B. S., Pelham, W. E., Applegate, B., Dahlke, A., Overmyer, M., & Lay-
ley, B. B. (2010). Very early predictors of adolescent depression and suicide attempts in children
with attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 67(10), 1044–1051.
doi:10.1001/archgenpsychiatry.2010.127.
Columbia University TeenScreen. (2004). Columbia TeenScreen Program. Retrieved from http://
www.teenscreen.org/images/stories/PDF/2004%20Annual%20Overview.pdf
D’Augelli, A. R., Grossman, A. H., Salter, N. P., Vasey, J. J., Starks, M. T., & Sinclair, K. O. (2005).
Predicting the suicide attempts of lesbian, gay, and bisexual youth. Suicide and Life-Threatening
Behavior, 35(6), 646–660. doi:10.1521/suli.2005.35.6.646
Dave, D., & Rashad, I. (2009). Overweight status, self-perception, and suicidal behaviors among
adolescents. Social Science & Medicine, 68(9), 1685–1691. doi:10.1001/archgenpsychia-
try.2010.127. doi:10.1016/j.socscimed.2009.02.015
Davis, J. M., & Brock, S. E. (2002). Suicide. In J. Sandoval (Ed.), Handbook of crisis counseling,
intervention and prevention in the schools (2nd ed., pp. 273–299). Hillsdale, NJ: Lawrence Erl-
baum Associates.
Davis, J. M., & Sandoval, J. (1991). Suicidal youth. San Francisco: Oxford.
Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth suicide prevention school-based guide:
School-based suicide prevention programs. Tampa, FL: Department of Child and Family Studies,
Division of State and Local Support, Louis de la Parte Florida Mental Health Institute, University
of South Florida.
Dubicka, B., Hadley, S., & Roberts, C. (2006). Suicidal behaviour in youths with depression treated
with new-generation antidepressant: Meta-analysis. British Journal of Psychiatry, 189, 393–398.
doi:10.1192/bjp.bp.105.011833
Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor, R. D., & Schellinger, K. B. (2011). The
impact of enhancing students’ social and emotional learning: A meta-analysis of school-based uni-
versal interventions. Child Development 82(1), 405–432. doi:10.1111/j.1467–8624.2010.01564
Everstine, D. S., & Everstine, L. E. (1983). People in crisis: Strategic therapeutic interventions. New
York: Brunner/Maze.
Faraone, S. V., & Kunwer, A. R. (2007). ADHD in children with comorbid conditions: ADHD and
depression. Medscape. Retrieved from http://www.medscape.org/viewarticle/555748_3
Galera, C., Bouvard, M. P., Encrenaz, G., Messiah A., & Fombonne, E. (2008). Hyperactivity-
inattention symptoms in childhood and suicidal behaviors in adolescence: The youth gazel cohort.
Acta Psychiatrica Scandinavica, 118(6), 480–489. doi:10.1111/j.1600–0447.2008.01262.x
Goldston, D. B., Daniel, S. S., Erkanli, A., Reboussin, B. A, Mayfield, A., Frazier, P. H., & Treadway,
S. L. (2009). Psychiatric diagnoses as contemporaneous risk factors for suicide attempts among
adolescence and young adults: Developmental changes. Journal of Consulting and Clinical Psy-
chology, 77(2), 281–290.
Goldston, D. B., Molock, S. D., Whitbeck, L. B., Murakami, J. L., Zayas, L. H., & Hall., G.
C. (2008). Cultural considerations in adolescent suicide prevention and psychosocial treatment.
American Psychologist, 31(1), 14–31. doi:10:1037/a0014732
Suicide 261
Gould, M. S., & Kramer, R. A. (2001). Youth suicide prevention. Suicide and Life-Threatening
Behavior, 3, 6–31. doi:10.1521/suli.31.1.5.6.24219
Gould, R. E. (1965). Suicide problems in children and adolescents. American Journal of Psycho-
therapy, 19, 228–246.
Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors.
Suicide and Life-Threatening Behavior, 37(5), 527–537. doi:10.1521/suli.2007.37.5.527
Hardt, J., Sidor, A., Nickel, R., Kappis, B., Petrak, P., & Egle, U. (2008). Childhood adversities and
suicide attempts: A retrospective study. Journal of Family Violence, 23(8), 713–718. doi:10.1007/
s10896–008–9196–1
Healy, D. (2009). Are selective serotonin reuptake inhibitors a risk factor for adolescent suicide?
Canadian Journal of Psychiatry, 54(2), 69–71.
Herek, G. M. (2000). The psychology of sexual prejudice. Current Directions in Psychological Sci-
ence, 9, 19–22. doi:10.2307.20182611
Huey, S., Henggeler, S. W., Rowland, M. D., Halliday-Boykins, C. A., Cunningham, P. B., Pickrel, S.
G., & Edwards, J. (2004). Multisystemic therapy effects on attempted suicide by youths present-
ing psychiatric emergencies. Journal of the American Academy of Child and Adolescent Psychia-
try, 43, 183–190. doi:10.1087/01.chi.0000101700.15837.f3
Jobes, D. A., Berman, A. L., & Josselsen, A. R. (1987). Improving the validity and reliability of
medical-legal certifications of suicide. Suicide and Life-Threatening Behavior, 17, 310–325.
doi:10.1111/j.1943–278X.1987.tb00071.x
Kalafat, J., & Lazarus, P. J. (2002). Suicide prevention in schools. In S. E. Brock, P. J. Lazarus, &
S. R. Jimerson (Eds.), Best practices in school crisis prevention and intervention (pp. 211–223).
Kalafat, J., & Ryerson, D. M. (1999). The implementation and institutionalization of a school-
based youth suicide prevention program. The Journal of Primary Prevention, 19(3), 157–175.
doi:10.1023/A:1022658826641
King, K. A., & Smith, J. (2000). Project SOAR: A training program to increase school counsel-
ors’ knowledge and confidence regarding suicide prevention and intervention. Journal of School
Health, 70(10), 402–407. doi:10.1111/j.1746–1561.2000.tb07227.x
Langhinrichsen-Rohling, J., Friend, J., & Powell, A. (2009). Adolescent suicide, gender, and culture:
A rate and risk factor analysis. Aggression and Violent Behavior, 14(5), 402–414. doi:10.1016/j.
avb.2009.06.010
Lee, J. B., & Bartlett, M. L. (2005). Suicide prevention: Critical elements for managing suicidal cli-
ents and counselor liability without the use of no-suicide contract. Death Studies, 29(9), 847–865.
doi:10.1080/07481180500236776
Lieberman, R., Poland, S., & Cowan, K. (2006). National Association of School Psychologists.
Retrieved from http://www.nasponline.org/resources/principals/Suicide Intervention in Secondary
Schools NASP Oct 2006.pdfhttp://www.nasponline.org/resources/p . . . %20NASSP%20Oct%20
2006.pdf
Lieberman, R. A., Poland, S., & Cassel, R. (2008). Best practices in suicide intervention. In A.
Thomas & J. Grimes (Eds.), Best practices in school psychology V (pp. 1457–1473). Bethesda,
Liebling, D. E. (March, 2010). An integrated approach to the assessment of adolescent suicide risk.
Paper session presented at the meeting of the National Association of School Psychologists Con-
ference, Chicago, Illinois.
Life Tributes. (2010). Retrieved from Crisis Management Institute http://www.cmionline.org/shop/
images/crmsect.g.5.2010.cjl.pdf
Manor, I., Gutnik, I., Ben-Dor., D. H., Apter, A., Sever, J., Tyano S., . . . Zalsmon, G. (2009).
Possible association between attention deficit hyperactivity disorder and attempted suicide in
adolescents—A pilot study. European Psychiatry, 25(3), 146–150.
Maris, R. W. (1992). How are suicides different? In R. W. Maris, A. L. Berman, J. T. Maltsberger,
& R. I. Yufit (Eds.), Assessment and prediction of suicide (pp. 65–87). New York: Guilford Press.
Mash, E. J., & Barkley, R.A. (2007). Assessment of childhood disorders. New York: Guilford Press.
Medina, C., & Luna, G. (2006). Suicide attempts among adolescent Mexican American students
enrolled in special education classes. Adolescence, 41, 299–312.
Merrell, K. M., Carrizales, D., Feurborn, L., Gueldner, B. A., & Tran, O. K. (2007). Strong
Kids: A social and emotional learning curriculum for students in grades 3–12. Baltimore: Paul H.
Brooks.
Miller, D. N. (2012). Non-suicidal self-injury. In J. Sandoval (Ed.), Child and adolescent suicidal
behavior: School-based prevention, assessment, and intervention (3rd ed.). New York: Guilford
Press.
Munoz-Plaza, C., Quinn, S. C., & Rounds, K. A. (2002). Lesbian, gay, bisexual, and transgender
students: Perceived social support in the high school environment. High School Journal, 85(4),
52–63. doi:10.1353/hsj.2002.0011
O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M.
(1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening
Behavior, 26, 237–252.
Otsuki, M., Kim, T., & Peterson, P. (2010). Fact sheet: Youth suicide. Southern California Aca-
demic Center of Excellence on Youth Violence Prevention, University of California, Riverside.
Retrieved from http://stopyouthviolence.ucr.edu/factsheets/FACTSHEET%20YouthSuicideRe-
visedSpring2010.pdf
Radkowsky, M., & Siegel, L. (1997). The gay adolescent: stressors, adaptations, and psychological
interventions. Clinical Psychology Review, 17, 191–216.
Ramsay, R. F., Tanney, B. L., Tierney, R. J., & Lang, W. A. (1996). Suicide intervention workshop
(6th ed.). Calgary, Canada: LivingWorks.
Reynolds, W. M. (1988). Suicidal Ideation Questionnaire. Odessa, FL: Psychological Assessment
Resources.
——— (2002). Reynolds Adolescent Depression Scale 2. Odessa, FL: Psychological Assessment
Resources.
Rosario, M., Schrimshaw, E. W., & Hunter, J. (2005). Psychological distress following suicidality
among gay, lesbian, and bisexual youths: Role of social relationships. Journal of Youth & Ado-
lescence, 34(2), 149–161.
Sabo, D., Miller, K. E., Melnick, M. J., Farrell, M. P., & Barnes, G. M. (2005). High school athletic
participation and adolescent suicide. International Review for the Sociology of Sport, 40(1), 5–23.
Sandoval, J., & Brock, S. E. (1996). The school psychologist’s role in suicide prevention. School
Psychology Quarterly, 11, 169–185. doi:10.1037/h0088927
Saunders, J., & Valente, S. (1987). Suicide risk among gay men and lesbians: A review. Death Stud-
ies, 11, 1–23.
Science Daily (2008, April). Does the internet really influence suicide behavior? Retrieved from
http://www.sciencedaily.com/releases/2008/04/080411082947.htm
——— (2010, April). Children who lose a parent to suicide more likely to die the same way. Retrieved
from http://www.sciencedaily.com/releases/2010/04/100421160013.htm
Screening for Mental Health. (2012). SOS Signs of Suicide Prevention Program (SOS). Retrieved
from http://www.mentalhealthscreening.org/programs/youth-prevention-programs/sos/
Shaffer, D., Gould, M. S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., & Flory, M. (1996).
Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339–348.
Shaffer, D., & Pfeffer, C. (2001). Practice parameter for the assessment and treatment of children
and adolescents with suicidal behavior. Journal of the American Academy of Child and Adolescent
Psychiatry 40, 24S–51S.
Sharaf, A. Y., Thompson, E. A., & Walsh, E. (2009). Protective effects of self-esteem and family
support on suicide risk behaviors among at-risk adolescents. Journal of Child & Adolescent Psy-
chiatric Nursing, 22(3), 160–168.
Siegel, D., & McCabe, P. C. (2009). Gauging media influence on adolescent suicide rates. NASP Com-
munique, 38(4). Retrieved from http://www.nasponline.org/publications/cq/mocq384suicide.aspx
Spirito, A., & Esposito-Smythers, C. (2006). Addressing adolescent suicide behavior. In P. Kendall
(Ed.), Child and adolescent therapy: Cognitive behavioral procedures (3rd ed., pp. 217–242).
New York: Guilford Press.
Suicide 263
Sorenson, S. B., & Rutter, C. M. (1991). Transgenerational pattern of suicide attempt. Journal of
Consulting and Clinical Psychology, 59(6), 861–866.
Sugai, G., & Horner, R. H. (2002). The evolution of discipline practices: School-wide positive behav-
ior supports. Child and Family Behavior Therapy, 24, 23–50.
Swahn, M. H., Bossarte, R. M., Ashby, J. S., & Meyers, J. (2010). Pre-teen alcohol use initiation and
suicide attempts among middle and high school students: Findings from the 2006 Georgia student
health survey. Addictive Behaviors, 35(5), 452–458.
Swahn, M. H., Reynolds, M. R., Tice, M., Miranda-Pierangeli, M. C., Jones, C. R., & Jones, I. R.
(2009). Perceived overweight, BMI, and risk for suicide attempts: Findings from the 2007 youth
risk behavior survey. Journal of Adolescent Health, 45(3), 292–295.
Tentoni, S. C., & Storm, H. A. (1990). Suicide postvention model for public schools: Expand-
ing the role of school psychology. Retrieved from http://www.eric.ed.gov/ERICWebPortal/search/
detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=ED398502&ERICExtSearch_
SearchType_0=no&accno=ED398502
Tran, O. K. (2008). The Strong Kids curricula for building social and emotional resiliency in children
and adolescents. Prevention in Counseling Psychology, 2, 7–10.
Weiss, C. L. A., & Cunningham, D. L. (2006). Suicide prevention in the schools. Baltimore, MD:
Center for School Mental Health Analysis and Action, Department of Psychiatry, University of
Maryland School of Medicine.
Zenere, F. J. (2008). Pathway of contagion: the identification of a youth suicide cluster. NASP Com-
munique, 37(4). Retrieved from http://www.nasponline.org/publications/cq/mocq374suicide.aspx
15 Lesbian, Gay, Bisexual, Transgender,
and Questioning (LGBTQ) Youth
Suzy R. Thomas
Lesbian, gay, bisexual, and transgender (LGBT) youth are a largely invisible minority
group at serious risk for a variety of physical, emotional, and social problems. Because of
widespread societal prejudice and lack of awareness, school personnel have, in general,
failed to protect or serve this vulnerable group. The estimate that about 10% of the gen-
eral population has a same-sex or bisexual orientation came out of Kinsey’s large-scale
research on sexual behavior during the 1940s and 1950s (Kinsey, Pomeroy, & Martin,
1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). This figure persists in popular culture,
though recent research argues that a more accurate number is probably 6–10% (Keen,
2007; Murray, 2011; Tharinger & Wells, 2000). It is impossible to determine the exact
number of sexual minority youth because many are unaware of their orientation, in a
“questioning” period regarding sexuality, or unable or unwilling to disclose or discuss the
issue with others. Regardless of the precise percentage, it is safe to assume that there are
lesbian, gay, bisexual, and questioning students in every school (Wells & Tsutsumi, 2005).
Sexual minority youth experience isolation, rejection, and internalized lack of self-accep-
tance. LGBT people of all ages face discrimination, harassment, and violence, much like any
other minority group. Unlike other minorities, however, lesbians, gays, bisexuals, and trans-
gender people commonly do not have the support of or solidarity with their families (Bidell,
2011b; Tharinger & Wells, 2000). An African American, Jewish, or Latino/a youth will not be
expelled from his or her home for being African American, Jewish, or Latino/a, whereas a gay
or lesbian youth might be (Bidell, 2011b; Tharinger & Wells, 2000; Wells & Tsutsumi, 2005).
Another category of sexual minority youth receiving more attention is the transgender
population, who may identify as “straight” or “gay” in terms of sexual orientation and
whose gender identification may differ from their biologically assigned gender (Baker,
2002; Robinson & Espelage, 2011). Although there are fewer transgender people than
lesbians, gays, or bisexuals, the population of transgender youth is thought to be at even
higher risk for academic, social, and mental health issues than LGB youth (D’Augelli, Pilk-
ington, & Hershberger, 2002; Greytak, Kosciw, & Diaz, 2009; Heck, Flentje, & Cochran,
2011; House, Van Horn, Coppeans, & Stepleman, 2011; Mustanski, Garofalo, & Emer-
son, 2010; Toomey, Ryan, Diaz, & Russell, 2011; Wells & Tsutsumi, 2005). Much less is
known about this group because less research has been done to date (House et al., 2011;
Robinson & Espelage, 2011; Wilson, Iverson, Garofalo, & Belzer, 2011); however, there is
an increasing awareness of transgender issues and some interesting new research that will
be reviewed in this chapter (Mustanski et al., 2010; Toomey, McGuire, & Russell, 2012).
Contemporary Research
When the previous edition of this text was published in 2002, there was a paucity of
research specifically aimed at issues related to sexual minority youth (Fontaine 1998; Fon-
taine & Hammond, 1996; Nesmith, Burton, & Cosgrove, 1999; Tharinger & Wells, 2000;
Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) Youth 265
van Heeringen & Vincke, 2000). Comments about the lack of research continued into the
early 2000s (Stone, 2003), and some still claim the research is limited (Hohnke & O’Brien,
2008). However, since the early 2000s, there has been an explosion of research directly
examining LGBTQ children and adolescents, comparing their experiences with those of
their straight counterparts, and using quantitative and qualitative methodologies in local,
regional, national, and even longitudinal studies (Carrillo & Fontdevila, 2011; DiFulvio,
2011; Galliher, Rostosky, & Hughes, 2004; Horn, 2006; Kann et al., 2011; Lassera &
Tharinger, 2003; Marshal, King, et al., 2012; Marshal, Sucato, et al., 2012; Murdock
& Bloch, 2005; Robinson & Espelage, 2011; Russell, Ryan, Toomey, Diaz, & Sanchez,
2011; Shields, Whitaker, Glassman, Franks, & Howard, 2011; Short, 2010; Varjas et al.,
2007; Williams & Chapman, 2011). Previous research was mostly confined to retrospec-
tive studies from adults (which were often flawed in that recollections from earlier periods
of time may be biased, distorted, or inaccurate), or community centers serving LGBTQ
adolescents (which affected the generalizability of data) (Lassera & Tharinger, 2003; Mur-
dock & Bloch, 2005). Earlier research samples were generally taken from bars, prisons,
and psychiatric wards, which were not representative samples; this approach also influ-
enced public opinion regarding homosexuality (Herdt, 1989).
School Issues
Despite the increase in research, many of the problems experienced by LGBTQ individuals,
and especially youth, persist. Schools have continued to be unresponsive to the needs and
issues of sexual minority youth, and teachers and other school personnel tend to ignore or
even participate in discrimination and ridicule towards LGBTQ students (Bidell, 2011b;
Hohnke & O’Brien, 2008; Hunter, Joslin, & McGowan, 2004; Kosciw, Greytak, Diaz,
& Bartkiewicz, 2010; Sears, 1992; Sember, 2006; Stone, 2003; Tharinger & Wells, 2000;
Varjas et al., 2007). Although there have been some advances in terms of laws protect-
ing LGBTQ individuals against discrimination at local, state, and national levels (Hunter
et al., 2004; Mercier, 2009; Murray, 2011), there have also been major legal battles over
issues ranging from the presence of Gay-Straight Alliance clubs in K–12 schools (discussed
later in the chapter; Bidell, 2011b; Mercier, 2009; Toomey et al., 2011), to whether coun-
selor training programs can insist that graduate students provide supportive counseling for
LGBTQ clients (Bidell, 2011a; also see Keeton v. Anderson-Wiley et al., 2011, and Ward
v. Wilbanks et al., 2012), to the even larger issue of same-sex marriage (see, for example,
Perry v. Brown, 2011, and Varnum v. Brien, 2009).
Psychiatric Classification Issues

Until the early 1970s, the traditional approach in the psychological and psychiatric com-
munities was to view homosexuality as an illness, despite research that demonstrated the
psychological health of gay people (Hooker, 1957). The helping professions saw homo-
sexuality as a pathological and treatable condition (Dworkin & Gutierrez, 1989). Conver-
sion therapy treatment involved attempting to change the gay, lesbian, or bisexual person’s
orientation by causing a “heterosexual shift” (Coleman, 1978).
In 1973, “homosexuality” was removed from the classification of mental disorders in
the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) (American Psychiat-
ric Association, 1968). The gay rights movement of the 1960s and 1970s and the removal
of homosexuality from the DSM-II forced the mental health field to reevaluate its under-
standing of and attitude towards homosexuality (Iasenza, 1989). However, the diagnosis
of “Gender Identity Disorder,” characterized by extreme discomfort and distress with
one’s assigned gender, still exists in the DSM-IV-TR (American Psychiatric Association,
266 Suzy R. Thomas
2000). This diagnosis may contribute to ongoing misunderstanding and heightened stig-
matization of and prejudice against transgender people, although some argue that there
is a potential benefit in terms of financial support through managed care for transgender
individuals seeking sex-reassignment surgery.
The field of psychology has moved towards a model that views homosexuality and
bisexuality as normal variations of sexual orientation, and therapeutic approaches have
been adapted accordingly. The mental health field has made great strides in supporting and
treating the LGBTQ community; however, newly trained therapists have expressed a lack
of confidence about working with gay couples and LGBT clients because much of their
training is framed in a heteronormative perspective, especially when it comes to working
with families or couples (Rock, Carlson, & McGeorge, 2010).
Mythical and Reality Issues

Many of the myths concerning homosexuality have been dispelled, or at least modified, in
recent years. Some of these myths include the notion that homosexuality is a mental illness,
a “lifestyle choice,” a condemnable sin, a contagious condition, or that gay people are
child molesters or “recruiters” (Baker, 2002; Berzon, 2001). However, some of these myths
continue to influence adults who work directly and indirectly with children and adoles-
cents, including psychologists, counselors, social workers, and educators (Sember, 2006;
Stone, 2003). Studies have shown that as much as 25% of the school-based harassment
experienced by LGBTQ youth may come from teachers, and that teachers and other school
personnel are much more likely to intervene on a student’s behalf over racist remarks
than homophobic ones (Greytak et al., 2009; Hohnke & O’Brien, 2008; Robinson &
Espelage, 2011; Sears, 1992; Tharinger & Wells, 2000; Valenti & Campbell, 2009). Even
when teachers demonstrate a positive attitude or willingness to be helpful, they report
inadequate training to support sexual minority youth and fear of professional retaliation
(Athanases & Larrabee, 2003; Bidell, 2011b; Valenti & Campbell, 2009).
Professional Preparation Issues

Studies have shown that the training received by school counselors and school psychologists
is also lacking with regard to LGBTQ issues and needs, especially when compared with mul-
ticultural competencies (Bidell, 2005; Bidell, 2011a; Bidell, 2011b; Stone, 2003). Although
some school-based mental health practitioners still espouse negative attitudes towards work-
ing with sexual minority youth, a large percentage are open and positive about the topic, but
in need of more knowledge, skills, and awareness (Bidell, 2011a; Graybill, Varjas, Meyers,
& Watson, 2009; Rock et al., 2010; Savage, Prout, & Chard, 2004). Both school coun-
selors and school psychologists are in a unique position within the school system to com-
bat homophobia and heterosexism, support LGBTQ youth through individual and group
counseling interventions, and work systemically to create an inclusive and accepting school
climate—and, in fact, these two groups are ethically bound by the codes of their associations
to do so (Bidell, 2011b; Burnes et al., 2009; D’Augelli et al., 2002; DePaul, Walsh, & Dam,
2009; Graybill et al., 2009; Heck et al., 2011; Hunter et al., 2004; Lassera & Tharinger,
2003; Murdock & Bloch, 2005; Singh, Urbano, Haston, & McMahon, 2010; Stone, 2003;
Tharinger & Wells, 2000; Varjas et al., 2007; Walcott, Meyers, & Landau, 2008; Wells &
Tsutsumi, 2005). In addition, the right of counselor education programs to teach graduate
students to support LGBTQ clients has been upheld in several courts of law, though these
cases were still under appeal at the time of the printing of this text (see Keeton v. Anderson-
Wiley et al., 2011, and Ward v. Wilbanks et al., 2012).
It is abundantly clear from the research that LGBTQ youth need supportive school-
based mental health practitioners and a safe school environment (Bass & Kaufman, 1996;
Graybill et al., 2009; Hunter et al., 2004; Short, 2010; Toomey et al., 2012; Williams &
Chapman, 2011). Russell, Ryan, Toomey, Diaz, and Sanchez (2011) make the poignant
comment that even a small improvement could have wide-reaching effects for the mental
health and adjustment of LGBTQ youth as they enter young adulthood. This chapter is
intended to reveal and discuss some of the key issues and struggles faced by sexual minor-
ity youth, and to offer concrete strategies for prevention and intervention at individual,
family, and school-wide levels.
Terminology
The previous section included numerous descriptive terms for the groups of young people
addressed in this chapter. Terminology has been complicated, confusing, and problematic
in this field, with good reason. It is common for oppressed groups to take control of lan-
guage to describe themselves, especially when others in positions of power have assigned
offensive or inaccurate terminology. An example of this is the term “homosexual,” which
is not preferred because it is derogatory, given the stigma associated with homosexuality
when it was categorized as a mental disorder. Phrases like “lesbian, gay, bisexual, trans-
gender, questioning” are a mouthful to say, and thus are often shortened to LGBTQ. The
descriptor “sexual minority youth” has been frequently used, though it carries the dis-
empowering label “minority.” “Queer” has become popular among youth; a somewhat
edgy word that can also be a slur, it is intended to capture everyone outside the domi-
nant category of heterosexual or “straight.” Many youth remain unaware of the struggles
endured by gay rights activists over the last 60+ years, and they may not have adopted any
specific language. Terminology can be a stumbling block for those new to working with
the LGBTQ population; and, because of stigma, oppression, and difficulties experienced
by LGBTQ individuals, it is important to understand and use terms correctly. Table 15.1
is intended to clarify terms used in this chapter, and increase awareness and understanding
among those who desire to work effectively with this diverse population.
A Developmental Perspective
According to several developmental theories, identity is acquired through the dynamic
interaction between individual and environment. Some developmental theorists conceptu-
alize life as a series of identifiable stages, which progress in a logical, interrelated sequence
as the individual ages (Fuhrmann, 1990). Erikson (1963) considered the individual from
a psychosocial perspective, and described each stage of life as involving a “normative cri-
sis,” or primary conflict that must be resolved in order for healthy progression to the next
stage to occur. The crisis of adolescence is one of “identity versus role confusion” (Erikson,
1963). Individuals who manage this stage well enter adulthood with a solid sense of values
and peace with who they are and an ability to deal with conflict and difficulties. Those
who do not handle the developmental task of adolescence well are likely to develop poor
habits, become withdrawn, or engage in self-destructive or delinquent behavior; they will
also be less likely to successfully move into the next stage of “intimacy versus isolation”
and form a healthy partnership with another person (Erikson, 1963; Fuhrmann, 1990).
The tasks of adolescence involve coping with a sudden and dramatic transformation of
identity in all areas, including bodily changes, an increase in sexual thoughts, emotional
changes, the achievement of new cognitive abilities, and a pronounced focus on social
issues outside the home (Garcia Preto, 2005). LGBTQ adolescents face these tasks as
268 Suzy R. Thomas
Table 15.1 LGBTQ Terminology
LGBTQ This acronym is formed from the words Lesbian, Gay, Bisexual, Trans-
gender, and Questioning. It is commonly used as an all-inclusive noun
such as LGBTQ youth or LGBTQ community.
Lesbian A girl or woman who has significant (to oneself) sexual or romantic
attractions primarily to members of the same gender or sex, or who iden-
tifies as a member of the lesbian community.1
Gay One who has significant (to oneself) sexual or romantic attractions
primarily to members of the same gender or sex, or who identifies as
a member of the gay community. May be of any gender identity, but is
often used to refer to gay males.1
Bisexual One who has significant (to oneself) sexual or romantic attractions to
members of both the same gender and/or sex and another gender and/or
sex, or who identifies as a member of the bisexual community.1
Transgender A person who transgresses gender norms and self-identifies as transgen-
der. Transgender people can have any sexual orientation.1
Questioning A person who is in the process of questioning sexual identity/orientation/
preference.1
Queer Reclaimed derogatory slang for the sexual minority community (e.g.,
Queer Nation). Not accepted by all the sexual minority community, espe-
cially older members.1
Ally A person who confronts homophobia, heterosexism, heterosexual privi-
lege, biphobia, transphobia, and society’s gender norms in themselves
and others on both a personal and institutional level.1
Homophobia Negative feelings, attitudes, actions, or behaviors towards anyone who
is lesbian, gay, bisexual, or transgender, or perceived to identify as any
of the above. Internalized homophobia is a fear of same-sex tendencies
within oneself and can lead to repression. Institutionalized homophobia
refers to homophobic laws, policies, and positions taken by social and
governmental institutions. Applied to bisexual people, this is known as
biphobia; for transgender people it is known as transphobia.2
Heterosexism The system of oppression that reinforces the belief in the inherent superi-
ority of heterosexuality and heterosexual relationships, thereby negating
gays’, lesbians’, and bisexuals’ lives and relationships.2
Sexual Minority Youth This is an umbrella term used to be broadly inclusive of people based on
marginalized sexual or gender identities. Some argue that the term fur-
ther marginalizes nonheterosexuals.3
1
From http://www.umkc.edu/HOUSING/lgbtqia.asp
2
From www.utexas.edu/student/housing/pdfs/staff/LGBTQ_Vocab.pdf
3
From Russell, S. T. (2010). Contradictions and complexities in the lives of lesbian, gay, bisexual, and trans-
gender youth. The Prevention Researcher, 17(4), 3–6.
adolescents, as well as additional issues associated with the emergence of their sexual
orientation. Thus, this period of development has been cited by researchers as exception-
ally complex for sexual minority youth (Cox, Dewaele, van Houtte, & Vincke, 2010;
D’Augelli et al., 2002; DeCrescenzo & Lombardi, 2001; Nesmith et al., 1999; Padilla,
Crisp, & Rew, 2010; Russell & Toomey, 2010; Tharinger & Wells, 2000).
Development of Sexual Orientation. Acquisition of sexual orientation has been described
in biological, psychological, and cultural terms. In general, sexual orientation development
is considered to be a process that may take a lifetime, with the ultimate goal of integrating
sexuality into one’s overall identity in a healthy manner (Berzon, 2001). An Eriksonian
framework can be useful in conceptualizing LGBTQ identity development, because of the
focus on tasks and stages, and the potential for crisis. Two classic developmental theorists
whose work continues to be cited as contributing to our understanding of the developmen-
tal issues regarding sexual orientation are Cass (1979, 1984) and Troiden (1988).
Stage Models. Cass (1979) saw gay identity development as similar to other identity for-
mation theories, and underscored the importance of recognizing the significance of both
psychological and social factors. She conceptualized lesbian or gay identity development
as a process in which the individual is actively involved in the acquisition of a “gay” iden-
tity. (Her work occurred prior to the arrival of comprehensive descriptors such as LGBTQ,
so the word “gay” is used in this section.) Although she posited that identity is a cogni-
tive construct, in a constant state of change, Cass’s (1979) developmental model includes
delineated places of beginning and end. The first two stages are “Identity Confusion”
and “Identity Comparison,” in which the individual experiences conflict and loss as the
awareness of same-sex attraction emerges. The stages continue through “Tolerance,” to
“Acceptance,” to “Pride,” a stage in which the individual may reject the dominant culture
and align with the LGBTQ community. At every developmental stage an alternate path
is presented, and the individual is able to choose whether to interrupt and suppress the
continued development of a gay identity. Cass described increasing identity development
as the result of increasing congruency between the private and public aspects of a person’s
identity, with the final stage depicted as “Identity Synthesis.” Within this framework, the
gay individual can achieve sufficient levels of congruency or integration, although com-
plete synthesis may be impossible because of societal prejudice.
Troiden (1988) articulated a similar model, with specific stages and increasing integra-
tion of the sexuality with other aspects of identity. His model includes: Sensitization (“I am
different”), Identity Confusion (“What if I am gay?”), Identity Assumption (“I am gay—
whether I tell anyone or not”), and Commitment (“Gay is who I am”). Most LGBTQ
youth may not reach this “final” stage in adolescence (Baker, 2002). Both theorists are still
referenced in current literature, though linear models of identity development have been
criticized for indicating that sexual orientation follows a step-by-step path. In addition,
early models imply that awareness occurs prior to sexual contact, or omit the occurrence
of sexual contact altogether. Some researchers argue that sexual contact may, in fact, pre-
cede awareness for some, and that it is essential to include the role of sexual experiences
in identity development (Carrillo & Fontdevila, 2011; Savin-Williams, 2005).
Contextual Models. The most current trend regarding lesbian, gay, and bisexual identity is
to consider its development vis-à-vis the interactions with or influences of racial, ethnic, socio-
political, and historical contexts, and to use or create models that view development in fluid,
comprehensive, interdisciplinary terms (Galliher, Rostosky, & Hughes, 2004; Hong, Espelage,
& Kral, 2011; Kivel & Kleiber, 2000; Savin-Williams, 2005). An ecological perspective (Bron-
fenbrenner, 1979) emphasizes the contexts in which the individual experiences development
of sexual identity and orientation, and the ways in which interactions within those contexts
(e.g., family, school, community, etc.) support or impede the developmental process. Examin-
ing the key role of relationships and the detrimental effect of rejection, attachment theorists
have proposed that when attachments are disrupted due to public or private acknowledgment
of an LGBTQ identity, the effects on the individual and the family system can be profound.
Successful identity acquisition requires connection with others, and the experience or even
risk of rejection by key figures can be a devastating blow in the midst of the identity develop-
ment process. If attachments were not secure from the beginning of an individual’s life, the
impact of loss will be even greater (Baiocco, D’Alessio, & Laghi, 2010; Bowlby, 1973, 1982;
Tharinger, 2008; Tharinger & Wells, 2000). Thus, current thinking positions the identity
formation process not solely within the individual, but in the context of the negotiations and
interactions between the individual and the environment (Lassera & Tharinger, 2003).
270 Suzy R. Thomas
While early same-sex sexual experiences are common and may not predict a same-sex
orientation, it is also true that a same-sex orientation may be well established by ado-
lescence. Gay identity often begins in childhood, with a generally unidentifiable feeling
or awareness of being “different” (Baker, 2002; Savin-Williams, 2005). It is true either
that awareness of sexual orientation is occurring earlier (Valenti & Campbell, 2009), or
that recent research is more accurate about the age at which sexual orientation begins
to inform identity development. A period of “questioning” appears to be quite common
(Keen, 2007). LGBTQ youth, more than any other age group, have actively resisted being
labeled in binary terms, and have insisted on viewing sexuality on a continuum, similar to
what Kinsey proposed in his early research (Kinsey et al., 1948, 1953; Short, 2010; Savin-
Williams, 2005). Regardless of whether sexual identity development occurs in defined
stages, the process takes time and requires intrapsychic and interpersonal adjustment.
“Passing” Versus “Coming Out”: The Crisis of Disclosure. Sexual orientation issues
complicate adolescence for youth in the realms of friendships, family, school, and com-
munity. The development of sexual orientation eventually raises the question of whether
to disclose one’s identity to others. Many lesbian, gay, and bisexual adolescents are aware
of the lack of social acceptance of, and hatred towards, homosexuality. They often attempt
to hide their sexuality, and to monitor behavior and appearance in order to “pass” as
heterosexual (Baker, 2002; Hohnke & O’Brien, 2008; Wells & Tsutsumi, 2005). LGBTQ
youth may try to avoid possible rejection from family, peers, and school personnel by not
revealing or discussing their sexual orientation. However, not all adolescents are able to
“pass” as heterosexual, and passing is fraught with its own set of documented stressors
(Cox et al., 2010; Murray, 2011; Tharinger & Wells, 2000).
The process of coming out often involves a combination of complex internal shifts
accompanied by the courageous risks of sharing one’s identity with family and community
(Berzon, 2001; DeCrescenzo & Lombardi, 2001; Planned Parenthood of Toronto, 2004).
Self-disclosure and coming out are not necessarily the same processes, because an indi-
vidual may “come out” by recognizing an LGBTQ identity without sharing it with others
(Berzon, 2001). Reck (2009) and Ryan, Russell, Huebner, Diaz, and Sanchez (2010) cite
the “invisibility factor” as the stage in which youth hide their sexual orientation, with
the implicit and unspoken understanding that family members will tolerate the secret but
might not accept the reality if it is made known. “Visibility management” is a term that
researchers use to describe the ways in which LGBTQ youth decide when to disclose their
sexual orientation and to whom. This process involves continual monitoring of self and
others and is recognized as a key element in LGBTQ identity development (Bontempo &
D’Augelli, 2002; Lassera & Tharinger, 2003; Tharinger, 2008), in which the risks of dis-
closure are at times as serious as those of staying “in the closet.”
On the other hand, coming out seems to be psychologically beneficial, and contributes
to healthy self-esteem, decreased risk, and positive adjustment (Cox et al., 2010; Savin-
Williams, 1989). Coming out to others can decrease isolation, help with identity integra-
tion, and increase intimacy (Lipkin, 1999). However, disclosure may result in painful
experiences, ranging from a period of difficult adjustment with eventual acceptance to
complete rejection and isolation for the LGBTQ person (D’Augelli, Hershberger, & Pilk-
ington, 1998; Padilla et al., 2010).
Parental Reaction. The literature underscores the importance of acceptance, specifi-
cally from parents or other primary caregivers, as an essential element in healthy identity
development for LGBTQ youth and the prevention of negative symptoms and suffering
(Heck et al., 2011; Nesmith et al., 1999; Padilla et al., 2010). Moreover, family acceptance
has lasting implications for physical and mental well-being through adolescence and into
adulthood (Ryan et al., 2010). However, many LGBTQ youth do not find support within
their families, and instead are at risk of being ridiculed, abused, or forced to leave home
(Bidell, 2011b; Tharinger & Wells, 2000). Disclosure precipitates a family crisis, which
may or may not be resolved eventually. Many parents project their misconceptions and
negative values about homosexuality onto their child, whom they begin to perceive as a
stranger. Parents frequently experience a sense of responsibility, guilt, and failure, as if they
somehow caused the “problem” and as if the child is doomed to have an unhappy life that
would not include heternormative milestones in adulthood such as marriage and having
children (Lassera & Tharinger, 2003; Reck, 2009; Strommen, 1989; Wells & Tsutsumi,
2005). Research on LGBTQ adolescents indicates that most want and expect to have
monogamous, long-term relationships and/or marriages, as well as children (D’Augelli,
Rendina, Sinclair, & Grossman, 2007).
Parents may also engage in a similar process of “visibility management,” trying to deter-
mine how and to whom they disclose the sexual orientation of their child, and a cycle of
adjustment that may parallel that of the LGBTQ youth (Baker, 2002; Lassera & Tharinger,
2003). Resources such as PFLAG (“Parents and Friends of Lesbians and Gays”) may be
especially useful for parents and caregivers. Often, family bonds are stronger than negative
attitudes or perceptions about homosexuality (Baker, 2002; Berzon, 2001; see Appendix).
Resilience and Risk Among LGBTQ Youth

Recent research has focused on resilience factors among LGBTQ youth, and some studies
indicate that many LGBTQ adolescents successfully adjust and adapt without engaging in
risk-taking behaviors or being subjected to the suffering that is commonly associated with
the profile of the sexual minority youth (Burnes et al., 2009; DiFulvio, 2011; Murdock &
Bloch, 2005; Nesmith et al., 1999; Robinson & Espelage, 2011; Savin-Williams, 2005).
Increased visibility of LGBTQ people in the media has been helpful to youth who are
struggling with their identity (Kivel & Kleiber, 2000).
It has also become clear that there are significant within-group variations that were
previously unknown (Murdock & Bloch, 2005; Robinson & Espelage, 2011; Savin-Wil-
liams, 2005). School-based practitioners need to remember that LGBTQ students may be
among the highest performing students in their schools, that they may be adjusting well
to their sexual identity, and that they may demonstrate resilience or take full advantage of
whatever buffering or protective factors are available to them within their families, peer
groups, and school and larger communities (Cox et al., 2010; DeCrescenzo & Lombardi,
2001; DiFulvio, 2011; Ryan et al., 2010; Savin-Williams, 2005; Wells & Tsutsumi, 2005).
It is also important that school-based personnel understand that the problems experienced
by LGBTQ youth arise from the hostile attitudes, discrimination, and stigmatization that
they experience from others, and not as a result of their sexual orientation (Burnes et al.,
2009; Cox et al., 2010; DiFulvio, 2011; House et al., 2011; Marshal, King, et al., 2012;
Tharinger, 2008; Wells & Tsutsumi, 2005).
Despite the focus on resilience and the studies that reflect a positive adjustment process
for some LGBTQ youth, there is still overwhelming evidence that sexual minority youth
are vulnerable in a variety of physical, emotional, and social ways. Common problems
of sexual minority youth have been well documented since the early 1990s, and include:
dropping out of school, school failure, running away from home, homelessness, sexual
abuse, prostitution, HIV/AIDS, sexually transmitted diseases, eating disorders, substance
abuse, depression, suicide, violence, harassment, discrimination, isolation, and lack of
support from family, peers, and school personnel (Baker, 2002; Bidell, 2011b; Cooley,
1998; D’Augelli et al., 1998; DiFulvio, 2011; Fontaine, 1998; Galliher et al., 2004; Heck
et al., 2011; Hong et al., 2011; Hohnke & O’Brien, 2008; House et al., 2011; Kann et al.,
discusses physical violence and hostile behavior, LGBT students also report experiencing
a less obvious form of bullying known as relational aggression. This covert form of bully-
ing is commonly characterized by ostracizing peers from group activities, gossiping, and
threatening the loss of friendships; a disturbing 88.2% of students in the 2009 National
School Climate Survey reported experiencing relational aggression related to sexual orien-
tation or gender identity (Kosciw et al., 2010). Students who may or may not be LGBTQ,
but who are perceived to be or who are gender-nonconforming, also suffer from this type
of aggression (Robinson & Espelage, 2011). Victimization often occurs over a period of
time, as opposed to a single incident, and largely goes unreported at school for fear that
there will not be any response or that a report will intensify the harassment (Berlan et al.,
2010; Craig, Pepler, & Blais, 2007; Murray, 2011; Varjas et al., 2007). Sometimes, how-
ever, students not only report the abuse but also fight back legally; a string of court cases
responding to school-based bullying and victimization has resulted in new legislation at
local and state levels intended to clarify and provide additional protection for LGBTQ
students (see, for example, Davis v. Monroe County Board of Education, 1999; Franks v.
Metropolitan Board of Public Education, 2009; Aaron Fricke v. Richard B. Lynch, 1980;
Gillman v. Holmes County School District, 2008; Nabozny v. Podlesny, 1996; PFLAG v.
Camdenton R-III School District, 2011; Pratt v. Indian River Central School District et al.,
2011; Sturgis v. Copiah County School District, 2011).
Laws that have been particularly helpful in promoting the rights of LGBTQ youth
include: the First Amendment of the U.S. Constitution, which has been cited in cases in
which freedoms of expression and association are threatened; the Equal Access Act of
1984, which has been used to allow Gay-Straight Alliances (GSAs) on school campuses
(discussed later in the chapter); Title IX, which is intended to prevent harassment based
on gender or sexuality; the U.S. Supreme Court decision in the case of Lawrence v. Texas,
which repealed sodomy laws and thus nationally legalized same-sex sexual activity; and
the Equal Protection Clause, which ensures protection for all students from harassment.
Individual states have expanded their antidiscrimination laws to include gender and sexual
orientation as protected categories in the workplace and in schools as well (Hunter et al.,
2004; Keen, 2007; Mercier, 2009; Murray, 2011). The American Civil Liberties Union
(ACLU) and the Lambda Legal Defense and Education Fund have been active in defend-
ing countless LGBTQ youth in cases of harassment, violence, and discrimination (see
Appendix).
Regardless of the advances in legislation, victimization of sexual minority youth remains
an ongoing and relentless problem. Schools change slowly, at best, even when court-
ordered to do so (Short, 2010). Much of the research on school-based bullying, verbal
abuse, and victimization leaves out the topic of sexual orientation (D’Augelli et al., 2002).
Research that has addressed victimization of LGBTQ youth reveals a disturbing connec-
tion between the abuse and the development of a host of mental and emotional problems.
The violence and harassment endured by sexual minority youth contribute to school drop-
out, truancy, anxiety and depression, posttraumatic stress symptoms, substance abuse,
risky sexual practices, and suicide (D’Augelli et al., 2002; Heck et al., 2011; House et al.,
2011; Murray, 2011; Shields et al., 2011; Varjas et al., 2007). Bontempo and D’Augelli
(2002) argue that victimization is, in fact, the primary variable in the development of men-
tal health, social, and physical problems. When LGBTQ youth are not victims of violence
and harassment, the likelihood that they will develop these problems is about the same as
it is for heterosexual youth (Bontempo & D’Augelli, 2002).
GLSEN Report Findings. A major catalyst in thrusting LGBT issues into mainstream
consciousness is the Gay, Lesbian and Straight Education Network (GLSEN) (see Appen-
dix). Since 1999, GLSEN has performed a national survey examining the school experience
274 Suzy R. Thomas
for LGBT youth every two years. The 2009 Climate Survey (Kosciw et al., 2010) includes
data on the frequency with which LGBT students experience various forms of harassment
and violence. Primary findings include the following: “88.9% of students heard ‘gay’ used
in a negative way (e.g., ‘that’s so gay’) frequently or often at school, and 86.5% reported
that they felt distressed to some degree by this” (p. 16). In addition, “84.6% were verbally
harassed (e.g., called names or threatened) at school because of their sexual orientation
and 63.7% because of their gender expression” (p. 26). And “61.1% of students reported
feeling unsafe at school because of their sexual orientation” (p. 22). Finally, “21.3% of
students . . . had been assaulted at school during the past year, most commonly because of
sexual orientation or gender expression” (p. 27).
Suicide. The combination of being unseen, unaccepted, and/or victimized can lead
LGBTQ teenagers to suicide. Many authors have noted a disproportionately high risk
of suicide among sexual minority youth, with estimates ranging from a rate of 2–3 to
3–4 times higher than the rates for heterosexual youth (Cooley, 1998; Fontaine, 1998;
Hohnke & O’Brien, 2008; Hong et al., 2011; McFarland, 1998; Muller & Hartman,
1998; van Heeringen & Vincke, 2000). This rate increases to up to 9 times higher if com-
ing out includes rejection from family members (Ryan, Huebner, Diaz, & Sanchez, 2009).
There is no way to know the exact number of suicide attempts or even completed suicides
within the LGBTQ youth population. What is clear is that sexual minority youth are at an
elevated risk for both depression and suicide (DiFulvio, 2011; Galliher et al., 2004; Jiang,
Perry, & Hesser, 2010; Mustanski et al., 2010; Newcomb & Mustanski, 2010; Russell
& Toomey, 2010; Shields et al., 2011). The research studies that have illuminated the
widespread problem of suicide among sexual minority youth have been accompanied by a
number of creative media efforts such as “The Trevor Project,” a 24-hour national hotline
for suicide prevention for LGBTQ youth; and “It Gets Better,” a YouTube video project
initiated by news columnist Dan Savage in response to a rash of suicides in the fall of 2010
(Savage & Miller, 2011; see Appendix).
Substance Abuse. Research indicates that LGBTQ youth may engage in substance
abuse, including alcohol, cigarettes, and prescription as well as illegal drug use, at higher
rates than their straight counterparts. These risks are often reported to be highest among
bisexual females and lesbians, as well as younger adolescents (ages 12–17) versus older
adolescents/young adults (ages 18–23) (Baiocco et al., 2010; Corliss et al., 2010; Marshal,
King, et al., 2012; Padilla et al., 2010). This difference was not true among Asian Pacific
Islanders, whose substance abuse rates spiked in later adolescence (Hahm, Wong, Huang,
Ozonoff, & Lee, 2008). Risk of substance abuse increases when the youth experiences
rejection upon coming out (Baiocco et al., 2010; Ryan et al., 2010).
Sexual Risk-Taking. Sexual risk-taking is another concern for the LGBTQ population,
especially in conjunction with higher rates of substance use and abuse (Herrick, Marshal,
Smith, Sucato, & Stall, 2011). Sexual minority youth appear to be less likely to ask for
help or information about sex, and more likely to engage in risky sexual practices; rates
are reported to be highest among gay males and bisexual students, and generally lower
among lesbians (Kann et al., 2011; Walcott et al., 2008). Young people in general are at
higher risk for HIV and other sexually transmitted diseases, in part because they ascribe
to the adolescent myths of invincibility and invulnerability (“it won’t happen to me”), and
are less savvy at negotiating mature conversations about sexual behavior. Sexual minority
youth are also at risk of contracting HIV because they are less likely to practice safer sex
and more likely to be in situations in which they are victimized (DeLonga et al., 2011;
Rotheram-Borus, Gillis, Reid, Fernandez, & Gwadz, 1997; Russell et al., 2011; Walcott
et al., 2008). In 2009, the Centers for Disease Control and Prevention reported 2,057 cases
of HIV infection across 40 states with anonymous testing procedures among adolescents
ages 13–19, and 6,237 among 20–24-year-olds. The cumulative AIDS cases for adoles-
cents diagnosed between ages 13–19 reached 8,535 in 2009, which is nearly triple the
number from June of 1997; and 42,920 for the 20–24 age group, a figure that nearly
doubled since June 1997 (Centers for Disease Control and Prevention, 1997).
Dropout and School Belonging. Missing school and/or dropping out of school are addi-
tional risk factors for sexual minority youth, and are often connected to the prevalence of
victimization, as mentioned in the previous section (Greytak et al., 2009; Kosciw et al.,
2010; Murdock & Bloch, 2005; Tharinger & Wells, 2000). School-based problems are
also related to a reduction in LGBTQ student perceptions of “belonging” in school, a
newer area of research. Examining LGBTQ student experiences through the lens of school
belonging allows for a more systemic, as opposed to individual, perspective. Having a
sense of belonging is a protective factor related to mental health and school success, espe-
cially for girls. Studies report that lower levels of belonging among LGBTQ students begin
to peak in middle school, a time when students perceive their schools as unwelcoming
and unsafe (Diaz, Kosciw, & Greytak, 2010; DiFulvio, 2011; Galliher et al., 2004; Hong
et al., 2011; McCallum & McLaren, 2010; Murdock & Bloch, 2005; Robinson & Espel-
age, 2011). Despite their knowledge of reported harassment, most heterosexual students
remain unaware of the lower levels of school belonging among their LGBTQ peers, believ-
ing that their schools are safe. This finding is likely to be reflective of the powerful impact
of homophobia and the norms of heterosexism (discussed later in the chapter) that char-
acterize most K–12 educational settings (Toomey et al., 2012).
Homelessness. There is a striking number of sexual minority youth among the overall
population of homeless youth. The primary factor contributing to the high rate of home-
lessness is family rejection (Bidell, 2011b; Tharinger & Wells, 2000; Wells & Tsutsumi,
2005). Homeless LGBTQ youth are at higher risk for substance abuse, child sexual abuse,
and prostitution; for homeless lesbians, suicide is an exceptionally high risk. Overall, sex-
ual minority homeless youth report being victims of physical and sexual assault in higher
numbers than straight homeless peers (Whitbeck, Chen, Hoyt, Tyler, & Johnson, 2004).
Homeless adolescents, especially gay males, often turn to “survival sex” in exchange for
food or shelter; LGBTQ homeless youth will also engage in “non-sexual street subsistence
strategies” such as panhandling or stealing in order to live on the streets (Whitbeck et al.,
2004, p. 331). Many homeless LGBTQ youth also report coming out at an earlier age
than nonhomeless youth. The high rates of homelessness and the specific types of suffering
endured by homeless LGBTQ youth make parental intervention, awareness, and educa-
tion more critical (Reck, 2009; Rosario, Schrimshaw, & Hunter, 2012; Whitbeck et al.,
2004). Even in San Francisco’s Castro District, a well-known sanctuary within the LGBTQ
community, sexual minority youth who are homeless suffer from invisibility, harassment
from the police, and abuse at the hands of adults (Reck, 2009).
Subgroup Issues
LGBTQ Youth of Color. Sexual minority youth of color face additional challenges as mem-
bers of two minority groups (Athanases & Larrabee, 2003; Chung & Katayama, 1998;
DeCrescenzo & Lombardi, 2001; DePaul et al., 2009; Hahm et al., 2008; Mustanski et al.,
2010; Savin-Williams, 2005; Wells & Tsutsumi, 2005). Once they become aware of their
sexual orientation, LGBTQ youth of color may not feel at home in either group, increasing
their isolation. For an adolescent from an ethnic minority group, coming out occurs in the
contexts of ethnic traditions, family values, and social networks. LGBTQ youth of color
risk rejection within their racial or ethnic communities because of their sexual orientation.
Homosexuality is widely perceived by people of color to be caused by the decadence of
276 Suzy R. Thomas
White, urban society (Folayan, 2001; Tremble, Schneider, & Appathurai, 1989). There is a
myth that the gay community is open and accepting because of its oppression by the major-
ity. Yet many non-White gays and lesbians experience discrimination and lack of acceptance
within the LGBTQ community (Herdt, 1989; Reck, 2009; Tremble et al., 1989).
LGBTQ adolescents have been assumed to be homogeneous (Herdt, 1989; Savin-
Williams, 2005). In reality, cultural differences affect the definition and expression of
homosexuality and the values associated with it. It is crucial to understand the different
meanings assigned to homosexuality and coming out in cross-cultural contexts. For exam-
ple, LGBTQ youth of color do not necessarily share the value of disclosure or “coming
out” commonly espoused by White gay men and lesbians (Herdt, 1989; Wells & Tsutsumi,
2005). Identity integration issues pose unique problems among Asians and Asian Pacific
Islanders, Latinos/as, and African Americans (Folayan, 2001; Gock, 2001; Gutierrez,
2001; Savin-Williams, 2005). A much more fluid understanding of gender and sexuality
exists in many Native American tribes, and the insistence on binary schemas to explain
these constructs does not make sense. The term “two-spirit” has been adopted by many
tribes as a spiritual/social identity that includes those whose gender or sexuality is neither
male nor female, neither gay nor straight. Other terms, like “berdache” and “Amazon,”
were imposed by others and are either confusing or insulting. Homophobia appears to be
less widespread among Native Americans than in other cultural groups (Tafoya, 2001).
Carrillo and Fontdevila (2011) have criticized much of the research conducted within the
United States on LGBTQ issues because it fails to accurately reflect the diversity of experi-
ences and variations across racial and ethnic groups.
Bisexual Youth. With the advent of more effective research, it has been possible to iden-
tify within-group differences for LGBTQ youth. A significant finding has been that bisexu-
als are at even higher risk in a number of areas, particularly suicide, substance abuse, and
sexual risk-taking (Corliss et al., 2010; Galliher et al., 2004; Kann et al., 2011; Marshal
et al., 2011; Murdock & Bloch, 2005; Robinson & Espelage, 2011; Tharinger & Wells,
2000; Walcott et al., 2008). Bisexuality is stigmatized within both the straight and gay
communities. Homophobia prevents the acceptance of sexuality as a variable construct,
and insists on a binary system for sexuality in which people are “either” gay or straight.
This dichotomy makes it difficult for people who identify as bisexual to feel accepted
anywhere. Youth, who are in the process of identity development in all areas, suffer more
acutely when identity confusion is present, and need support in conceptualizing sexuality
as fluid and evolving (Wells & Tsutsumi, 2005).
Transgender Youth. Recent research has attempted to include the transgender experi-
ence within studies of sexual minority youth, and to focus exclusively on illuminating
issues specific to transgender youth (Greytak et al., 2009; House et al., 2011; Mustan-
ski et al., 2010; Robinson & Espelage, 2011; Wilson et al., 2011). Transgender youth
report increased vulnerability in key areas such as absenteeism, substance abuse, verbal
and physical abuse within the home, and suicide (Heck et al., 2011; Ryan et al., 2011;
Toomey et al., 2011; Wilson et al., 2011). It has also been suggested that transgender youth
may be especially prone towards mental illness (Mustanski et al., 2010), and that the
frequency with which they are victimized at school and within their communities is even
higher than the rates for LGB youth (D’Augelli et al., 2002). HIV risk is especially high
for male-to-female (MTF) and female-to-male (FTM) transgender individuals who are
sexually involved with males. As with the LGB youth community, the variable of parental
support is crucial in the prevention of mental health issues and suffering for transgender
youth (Wilson et al., 2011).
It is important to distinguish the categories of sexual orientation from gender identity,
as they represent different social constructs. One’s gender identity is separate from one’s
sexual orientation—for example, a student could identify as transgender and heterosexual.
These marginalized groups have been “lumped together,” although one subcategory may
or may not relate to the issues and needs of another. Similar to the bisexual population and
LGB youth of color, the transgender population has not been completely accepted within
the larger gay community. And transgender people do not necessarily wish to be part of
the LGB community, either. For transgender youth, all of these complex social dynamics,
which have existed for years, make coming out an even more confusing and complicated
process, in which fitting in anywhere may feel impossible (Baker, 2002; Burnes et al., 2009;
Reck, 2009; Tremble et al., 1989).
“Gender identity disorder,” as a diagnosis in the DSM, brings another level of stigma
to transgender people, and poses additional difficulties during adolescence (Baker, 2002;
Hunter et al., 2004). Gender identity disorder implies a deep sense of discomfort and
a resulting impairment in functioning, qualities that frequently characterize transgen-
der youth. It is very likely, however, that many or most of these symptoms stem from
negative attitudes, prejudice, and transphobia; if society were more accepting of gender-
nonconforming and transgender individuals, perhaps we would see a decline in their
mental health risks.
In addition to the First Amendment, Title IX, and the Equal Protection Clause, trans-
gender students should be guaranteed rights under the Due Process Clauses of the U.S.
Constitution, which relate to protections regarding personal appearance (http://www.
glsen.org/cgi-bin/iowa/all/library/record/1289.html; Hunter et al., 2004). In spite of these
rights, transgender youth experience harassment and discrimination at excessively high
rates, and receive even less support in their schools than LGB youth (Greytak et al., 2009;
Hunter et al., 2004; Wells & Tsutsumi, 2005). It is perhaps surprising, then, to note that
transgender youth are more likely than their LGB peers to raise issues related to sexual
minority youth in the classroom; this is one noticeable sign of resilience within the trans-
gender youth community (Greytak et al., 2009).
Research has resulted in growing awareness of specific challenges faced by this sub-
population, and various efforts have been undertaken to support transgender youth within
organizations that have served the LGB youth community. In 2009, a subdivision of the
American Counseling Association (ACA) called the Association for Lesbian, Gay, Bisexual
& Transgender Issues in Counseling (ALGBTIC) published the “Competencies for Coun-
seling with Transgender Clients” (Burnes et al., 2009). This document approaches work-
ing with transgender people from multicultural, feminist, and social justice perspectives,
and uses the eight standards established by the Council of Accredited Counseling and
Related Educational Programs (CACREP) as a guide. The competencies address overall
health and development, relationships, assessment, and diagnosis; they also suggest inter-
ventions and propose strategies for counselors to understand their own potential for bias
and stereotyping.
Prevention
A Systems Perspective: Heteronormativity, Heterosexism, & Homophobia in Schools. A
school is a system with subsystems, including students, teachers, school counselors and
school psychologists, administrators, and parents, each of which interacts with and influ-
ences the others. Each subsystem has adopted roles and rules for functioning, some of
which must be changed if LGBTQ youth are to survive and be given the opportunity to
have a safe and affirming school experience. For example, adults often deny or ignore the
existence of LGBTQ youth, and tend to omit or devalue the historical and present-day
contributions of gays and lesbians. They may even contribute to the discrimination so
278 Suzy R. Thomas
commonly experienced by sexual minority youth. Students are allowed to tease, harass,
and harm those who do not conform to traditional sex-role expectations.
The presence of homophobia, heterosexism, and heteronormativity prevents individu-
als from questioning norms, and fosters intolerance of difference (Walcott et al., 2008).
Homophobia comes from stereotypes, fear, negative assumptions, and discrimination;
more than “attitudes,” it may take the form of violence (Berzon, 2001; Herrick et al.,
2011; Kivel & Kleiber, 2000; McCallum & McLaren, 2010; Planned Parenthood of
Toronto, 2004; Short, 2010; Tharinger, 2008; Ueno, 2010).
Although homophobia is probably the most well-known term to describe discrimi-
nation against LGBTQ people, heterosexism is a more accurate descriptor because it
reflects the institutionalized nature of antigay prejudice, justifies victimization, and sup-
ports the notion that heterosexuality is superior (Athanases & Larrabee, 2003; Baker,
2002; Burnes et al., 2009; Hong et al., 2011; Murray, 2011; Tharinger & Wells, 2000;
van Heeringen & Vincke, 2000). Heterosexism takes place through both discourse and
behaviors, and through not only the oppression of LGBTQ individuals but also the
denial of their very existence (Athanases & Larrabee, 2003; Baker, 2002). Children are
socialized in school to adopt gender-specific behavior and to reject the gender-atypical
behavior of “tomboys” and “sissies” (Bontempo & D’Augelli, 2002). Masculinity and
violence are sanctioned in schools, contributing to real and perceived lack of safety for
gender-nonconforming students (Tharinger, 2008). Research indicates that children in
middle school are more likely to demonstrate homophobic and heterosexist attitudes
and behaviors than high school students, and that girls are less likely than boys to engage
in prejudicial acts towards others based on real or perceived sexual orientation (Horn,
2006; Ueno, 2010). Boys are more likely to be victimized based on real or perceived
sexual orientation, however (Baker, 2002; D’Augelli et al., 2002; Galliher et al., 2004;
Russell et al., 2011; Ryan et al., 2010).
Heteronormativity upholds a rigid view of gender and sexuality and delineates a hierar-
chy for “normal” and “deviant” behavior (Bontempo & D’Augelli, 2002; Russell, 2010;
Toomey et al., 2012; Walcott et al., 2008). Heteronormativity and assumptions of hetero-
sexuality obscure gay identity and contribute to stereotypes (Kivel & Kleiber, 2000) and
“othering” of LGBTQ individuals, a process that parallels racism (DiFulvio, 2011). In
fact, Meyer (2003) coined the term “minority stress theory,” which has been applied to
LGBTQ experiences in order to explain high levels of mental and physical health problems.
Minority stress theory holds that the stressful experience of living with ongoing rejection
and victimization can contribute to a wide range of problems that are not innately related
to being LGBTQ but caused by the environment (Burnes et al., 2009; Cox et al., 2010;
House et al., 2011; Marshal, King, et al., 2012).
When individuals experience negative attitudes and treatment on the basis of their
actual or perceived sexual orientation, they may become convinced that they are infe-
rior, delinquent, mentally ill, and so on. This process of internalizing prejudice is simi-
lar to the internalized racism experienced by people of color. Internalized homophobia
increases when acceptance from others is lower, making it less likely that a person will ask
for help, and contributing to mental health problems (Baker, 2002; Baiocco et al., 2010;
Cox et al., 2010; DeLonga et al., 2011; Herrick et al., 2011; Hohnke & O’Brien, 2008;
Nesmith et al., 1999; Newcomb & Mustanski, 2010; Planned Parenthood of Toronto,
2004; Toomey et al., 2012; Williams & Chapman, 2011).
The Role of the School-Based Mental Health Practitioner. School-based mental health
practitioners are in a unique position to assist LGBTQ youth in (a) developing a healthy
sexual identity, (b) adjusting to their sexual orientation, (c) coping with prejudice, and
(d) deciding how and to whom to disclose their sexual orientation. School counselors
and school psychologists who address this issue must be both creative and courageous in
developing programs and interventions that fit the needs of their schools.
School-based mental health practitioners can have a positive impact on the lives of
all students, by working directly with the LGBTQ student population and by fostering
awareness, understanding, and acceptance among all members of the school community.
In order to do so, it is essential for school counselors and school psychologists to engage in
reflection about their own attitudes and potential areas of bias. The next sections describe
the need for self-awareness, followed by suggestions for direct and indirect service inter-
ventions.
Self-Awareness. In order to be effective, school-based mental health practitioners must
be aware of their own attitudes, informed about referral sources, and accepting of sexual
minority students (Baker, 2002; Barrett & McWhirter, 2002; Hohnke & O’Brien, 2008;
Tharinger & Wells, 2000). Without education and awareness, school counselors and school
psychologists are likely to remain inattentive to LGBTQ students. Adults who attempt to
address the needs of LGBTQ students must deal with and heal from their own prejudice
or ignorance through self-assessment, which can take the form of values clarification exer-
cises, talking with others, and similar activities. Self-education can also include reading
books and articles or watching movies with LGBTQ characters or themes (Iasenza, 1989).
Since school-based mental health practitioners are trained in advocacy, social justice, com-
munication skills, and conflict resolution, they have the ideal background to facilitate the
difficult dialogues that need to take place in order to promote systemic change within their
schools, and to empower LGBTQ youth to be resilient and healthy as they move through
adolescence into young adulthood (Singh et al., 2010). Many school-based practitioners
may not have had adequate training to work effectively with LGBTQ youth, and may need
to engage in additional activities to become competent. Bidell (2005) developed the Sexual
Orientation Counselor Competency Scale (SOCCS) to assess counselor attitudes, skills,
and knowledge regarding LGBTQ clients. In a study (2011a) in which Bidell compared
counselor competence in the area of sexual orientation with multicultural issues, partici-
pants scored much lower on the SOCCS, indicating a need for further skill development.
Primary Prevention. Strategies for working with LGBTQ youth combine primary and
secondary prevention methods in a comprehensive effort to address prejudice and hetero-
sexism at school and protect vulnerable populations. Primary prevention measures include
in-service training, policy making, and school-wide culture reform.
In-Service Training. School-based practitioners can raise awareness by presenting the
disturbing statistics regarding common problems faced by LGBTQ youth; this strategy can
help to justify the need for working with this population and to gain the support of admin-
istrators and other members of the school system by focusing on safety instead of sexuality
(Muller & Hartman, 1998). School-based mental health practitioners can educate teach-
ers and administrators by conducting or arranging for in-service training on LGBT issues.
This recommendation has been supported in the research (DePaul et al., 2009; Graybill
et al., 2009; Tharinger & Wells, 2000). Practitioners can also help teachers learn how to
handle name-calling in class and offer suggestions for curricular reform. The inclusion of
LGBT issues in curriculum will help alleviate the sense of cognitive isolation felt by many
sexual minority youth (Baker, 2002; Graybill et al., 2009; Lipkin, 1994; Murray, 2011;
Sember, 2006; Tharinger & Wells, 2000).
School counselors and psychologists can also run educational groups and make class-
room and school-wide presentations, including a diversity day or week at school with
presentations, videos, speakers, discussion, and exercises (Bass & Kaufman, 1996). Alter-
native activities that deal with prejudice in a more general way can be provided for stu-
dents who do not wish to participate, or whose parents do not permit their participation.
280 Suzy R. Thomas
Interventions can also include participation by community groups and supportive school-
community partnerships (DePaul et al., 2009). In general, there is more support for
LGBTQ youth today through school-based and community programs, as well as the Inter-
net (DeCrescenzo & Lombardi, 2001).
School Policy. School-based practitioners can help develop and enforce school policies
that protect, support, and affirm lesbian, gay, bisexual, and transgender students, staff,
and parents (Bass & Kaufman, 1996; Graybill et al., 2009; Kann et al., 2011; Robinson,
2010). Establishing and enforcing policies that prohibit harassment of LGBTQ youth were
previously considered to be less controversial than other interventions (Rienzo, Button,
& Wald, 1997). However, the rise in litigation resulting from hate crimes, harassment,
and victimization on school campuses and in the larger community makes policy reform
a much more charged and potentially impactful intervention to tangibly improve the lives
and safety of LGBTQ youth.
Gay-Straight Alliances. A significant intervention that has become widely popular
and particularly controversial since the early 1990s is the Gay-Straight Alliance move-
ment, which was influenced by a pioneering school-based program that is still in exis-
tence, Project 10 of Los Angeles, aimed at preventing school dropout among LGBTQ
youth (Bidell, 2011b; Hohnke & O’Brien, 2008). A Gay-Straight Alliance (GSA) is a
school-based student group or club (Bidell, 2011b; Valenti & Campbell, 2009). Mem-
bership in a GSA is voluntary and open to students who identify as LGBTQ, who have
a family member or friend who is LGBTQ, and those who identify as straight allies to
the LGBTQ community. The mission of a GSA is to foster campus safety for all students
regardless of sexual orientation, promote tolerance, and celebrate diversity. In an effort
to bring awareness to some of the issues that LGBTQ youth face, GSAs often participate
in national campaigns sponsored by GLSEN such as “Ally Week,” “No-Name Calling
Week,” and “The Day of Silence” (see Appendix). GSAs have been recommended as a
powerful, school-wide intervention against heterosexism and are aimed at protecting
LGBTQ students (Kann et al., 2011; Murray, 2011; Varjas et al., 2007). Research dem-
onstrates that GSAs have an overall positive influence on students and school climate;
specifically, GSAs promote higher levels of belonging and perceptions of safety, and a
reduction in rates of suicide, substance abuse, depression, and anxiety (DiFulvio, 2011;
Heck et al., 2011; Murray, 2011; Russell et al., 2011; Tharinger & Wells, 2000; Toomey
et al., 2012; Wells & Tsutsumi, 2005).
Part of the success of a GSA rests on the involvement of a faculty or staff member serving
as a group advisor. However, prospective advisors are often troubled by potential profes-
sional ramifications of GSA involvement, personal concerns regarding their safety, and the
many legal controversies over GSAs (Bidell, 2011b; Valenti & Campbell, 2009).
Prevention and Intervention Strategies at Various School Levels. Most of the interven-
tions and strategies discussed in this chapter would be primarily applicable at the middle
and high school levels. Many of the problems faced by LGBTQ youth, such as suicidal
ideation and substance abuse, would not, in many cases, appear until then. In addition,
LGBTQ adolescents are more likely to be able see the connections between their experi-
ences and their emerging sexuality than younger children. However, given that sexual iden-
tity awareness often begins in early childhood, it is possible for younger children to have
an awareness of sexual orientation or gender identity. They may have parents or other
family members who are LGBT, which would contribute to their understanding of sexual
orientation and gender identity. An appropriate intervention at the elementary school
level might be a classroom discussion about different kinds of families (i.e., those with a
mom and a dad, or with two moms or two dads, or a single mom or a grandmother, and
so on). Counselors and psychologists who work in an informed and accepting way with
younger children who may be LGBTQ may help prevent some of the problems typically
experienced by these students by the time they reach secondary school.
Secondary Prevention Strategies. The direct service counseling suggestions described
in this section serve as secondary prevention tools because they aim to protect LGBTQ
students and to prevent or reduce the development of physical, social, and emotional
problems. Given the unique stressors faced by transgender and bisexual subpopulations,
school-based mental health practitioners should also take special care to educate them-
selves about these groups to ensure that they can provide adequate support. School coun-
selors and school psychologists should also pay attention to the specific needs of LGBTQ
youth of color, as these students face a variety of issues associated with the interactions
between their ethnic and sexual identities (Athanases & Larrabee, 2003; Chung & Kata-
yama, 1998; DeCrescenzo & Lombardi, 2001; DePaul et al., 2009; Hahm et al., 2008;
Mustanski et al., 2010; Wells & Tsutsumi, 2005).
School counselors and school psychologists must be viewed by students and adults
as approachable regarding the topic of sexual orientation. When discussing sexuality and
relationships with a student, they should use gender-neutral language, and not assume that
the student is heterosexual (DePaul et al., 2009; Wells & Tsutsumi, 2005). They should
also be at the forefront in intervening when homophobic language is used by students and/
or adults on the school campus (Murdock & Bloch, 2005). Table 15.2 offers practical sug-
gestions for school-based practitioners working with LGBTQ youth.
Specific counseling strategies when working with LGBTQ youth are in some ways no
different than those used with any student. The following skills are useful in counsel-
ing sexual minority youth: (a) accurate, empathic listening; (b) conveying acceptance and
respect; (c) providing a safe, confidential environment; (d) assisting with developmental,
interpersonal, and adjustment issues; (e) assessing for problems and stressors; (f) identify-
ing and mobilizing resources; (g) exploring and promoting coping tools; and (h) offering
accurate educational information about sexual orientation, HIV, and support services and
other resources for LGBTQ adolescents.
When working with a student whom you know or suspect to be LGBTQ, there are some
specific issues to be aware of. For example, some students may be unaware of their sexual
orientation, and it is critical not to directly address sexual orientation before they do. It is
important for lesbian, gay, bisexual, transgender, and questioning students to be “met” by
a counselor wherever they are in their understanding and expression of their sexual orien-
tation or gender identity, and not to feel pressured to label themselves prematurely. There
should be room for exploration and openness, and interventions should be individually
designed to meet the specific needs of each student.
Group and Family Counseling Suggestions. Given that group counseling can be an
effective intervention for students and an efficient use of counselor time, school-based
mental health practitioners can develop and facilitate a support or therapeutic group for
LGBTQ adolescents. This is a different type of support than that provided by a club such
as a GSA, discussed earlier in the chapter. The school counselor/psychologist who orga-
nizes a support group or counseling group for LGBTQ students can encourage students
to build age-appropriate social networks. Support groups can help students to overcome
isolation and decrease the likelihood of risky behavior (Rienzo et al., 1997).
School-based mental health practitioners can also provide family support and assistance
with adjustment and acceptance (Cooley, 1998; DePaul et al., 2009; Murdock & Bloch,
2005). Counselors and psychologists must honor confidentiality and students’ constitu-
tional rights to privacy, and not share information that could jeopardize the student’s
safety with family members without the student’s consent; that is, counselors and psychol-
ogists should be careful not to “out” LGBTQ students to others. This can be challenging
282 Suzy R. Thomas
Table 15.2 How School-Based Practitioners Can Help LGBTQ Youth
Personal Issues Counselors and psychologists can assist LGBTQ students with:
• identity development, self-esteem, and self-acceptance;
• social, emotional, and physical problems through individual and group
counseling;
• community counseling resources;
• consistent support and protection from harassment and harm.
Academic Issues The academic counseling needs of LGBTQ students are in many ways the
same as those of any student. However:
• LGBTQ students are disproportionately more likely to consider drop-
ping out of school because of harassment or abuse (Greytak et al., 2009;
Murdock & Bloch, 2005; Tharinger & Wells, 2000);
• LGBTQ student safety must be addressed in order to promote academic
and personal growth;
• legal rights should be protected within the school community (Hunter
et al., 2004; Keen, 2007; Mercier, 2009; Murray, 2011).
Therefore, counselors working with LGBTQ students should assess for risk
of dropout, and work to address harassment and victimization at school.
Relationship Issues LGBTQ students may require support and assistance with relationships, to
find safe ways to socialize with other sexual minority youth, or to find com-
panionship. Also:
• they may want to come out to their straight friends and/or families, and
may or may not experience acceptance within these important relation-
ships;
• school counselors and school psychologists can help LGBTQ students to
explore the possible consequences of coming out, and offer community
resources and referrals for support;
• school personnel should not encourage students to come out to their
families or friends unless they are certain of the students’ safety, abil-
ity to handle emotional repercussions, and the potential for acceptance
from loved ones;
• by working to create an affirming school environment, counselors and
psychologists can be assured that there is at least one safe and support-
ive place for these students.
when counseling minors, because parents also have many rights vis-à-vis their children.
However, because of the dangers faced by so many LGBTQ youth, it is best to proceed
cautiously and focus on the safety of the student (Hunter et al., 2004).
Crisis Counseling Suggestions. Because of the serious nature of some of the problems
commonly experienced by sexual minority youth, counselors and psychologists must
assess for (a) depression and suicidal ideation, (b) substance abuse, (c) school failure and
risk of dropping out of school, and (d) abuse or harassment inside and/or outside the
home. School personnel may be called upon to engage in crisis counseling with LGBTQ
students. In situations where the student’s immediate safety is paramount, school-based
mental health practitioners must be able to take appropriate action and focus on short-
term outcomes. Some general principles of crisis counseling (Chapter 1) include: (a) taking
action and intervening immediately, (b) expressing concern and displaying competence,
(c) listening carefully and reflecting the student’s feelings, (d) widening the circle of sup-
port and providing resources, (e) helping the student accept that the crisis has occurred,
(f) discouraging blaming and avoiding false reassurance, (g) engaging in focused problem
solving, and (h) making appropriate reports as well as referrals when the issue is beyond
the professional’s scope of practice.
When the issue does not involve a crisis, the counselor or psychologist can work with
the student to improve self-esteem and self-acceptance, and help the student to find other
useful resources. School-based mental health practitioners can alleviate some of the isola-
tion experienced by sexual minority youth and provide support by working directly with
students in a positive, open, informed, and accepting manner.
Finding and Displaying Resources. Counselors can make their offices LGBTQ-friendly
by displaying LGBTQ-related books and posters. They can place fliers with local resources
for lesbian, gay, bisexual, and transgender people in hallways or other places where stu-
dents can pick them up anonymously. Paying attention to the way in which your office
could become a welcoming space for LGBTQ students has been a frequent recommenda-
tion in the literature (Graybill et al., 2009; Murdock & Bloch, 2005; Wells & Tsutsumi,
2005). School libraries are an excellent resource for LGBTQ students to access informa-
tion privately. Straight students with LGBTQ friends or family members may also benefit
from the school library. Additionally, educators will likely seek out this information if
they are aware they are working with LGBTQ adolescents (Gough & Greenblatt, 1992).
School counselors should become familiar with resources at colleges and universities
that address LGBTQ issues, such as campus clubs and support programs, and policies
in dormitories that protect students. While the Internet is a helpful resource as well, it is
best for counselors to visit these places personally or call them in order to gain familiarity
with the services they offer. Although the literature strongly suggests that school-based
practitioners be willing to work directly with LGBTQ youth as opposed to referring them
to outside agencies, those who are too uncomfortable with the issue of sexual orientation
or gender identity to work effectively with this population or to provide them with direct
services should have an accurate referral and resource list as a minimum effort to serve
these students (Wells & Tsutsumi, 2005).
Conclusion
The problems of sexual minority youth do not result directly from the emergence of sex-
ual orientation or gender identity. Rather, they are caused by widespread societal preju-
dice and heterosexism—the negative attitudes, feelings, and beliefs that people hold and
express towards LGBT people (Athanases & Larrabee, 2003; Baker, 2002; Burnes et al.,
2009; Hong et al., 2011; Murray, 2011; Tharinger & Wells, 2000; van Heeringen &
Vincke, 2000). Given that, resistance to change can be expected. In fact, resistance is well
documented and reflected in high levels of victimization in schools and lack of intervention
by teachers and other school personnel, as well as the increase in litigation. Awareness and
visibility have also increased, providing more support for LGBTQ youth but also more
potential for becoming targets of hate crimes and discrimination.
Regardless of societal recognition or acceptance of homosexuality, a percentage of chil-
dren will grow up to be lesbian, gay, bisexual, and transgender. LGBTQ students will
continue to suffer in physical, emotional, and social ways unless schools intervene. Most
school communities, however, can be characterized as unsupportive in nature. Many stu-
dents do not believe they will receive help or acceptance regarding sexual orientation or
gender identity issues from adults in their schools (Bidell, 2011b; Hohnke & O’Brien,
2008; Hunter et al., 2004; Kosciw et al., 2010; Sears, 1992; Sember, 2006; Stone, 2003;
Street, 1994; Tharinger & Wells, 2000; Varjas et al., 2007). It is not necessary for a
school-based mental health practitioner to be lesbian, gay, bisexual, or transgender in
order to work effectively with LGBTQ youth. Whether gay or straight, school counselors
and school psychologists can provide a visible presence in support of LGBTQ people. It is
the responsibility of school counselors, school psychologists, and other educators to work
284 Suzy R. Thomas
with LGBTQ youth in an informed and accepting manner and to play a role in implement-
ing changes on their behalf, in order to ensure the safety of all students and the promotion
of a healthier, more tolerant society.
REFERENCES
(2nd ed.). Washington, DC: Author.
(4th ed., text rev.). Washington, DC: Author.
Athanases, S. Z., & Larrabee, T. G. (2003). Toward a consistent stance in teaching for equity:
Learning to advocate for lesbian- and gay-identified youth. Teaching and Teacher Education, 19,
237–261. doi:10.1016/S0742–051X(02)00098–7
Baiocco, R., D’Alessio, M., & Laghi, F. (2010). Binge drinking among gay and lesbian youths: The
role of internalized sexual stigma, self-disclosure, and individuals’ sense of connectedness to the
gay community. Addictive Behaviors, 35, 896–899. doi:10.1016/j.addbeh.2010.06.004
Baker, J. M. (2002). How homophobia hurts children: Nurturing diversity at home, at school, and
in the community. Binghamton, NY: Haworth Press.
Barrett, K. A., & McWhirter, B. T. (2002). Counselor trainees’ perceptions of clients based on client
sexual orientation. Counselor Education and Supervision, 41(3), 219–232.
Bass, E., & Kaufman, K. (1996). Free your mind: The book for gay, lesbian, and bisexual youth—
And their allies. New York: HarperCollins.
Berlan, E. D., Corliss, H. L., Field, A. E., Goodman, E., & Austin, B. S. (2010). Sexual orientation
and bullying among adolescents in the Growing Up Today Study. Journal of Adolescent Health, 46,
366–371.
Berzon, B. (2001). Developing a positive gay and lesbian identity. In B. Berzon (Ed.), Positively gay:
New approaches to gay and lesbian life (pp. 18–31). Berkeley, CA: Celestial Arts.
Bidell, M. P. (2005). The Sexual Orientation Counselor Competency Scale: Assessing attitudes,
skills, and knowledge of counselors working with lesbian, gay, and bisexual clients. Counselor
Education and Supervision, 44(4), 267–279.
——— (2011a). Making the grade? Exploring the sexual orientation counselor competency of
school counselors. Paper presented at the national conference of the Center for Excellence in
School Counseling and Leadership—Empowering School Counselors and Educators to Support
LGBTQI Youth, San Diego, CA.
——— (2011b). School counselors and social justice advocacy for lesbian, gay, bisexual, transgen-
der, and questioning students. Journal of School Counseling, 9(10), 1–22. Retrieved from http://
www.jsc.montana.edu/articles/v9n10.pdf
Bontempo, D. E., & D’Augelli, A. R. (2002). Effects of at-school victimization and sexual orientation
on lesbian, gay, or bisexual youths’ health risk behavior. Journal of Adolescent Health, 30, 364–374.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation, anxiety, and anger. New York: Basic
Books.
——— (1982). Attachment and loss: Vol. I. Attachment (2nd ed.). New York: Basic Books.
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design.
Burnes, T. R., Singh, A. A., Harper, A., Pickering, D. L., Moundas, S., Scofield, T., . . . Hosea, J.
(2009). Association for lesbian, gay, bisexual, and transgender issues in counseling (ALGBTIC):
Competencies for counseling with transgender clients. Association of Lesbian, Gay, Bisexual, and
Transgender Issues in Counseling. Alexandria, VA: Author.
Carrillo, H., & Fontdevila, J. (2011). Rethinking sexual initiation: Pathways to identity formation
among gay and bisexual Mexican male youth. Archives of Sexual Behavior, 40, 1241–1254.
doi:10.1007/s10508–010–9672–6
Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality,
4(3), 219–235.
——— (1984). Homosexual identity formation: Testing a theoretical model. The Journal of Sex
Research, 20(2), 143–167.
Centers for Disease Control and Prevention. (1997). HIV-AIDS surveillance report, mid-year, 9(1).
Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/reports/pdf/hivsur91.pdf
Centers for Disease Control and Prevention. (2009). HIV-AIDS surveillance report: Diagnoses of
HIV infection and AIDS in the United States and dependent areas. Retrieved from http://www.
cdc.gov/hiv/surveillance/resources/reports/2009report/
Chung, Y. B., & Katayama, M. (1998). Ethnic and sexual identity development of Asian-American
lesbian and gay adolescents. Professional School Counseling, 1(3), 21–25.
Coleman, E. (1978). Toward a new model of treatment of homosexuality: A review. Journal of
Homosexuality, 3(4), 345–359.
Cooley, J. J. (1998). Gay and lesbian adolescents: Presenting problems and the counselor’s role.
Professional School Counseling, 1(3), 30–34.
Corliss, H. L., Rosario M., Wypij, D., Wylie S. A., Frazier, A. L., & Austin, S. B. (2010). Sexual
orientation and drug use in a longitudinal cohort study of U.S. adolescents. Addictive Behaviors
35, 517–521. doi:10.1016/j.addbeh.2009.12.019
Cox, N., Dewaele, A., van Houtte, M., & Vincke, J. (2010). Stress-related growth, coming out, and
internalized homonegativity in lesbian, gay, and bisexual youth. An examination of stress-related
growth within the Minority Stress Model. Journal of Homosexuality, 58(1), 117–137. doi:10.10
80/00918369.2011.533631
Craig, W., Pepler, D., & Blais, J. (2007). Responding to bullying: What works? School Psychology
International, 28(4), 465–477.
D’Augelli, A. R., Hershberger, S. L., & Pilkington, N. W. (1998). Lesbian, gay, and bisexual youth
and their families: Disclosure of sexual orientation and its consequences. American Journal of
Orthopsychiatry, 68(3), 361–371.
D’Augelli, A. R., Pilkington, N. W., & Hershberger, S. L. (2002). Incidence and mental health impact
of sexual orientation victimization of lesbian, gay, and bisexual youths in high school. School
Psychology Quarterly, 17(2), 148–167.
D’Augelli, A. R., Rendina, H. J., Sinclair, K. O., & Grossman, A. H. (2007). Lesbian and gay youth’s
aspirations for marriage and raising children. Journal of LGBT Issues in Counseling, 1(4), 77–98.
DeCrescenzo, T., & Lombardi, E. (2001). The brave new world of gay and lesbian youth. In B.
Berzon (Ed.), Positively gay: New approaches to gay and lesbian life (pp. 360–378). Berkeley, CA:
Celestial Arts.
DeLonga, K., Torres, H. L., Kamen, C., Evans, S. N., Lee, S., Koopman, C., & Gore-Felton, C.
(2011). Loneliness, internalized homophobia, and compulsive Internet use: Factors associated with
sexual risk behavior among a sample of adolescent males seeking services at a community LGBT
center. Sexual Addiction & Compulsivity, 18(2), 61–74. doi:10.1080/10720162.2011.581897
DePaul, J., Walsh, M. E., & Dam, U. C. (2009). The role of school counselors in addressing sexual
orientation in schools. Professional School Counseling, 12(4), 300–308.
Diaz, E. M., Kosciw, J. G., & Greytak, E. A. (2010). Social connectedness for lesbian, gay, bisex-
ual, and transgender youth: In-school victimization and institutional supports. The Prevention
Researcher, 17(3), 15–17.
DiFulvio, G. T. (2011). Sexual minority youth, social connection and resilience: From personal
struggle to collective identity. Social Science & Medicine, 72, 1611–1617. doi:10.1016/j.socs-
cimed.2011.02.045
Dworkin, S. H., & Gutierrez, F. (1989). Counselors be aware: Clients come in every size, shape,
color, and sexual orientation. Journal of Counseling and Development, 68, 6–8.
Erikson, E. (1963). Childhood and society (2nd ed.). New York: Norton Press.
Folayan, A. (2001). African-American issues: The soul of it. In B. Berzon (Ed.), Positively gay: New
approaches to gay and lesbian life (pp. 318–324). Berkeley, CA: Celestial Arts.
Fontaine, J. H. (1998). Evidencing a need: School counselors’ experiences with gay and lesbian stu-
dents. Professional School Counseling, 1(3), 8–14.
Fontaine, J. H., & Hammond, N. L. (1996). Counseling issues with gay and lesbian adolescents.
Adolescence, 31(124), 817–830.
286 Suzy R. Thomas
Fuhrmann, B. S. (1990). Adolescence, adolescents (2nd ed.). Glenview, IL: HarperCollins.
Galliher, R. V., Rostosky, S. S., & Hughes, H. K. (2004). School belonging, self-esteem, and depres-
sive symptoms in adolescents: An examination of sex, sexual attraction status and urbanicity.
Journal of Youth and Adolescence, 33(3), 235–245.
Garcia Preto, N. (2005). Transformation of the family system during adolescence. In B. Carter &
(3rd ed., pp. 274–286). Boston: Allyn and Bacon.
Gock, T. S. (2001). Asian-Pacific Islander issues: Identity integration and pride. In B. Berzon (Ed.),
Positively gay: New approaches to gay and lesbian life (pp. 334–341). Berkeley, CA: Celestial Arts.
Gough, C., & Greenblatt, E. (1992). Services to gay and lesbian patrons: Examining the myths.
Library Journal, 117(1), 59–63.
Gover, J. (1994, September/October). Gay youth: A suicide risk. Student Assistance Journal, 29–31, 37.
Graybill, E. C., Varjas, K., Meyers, M., & Watson, L. B. (2009). Content-specific strategies to advo-
cate for lesbian, gay, bisexual, and transgender youth: An exploratory study. School Psychology
Review, 38(4), 570–584.
Greytak, E. A., Kosciw, G., & Diaz, E. M. (2009) Harsh realities: The experiences of lesbian, gay,
bisexual and transgender youth in our nation’s schools. New York: GLSEN.
Gutierrez, E. (2001). Latino issues: Gay and lesbian Latinos claiming La Raza. In B. Berzon (Ed.),
Positively gay: New approaches to gay and lesbian life (pp. 325–333). Berkeley, CA: Celestial Arts.
Hahm, C. H., Wong, F. Y., Huang, Z. J., Ozonoff, A., & Lee, J. (2008). Substance use among Asian
Americans and Pacific Islanders sexual minority adolescents: Findings from the National Longi-
tudinal Study of Adolescent Health. Journal of Adolescent Health, 42, 275–283.
Heck, N. C., Flentje, A., & Cochran, B. N. (2011). Offsetting risks: High school gay-straight alli-
ances and lesbian, gay, bisexual, and transgender (LGBT) youth. School Psychology Quarterly,
26(2), 161–174.
Herdt, G. (1989). Introduction: Gay and lesbian youth, emergent identities, and cultural scenes at
home and abroad. Journal of Homosexuality, 17(1–2), 1–41.
Herrick, A. L., Marshal, M. P., Smith, H. A., Sucato, G., & Stall, R. D. (2011). Sex while intoxi-
cated: A meta-analysis comparing heterosexual and sexual minority youth. Journal of Adolescent
Health, 48, 306–309.
Hohnke, M., & O’Brien, P. (2008). Discrimination against same sex attracted youth: The role of the
school counselor. Australian Journal of Guidance & Counselling, 18(1), 67–75.
Hong, J. S., Espelage, D. L., & Kral, M. J. (2011). Understanding suicide among sexual minority
youth in America: An ecological systems analysis. Journal of Adolescence, 34, 885–894.
Hooker, E. A. (1957). The adjustment of the male overt homosexual. Journal of Projective Tech-
niques, 21, 18–21.
Horn, S. S. (2006). Heterosexual adolescents’ and young adults’ beliefs and attitudes about homo-
sexuality and gay and lesbian peers. Cognitive Development 21, 420–440. doi:10.1016/j.cog-
dev.2006.06.007
House, A. S., Van Horn, E., Coppeans, C., & Stepleman, L. M. (2011). Interpersonal trauma and
discriminatory events as predictors of suicidal and nonsuicidal self-injury in gay, lesbian, bisexual,
and transgender persons. Traumatology, 17(2), 75–85. doi:0.1177/1534765610395621
Hunter, N. D., Joslin, C. G., & McGowan, S. M. (2004). The rights of lesbians, gay men, bisexuals,
and transgender people: An American Civil Liberties Union handbook (4th ed.). New York: New
York University Press.
Iasenza, S. (1989). Some challenges of integrating sexual orientations into counselor training and
research. Journal of Counseling and Development, 68, 73–76.
Jiang, Y., Perry, D. K., & Hesser, J. E. (2010). Adolescent suicide and health risk behaviors: Rhode
Island’s 2007 Youth Risk Behavior Survey. American Journal of Preventive Medicine, 38(5), 551–555.
Kann, L., O’Malley Olsen, E., McManus, T., Kinchen, S., Chyen, D., Harris, W. A., & Wechsler, H.
(2011). Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades
9–12—Youth risk behavior surveillance, selected sites, United States, 2001–2009 (Morbidity and
Mortality Weekly Report, No. 60). U.S. Department of Health and Human Services: Centers for
Disease Control and Prevention.
Keen, L. (2007). Out law: What LGBT youth should know about their legal rights. Boston: Beacon
Press.
Keeton v. Anderson-Wiley et al., No. 10-13925 (11th Cir., Dec. 16, 2011).
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Phila-
delphia: W. B. Saunders.
Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the
human female. Philadelphia: W. B. Saunders.
Kivel, B. D., & Kleiber, D. A. (2000). Leisure in the identity formation of lesbian/gay youth: Per-
sonal, but not social. Leisure Sciences, 22, 215–232.
Kosciw, J. G., Greytak, E. A., Diaz, E. M., & Bartkiewicz, M. J. (2010). The 2009 National School
Climate Survey: The experiences of lesbian, gay, bisexual, and transgender youth in our nation’s
schools. New York: GLSEN.
Lassera, J., & Tharinger, D. (2003) Visibility management in school and beyond: A qualita-
tive study of gay, lesbian, bisexual youth. Journal of Adolescence, 26, 233–244. doi:10.1016/
S0140–1971(02)00132-X
Lipkin, A. (1994). The case for a gay and lesbian curriculum. The High School Journal, 77(1–2), 95–107.
——— (1999). Understanding homosexuality, changing schools: A text for teachers, counselors and
administrators. Boulder, CO: Westview Press.
Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., . . . Brent, D. A.
(2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A
meta-analytic review. Journal of Adolescent Health, 49, 115–123.
Marshal, M. P., King, K. M., Stepp, S. D., Hipwell, A., Smith, S., Chung, T., . . . Markovic, N.
(2012). Trajectories of alcohol and cigarette use among sexual minority and heterosexual girls.
Journal of Adolescent Health 50, 97–99. doi:10.1016/j.jadohealth.2011.05.008
Marshal, M. P., Sucato, G., Stepp, S. D., Hipwell, A., Smith, H. A., Friedman, M. S., . . . Markovic,
N. (2012). Substance use and mental health disparities among sexual minority girls: Results from
the Pittsburgh Girls Study. Journal of Pediatric and Adolescent Gynecology, 25, 15–18.
McCallum, C., & McLaren, S. (2010). Sense of belonging and depressive symptoms among GLB
adolescents. Journal of Homosexuality, 58(1), 83–96.
McFarland, W. P. (1998). Gay, lesbian, and bisexual student suicide. Professional School Counsel-
ing, 1(3), 26–29.
Mercier, M. T. (2009). Fighting to fit in: Gay-straight alliances in schools under United States jurispru-
dence. International Journal of Human Rights, 13, 177–191. doi:10.1080/ 13642980902758101
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual popula-
tions: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697.
Muller, L. E., & Hartman, J. (1998). Group counseling for sexual minority youth. Professional
School Counseling, 1(3), 38–41.
Murdock, T. B., & Bloch, M. B. (2005). Risk and protective factors for poor school adjustment in
lesbian, gay, and bisexual (lgb) high school youth: Variable and person-centered analyses. Psychol-
ogy in the Schools, 42(2), 159–172.
Murray, O. (2011). Queer youth in heterosexist schools: Isolation, prejudice and no clear supportive
policy frameworks. Multicultural Perspectives, 13(4), 215–219.
Mustanski, B. S., Garofalo, R., & Emerson, E. M. (2010). Mental health disorders, psychological
distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths.
American Journal of Public Health, 100(12), 2426–2432.
National Coalition of Anti-Violence Programs (NCAVP). (2009). Hate violence against lesbian, gay,
bisexual, and transgender people in the United States. New York: Anti-Violence Project.
Nesmith, A. A., Burton, D. L., & Cosgrove, T. J. (1999). Gay, lesbian, and bisexual youth and young
adults: Social support in their own words. Journal of Homosexuality, 37(1), 95–108.
Newcomb M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental health
problems: A meta-analytic review. Clinical Psychology Review, 30, 1019–1029. doi:10.1016/j.
cpr.2010.07.003
Padilla, Y. C., Crisp, C., & Rew, D. L. (2010). Parental acceptance and illegal drug use among gay,
lesbian, and bisexual adolescents: Results from a national survey. Social Work, 55(3), 265–275.
288 Suzy R. Thomas
Planned Parenthood of Toronto. (2004). Hear me out: True stories of teens educating and confront-
ing homophobia. Toronto, Canada: Second Story Press.
Reck, J. (2009). Homeless, gay, and transgender youth of color in San Francisco: “No one likes street
kids”—Even in the Castro. Journal of LGBT Youth, 6(2–3), 223–242.
Rienzo, B. A., Button, J. W., & Wald, K. D. (1997). School based programs addressing gay/lesbian/
bisexual youth issues. Journal of the International Council for Health, Physical Education, Rec-
reation, Sport and Dance, 33(2), 21–25.
Robinson, K. (2010). A study of young lesbian and gay people’s school experiences. Educational
Psychology in Practice, 26(4), 331–351.
Robinson, J. P., & Espelage, D. L. (2011). Inequities in educational and psychological outcomes between
LGBTQ and straight students in middle and high school. Educational Researcher, 40(7), 315–330.
Rock, M., Carlson, T. S., & McGeorge, C. R. (2010). Does affirmative training matter? Assessing
CFT students’ beliefs about sexual orientation and their level of affirmative training. Journal of
Marital & Family Therapy, 36(2), 171–184.
Rosario, M., Schrimshaw, E. W., & Hunter, J. (2012). Risk factors for homelessness among lesbian,
gay, and bisexual youths: A developmental milestone approach. Children and Youth Services
Review, 34, 186–193.
Rotheram-Borus, M. J., Gillis, J. R., Reid, H. M., Fernandez, M. I., & Gwadz, M. (1997). HIV
testing, behaviors, and knowledge among adolescents at high risk. Journal of Adolescent Health,
20(3), 216–225.
Russell, S. T. (2010) Contradictions and complexities in the lives of lesbian, gay, bisexual, and trans-
gender youth. The Prevention Researcher, 17(4), 3–6.
Russell, S. T., Ryan C., Toomey, R. B., Diaz, R. M., & Sanchez J. (2011). Lesbian, gay, bisexual, and
transgender adolescent school victimization: Implications for young adult health and adjustment.
Journal of School Health, 81, 223–230.
Russell, S. T., & Toomey, R. B. (2010). Men’s sexual orientation and suicide: Evidence for U.S.
adolescent-specific risk. Social Science & Medicine, 1–7. doi:10.1016/j.socscimed.2010.07.038
Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Family rejection as a predictor of negative
health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1),
346–352. doi:10.1542/peds.2007–3524
Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adoles-
cence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing,
23(4), 205–213. doi:10.1111/j.1744–6171.2010.00246.x
Savage, D., & Miller, T. (Eds.). (2011). It gets better: Coming out, overcoming bullying, and creating
a life worth living. New York: Penguin.
Savage, T. A., Prout, H. T., & Chard, K. M. (2004). School psychology and issues of sexual orienta-
tion: Attitudes, beliefs, knowledge. Psychology in the Schools, 41(2), 201–210.
Savin-Williams, R. (1989). Coming out to parents and self-esteem among gay and lesbian youths.
Journal of Homosexuality, 18(1–2), 1–35.
Savin-Williams, R. C. (2005). The new gay teenager. Cambridge, MA: Harvard University Press.
Sears, J. T. (1992). Educators, homosexuality, and homosexual students: Are personal feelings
related to professional beliefs? Journal of Homosexuality, 22(3–4), 29–79.
Sember, B. M. (2006). Gay and lesbian rights: A guide for GLBT singles, couples and families (2nd
ed.). Naperville, IL: Sphinx.
Shields, J. P., Whitaker, K., Glassman, J., Franks, H. M., & Howard, K. (2011). Impact of victimiza-
tion on risk of suicide among lesbian, gay, and bisexual high school students in San Francisco.
Journal of Adolescent Health, 50(4), 418–420. doi:10.1016/j.jadohealth.2011.07.009
Short, D. (2010). Conversations in equity and social justice: Constructing safe schools for queer
youth. Journal for Critical Education Policy Studies, 8(2), 329–357.
Singh, A. A., Urbano, A., Haston, M., & McMahon, E. (2010). School counselors’ strategies for
social justice change: A grounded theory of what works in the real world. Professional School
Counseling, 13(3), 135–145.
Stone, C. (2003). Counselors as advocates for gay, lesbian, and bisexual youth: A call for equity and
action. Journal of Multicultural Counseling and Development, 31(1), 143–155.
Street, S. (1994). Adolescent male sexuality issues. The School Counselor, 41, 319–325.
Strommen, E. F. (1989). “You’re what?”: Family member reactions to the disclosure of homosexual-
ity. Journal of Homosexuality, 18(1–2), 37–56.
Tafoya, T. (2001). Native gay and lesbian issues: The Two-Spirit people. In B. Berzon (Ed.), Posi-
tively gay: New approaches to gay and lesbian life (pp. 342–358). Berkeley, CA: Celestial Arts.
Tharinger, D. J. (2008). Maintaining the hegemonic masculinity through selective attachment,
homophobia, and gay-baiting in schools: Challenges to intervention. School Psychology Review,
37(2), 221–227.
Tharinger, D., & Wells, G. (2000). An attachment perspective on the developmental challenges of
gay and lesbian adolescents: The need for continuity of caregiving from family and schools. School
Psychology Review, 29(2), 158–172.
Toomey, R. B., McGuire, J. K., & Russell, S. T. (2012). Heteronormativity, school climates, and per-
ceived safety for gender nonconforming peers. Journal of Adolescence, 35, 187–196. doi:10.1016/j.
adolescence.2011.03.001
Toomey, R. B., Ryan, C., Diaz, R. F., & Russell, S. T. (2011). High school gay–straight alliances
(GSAs) and young adult well-being: An examination of GSA presence, participation, and per-
ceived effectiveness. Applied Developmental Science, 15(4), 175–185.
Tremble, B., Schneider, M., & Appathurai, C. (1989). Growing up gay or lesbian in a multicultural
context. Journal of Homosexuality, 17(3–4), 253–267.
Troiden, R. R. (1988). Gay and Lesbian identity: A sociological analysis. New York: General Hall.
Ueno, K. (2010). Patterns of cross-orientation friendships in high schools. Social Science Research
39, 444–458. doi:10.1016/j.ssresearch.2009.10.001
Valenti, M., & Campbell, R. (2009). Working with youth on LGBT issues: Why gay-straight alli-
ance advisors become involved. Journal of Community Psychology, 37, 228–248. doi:10.1002/
jcop.20290
van Heeringen, C., & Vincke, J. (2000). Suicidal acts and ideation in homosexual and bisexual
young people: A study of prevalence and risk factors. Social Psychiatry Psychiatric Epidemiology,
35, 494–499.
Varjas, K., Graybill, E., Mahan, W., Meyers, J., Dew, B., Marshall, M., . . . Birckbichler, L. (2007).
Urban service providers’ perspectives on school responses to gay, lesbian, and questioning stu-
dents: An exploratory study. Professional School Counseling, 11(2), 113–119.
Walcott, C. M., Meyers, A. B., & Landau, S. (2008). Adolescent sexual risk behaviors and school-
based sexually transmitted infection/HIV prevention. Psychology in the Schools, 45(1), 39–51.
Ward v. Wilbanks et al., Nos. 10-2100/2145 (6th Cir., Jan. 27, 2012).
Wells, K., & Tsutsumi, L. M. (2005). Creating safe, caring and inclusive schools for LGBTQ students:
A guide for counsellors. Retrieved from http://www. teachers.ab.ca/NR/rdonlyres/85653D2F-
2630–4546-B53C09C841B25BC5/ 0/CreatingSafeCaringandInclusiveSchoolsforLGBTStudents.
pdf
Whitbeck, L. B., Chen, X., Hoyt, D. R., Tyler, K. A., & Johnson, K. D. (2004). Mental disorder,
subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway
adolescents. Journal of Sex Research, 41, 329–342.
Williams, K. A., & Chapman, M. V. (2011). Comparing health and mental health needs, service use,
and barriers to services among sexual minority youths and their peers. Health & Social Work,
36(3), 197–206.
Wilson, E. C., Iverson, E., Garofalo, R., & Belzer, M. (2011). Parental support and condom use
among transgender female youth. Journal of the Association of Nurses in AIDS Care, 23(4),
306–317. doi:10.1016/j.jana.2011.09.001
Appendix
Numerous organizations and resources serve the LGBT community, nationally and locally.
Table 15.3 provides contact information and a brief description of several prominent
national and online resources. These groups are committed to supporting the rights of
LGBT people (advocacy), informing the public about issues connected to the LGBT com-
munity (education), and/or offering support and crisis services (support services).
Table 15.3 Resources for School-Based Mental Health Practitioners
American Civil ACLU http://www.aclu.org National organization protecting

Liberties Union constitutional rights and civil liber
ties; LGBT Project with a focus on
ADVOCACY
LGBT youth and schools

Human Rights HRC http://www.hrc.org Civil rights organization lobbying
Campaign for legal equality for
the LGBT community
Lambda Legal Lambda http://www. National legal organization
Defense and Legal lambdalegal.org advocating for LGBT people
Education Fund and people with HIV
Gay and GLAAD http://www.glaad.org Group that encourages the
Lesbian fair, accurate, and genuine
Alliance portrayal of LGBT people in the
Against media; grassroots collaborative
EDUCATION
Defamation efforts
Gay Lesbian GLSEN http://www.glsen.org National education organization
and Straight promoting safety and equality for
Education all students; biennial
Network school-climate research;
awareness-raising campaigns
GSA Network http://gsanetwork.org Organization connecting and
supporting school-based GSAs;
training and education services
GLBT National http://www.glnh.org Confidential telephone and
Help Center Youth Talkline: Internet peer-counseling;
1.800.246.PRIDE information and resources for
LGBTQ youth
SUPPORT SERVICES
It Gets Better http://www.itgets Internet video project fostering

Project better.org hope for LGBTQ youth through
personal stories and reflections
from LGBT adults and celebrities
Parents, PFLAG http://www.pflag.org Support through meetings,
Families and helplines, and education; offers
Friends of local chapter services nationwide
Lesbians
and Gays
The Trevor http://www. National suicide and crisis inter
Project thetrevorproject.org vention hotline for LGBTQ youth
Trevor Lifeline:
1.866.488.7386
16 Adolescent Pregnancy and Parenthood
Katherine Hadley Cornell
One third of all females in the United States become pregnant at least once before they
reach the age of 20 (National Campaign to Prevent Teen and Unplanned Pregnancy, 2008).
Pregnancy and parenting can have a dramatic impact on likely every facet of the daily life
of a teenager, as well as on his or her long-term future. Reaching out to teens at risk for,
during, and after pregnancy is therefore paramount and the educational setting is a prime
arena for such interventions.
Prevalence
National statistics estimate that nearly half of all American teenagers have had sexual
intercourse (Centers for Disease Control and Prevention, 2012; Chandra, Mosher, Copen,
& Sionean, 2011). Alarmingly, sexually active teens who are not using any form of birth
control have a 85% chance of becoming pregnant within 1 year, drawing attention to
the importance of promoting safe sex education (Trussell, 2011). Over 700,000 teenage
girls become pregnant in the United States every year, with more than 400,000 giving
birth (Kost & Henshaw, 2012). That translates to one in six women in the United States
becoming teen mothers (Perper & Manlove, 2009). Twenty percent of teen pregnancies
are from females who have already given birth before (Schelar, Franzetta, & Manlove,
2007). “Rapid repeat pregnancy,” or pregnancy within 1–2 years of a previous pregnancy
outcome, has become another major focus of pregnancy prevention (Crittenden, Boris,
Rice, Taylor, & Olds, 2009).
Social Costs
Among all industrialized countries, the United States has the highest rate of teenage preg-
nancy (UNICEF, 2001; United Nations, 2006). Our country’s elevated rates have been attrib-
uted, not to higher sexual activity among youth, but to issues related to the use of birth
control—namely, lack of use, inconsistent use, and method of birth control (Darroch, Frost,
Singh, & The Study Team, 2001). Some argue that the higher rate of teen pregnancy in the
United States is a reflection of the fact that teenage sexual activity is less acceptable in our
society and access to contraception is more limited, compared to other countries (Darroch
et al., 2001). However, others challenge that the lower use of contraception is, in fact, due
to a decreased motivation by American adolescents to prevent pregnancy (Sheeder, Tocce, &
Stevens-Simmon, 2009). In other words, American teenagers may not view teen pregnancy
in the same negative light as society and, thus, not see it as something to try to avoid.
Thank you to Robert Lucio of Saint Leo University in Florida for his assistance in providing valuable sources
for reference.
292 Katherine Hadley Cornell
Each year, the United States spends an estimated $9.1 billion on childbearing for moth-
ers under the age of twenty (Hoffman, 2006). This figure is largely influenced by the nega-
tive effects associated with being a teen mother, including the cost of health care, welfare,
prison costs of male offspring in adulthood, and lower taxes paid due to lower earnings
(Hoffman, 2006). Children of teen mothers are more likely to be born into poverty than
children of women who are high school graduates, over twenty, and married (National
Campaign to Prevent Teen and Unplanned Pregnancy, 2010).
The purpose of this chapter is to provide an overview of the impact of pregnancy in
youth, the associated risk and protective factors, the effective prevention and intervention
strategies and empirically supported programs, and detailed strategies for schools and
school counselors to employ.
Negative Outcomes of Teen Pregnancy

Teen parenthood has been found to have a number of negative consequences for both teen-
agers and their offspring, including problems with poorer physical health, mental health,
academic functioning, and financial situation (Coley & Chase-Lansdale, 1998; Corcoran,
1998; Jaffee, Caspi, Moffitt, Belsky, & Silva, 2001; Jutte et al., 2010; Lipman, Georgiades,
& Boyle, 2011).
For Pregnant Teens

Although the majority of research on teen pregnancy focuses on teen mothers, it is impor-
tant to recognize the impact of the pregnancy itself on the teenager. Pregnancy can be an
overwhelming process, even for those with planned pregnancies, and this is only exacer-
bated by the stressors inherent to adolescence. In addition to the physical changes that
occur (such as fatigue), neurological changes also appear to take place during pregnancy
(Murkoff & Mazel, 2009).“Pregnancy brain” has become the colloquial term used to
depict the apparent cognitive decline, such as forgetfulness, that takes place during preg-
nancy (Peterson, 2012).
Additional concerns may affect those who do not carry the pregnancy to term, either
due to miscarriage, stillbirth, termination due to medical necessity, or elective abortion.
Such experiences may cause feelings of guilt and loss. Reactions to these experiences are
likely to be influenced by whether the pregnancy was planned and the wantedness of the
pregnancy. An Australian study found an increased risk of substance use and affective
disorders in young women, regardless of whether the loss of pregnancy was spontaneous
or elective (Dingle, Alati, Claravino, Najman, & Williams, 2008). Giving a child up for
adoption may also have lasting effects for the adolescent mother.
For Teen Mothers

Teen pregnancy has a risk factor for emotional difficulties, high school dropout, and low
earning potential. The negative consequences associated with pregnancy are, naturally,
made worse with each subsequent birth during a mother’s youth (Crittenden et al., 2009;
Klerman, Cliver, & Goldenberg, 1998; King, 2003; Partington, Steber, Blair, & Cisler,
2009; Zhu, 2005). Since approximately one in five teen pregnancies is a repeat pregnancy
(Schelar et al., 2007), difficulties can mount.
Teen motherhood is highly associated with emotional distress, and increased likelihood of
having a psychological disorder has been linked to teen motherhood (Boden, Fergusson, &
Horwood, 2008; Chang & Fine, 2007; Chang et al., 2004; Coley & Chase-Lansdale, 1998;
Adolescent Pregnancy and Parenthood 293
Hodgkinson, Colantuoni, Roberts, Berg-Cross, & Belcher, 2010; Larson, 2004; Spence,
2008). In fact, the rate of major depression, anxiety disorder, suicidal ideation, and attempted
suicide has been found to be higher for those who had a child prior to age 18, compared to
those who had a child between age 21 through 25 (Boden et al., 2008). Depression, in par-
ticular, appears to be highly common in teen mothers (Sadler et al., 2007), and there is some
evidence that postpartum depression is more prevalent in this subgroup compared to the
general population (Barnet, Liu, & DeVoe, 2008; Lanzi, Bert, & Jacobs, 2009). One study
found that among first-time mothers, teen mothers endorsed higher rates of depression on the
Beck Depression Inventory (BDI) both at birth and 6 months postpartum than adult mothers
(Lanzi et al., 2009). Another study found that depressive symptoms were an independent risk
factor for subsequent pregnancy in African American teenagers (Barnet et al., 2008).
Emotional difficulties in teen mothers can have a negative impact on their children.
Higher depressive symptoms in teen mothers have been associated with decreased positive
parenting practices and decreased adaptive behaviors by the infant towards the mother
(Lanzi et al., 2009), which can have long-term effects on the emotional functioning of the
child. In the first few years of parenting, teen mothers have been found to be less respon-
sive, less verbal, and less sensitive to their child (Culp, Appelbaum, Osofsky, & Levy,
1988; Lanzi et al., 2009; Lounds, Borkowski, & Whitman, 2006). Such a parenting style
is associated with emotional and developmental problems for children.
How a teenager feels about her pregnancy can actually have negative later effects on
both her postpartum mood and her parenting style, which can lead to lasting negative
effects for both her and her child. This conclusion is based on the results from a study
of Latino adolescents over three time points (pregnancy, 6 months postpartum, and 12
months postpartum). East, Chien, and Barber (2012) identify a transactional relationship
between Latino adolescent feelings about the pregnancy (e.g., intentions, wantedness, and
regret) and both their mental health and their parenting experiences.
For Teen Fathers

Teen fatherhood is associated with negative consequences for both the father and his
offspring (Fletcher & Wolfe, 2012; Futris, Nielsen, & Olmstead, 2010; Sipsma, Biello,
Cole-Lewis, & Kershaw, 2010). These consequences are similar to those associated with
teen mothers, such as high school dropout and lower earning potential, compared to their
nonparenting peers (Bunting & McAuley, 2004). Faced with the burden of having to
support a child, some teen fathers feel compelled to drop out of school in order to begin
earning a living at an earlier age.
Teen fathers are at a high risk for low and inconsistent levels of involvement with their
children, with involvement steadily declining over time (Coley & Chase-Lansdale, 1998;
Hamilton, Martin, &Ventura, 2012). In fact, studies have found that, after 3 years, only
one third of teen fathers were actively involved in their child’s life (Kalil, Ziol-Guest, &
Coley, 2005; Lewin, Mitchell, Burrell, Beers, & Duggan, 2011). Poor paternal involve-
ment is associated with a host of negative consequences for the child. Compared to chil-
dren with involved fathers, children of uninvolved fathers are more likely to demonstrate
emotional and behavioral problems, including increased drug use, criminal behavior, and
incarceration (Mandara & Murray, 2000; Townsend, 2003).
For Children of Teen Mothers

Children of teen mothers are more likely to be born of lower birth weight, which is linked
to a number of long-term negative outcomes (Murkoff & Mazel, 2009). During childhood
and adolescence, children of teen mothers are associated with a number of negative effects,
including developmental delays, poor academic performance, school failure and behavior
problems, and becoming teen parents themselves (Blankson et al., 1993). When compared
to children of older mothers, children of teen mothers are more likely to have difficul-
ties in math and reading, receive special education services, and demonstrate delinquency
(Dahinten, Shapka, & Willms, 2007; Shaw, Lawlor, & Najman, 2006). In a review of
school-based clinics between 1997 and 2006, the outcome for children of teen mothers
was found to be most predicted by the mother’s level of education, stressing the signifi-
cance of delaying pregnancy and encouraging academic advancement (Strunk, 2008).
Offspring of teen mothers are also at increased risk of mental health problems, including
somatic complaints, anxiety, thought and attention problems, and aggression (Dahinten
et al., 2007; Shaw et al., 2006). Fascinatingly, in a study of Australian twins in which one
twin was a teenage mother and the other delayed pregnancy, Harden et al. (2007) found
that that the children of adolescent mothers experienced more mental health difficulties
than either their younger siblings or their first cousins. Thus, the authors assert that these
findings suggest that the mental health impact of teenage pregnancy on the offspring is not
explained by genetics and family influences.
The Notion of Negative Outcomes

While the widespread belief is that teen pregnancy has devastating effects on the adoles-
cent and her offspring, there is some research that challenges the notion of pregnancy as
itself a negative outcome. Sisson (2012) argues that the presumed devastating effects of
teen pregnancy are greatly unfounded in research due to a failure to include appropriate
comparison groups. Instead, she cites research that refutes possible negative effects and
even suggests some positive outcomes of teen pregnancy on both the parent and the child.
Sisson (2012) insists that the future for those growing up in poverty was already bleak and,
consequently, early childbirth is not otherwise derailing them from a prosperous future,
in regards to post–high school academic and economic attainment. Rather than negative
outcomes, she argues that the presumed disadvantages are preexisting based on socioeco-
nomic status. Nonetheless, Sisson (2012) asserts that teens still deserve to live their ado-
lescence without the burden of children and for that reason advocates for delaying, rather
than preventing, teen pregnancy and asserts the value of prevention measures through that
perspective. Although teen pregnancy may not worsen the outcome of all poor teenagers,
one could argue that it hinders the opportunity for socioeconomic advancement and per-
petuates the negative consequences associated with poverty from generation to generation,
and therefore warrants serious interventions.
Proponents of school-based programs would argue that negative outcomes associated
with teen pregnancy can be offset by participation in programs that involve counseling,
health care, and education about health and child development (Strunk, 2008). However,
the effectiveness of school-based programs has also been debated. A meta-analysis found
school-based programs to be ineffective in improving educational attainment of African
American teen mothers (Baytop, 2006).
Risk Factors
There are a number of risk factors associated with teen pregnancy, including mental
health, prior pregnancy, socioeconomic status, and family background (Kirby, Lepore, &
Ryan, 2005; Miller, Benson, & Galbraith, 2001; U.S. Department of Health and Human
Services, 2010; Xie, Cairns, & Cairns, 2001).
Mental Health
A host of mental health factors have been associated with the increased likelihood of
becoming pregnant during adolescence, including emotional distress, anxiety, depression,
conduct problems, negative early childhood experiences, and abuse (Anda et al., 2002;
Brown, Harris, Woods, Buman, & Cox, 2012; Khurana, Cooksey, & Gavazzi, 2011; Noll,
Shenk, & Putnam, 2009; Quinlivan, Tan, Steele, & Black, 2004; Woodward, Fergusson,
& Horwood, 2001).
In analyzing longitudinal data from two national surveys (the U.S. National Longi-
tudinal Study of Adolescent Health and the Early Childhood Longitudinal Study-Birth
Cohort), Mollborn and Morningstar (2009) found that emotional distress was higher in
teenage mothers compared to both their peers without children as well as adult moth-
ers. Distress occurred prior to pregnancy, postpartum, and into adulthood. Among the
other groups examined, teenage pregnancy was predicted by a combination of factors,
some of which are often associated with poverty, including low socioeconomic status,
poor academic performance, prior sexual experience, and family structure (Mollborn &
Morningstar, 2009). Interestingly, the authors found that distress was predictive of teenage
pregnancy only among impoverished teenagers. One study of primarily African American
teenagers found that the rate of rapid repeat pregnancies was higher among teenagers who
were depressed (Barnet, Liu, & DeVoe, 2008). These findings challenge the notion of a
unidirectional relationship between teenage pregnancy and emotional distress, in addition
to revealing the complex interactions between mental health, socioeconomic status, and
teenage pregnancy.
Behavioral problems have also been associated as risk factors for teenage pregnancy
(Miller et al., 2001; Xie et al., 2001). In analyzing a longitudinal study of 533 females
from birth to age 20 in New Zealand, Woodward, Fergusson, and Horwood (2001) found
that those demonstrating conduct problems were three and a half times more likely to
become pregnant than their peers. The authors also found that teenagers with attentional
problems were at an increased risk for teenage pregnancy. Other research has found that
both male and female teenagers who engaged in aggressive and disruptive school behaviors
were at increased risk of becoming parents by the time they reached early adulthood (Gest,
Mahoney, & Cairns, 1999). A study consisting of primarily African American teenage
girls found that those who engaged in aggressive behaviors and experienced a later age
of menarche were at greater risk for rapid repeat pregnancies (Crittenden et al., 2009). In
contrast, early maturation has also been associated with increased risk of teenage preg-
nancy (Woodward et al., 2001). Thus, it appears that reaching puberty outside of the
expected age range—be it late or early—may place a female at greater risk for pregnancy
during adolescence.
Research has shown that those who experience early negative experiences in childhood
are at greater risk for pregnancy prior to adulthood (Hillis et al., 2004; Nettle, Coall, &
Dickins, 2011; Woodward et al., 2001). An Australian study found that mothers who gave
birth before the age of 20 were more likely to have parents who separated or divorced
and more likely to have witnessed violence between their parents, compared to those who
gave birth after the age of 20 (Quinlivan et al., 2004). Parental instability and maternal
role models who were young mothers have also been associated with teenage pregnancy
in New Zealand (Woodward et al., 2001).
In analyzing 20 studies on teenage pregnancy, Logan, Halcombe, Ryan, Manlove, and
Moore (2007) found a high incidence of sexual abuse and teenage parenting. This rela-
tionship was stronger for male survivors of sexual abuse than female survivors. Higher
rates of teenage parenting has been found in survivors of physical abuse and neglect that
occurred during preschool years, compared to those who did not experience such trauma,
with the greatest association for all girls and for boys who experienced more severe abuse
(Herrenkohl, Herrenkohl, Egolf, & Russo, 1998).
Prior Pregnancy
Teen mothers are probably the most vulnerable population, given the high rate of repeat
pregnancies among this population (Schelar et al., 2007). Furthermore, one third of repeat
pregnancies are reportedly planned (Boardman, Allsworth, Phipps, & Lapane, 2006). This
finding poses difficult challenges for prevention if teenagers are pursuing multiple preg-
nancies.
Family Background
Certain family dynamics have been found to influence the likelihood of teen pregnancy. In
a 5-year longitudinal study looking at non-White families at three time points, East and
Khoo (2005) found that family dynamics and sibling relationships appear to influence the
behaviors of younger adolescent siblings of teenage mothers. Specifically, single-parent
households were associated with increased warmth and closeness between female siblings,
which decreased the likelihood of substance use and high-risk sexual behaviors. Having
a dominant older sister was associated with younger male and female siblings being more
likely to engage in a number of high-risk sexual behaviors, including first having sex at
a young age, high frequency of sex, and lack of contraception use. Increased drug and
alcohol use was also associated with increased high-risk sexual behaviors (East & Khoo,
2005). In a one-and-a-half-year longitudinal study with two time points, younger female
siblings of parenting teen mothers were the most likely to experience pregnancy and had
the highest levels of drug and alcohol use, compared to younger male siblings of parenting
teen mothers and younger siblings of non-parenting older sisters (East & Jacobson, 2001).
The more time that younger adolescent siblings had to care for their older sister’s children,
the more likely they were to be engaging in behaviors associated with negative outcomes,
including permissive sexual behavior (East & Jacobson, 2001). This relationship was not
true for younger male siblings, which the authors suggested could relate to the different
dynamics inherent in sister-brother relationships, compared to sister-sister relationships,
which can include emulation and competition (East & Jacobson, 2001). Additionally,
being the offspring of a teen mother is also a risk factor for teen pregnancy, suggesting a
cyclical effect of teenage pregnancy (Blankson et al., 1993).
Socioeconomic Status
Being a teen parent is commonly associated with low socioeconomic status. However, teen
parents are often already of low socioeconomic status prior to pregnancy—as opposed to
it being a direct result of pregnancy (Sisson, 2012). Some argue that poverty and lack of
education are perhaps most responsible for the negative outcomes associated with teen
mothers (e.g., welfare dependence, social problems, health problems), as opposed to the
age of pregnancy itself (Harris & Franklin, 2007). A New Zealand study found that indi-
vidual factors prior to teen pregnancy, such as a history of conduct disorder, low IQ, and
low educational attainment, partially accounted for the adverse mental health, interper-
sonal, and socioeconomic difficulties that young mothers were facing at age 26 (Jaffee,
2002). Nonetheless, the difficulties associated with these risk factors were intensified by
early childbearing (Jaffee, 2002).
Perspective on Teen Pregnancy
It may seem obvious, but it is still worth mentioning, that a teenager’s perspective on teen-
age pregnancy can have an impact on the likelihood of teen pregnancy. If a teenager does
not see teen pregnancy as something to avoid (and/or if this is something that they see as
something to aspire to) then they are probably less likely to take measures to avoid preg-
nancy, such as through abstinence, contraceptive use, etc. (Sheeder et al., 2009).
Protective Factors
A number of protective factors to delay pregnancy have been identified in the literature
(Ehrlich & Vega-Matos, 2000; Kirby & Lepore, 2007). Those teenagers with greater aca-
demic success, higher aspirations about their future, and stronger connections to home,
school, and community have been found to be more likely to abstain from risky sexual
activity (Ehrlich & Vega-Matos, 2000; Kirby, 2007; Suellentrop, 2011).
A report summarizing over 400 research studies found that there are a number of risk
and protective factors influencing an adolescent’s decision to have or not have sex, grouped
into four major categories: (a) Individual biological factors (e.g., age, gender, physical matu-
rity); (b) Personal and family disadvantage, disorganization, and dysfunction; (c) Values
and attitudes towards sex, or modeled behavior; and (d) “Connection to adults and orga-
nizations that discourage sex, unprotected sex, or early childbearing” (Kirby & Lepore,
2007, p. 1). Kirby and Lepore (2007) advocate for targeting those factors that are mal-
leable in the teenagers’ lives when structuring interventions, as opposed to those that can-
not be changed.
Future-Oriented
Teens that demonstrate greater academic success and/or have higher professional aspira-
tions are less likely to engage in risky behaviors and less likely to experience pregnancy
(Ehrlich & Vega-Matos, 2000; Sheeder et al., 2009). Therefore, many programs have
focused on academic engagement, which is likely to improve outcomes, not only for the
teen parents, but also for their offspring. Encouraging students to develop life goals is
one intervention, such that a pregnancy would be viewed as a risk to their planned future
(Sheeder et al., 2009).
Positive Social Connections

Positive social connections, in the form of community involvement and/or strong familial
connections, appear to decrease the likelihood of teenage pregnancy. Enrollment in com-
munity-based programs and service learning has been found to reduce pregnancy (Suel-
lentrop, 2011), likely through engaging teenagers in after-school activities and possibly
promoting future-oriented interests. After-school programs for teens have also been found
effective in reducing teen pregnancy, primarily through the increased use of contraception
(Manlove, Franzetta, McKinney, Romano-Papillo, & Terry-Humen, 2003).
Father Involvement for Offspring

Father involvement has been associated with greater cognitive, developmental, and aca-
demic outcomes for offspring, compared to children who are not exposed to parent
involvement. Lamb, Pleck, Charnov, and Levine (1987) define father involvement as
multidimensional, including engagement, accessibility, and responsibility. Higher prenatal
involvement by the father has been associated with greater father involvement with his off-
spring postpartum, including more physical care, nurturance, caregiving, and engagement
in cognitively stimulating activities (Bronte-Tinkew, Ryan, Carrano, & Moore, 2007;
Cabrera, Shannon, West, & Brooks-Gunn, 2006).
Early father involvement is associated with fewer cognitive delays compared to those
without (Bronte-Tinkew, Carrano, Horowitz , & Kinukawa, 2008). In a longitudinal study
that followed children from birth to age 10, Howard, Lefever, Borkowski, and Whitman
(2006) found a positive association between father involvement and child academic per-
formance at each time point. Similarly, other studies found a positive relationship between
father involvement and child academics in regards to better learning outcomes and higher
academic levels. Specifically, children of involved fathers had greater school readiness and
entrance to kindergarten (Jackson, Choi, & Franke, 2009), higher performance on reading
and math tests (Cabrera, Shannon, & Tamis-LeMonda, 2007; McBride, Schoppe-Sullivan,
& Ho, 2005), and greater attainment of high school graduation and higher degrees (Flouri
& Buchanan, 2004). Furthermore, children of involved fathers are more likely to enjoy
school (Flouri & Buchanan, 2004), perform better in school (Howard et al., 2006), try
harder in school (Alfaro, Umaña-Taylor, & Bámaca, 2006), as well as to attend school
regularly, pass grades, and avoid disciplinary problems (Nord & West, 2001). Of note,
some research has found that the effects of father involvement on child educational out-
comes to be greater for male than for female offspring.
The impact of father involvement appears to have a positive emotional and social impact
on children as well. Children who have involved fathers also engage in healthier relation-
ships and experience better overall adjustment, compared to children whose fathers are
not involved after birth (Flouri & Buchanan, 2003; Hawkins & Palkovitz, 1999; Saracho
& Spodek, 2008).
Types of Prevention and Intervention Programs

There are a variety of services in the United States addressing teen pregnancy. School-based
programs have been found effective in reducing teen pregnancy (Suellentrop, 2011), repeat
pregnancy (Key, Gebregziabher, Marsh, & O’Rourke, 2008), and the negative effects asso-
ciated with teen pregnancy (Williams & Sadler, 2001; Lanzi et al., 2009). School-based pro-
grams can include special services either within a mainstream school setting or through an
alternative school setting designed specifically for pregnant teenagers. Services can involve
pregnancy prevention programs, comprehensive school-based programs for pregnant ado-
lescents and/or adolescent parents, and even universal programs for all students. The pro-
gram may also offer health care, child care, life skills programs, and vocational training.
Preventing Pregnancy
Pregnancy prevention programs including safe-sex education have proven successful in
reducing pregnancy and/or decreasing subsequent pregnancy (Key et al., 2008; Kirby,
2007; Suellentrop, 2011). Based on national data collected between 2006 and 2008, teen-
age males ages 15 to 17 were less likely than females to have received formal instruction
on methods of birth control (Martinez, Abma, & Copin, 2010).
Curriculum-based sexual education is a primary prevention method used to try to reduce
teen pregnancy. While the focus of school-based programs on pregnancy has traditionally
targeted prevention through “abstinence-only” programs, this approach is now viewed as
outdated, as governmental agencies and the general population have recognized the fact
that many adolescents are having sex and, as a result, some are becoming pregnant. This
conclusion was solidified after a federally funded investigation of abstinence-only-until-
marriage programs found them to be ineffective in decreasing teenage sexual activity or
the spread of HIV (Trenholm et al., 2001). In fact, such programs may have been counter-
productive by discouraging some teens from using contraception (Kirby, 2001). Federally
funded programs have since expanded to “abstinence-plus” programs, offering informa-
tion about safe sex, as well as abstinence. Challenging previous popular notions about
sex education, Bennett and Assefi (2005) reviewed randomized controlled trials of school-
based programs and found that prevention programs that included safe sex education did
not, in fact, lead to increased sexual activity in students. The American Academy of Pedi-
atrics, the American Medical Association (AMA), the American Psychological Association
(APA), the American Public Health Association (APHA), and the National Association of
School Psychologists (NASP) all support the use of comprehensive sex education in schools
for teenagers, which includes information and access to contraception.
Research has shown that programs that offer safe-sex education are most effective in
decreasing pregnancy and sexually transmitted infections (STIs; Kirby, 2007; Suellentrop,
2011). The most effective prevention programs include a curriculum that works in concert
with community values and available resources; focuses on clear, specific health goals that
send a clear message; and addresses risk factors and protective factors (Kirby, 2007). Facil-
itators should take a firm stance in promoting abstinence and contraceptive use, rather
than merely presenting choices when presenting information about sex education (Mey-
ers, Sylvester, & Landau, 2010; Suellentrop, 2011). In addition, effective programs should
actively engage participants, allowing for personalization of information, addressing peer
pressure, and teaching effective communication skills (Suellentrop, 2011). The following
types of programs for teens were identified by the National Campaign to Prevent Teen and
Unplanned Pregnancy as effective in delaying sexual activity, improving contraception use
among sexually active teens, and decreasing teen pregnancy (Suellentrop, 2011):
1) Curriculum-based education (typically encouraging abstinence and contraceptive use);

2) Service learning (involving students in community service activities and ideally includ-
ing time designated for processing student reactions to these activities);
3) Youth development (promoting consideration for future aspirations through engage-
ment in a broad range of activities); and
4) Parent programs (involving both adolescents and their parents) and community-wide
programs (encouraging community involvement).
Reducing Negative Outcomes for Teen Mothers and Their Offspring

The responsibilities of raising a child while going to school may be overwhelming for a
teenager. The most effective programs for teen mothers and their children appear to be
those that are comprehensive and involve a variety of delivery techniques (Hoyt & Broom,
2002). These programs can involve health, educational, and social services, including med-
ical care (either within the school or through collaboration with an outside agency), case
management, counseling services, parenting classes, and on-site child care (Amin, Browne,
Ahmed, & Sato, 2006; Manlove, 2007; Sadler et al., 2007). The inclusion of counseling
and medical prevention and intervention services can help better prepare pregnant teen-
agers for motherhood through building positive coping and parenting skills, as well as
providing necessary medical care (Lanzi et al., 2009). Programs may also sometimes serve
to supplement or compensate for a possible lack of social supports at home (Sadler et al.,
2007) and offer access to services that they might otherwise not have.
Nationally, only 40% of teen mothers will graduate from high school, compared to
75% of teens with similar social and economic backgrounds who don’t have a child as a
teenager (National Campaign to Prevent Teen and Unplanned Pregnancy, 2008). For this
reason, some programs target dropout prevention as a key element of serving teen parents,
as this is believed to be a way to help reduce some of the negative effects that are often
associated with teen pregnancy, such as low educational attainment and low earnings.
Enrollment in a school-based program has been associated with increased school engage-
ment and higher educational aspirations, which have both been shown to be protective
factors against adolescent pregnancy (Amin et al., 2006; Sadler et al., 2007). Teen parent-
ing programs have been found to improve graduation rates, increase employment rates,
and reduce rates of rapid repeat pregnancy (Crean, Hightower, & Allen, 2001; Philliber,
Brooks, Lehrer, Oakley, & Waggoner, 2003).
The Center for Assessment and Policy Development identifies five key elements for
school-based programs in assisting teen parents and their children (Batten & Stowell,
1996):
1) Providing flexible schooling to enable completion of high school and/or GED pro-
gram;
2) Providing case management and family support services;
3) Providing prenatal care and reproductive health services;
4) Providing quality child care and promoting preventative health care for children; and
5) Offering parenting and life-skills training and supportive services
Because the elements proposed may be logistically challenging to implement in a main-

stream school, alternative school-based programs may be better able to serve students who
are interested in receiving these comprehensive supports. Typically, alternative school-
based programs include regular academic courses, reproductive health and family plan-
ning services, skills training, financial assistance, and social services (Amin et al., 2006).
In a study comparing a sample of pregnant teenagers and teen mothers enrolled in an
alternative school-based program (offering health, education, and social services) to those
not enrolled, Amin, Browne, Ahmed, and Sato (2006) found that those participating in the
program were more likely to have loftier educational aspirations, improved reproductive
health outcomes, greater contraceptive use, and better breastfeeding practices than non-
enrollees. Whether this outcome is a reflection of the interests of those who elect to enroll
or the product of their enrollment is unclear.
Prenatal care, educational support and child care, and family planning after the child
is born have been found to have the most long-term impacts on the life of both the teen
mother and her child (Williams & Sadler, 2001). Teen mothers who are involved in pro-
grams that provide both education and day care are more likely to have higher graduation
rates than their parenting peers (Crean et al., 2001). Part of this success appears to be that
continued enrollment in the program was contingent on school attendance. Utilization
of day-care programs has also been associated with increased likelihood of teen moth-
ers getting postsecondary training and becoming self-supporting (Campbell, Breitmayer,
& Ramey, 1986). In regards to benefits for the child, school-based child care can offer a
consistent nurturing and stimulating environment to the child and can provide the oppor-
tunity for prevention and early intervention for these offspring, including the opportunity
to identify possible developmental delays (Sadler et al., 2007). Cognitive development of
children born to teen parents has been shown to be significantly and consistently higher
when the children were enrolled in day-care programs compared to those who were not
(Campbell et al., 1986).
Some programs offer home visitation as an important component, making services that
much more easily accessible for teenagers (Key et al., 2008). Such programs typically
provide health and education for teen mothers, often involving nurses and/or social work-
ers. Key, Gebregziabher, Marsh, and O’Rourke (2008) offered an intensive program that
included home visitation by a social worker, school-based services, group education and
support, and comprehensive medical care. This particular program was found to reduce
subsequent birth rates by 50% as well as to improve graduation rates, compared to the
control group.
Timing and duration of enrollment in teen parenting programs appear to be relevant
factors in measured success. Enrolling teen parents in a program prior to the delivery of
their baby showed a significant decrease in later reported incidences of child abuse and
neglect (Honig & Mornin, 2001). Parenting programs during pregnancy can also improve
the health and development of the child. One program designed to enhance the parenting
skills and maternal health behaviors through a home visiting program with teen parents
demonstrated a low-birth weight rate of only 4.6%, which was below the local average of
13.5% and the national average of 9.42% (Flynn, 1999). Sangalang (2006) found that the
benefits of a teen parenting program are often not fully realized until a student has been
enrolled for 2 years; the reality of this could naturally influence attrition.
Parenting programs provide an opportunity for teen parents to be educated about proper
expectations, which can enhance parenting practices. While teen mothers do appear to
have knowledge about the sequence of developmental abilities, research suggests that they
are less knowledgeable about developmental timing and anticipating developmental mile-
stones to occur earlier than normal, which can lead to unrealistic expectations of their
children (Tamis-Lemoda, Shannon, & Spellman, 2002). In addition, knowledge was lower
when looking at the second and third years of life, compared to the first year of develop-
ment. Looking at the effect of parenting education classes on the knowledge and attitudes
of teen parents, Mann, Pearl, and Behle (2004) found significant gains between pre- and
post-tests. These encouraging findings suggest that parenting education can be used suc-
cessfully to increase knowledge about growth and development, with the hope that such
gains will result in better parenting skills and fewer instances of child abuse and neglect.
If school-based services are not available or insufficient, Early Head Start (EHS) may be
a viable alternative for low-income teen mothers. While not designed specifically for teen
mothers, EHS is a federally funded program that provides services to pregnant women and
their children up to age 3, offering a wide range of supports, including health care, parent
education, and in-home child development services.
Programs for Teen Fathers

While some programs include fathers in their mission and services, there is a shortage
of programs designed specifically to target teen fathers (Rozie-Battle, 2003). The Teen
Father Academy (TFA) in Central Florida is a six-month program for teen fathers of dis-
advantaged backgrounds, focusing on distinct modules to foster either father involvement
or academic attainment. Research has shown that participation in programs for young
fathers is associated with greater father involvement and responsibility (Mazza, 2002),
which can improve the welfare of the child.
Life Skills Programs

Life skills programs are strength-based programs that target and improve upon valuable
skills. These programs are future-oriented and help to promote academic achievement
and the formation of career goals, and have been found effective in reducing the rate of
pregnancies and repeat pregnancies. Taking Charge, the first empirically supported pro-
gram designed to improve academic achievement and life skills self-sufficiency for teenage
mothers, was created specifically to decrease school dropout and increase preparedness
for economic independence (Harris & Franklin, 2007). Sisson (2012) advocates for life
skills–based opportunities, through programs that are more positively focused and more
applicable to those at risk by offering greater access to postsecondary education or well-
paid jobs. Although a strengths-based program could be readily implemented in schools
to help build valuable life skills for teen mothers, it is not a comprehensive program and
therefore may not meet all the needs of a pregnant or parenting adolescent (Cornell &
Lucio, 2010).
Universal Programs
While the general trend is to specifically target pregnant and parenting teens, some pro-
grams stress the importance of universal interventions that benefit all youth while reducing
teen pregnancy, and that can be presented to the entire student body (Ehrlich & Vega-
Matos, 2000). Building personal goals for success as a way to improve academic success
and to reduce teen pregnancy has been stressed as an important part of universal pro-
grams (Ehrlich & Vega-Matos, 2000). Other programs, rather than focusing primarily
on addressing sexual behaviors, embrace a holistic model that conceptualizes the teen as
a whole person, with enrichment activities such as promoting involvement in community
outreach (Allen, Seitz, & Apfel, 2007). The Youth Development Model is one example of
a holistic model that identifies seven necessary self-perceptions for healthy development:
safety and structure, belonging, self-worth, control over one’s life, closeness to others,
mastery and competence, and self-awareness (Pittman & Cahill, 1991). This model chal-
lenges educational institutions to foster five competency areas: health/physical, personal/
social, cognitive/creative, vocational, and citizenship.
The Roles of the School Mental Health Counselor

The role of the school mental health counselor is one of wearing many hats. This is cer-
tainly true when working with students who are pregnant and parenting, as they face a
multitude of new issues and experiences.
Counselor
School counseling is an important component of school-based services for pregnant teens
(Lanzi et al., 2009; Strunk, 2008). With regard to preventing repeat pregnancies, research
has found individual counseling to be more effective than group counseling (Klerman,
2004). Hence, it will be necessary to consider both the format as well as the content of
therapy when addressing this population. Building communication between teenagers and
their parents has been found to increase contraception use and prevents both planned and
unplanned pregnancy (Suellentrop, 2011). Thus, it may be beneficial to incorporate the
families of pregnant teens into intervention. Working with families comes with possible
logistical difficulties, given the time constraints of the school day if the teen’s parents work,
in addition to therapeutic challenges if the student and/or parent are resistant to such
participation.
School counselors are often limited by the resources of their school and may feel inhib-
ited by the social climate around them. While financial restraints may deter the creation
of a large-scale program, or administrative restrictions may inhibit the school-wide dis-
tribution of contraception, the integral role of the school counselor remains: to provide a
supportive and confidential outlet for students to lean on. School mental health counselors
can offer invaluable support in regards to counseling for expectant parents, teen parents,
and their families.
Emotional Support. Providing counseling for those students who appear to be at risk, or
who seek out support, is one way to help students work through some of the struggles of
being an adolescent and possibly to delay teen pregnancy. Noting the associations between
teenage pregnancy and emotional distress, Mollborn and Morningstar (2009) encourage
both to be viewed as possible risk factors for the other and consequently each warrants
targeting for intervention. Given their findings, this would be especially true for teenagers
who are in poverty, who are further at risk.
It is important that counselors are cognizant of the fact that teens may have some
ambivalence or even positive feelings about teen pregnancy and that such a viewpoint may
influence their safe sex practices (Herrman & Waterhouse, 2011). In one study in particu-
lar, males were also found to have more positive viewpoints about teen pregnancy than
females (Herrman & Waterhouse, 2011), making them important targets as well. Further-
more, because teenagers may not view pregnancy as a negative outcome, it is important
that prevention strategies include frank discussions of the pros and cons of pregnancy
(Herrman & Waterhouse, 2011). Because lower-income and minority adolescents were
found to have more positive views about teen parenting, Herrman and Waterhouse (2011)
suggest that poorer adolescents may respond best to interventions that are focused on job
attainment through realistic goal setting, emphasis of the importance of education, and
education about the economic and logistical burden of raising a child.
Working in Middle School. While the majority of pregnancies in girls under the age of
20 occur during the latter half of adolescence, younger girls are also having children. This
population is especially vulnerable, given the high rate of repeat pregnancies among those
under 20 years old, and therefore should be targeted as well. This younger group likely
has had less exposure to sex education and may be naive to the possibility and realities
of pregnancy. Encouragingly, early prevention programs for middle schoolers that focus
on delaying the initiation of sex, through the use of theory-driven, curriculum-based pro-
gramming on the risk of HIV and STIs and on pregnancy prevention, have proven effective
(Tortolero et al., 2010).
If the school counselor happens to be aware of the family dynamics of their student
body, this may be useful information for targeting at-risk students, such as the siblings of
teenage mothers (Herrman & Waterhouse, 2011). Reaching out to younger female siblings
early in adolescence and focusing on sibling dynamics and family stressors serve as impor-
tant early intervention strategies to decrease risky behaviors and teenage pregnancy in this
vulnerable population (East & Jacobson, 2001; East & Khoo, 2005).
Students who are already pregnant may not independently seek out therapeutic support
services. As a result, it may be necessary to seek out pregnant students and offer yourself
as a resource and/or provide other resources. For obvious reasons, teen fathers may be
harder to target and may require additional efforts. It is possible that teen males may be
more responsive to male counselors, as opposed to females. If there are no male mental
health counselors in the school, it may be helpful to identify positive male role models in
the school and within the community to be possible supports for male teens and perhaps to
address the student body at large. Having a working relationship with male counselors in
the community and informing students of these resources may also benefit male students.
A school mental health counselor should keep in mind that he or she may be the first
person who the student has come to in disclosing the pregnancy. Because the student
herself may not have formed an opinion about the pregnancy, it is vital that the coun-
selor respond sensitively and in a supportive way. Helping the teenager to explore her
options and encouraging her to seek medical attention are two primary responses to
learning of the pregnancy. In addition, finding out if the pregnant student has informed
her parents, and, if not, discussing the pros and cons of telling her parents, is also an
important discussion. This also relates to ethical issues regarding informing parents of
teenage pregnancy, given the possible safety and health risks involved. Some schools
have adopted policies to help protect students’ confidentiality regarding pregnancy,
while most others may view it as essential reporting. Being up-front with the teenager
about your responsibilities to inform parents, as well as allowing them to be an active
participant in the process, can help to maintain rapport. Whether the pregnant student
chooses to keep the pregnancy may obviously influence the necessity of informing the
parents, although state laws or financial constraints may require parental consent should
she decide to terminate the pregnancy.
Dealing with Grief and Loss. Grief and loss counseling may be appropriate if the student
chooses to terminate the pregnancy, loses the pregnancy, or elects to give the child up for
adoption. If the pregnant teen carries the baby to term, it will be important to prepare the
pregnant student for the possibility of postpartum depression and to look out for signs and
symptoms of this postpartum. Logistically, this can be challenging as the student may be
absent from school following the birth, further necessitating the need to alert the student,
and possibly those who will be caring for her postpartum, of the signs and symptoms for
which to look out. In addition, having the counselor available by phone while the student
is absent from school during pregnancy and/or postpartum may be therapeutically appro-
priate, and if so, discussing the parameters of this telephone relationship will likely be
necessary (e.g., what numbers to use, time restrictions, limitations of non-face-to-face con-
versations, and possible termination of this telephone relationship). The counselor should
also consider whether he or she is comfortable visiting the teen mother and her baby in
the hospital and should be prepared for how best to handle such invitations. Because the
therapeutic relationship may become especially strong during the pregnancy, it will also
be important to establish how the relationship will progress should the student take an
extended leave of absence, drop out of school, graduate, etc., as ethically the expectations
for treatment and termination should be clear to both parties.
Supporting Good Parenting. Counseling for teen parents is also important. East et al.
(2012) assert that higher pregnancy intendedness and wantedness are associated with more
positive adjustment to parenting and, therefore, they urge professionals not to view these
characteristics as negative. Additionally, the authors found that a mother’s mental health
or experiences can inform her evaluation of the pregnancy. In working with teen parents,
Savio Beers and Hollo (2009) urge the following considerations: 1) the developmental
stage and progression of both teen parents; 2) the multigenerational family dynamic; and
3) the significance and fragility of the teen parent relationship to all those involved. While
multigenerational support can be helpful in providing child care and allowing pursuit of
the teen individual goals, the authors assert that it can also hinder a teen parent’s devel-
opment as a parent and as an individual; thus, this warrants careful consideration (Savio
Beers & Hollo, 2009).
Educator
While formal education is provided by school teachers, the school counselor can often edu-
cate teenagers on facts surrounding teen pregnancy as well as important life skills. NASP
takes a firm stance that school psychologists should be informed about sex education
themselves and prepared to educate students in this area, in addition to providing related
services (Meyers et al., 2010).
Educating students about peer pressure and statutory rape can help to enlighten students
about some of the realities that they may be facing. This is of course a very sensitive issue
and will require some finesse. Obviously, as a mandated reporter, this conversation could
result in necessary reporting, which is likely to challenge the therapeutic relationship. The
reality, however, is that the majority of teen pregnancies are the result of a sexual relation-
ship with an older male. While the male may still be in high school, the age difference
may still be considered inappropriate and abusive by legal standards. Thus, it is important
to be aware of state laws regarding statutory rape. When the male is substantially older,
it may be therapeutically relevant to explore the nature of the relationship (i.e., why the
student may be electing to date someone 10 years her senior). Whether the student views
the encounter as consensual and the fact that it may be illegal warrant discussion and
response. Sexual assault counseling may be another facet of the therapeutic relationship
or of necessary referral services.
While sex education classes may have educated students on the fundamentals of preg-
nancy, many teenagers may be uninformed or misinformed about the realities of preg-
nancy. There are many physical changes that occur that could be especially unsettling if
unexpected. For example, inevitable and necessary weight gain, fatigue and nausea (espe-
cially during the first trimester), food cravings, mood swings, heartburn (often in response
to particular foods), frequent urination, and possible loss of bladder control are all gener-
ally considered normal during pregnancy (Murkoff & Mazel, 2009). School mental health
counselors working with pregnant teenagers should educate themselves on these and other
common symptoms of pregnancy, as well as uncommon symptoms that warrant immedi-
ate medical attention. Stressing the importance of abstaining from drugs, alcohol, and
smoking during pregnancy is critical, as they may not recognize the harmful effects that
these substances can have on the baby. Similarly, educating them on the importance of eat-
ing healthfully and increasing their caloric intake can be helpful, especially if you observe
the pregnant student eating junk food to curb hunger. Encouraging pregnant teenagers
to seek medical care early and throughout the pregnancy is paramount. In order to help
facilitate this, it may be beneficial to offer referrals for affordable and accessible health
care, as discussed ahead in the section about the role of case manager.
The costs of having a child (financial, emotional, and social) are difficult to anticipate
and fully comprehend for parents of any age. Encouraging teenagers to consider these
many facets can be important in helping them to plan for their future. Learning how to
budget and balance, both their finances and their time, is an important life skill that is
especially important when one becomes a caregiver. In collaboration with administration,
school counselors are in a prime position to help organize school-wide educational pro-
grams to raise awareness about teen pregnancy and offer resources through facilitating
such programs or helping to coordinate involvement from others in the community. If such
programs are run in the school, it is important for counselors to be available for support,
with the expectation that students may have subsequent questions about which they might
want to speak with a counselor privately.
While any day is certainly a good day to broach these subjects in the schools, the
National Day to Prevent Teen Pregnancy (held during the first week in May) is an excel-
lent platform for raising awareness about teen pregnancy and fostering discussions among
students. School counselors could hold workshops about sex education and utilize some
of the resources available from the National Campaign to Prevent Teen and Unplanned
Pregnancy designed to foster discussions, in addition to the safe sex online quiz, which
can help students test their knowledge and perhaps reevaluate what they had previously
thought was appropriate and safe (http://www.thenationalcampaign.org/national/default.
aspx). The results of the quiz are used to generate statistics about teen knowledge regard-
ing safe sex.
Case Manager
While counseling is certainly the primary role of the school mental health provider, case
management is possibly his or her most important function when working with expectant
teens and teen mothers due to the benefit and need for support and resources. Indeed, this
has been identified as a key component of effective programs (Key et al., 2008).
Utilizing school-affiliated agencies and establishing a collaborative relationship can help
to extend the supports that pregnant and parenting students have available. Informing teen
parents and their families of such programs and explaining the value of this involvement
may be necessary. Expanded school mental health counselors may have more time avail-
able to serve this population, compared to counselors employed directly by the school. It is
also possible that they may have access to varied resources that might enhance the support
available to these students.
Faced with the prospect of pregnancy or raising a child, teenagers who are expecting
may be unaware of the many resources available in the community. It is important that
counselors have a list of up-to-date resources available and ready to disseminate, including
resources of inexpensive health care facilities for reproductive health and child health care,
child care, and parent training, as well as vocational resources.
In addition to pregnancy-related resources, school counselors should also be aware of
broader community programs, especially those involving service learning. As previously
mentioned, research has found that teenage participation in enriching community-based
activities and service learning can reduce the rate of teen pregnancy and repeat pregnancy.
In fact, of the 24 programs listed as evidenced-based by the National Campaign to Prevent
Teen and Unplanned Pregnancy, 15 focused on global youth development and included
parent and community involvement (Suellentrop, 2011).
Advocate
Being an advocate for expectant students and teen parents is another possible role that
school mental health counselors can and should assume. Informing students of their
rights as students, mothers, and fathers, respectively, can be invaluable. Pregnant stu-
dents have the right to the same educational opportunities in federally funded schools
as those students who are not pregnant under Title IX of the Education Act of 1972,
which forbids institutions receiving federal funding from discrimination against stu-
dents based on the students’ sex, family, or marital status. This includes classes as well
as extracurricular activities. Students may elect to attend a separate school for only
pregnant students (i.e., an alternative school-based program), but they should not be
pressured to do so, as they have the right to remain at their regular public school. The
Center for Assessment and Policy Development (CAPD) has developed strategies for
how Title IX can be used to protect the rights of pregnant students. They include a
checklist to rate a school’s compliance with Title IX as well as a list of common ailments
that pregnant women often face and reasonable accommodations that the school can
provide (Wolf, 1999).
Pregnant teens and teen mothers should be made aware of their rights to receive excused
absences for obstetric appointments and recovery from childbirth, as well as doctor’s
appointments for their child (Wolf, 1999). Encouraging students to try to remain on top
of their schoolwork and homework and encouraging them to seek out missed assignments
is also important, in addition to collaborating with teachers. When necessary, school coun-
selors may need to remind teachers of teen parents’ rights to excused absences and help
to ensure that they receive missed work for these excused absences. Manlove (2007) rec-
ommends that schools create individualized graduation plans for pregnant and parenting
students. School counselors can help in this area by suggesting, pursuing, and assisting in
the development of such plans.
Teen fathers also have paternity rights that they may wish to consider. A teen father may
be interested in being involved, but unaware that he is entitled to participate, even if he
is no longer romantically involved with the child’s mother. Even if he is not interested in
being involved in raising the child, it is important that a teen father is aware of the legal
responsibilities to which he may be held accountable.
Conclusion
Although a widespread reality across the country, teen pregnancy remains a controversial
issue with many complex facets to consider. Risk and protective factors appear to have
the common threads of level of academic investment, future-oriented thinking, and socio-
economic status.
There are a number of different types of intervention and prevention programs avail-
able. Universal, life skills, and future-oriented school programs are likely to have the
most widespread impact on teens in reducing the rate of pregnancy. This type of format
expands upon evidenced-based programs that teach life skills to pregnant and parenting
teens by including the entire student body, in order to take a more preventative approach
and encourage future-oriented thinking and skills. In simplest terms, if students are more
invested in their future, they should be less likely to engage in risky behaviors that lead to
teen pregnancy. For those students who become pregnant, either accidentally or by choice,
it is hoped that this design would also offer them the vision to stay invested in school in
pursuit of their future goals.
Ideally, schools would have the resources to provide comprehensive services for preg-
nant and parenting students; however, a lack of such services in the school should not
deter school mental health counselors from reaching out to students. Regardless of the
resources available, the school mental health counselor can provide a variety of supports
for teenagers who are engaging in risky behaviors, expecting teenagers, and teen parents
and their families.
REFERENCES
Allen, J., Seitz, V., & Apfel, N. (2007). The sexually mature teen as a whole person: New direc-
tions in prevention and intervention for teen pregnancy and parenthood. Child development and
social policy: Knowledge for action (pp. 185–199). Washington, DC: American Psychological
Association.
Alfaro, E., Umaña-Taylor, A., & Bámaca, M. (2006). The influence of academic support on Latino
adolescents’ academic motivation. Family Relations, 55, 279–291.
Amin, R., Browne, D. C., Ahmed, J., & Sato, T. (2006). A study of an alternative school for pregnant
and/or parenting teens: Quantitative and qualitative evidence. Child and Adolescent Social Work
Journal, 23(2), 172–196.
Anda, R. F., Chapman, D. P., Felitti, V. J., Edwards, V., Williamson, D. F., Croft, J. B., & Giles, W.
H. (2002). Adverse childhood experiences and risk of paternity in teen pregnancy. Obstetrics &
Gynecology, 100(1), 37–45. doi:10.1016/S0029–7844(02)02063-X
Barnet, B., Liu, J., & DeVoe, M. (2008). Double jeopardy: depressive symptoms and rapid sub-
sequent pregnancy in adolescent mothers. Archives of Pediatric Adolescent Medicine 162(3),
246–252.
Batten, S. T., & Stowell, B. G. (1996). School-based programs for adolescent parents and their young
children: Guidelines for quality and best practice. Center for Assessment and Policy Development
(CAPD). Retrieved from http://www.capd.org/pubfiles/pub-1996-10-06.pdf
Baytop, C. M. (2006). Evaluating the effectiveness of programs to improve educational attainment
of unwed African American teen mothers: A meta analysis. The Journal of Negro Education,
75(3), 458–477.
Bennett, S., & Assefi, N. (2005). School-based teenage pregnancy prevention programs: A systematic
review of randomized controlled trials. Journal of Adolescent Health, 36(1), 72–81.
Blankson, M. L., Cliver, S. P., Goldenberg, R. L., Hickey, C. A., Jin, J., & Dubard, M. B. (1993).
Health behavior and outcomes in sequential pregnancies of black and white adolescents. Journal
of American Medical Association, 269(11), 1401–1403.
Boardman, L. A., Allsworth, J., Phipps, M. G. & Lapane, K. L. (2006). Risk factors for unintended
versus intended rapid repeat pregnancies among adolescents. Journal of Adolescent Health, 39(4),
597–598.
Boden, J. M., Fergusson, D. M., & Horwood, L. J. (2008). Early motherhood and subsequent life
outcomes. The Journal of Child Psychology and Psychiatry, 49(2), 151–160.
Bronte-Tinkew, J., Carrano, J., Horowitz, A., & Kinukawa, A. (2008). Involvement among resident
fathers and links to infant cognitive outcomes. Journal of Family Issues, 29(4), 1211–1244.
Bronte-Tinkew, J., Ryan, S., Carrano, J., & Moore, K. A. (2007). Resident fathers’ pregnancy inten-
tions, prenatal behavior, and links to involvement with infants. Journal of Marriage and Family,
69(4), 977–990.
Brown, J., Harris, S., Woods, E., Buman, M., & Cox, J. (2012). Longitudinal study of depressive
symptoms and social support in adolescent mothers. Journal of Maternal and Child Health, 16(4),
894–901. doi:10.1007/s10995–011–0814–9
Bunting, L., & McAuley, C. (2004). Research review: Teenage pregnancy and parenthood: The role
of fathers. Child and Family Social Work, 9(3), 295–303.
Cabrera, N., Shannon, J., & Tamis-LeMonda, C. S. (2007). Fathers’ influence on their children’s
cognitive and emotional development: From toddlers to Pre-K. Applied Developmental Science,
11(4), 208–213.
Cabrera, N., Shannon, J., West, J., & Brooks-Gunn, J. (2006). Parental interactions with Latino infants:
Variation by country of origin and English proficiency. Child Development, 77(5), 1190–1207.
Campbell, F. A., Breitmayer, B., & Ramey, C. T. (1986). Disadvantaged single teenage mothers and
their children: Consequences of free educational day care. Family Relations, 35(1), 63–68.
Centers for Disease Control and Prevention. (2012). Youth risk behavior surveillance—United States,
2011, surveillance summaries, 61(4), 1–162. Washington, DC: Author.
Chandra, A., Mosher, W. D., Copen, C., & Sionean, C. (2011). Sexual behavior, sexual attraction,
and sexual identity in the United States: Data from the 2006–2008 National Survey of Fam-
ily Growth. National Health Statistics Reports, 36, 1–36. Hyattsville, MD: National Center for
Health Statistics.
Chang, Y., & Fine, M. A. (2007). Modeling parenting stress trajectories among low-income young
mothers across the child’s second and third years: Factors accounting for stability and change.
Journal of Family Psychology, 21(4), 584–594.
Chang, Y., Fine, M. A., Ispa, Y., Thornburg, K. R., Sharp, E., & Wolfenstein, M. (2004). Under-
standing parenting stress among young, low-income, African-American, first-time mothers. Early
Educational Development, 15(3), 265–282.
Coley, R. L., & Chase-Lansdale, P. L. (1998). Adolescent pregnancy and parenthood: Recent evi-
dence and future directions. American Psychologist, 53(2), 152–166.
Corcoran, J. (1998). Consequences of adolescent pregnancy/parenting: A review of the literature.
Social Work in Health Care, 27(2), 49–67.
Cornell, K. H., & Lucio, R. (2010). The role of school mental health services in addressing adoles-
cent pregnancy. Advances in School Mental Health Promotion, 3(3), 36–47.
Crean, H. F., Hightower, A.D., & Allen, M. J. (2001). School-based child care for children of teen
parents: Evaluation of an urban program designed to keep young mothers in school. Evaluation
and Program Planning, 24(3), 267–275.
Crittenden, C. P., Boris, N. W., Rice, J. C., Taylor, C. A., & Olds, D. A. (2009). The role of mental
health factors, behavioral factors, and past experiences in the prediction of rapid repeat pregnancy
in adolescence. Journal of Adolescent Health, 44(1), 25–32. doi:10.1016/j.jadohealth.2008.06.003
Culp, R., Appelbaum, M., Osofsky, J. D., & Levy, J. (1998). Adolescent and older mothers: Com-
parison between prenatal maternal variables and newborn interaction measures. Infant Behavior
and Development, 11(3), 357–366.
Dahinten, V. S., Shapka, J. D., & Willms, J. D. (2007). Adolescent children of adolescent moth-
ers: The impact of family functioning on trajectories of development. Youth Adolescence, 36(2),
195–212. doi:10.1007/s10964–006–9140–8
Darroch, J. E., Frost, J. J., Singh, S., & The Study Team. (2001). Teenage sexual and reproductive
behavior in developed countries: Can more progress be made? Occasional Report, No. 3. New
York: Alan Guttmacher Institute.
Dingle, K., Alati, R., Clavarino, A., Najman, J. M., & Williams, G. (2008). Pregnancy loss and
psychiatric disorders in young women: An Australian birth cohort study. British Journal of Psy-
chiatry, 193(3), 455–60.
East, P., Chien, N., & Barber, J. (2012). Adolescent pregnancy intentions, wantedness, and regret:
cross-lagged relations with mental health and harsh parenting. Journal of Marriage and Family,
74(2), 167–185.
East, P. L., & Jacobson, L. J. (2001). The younger siblings of teenage mothers: A follow-up of their
pregnancy risk. Developmental Psychology, 37(2), 254–264. doi:10.1037/0012–1649.37.2.254
East, P. L., & Khoo, S. (2005). Longitudinal pathways linking family factors and sibling relationship
qualities to adolescent substance use and sexual risk behaviors. Journal of Family Psychology,
19(4), 571–580. doi:10.1037/0893–3200.19.4.571
Ehrlich, J., & Vega-Matos, C. A. (2000). The impact of adolescent pregnancy and parenthood
on educational achievement: A blueprint for education policymakers’ involvement in prevention
efforts. Alexandria, VA: National Association of State Boards of Education.
Fletcher, J. M., & Wolfe, B. L. (2012). The effects of teenage fatherhood on young adult outcomes.
Economic Inquiry, 50(1), 182–201. doi:10.1111/J.1465–7295.2011.00372
Flouri, E., & Buchanan, A. (2003). What predicts fathers’ involvement with their children? A pro-
spective study of intact families. British Journal of Developmental Psychology, 21(1), 81–97.
Flouri, E., & Buchanan, A. (2004). Early father’s and mother’s involvement and child’s later educa-
tional outcomes. British Journal of Educational Psychology, 74(2), 141–153.
Flynn, L. (1999). The adolescent parenting program: Improving outcomes through mentorship.
Public Health Nursing, 16(3), 182–189.
Futris, T., Nielsen, R., & Olmstead, S. (2010). No degree, no job: Adolescent mothers’ perceptions
of the impact that adolescent fathers’ human capital has on paternal financial and social capital.
Child and Adolescent Social Work Journal, 27(1), 1–20.
Gest, S. D., Mahoney, J. L., & Cairns, R. B. (1999). A developmental approach to prevention research:
Configural antecedents of early parenthood. American Journal of Community Psychology, 27(4),
543–565.
Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2012). Births: Preliminary data for 2011. National
vital statistics reports, 60(2), 1–25. Hyattsville, MD: National Center for Health Statistics.
Harden, K. P., Lynch, S. K., Turkheimer, E., Emery, R. E., D’Onofrio, B. M., Slutskey, W. S., . . .
Martin, N. G. (2007). Behavior genetic investigation of adolescent motherhood and offspring
mental health problems. Journal of Abnormal Psychology, 116(4), 667–683.
Harlap, S., Kost, K., & Forrest, J. D. (1991). Preventing pregnancy, protecting health: A new look
at birth control choices in the United States. New York: Alan Guttmacher Institute.
Harris, M. B., & Franklin, C. (2007). Taking charge: A school-based life skills program for adoles-
cent mothers. New York: Oxford Press.
Hawkins, A. J., & Palkovitz, R. (1999). Beyond ticks and clicks: The need for more diverse and broader
conceptualizations and measures of father involvement. The Journal of Men’s Studies, 8(1), 11–32.
Herrenkohl, E. C., Herrenkohl, R. C., Egolf, B. P., & Russo, M. J. (1998). The relationship between
early maltreatment and teenage parenthood. Journal of Adolescence, 21(3), 291–303.
Herrman, J. W., & Waterhouse, J. K. (2011). What do adolescents think about teen parenting? West-
ern Journal of Nursing Research, 33(4), 577–592. doi:10.1177/0193945910381761
Hillis, S. D., Anda, R. F., Dube, S. R., Felitti, V. J., Marchbanks, P. A., & Marks, J. S. (2004). The
association between adverse childhood experiences and adolescent pregnancy, long-term psycho-
social consequences, and fetal death. Pediatrics, 113(2), 320–327. doi:10.1542/peds.113.2.320
Hodgkinson, S. C., Colantuoni, E., Roberts, D., Berg-Cross, L., & Belcher, H. M. E. (2010). Depres-
sive symptoms and birth outcomes among pregnant teenagers. Journal of Pediatric and Adoles-
cent Gynecology, 23(1), 16–22.
Hoffman, S. (2006). By the numbers. Washington, DC: National Campaign to Prevent Teen Pregnancy.
Honig, A. S., & Mornin, C. (2001). When should programs for teen parents and babies begin? Lon-
gitudinal evaluation of a teen parents and babies program. The Journal of Primary Prevention,
21(4), 447–454.
Howard, K. S., Lefever, J. E. B., Borkowski, J. G., & Whitman, T. L. (2006). Fathers’ influence in the
lives of children with adolescent mothers. Journal of Family Psychology, 20(3), 468–476.
Hoyt, H., & Broom, B. (2002). School-based teen pregnancy prevention programs: A review of the
literature. The Journal of School Nursing, 18(1), 11–17.
Jackson, A. P., Choi, J., & Franke, T. M. (2009). Poor single mothers with young children: Master,
relations with nonresident fathers, and child outcomes. Social Work Research, 33(2), 95–106.
Jaffee, S. (2002). Pathways to adversity in young adulthood among early child bearers. Journal of
Family Psychology, 16(1), 38–49.
Jaffee, S., Caspi, A., Moffitt, T. E., Belsky, J., & Silva, P. (2001). Why are children born to teen moth-
ers at risk for adverse outcomes in young adulthood? Results from a 20-year longitudinal study.
Development and Psychopathology, 13(2), 377–397.
Jutte, D.P., Roos, N.P., Brownell, M., Briggs, G., MacWilliam, L., & Roos, L. L. (2010). The ripples
of adolescent motherhood: Social, educational and medical outcomes for children of teen and
prior teen mothers. Academic Pediatrics, 10(5), 293–301.
Kalil, A., Ziol-Guest, K. M., & Coley, R. L. (2005). Perceptions of father involvement patterns in
teenage-mother families: Predictors and links to mothers’ psychological adjustment. Family Rela-
tions, 54(2), 197–211.
Key, J. D., Gebregziabher, M., Marsh, L. D., & O’Rourke, K. M. (2008). Effectiveness of an inten-
sive school-based intervention for teen mothers. Journal of Adolescent Medicine, 42(4), 394–400.
Khurana, A., Cooksey, E. C., & Gavazzi, S. M. (2011). Juvenile delinquency and teenage pregnancy.
Psychology of Women Quarterly, 35(2), 282–289.
King, J. C. (2003). The risk of maternal nutritional depletion and poor outcome increases in early
or closely spaced pregnancies, Journal of Nutrition, 133(5), 17325–17365.
Kirby, D. (2001). Emerging answers: Research findings on programs to reduce teen pregnancy.
Washington, DC: National Campaign to Prevent Teen Pregnancy.
Kirby, D. (2007). Emerging answers 2007: Research findings on programs to reduce teen pregnancy
and sexually transmitted diseases. Washington, DC: National Campaign to Prevent Teen and
Unplanned Pregnancy.
Kirby, D., & Lepore, G. (2007). Sexual risk and protective factors summary: Factors affecting teen sex-
ual behavior, pregnancy, childbearing and sexually transmitted disease: Which are important? Which
can you change? Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy.
Kirby, D., Lepore, G., & Ryan, J. (2005). A matrix of risk and protective factors affecting teen sexual
behavior, pregnancy, childbearing, and sexually transmitted disease. Washington, DC: National
Campaign to Prevent Teen and Unplanned Pregnancy.
Klerman, L. (2004). Another chance: Preventing additional births to teen mothers. Washington, DC:
National Campaign to Prevent Teen Pregnancy.
Klerman, L. V., Cliver, S. P., & Goldenberg, R. L. (1998). The impact of short interpregnancy inter-
vals on pregnancy outcomes in a low-income population. American Journal of Public Health,
88(8), 1182–1185.
Kost, K., & Henshaw, S. (2012). U.S. teenage pregnancies, births and abortions, 2008: National
trends by age, race and ethnicity. New York: Guttmacher Institute. Retrieved from http://www.
guttmacher.org/pubs/USTPtrends08.pdf
Lamb, M. E., Pleck, J. H., Charnov, E. L., & Levine, J. A. (1987). A biosocial perspective on paternal
behavior and involvement. In J. B. Lancaster, J. Altaman, A. Rossi, & R. L. Sherrod (Eds.), Par-
enting across the lifespan: Biosocial perspectives (pp. 11–42). Hawthorn, NY: Aldine de Gruyter.
Lanzi, R. G., Bert, S. C., & Jacobs, B. K. (2009). Depression among a sample of first-time adolescent
and adult mothers. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 194–202. doi:10.
1111/j.1744–6171.2009.00199
Larson, N. C. (2004). Parenting stress among adolescent mothers in the transition to adulthood.
Child and Adolescent Social Work Journal, 21(5), 457–476.
Lewin, A., Mitchell, S. J., Burrell, L., Beers, L. S., & Duggan, A. K. (2011). Patterns and predictors
of involvement among fathers of children born to adolescent mothers. Journal of Family Psychol-
ogy, 14(4), 335–353.
Lipman, E. L., Georgiades, K., & Boyle, M. H. (2011). Young adult outcomes of children born to
teen mothers: effects of being born during their teen or later years. Journal of the American Acad-
emy of Child and Adolescent Psychiatry, 50(3), 232–241.
Logan, C., Halcombe, E., Ryan, S., Manlove, J., & Moore, K. (2007). Childhood sexual abuse and
teen pregnancy: A white paper. Washington, DC: Child Trends.
Lounds, J. J., Borkowski, J. G., & Whitman, T. L. (2006). The potential for child neglect:
The case of adolescent mothers and their children. Child Maltreatment, 11(3), 281–294.
doi:10.1177/1077559506289864
Mandara, J., & Murray, C. B. (2000). Effects of parental marital status, income, and family function-
ing on African American adolescent self-esteem. Journal of Family Psychology, 14(3), 475–490.
Manlove, J. (2007). When girls don’t graduate, we all fail: A call to improve high school graduation
rates for girls. Washington, DC: National Women’s Law Center.
Manlove, J., Franzetta, K., McKinney, K., Romano-Papillo, A., & Terry-Humen, E. (2003). A good
time: After-school programs to reduce teen pregnancy. Washington, DC: National Campaign to
Prevent Teen Pregnancy.
Mann, M. B., Pearl, P. T., & Behle, P. D. (2004). Effects of parent education on knowledge and
attitudes. Adolescence, 39(154), 355–360.
Martinez, G., Abma, J. C., & Copin, C. E. (2010). Educating teenagers about sex in the United
States. Hyattsville, MD: U.S. Department of Health and Human Services.
Mazza, C. (2002). Young dads: The effects of a parenting program on urban African American
adolescent fathers. Adolescence, 37(148), 681–693.
McBride, B. A., Schoppe-Sullivan, S. J., & Ho, M. (2005). The role of father involvement in schools
in mediating contextual influences on student achievement. Journal of Applied Developmental
Meyers, A. B., Sylvester, B. A., & Landau, S. (2010). Pregnancy in adolescence: Information for
parents and educators. In A. Canter, L. Z. Paige, & S. Shaw (Eds.), Helping children at home and
school III: Handouts for families and educators (55–58). Bethesda, MD: National Association of
School Psychologists.
Miller, B., Benson, B., & Galbraith, K. (2001). Family relationships and adolescent pregnancy risk:
A research synthesis. Developmental Review, 21(1), 1–138.
Mollborn, S., & Morningstar, E. (2009). Investigating the relationship between teenage childbear-
ing and psychological distress using longitudinal evidence. Journal of Health and Social Behavior,
50(3), 2009.
Murkoff, H., & Mazel, S. (2009). What to expect when you’re expecting (4th ed.). New York:
Workman.
National Campaign to Prevent Teen and Unplanned Pregnancy. (2008). Fact sheet: How is the 3 in
10 calculated? Washington, DC: Author.
National Campaign to Prevent Teen and Unplanned Pregnancy. (2010). Why it matters: Linking teen
pregnancy prevention to other critical social issues. Washington, DC: Author.
Nettle, D., Coall, D. A., & Dickins, T. E. (2011). Early-life conditions and age at first pregnancy in
British women. Proceedings of the Royal Society B: Biological Sciences, 278(1712), 1721–1727.
doi:10.1098/rspb.2010.1726
Noll, J. G., Shenk, C. E., & Putnam, K. T. (2009). Childhood sexual abuse and adolescent pregnancy: A
meta-analytic update. Journal of Pediatric Psychology, 34(4), 366–378. doi:10.1093/jpepsy/jsn098
Nord, C. W., & West, J. (2001). Fathers’ and mothers’ involvement in their children’s schools by
family type and resident status. Washington, DC: U. S. Department of Education, National Center
for Education Statistics.
Partington, S. N., Steber, D. L., Blair, K. A., & Cisler, R. A. (2009). Second births to teenage moth-
ers: Risk factors for low birth weight and preterm birth. Perspectives on Sexual and Reproductive
Health, 41(2), 101–109. doi:10.1363/4110109
Perper, K., & Manlove, J. (2009). Estimated percentage of females who will become teen mothers:
Differences across states. Washington, DC: Child Trends March 2009. Report No. 2009–09.
Peterson, B. (2012). Mommy mind. Newsweek, 159(9/10), 18–19.
Philliber, S., Brooks, L., Lehrer, L., Oakley, M., & Waggoner, S. (2003). Outcomes of teen parenting
programs in New Mexico. Adolescence, 38(151), 535–553.
Pittman, K. J., & Cahill, M. (1991). A new vision: Promoting youth development. Washington,
DC: Academy for Educational Development, Center for Youth Development and Policy Research.
Quinlivan, J. A., Tan, L. H., Steele, A., & Black, K. (2004). Impact of demographic factors, early
family relationships and depressive symptomatology in teenage pregnancy. Australian and New
Zealand Journal of Psychiatry, 38(4), 197–203. doi:10.1111/j.1440–1614.2004.01336
Rozie-Battle, J. (2003). Economic support and the dilemma of teen fathers. Journal of Health and
Social Policy, 17(1), 73–86.
Sadler, L., Swartz, M., Ryan-Krause, P., Seitz, V., Meadows-Oliver, M., Grey, M., & Clemmens, D.
(2007). Promising outcomes in teen mothers enrolled in a school based parent support program
and childcare center. Journal of School Health, 77(3), 121–130.
Sangalang, B. (2006). Teenage mothers in parenting programs: Exploring welfare outcomes during
early transition to parenthood. Families in Society, 87(1), 105–111.
Saracho, O., & Spodek. B. (2008). Fathers: The invisible parents. Early Child Development and
Care, 178(7/8), 821–836.
Savio Beers, L. A., & Hollo, R. E. (2009). Approaching the adolescent-headed family: A review of
teen parenting. Current Problems in Pediatric Health Care, 39(9), 216–233.
Schelar, E., Franzetta, K., & Manlove, J. (2007). Repeat teen childbearing: Differences across
states by race and ethnicity. Child Trends Research Brief, 23, 1–7. Retrieved from http://www.
childtrends.org/Files/Child_Trends-2007_10_25_RB_Repeat.pdf
Shaw, M., Lawlor, D. A., & Najman, J. M. (2006). Teenage children of teenage mothers: Psychologi-
cal, behavioural and health outcomes from an Australian prospective longitudinal study. Social
Science & Medicine, 62(10), 2526–2539.
Sheeder, J., Tocce, K., & Stevens-Simon, C. (2009). Reasons for ineffective contraceptive use ante-
dating adolescent pregnancies part 1: An indicator of gaps in family planning services. Maternal
and Child Health Journal, 13(3), 295–305.
Sipsma, H., Biello, K. B., Cole-Lewis, H., & Kershaw, T. (2010). Like father, like son: The intergen-
erational cycle of adolescent fatherhood. American Journal of Public Health, 100(3), 517–524.
Sisson, G. (2012). Finding a way to offer something more: Reframing teen pregnancy prevention.
Sexuality Research and Social Policy, 9(1), 57–69.
Spence, N. J. (2008). The long-term consequences of childbearing: Physical and psychological
well-being of mothers in later life. Research on Aging November, 30, 722–751. doi:10.1177/
0164027508322575
Strunk, J. (2008). The effect of school-based health clinics on teenage pregnancy and parenting out-
comes: An integrated literature review. The Journal of School Nursing, 24(1), 13–20.
Suellentrop, K. (2011). What works 2011–2012: Curriculum-based programs that help prevent teen
pregnancy. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy.
Tamis-Lemoda, C. S., Shannon, J., & Spellman, M. (2002). Low-income adolescent mothers’ knowl-
edge about domains of child development. Infant Mental Health Journal, 23(1–2), 88–103.
Title IX of the Education Act, 20 U.S.C. § 1681 (1972).
Tortolero, S., Markham, C., Peskin, M., Shegog, R., Addy, R., Escobar-Chaves, S., & Baumler, E.
(2010). It’s your game: Keep it real: Delaying sexual behavior with an effective middle school
program. Journal of Adolescent Health, 46(2), 169–179.
Townsend, S. S. (2003). Fatherhood: A judicial perspective on unmarried fathers and the changing
role of the family court. Family Court Review, 41(3), 354–361.
Trenholm, C., Devaney, B., Fortson, K., Quay, L., Wheeler, J., & Clark, M. (2001). Impacts of four
Title V, Section 510, abstinence education programs: Final report, submitted to the U.S. Dept. of
Health & Human Services, Office of the Assistant Secretary for Planning & Evaluation. Princeton,
NJ: Mathematica Policy Research.
Trussell, J. (2011). Contraceptive failure in the United States. Contraception, 83(5), 397–404.
UNICEF. (2001, July 3). A league table of teenage births in rich nations. Innocenti Report Card No. 3.
Florence, Italy: UNICEF Innocenti Research Centre.
United Nations. (2006). Demographic yearbook 2006. New York: United Nations Statistics Division.
U.S. Department of Health and Human Services, Administration for Children and Families, Admin-
istration on Children, Youth and Families, Children’s Bureau. (2010). Child maltreatment 2009.
Washington, DC: Department of Health and Human Services.
Williams, E., & Sadler, L. (2001). Effects of an urban high school-based child care center on self-
selected adolescent parents and their children. Journal of School Health, 71(2), 47–53.
Wolf, W. (1999). Using Title IX to protect the rights of pregnant and parenting teens. Center for
Assessment and Policy Development. Retrieved from http://www.capd.org/pubfiles/pub-1999–
10–01.pdf
Woodward, L., Fergusson, D. M., & Horwood, L. J. (2001). Risk factors and life processes associ-
ated with teenage pregnancy: Results of a prospective study from birth to 20 years. Journal of
Marriage and Family, 63(4), 1170–1184. doi:10.1111/j.1741–3737.2001.01170
Xie, H., Cairns, B. D., & Cairns, R. B. (2001). Predicting teen motherhood and teen fatherhood:
Individual characteristics and peer affiliations. Social Development, 10(4), 488–511.
Zhu, B. P. (2005). Effect of interpregnancy interval on birth outcomes: Findings from three recent
U.S. studies. International Journal of Gynecology & Obstetrics, 89, 525–533.
17 Conflict and Crisis Within the Family
System
Suzy R. Thomas & Jeff Cook
Crisis or conflict within the family system can be productive or debilitating, short-lived
or perpetual, involving one or all of the family members. The way in which families func-
tion when crisis is not present will influence their approach and responses when a crisis
emerges. The school-based mental health practitioner may be called upon by the student,
a parent or caregiver, a teacher, or administrator to intervene in a conflict or crisis, or to
work proactively to prevent problems. It may be the case that all family members are open
to help from the school-based practitioner, or that none of them are willing to seek or
accept such assistance. There can be significant resistance to interventions during a crisis,
or openness in the time of the crisis followed by resistance, once the acute period of distress
has passed. Working with families in conflict or crisis presents some unique challenges and
opportunities for the school-based mental health practitioner, who must be self-aware,
able to set and maintain appropriate boundaries, and have access to a wide range of skill
sets that can be applied with families.
This chapter approaches the topics of family conflict and family crisis from traditional,
multicultural, systemic, and ecological perspectives. We will present an overview of con-
flict versus crisis, along with some recommendations for managing countertransference
and promoting self-awareness for the school-based mental health practitioner. Next we
will review the role of school counselors and school psychologists as consultants in order
to provide a foundation for working with families and teachers on behalf of students. Key
concepts from systems theories, attachment theory, and well-known counseling theories
follow, with specific prevention and intervention strategies for common types of conflict
and crisis present for students and families during K–12 school years.
Conflict and Crisis Within the Family System of the Adolescent

Adolescence is a time period that tends to incite tension in families. The exact nature of
the tension should be understood within a cultural context, however, and the school-based
practitioner should not assume the conflict is due to the teenager’s need for increased
independence, as this Western perspective ignores cross-cultural realities. The crises of
adolescence have been studied extensively and certainly represent a significant area of con-
cern for many families. Much of the literature in this area reflects a Euro-centric view of
adolescent developmental challenges that may not be applicable, relevant, or appropriate
in counseling families from ethnically diverse backgrounds (Garcia-Preto, 2005).
Adolescence is a developmental period that involves multiple changes on physical, psy-
chological, cognitive, and social levels (Garcia-Preto, 2005; McKinney & Renk, 2011).
Research indicates that the frequency of parent-adolescent conflict increases in early ado-
lescence and generally decreases slowly from that point on, and that middle adolescence
can see the most intense conflict between parents/caregivers and adolescents. This period
Conflict and Crisis Within the Family System 315
of growth and development is important not only because of the identity that is developing
as the adolescent moves towards adulthood, but also for the opportunity to learn valuable
conflict resolution and conflict management skills (Branje, van Doorn, van der Valk, &
Meeus, 2009; Missotten, Luyckx, Branje, Vanhalst, & Goossens, 2011). These skills are
more likely to emerge when parents are involved, responsive, supportive, and able to con-
tribute to the development of a flexible family environment, and when their expectations
for their children are developmentally appropriate (McKinney & Renk, 2011). Individuals
who experience excessive conflict during this stage—even typical types of conflict—may
also experience higher levels of depression upon entering young adulthood. The school
can serve as a buffering factor for adolescents in the midst of family conflict (Herrenkohl,
Kosterman, Hawkins, & Mason, 2009).
Many parents note that their child, upon entering adolescence, seems to have become a
different person, one whom they cannot relate to. The boy who used to sit on his mom’s
lap and talk about his day now comes home and spends hours in his room, responding
to questions with monosyllabic answers such as “OK,” “fine,” or “dunno.” The little
girl who used to play catch with Dad in the backyard now argues over everything, roll-
ing her eyes and stomping out of the room when asked what seems to the parent like a
simple question. Communication can become more than strained during preadolescence
and adolescence, with high levels of frustration on both sides. Adolescents who engage in
conflict with their family members and who do not have strong conflict resolution skills
show higher levels of internalized symptoms like depression and externalized symptoms
such as aggression (Branje et al., 2009).
Research suggests that a degree of conflict is normal. While teenagers typically assign
blame to their parents in times of conflict, parents tend to view conflict as a chance to teach
their children new skills. Without any framework for conflict resolution, however, family
members are often unable to successfully mediate conflict (Riesch et al., 2002). Basic skills
regarding communication, taking a break during an argument, giving constructive feed-
back, and accepting mutual responsibility, however, can be taught (Riesch et al., 2002); the
school-based practitioner can facilitate the adoption of these techniques in family sessions
during times of conflict, and develop curriculum on this topic for school-wide assemblies
or parent education seminars.
From a systemic point of view, the family of the adolescent is in a time of intergenera-
tional change, as several members typically enter a new life cycle at the same time. As chil-
dren become adolescents, parents are often entering middle age, while grandparents reach
retirement age. The conflicting demands caused by these changes can make adolescence a
difficult time not only for young people but also for all members of the family system (Gar-
cia-Preto, 2005). Transitions from elementary to middle school or middle school to high
school represent potential crises for the student and also for the family. Family “checkups”
are one type of school-based effort intended to prevent and reduce conflict during times
of transition. This might involve a proactive outreach program to families preparing for
the move from middle school to high school (Dishion et al., 2008; Van Ryzin, Stormshak,
& Dishion, 2011). A family that has built strong communication and coping skills while
children were in earlier stages will fare better during the period of adolescent development,
regardless of other challenges that may be present during this time (Branje et al., 2009).
Certainly, the number of physical, cognitive, and social changes experienced during ado-
lescence is overwhelming for some teens and their parents/caregivers. Risk-taking behav-
iors often increase during this period of time, and peer pressure can take on a heavier role.
Adolescents may experiment with drugs and alcohol and sexual activity, all of which pose
risks to their health and well-being in adolescence and young adulthood (Garcia-Preto,
2005; Van Ryzin et al., 2011). The Centers for Disease Control and Prevention (2010)
316 Suzy R. Thomas & Jeff Cook
report that, in 2009, “per mile driven, teen drivers ages 16–19 (were) four times more
likely than older drivers to crash.” Risk-taking behaviors like reckless driving and drug
and alcohol experimentation contribute to arguments about safety and freedom and may
result in a family crisis if there is an accident. School-based prevention addressing these
topics is ideal because of the prevalence of dangerous behaviors among adolescents. Inter-
ventions in this area may be precipitated by a crisis, in which the practitioner is called upon
to offer triage support to the family.
Conflict Versus Crisis: Some Key Distinctions

There are some similarities between conflict and crisis, and some fundamental differences.
Conflict is a normal and inevitable part of relationships, and can arise for many reasons.
The key with conflict is how the parties involved communicate with one another, how
they conceptualize the conflict, and how they approach resolution. There are a num-
ber of interpersonal conflict styles identified in the literature that can be useful to the
school-based mental health practitioner working with families. The most popular model
is that of Wilmot and Hocker (2010) and includes the styles of collaborator, compromiser,
accommodator, avoider, and competitor. As these names suggest, when faced with conflict,
people tend to take on a role of working together, working against, or disengaging.
As with conflict, crisis can be seen as a normal occurrence throughout the course of one’s
life, though there are many different types of crises that one may experience. There are
natural crises that result from developmental changes within an individual and/or family
system. For example, when children become adolescents, they face the tasks associated
with that stage; successfully navigating through adolescence diminishes the potential for
developmental crisis, although conflict during this stage can easily escalate into crisis.
When an external force affects a family—for example, when a primary caregiver loses a
job—the entire family can be thrown into a crisis. Some crises are short-lived; in the previ-
ous example, if the primary caregiver finds another job quickly, the crisis of job loss may
be fleeting. Crises of a longer duration may result from external or internal forces, or a
combination of the two, and may affect each member of the family system to a different
degree or in different ways. In the case of untreated addiction, for example, the addicted
family member may suffer indefinitely, and other family members will respond in a variety
of ways, as described in the literature on addiction and codependency. The family may
experience times of acute crisis (e.g., when the addict is arrested for driving under the influ-
ence), and may begin to learn to live in a state of perpetual crisis that becomes familiar as
a way of life.
It is important for the school-based mental health practitioner to be able to differentiate
between conflict and crisis, as well as to determine whether a crisis is short-term or ongo-
ing within the family system, externally imposed or arising out of dysfunctional family pat-
terns, stemming from a natural developmental occurrence or resulting from a psychosocial
issue such as addiction or mental illness. Having an initial sense of the definition of the
issue brought by the family will help the professional to design the most appropriate inter-
ventions, whether it be teaching communication or conflict resolution skills, normalizing
the issue within the context of developmental changes, or suggesting additional resources
or referrals for immediate or ongoing support.
To prepare for a role helping families, school-based mental health practitioners must
understand the nature of family systems and the influence of ecological, or external, dynam-
ics on families; they must also possess a sense of what defines a “healthy,” or “functional,”
family within a specific context, which includes developmental, cultural, and structural
variations. There are many avenues through which stress enters a family system. Whether
it be external forces ranging from violence or disaster to death or divorce—which are the
focus of other chapters in this text—or internal dynamics such as interpersonal or inter-
generational conflict common to family systems—the primary focus of this chapter—crisis
within families is to be expected. In manageable doses, crisis resolution may be a key
ingredient to personal and family growth. Yet families often find themselves stuck in crisis,
unable to return to a state of homeostasis or balance.
“Family” in the 21st Century

Children are raised by biological parents, stepparents, foster parents, adoptive parents,
grandparents, older siblings, and various other significant caregivers, making today’s
families increasingly complex and multifaceted. Moreover, conflict or crisis can and does
emerge within whatever family constellation the child lives in, and the school-based men-
tal health practitioner must become familiar with the key players in that system. Family
systems models have adapted their language and approach in response to changing family
structures, because traditionally they conceptualized family work as involving a hetero-
sexual, married couple with their own biological children. The very structure of “family”
has become much more broadly defined and diverse (Horne, 2000; Sayger, Homrich, &
Horne, 2000).
By addressing family crisis from a systemic lens that considers the impact of ecological
influences and developmental realities, family crisis can be contextualized to a variety of
family structures. With divorce, single-parent, stepparent, same-sex parents, and remar-
riage rates continuing to increase, school counselors and school psychologists are called
upon to help families form new roles and responsibilities, grieve the loss of established
identities and relationships, develop new traditions, navigate within dominant societal
influences, and support children who face the difficulty of adjusting to two or more family
systems (Becvar & Becvar, 2009; Horne, 2000).
Protective Factors: Well-Functioning Families and Crisis

In the early years of research on families, the family structure itself was an indication
of the quality of health, such as whether a father was present or absent, or whether
the family was intact or divorced (Becvar & Becvar, 2009). Mainstream mental health
models have tended to categorize people through binary terms, as normal or abnormal,
sick or healthy. Early family therapy addressed traditional families from a deficit model
that focused on the structure of a family as either functional or dysfunctional (Becvar &
Becvar, 2009). Current models view family functionality as variable over time and lying
on a continuum.
From a systems perspective, all behavior makes sense within a given context. The con-
tinuum between healthy and unhealthy functioning has generally been based upon the
family’s effectiveness in reaching individual and family goals (Sayger et al., 2000). There-
fore, functionality may be defined as a family’s success in achieving specific family goals
(Becvar & Becvar, 2009).
Characteristics of Well-Functioning Families

Though defining family health has shifted to reflect more diversity in structure, there have
been some consistent patterns within the literature that help to describe a well-functioning
family. The characteristics of well-functioning families include clear lines of authority, fair
implementation of rules and consequences, caring and nurturing among family members,
room for both individual and family goals, shared responsibilities, unique rituals and tra-
ditions, and the support of relationships beyond the immediate family system. In essence,
well-functioning families allow for unity as well as autonomy, and are characterized by
a flexible structure in which roles are defined and intended to support the growth of all
members (Becvar & Becvar, 2009; Sayger et al., 2000; Sayger & Horne, 2000). Com-
munication in well-functioning families is honest and congruent in terms of the “match”
between words and body language. Family members feel safe to ask for clarity when they
are confused or uncertain, and the flexibility and adaptability of the system guide members
in their efforts to communicate effectively with one another (Becvar & Becvar, 2009).
A significant component of healthy communication is a family member’s ability to
understand the true emotions behind words or underneath behavior, with the goal of
being known and understood (Faber & Mazlish, 1980). This concept is particularly
important during times of family crisis. Communication involves messages that may be
acknowledged and repeated so that understanding is established among family members;
the communication process may become more complex and difficult during times of high
stress. All emotions have a purpose, and they often serve to motivate behavior (Fiske,
2002; Johnson & Greenman, 2006; Mennin & Farach, 2007). Feelings of anxiety, anger,
sadness, and regret are useful and potentially productive. The healthy and safe sharing
of an emotion such as anger or disappointment, for example, can result in increased inti-
macy between family members, mutual understanding, and the potential for acknowledg-
ing or changing an existing pattern. In this regard, dysfunction may be thought of as a
family member’s inability to access and process emotions, and to share these openly with
another (Kristjánsson, 2003). Healthy regulation of emotions (Tugade & Fredrickson,
2007) invites individuals and families to become more aware of their feelings and more
mobilized to deal with family crisis. Emotional regulation is another hallmark of healthy
family systems, one that helps to foster a “safe” atmosphere where communication and
growth can occur.
Prevention: Creating the Well-Functioning Family

Family crisis can be averted or ameliorated by parent education or parenting classes. There
are numerous examples of successful programs that focus on the specific prevention of
mood or conduct disorders through parent training and education, especially in the pre-
school or elementary school stages (Brotman et al., 2011; Brotman, Kingston, Bat-Chava,
Calzada, & Caldwell, 2008; Dishion et al., 2008; Fristad, Gavazzi, Centolella, & Sol-
dano, 1996; Reid, Webster-Stratton, & Baydar, 2004). There are also programs aimed at
increasing trust and communication and promoting conflict resolution between parents
and children (Anderson & Nuttall, 1987; Chow et al., 2010; United States Department
of Education, 1999). The popularity of these existing programs waxes and wanes over
time, and is often dependent upon current trends and obviously on funding priorities in
individual school districts.
Although it may be useful to partner with community organizations that offer parent
education programs or to bring outside facilitators to the school to conduct workshops,
school-based mental health practitioners themselves not only have the skills to offer such
prevention programs, but also are in an ideal position to facilitate various types of preven-
tion efforts for parents and caregivers. Because they are familiar with the culture of their
schools, the demographics of their families, and the specific types of conflicts and crises
that are most common in their communities, school-based mental health practitioners can
be instrumental in the prevention of crisis and conflict through the promotion of healthy
communication and effective parenting strategies.
In order to determine what sort of prevention program would be most useful, the
school-based mental health practitioner could conduct a needs assessment following the
principles of collaborative action research, in which practitioners study themselves and
their constituents in their own environment in order to develop interventions tailored to
meet the needs of their communities and to evaluate the effectiveness of those interven-
tions (Rowell, 2005). A parent education program could then be planned in response to
the identified areas of need. Potential topics for a parent education series could focus on
conflict and crisis prevention through communication skills training, empathy building,
and mediation and resolution techniques.
Depending on the needs of the school, this type of prevention effort could take place
as a series or as a one-time workshop that could be offered annually. There are several
advantages to a group format that includes parents/caregivers, including the “normal-
izing” effect of spending time with other families and hearing about common struggles.
When parents/caregivers come together in a group, they may be more likely to realize
and accept that conflict is an expected part of living in a family. Participants will learn
not only from the facilitator, but also from one another, which is empowering for those
who can share what is already working in their families and encouraging for those who
are feeling overwhelmed or challenged. Group sessions with parents/caregivers as well as
children could include smaller breakout groups that mix adults and children from dif-
ferent families. This format would provide a powerful opportunity for children to learn
about other family structures, and for parents/caregivers to hear alternative approaches to
parenting. Parents/caregivers who attend the workshop or series could become mentors
to new attendees the following year, offering advice and tips to incoming participants,
sharing what to expect from children at different developmental stages, and reflecting on
their own successes. This strategy would create additional resources for conflict and crisis
prevention within the school community.
The school-based practitioner can incorporate the use of technology into parent educa-
tion and prevention efforts as well. For example, a workshop or lecture series could be
videotaped and posted on the school’s web site with a link for those who were unable to
attend. The school web site could include a discussion board or listserve for parents/care-
givers to network with one another and share insights about parenting, communication
strategies, and conflict resolution techniques.
Conflict and Crisis Intervention With Families
An Ecological Lens Regarding Family Systems: Examining Crisis in Larger Contexts

Many school counselors and school psychologists today are heavily trained in the cogni-
tive-behavioral modalities, and may resist the more insight-oriented, person-centered, or
somatic approaches. School-based mental health practitioners may also feel interested but
less prepared to engage in family work because their training may have been inadequate
in this area (Bryan & Griffin, 2010; Paylo, 2011; Sheridan & Gutkin, 2000). Working
with families has been identified as an underutilized but necessary role for both school
counselors and school psychologists, who may historically have been inclined to refer
families outside of the school for family therapy (Eppler & Weir, 2009). In addition, it has
been shown that schools are becoming even more important as comprehensive sources of
social and emotional support through mental health services as fewer people have access
to these services through health care providers. Finally, children are more likely to utilize
school-based mental health services than to follow up on a referral to an outside clinic
(Burns et al., 1995; Power, Eiraldi, Clarke, Mazzuca, & Krain, 2005).
Recognizing Countertransference and Increasing Self-Awareness
Whether you are a novice or a veteran in the field, you are also someone who was once
a child, an adolescent, and a member of your own family of origin, with its distinc-
tive styles of communication and conflict. In that context, you adopted one or more
roles and internalized the rules of your family system, and this process shaped who you
are—professionally as well as personally. It is inevitable that, at times, the specific issues
faced by your students and their family systems will resonate with your own life. This
recognition of similarities is not, in itself, countertransference. Furthermore, counter-
transference is not a sign that you are doing something “wrong.” There is no way to
avoid or prevent countertransference at all times. Even the most reflective and self-aware
practitioner will undoubtedly experience it. Working with a family in conflict or crisis
represents a time when you are more likely to experience countertransference because
of themes that may trigger your own history, causing you to lose objectivity and become
reactive (Gehart, 2010). During conflict or crisis, countertransference can arise if you
overidentify with a student’s issue because you had the same issue when you were that
age, or if the parents/caregivers respond in ways that were similar to what you experi-
enced as a child or adolescent.
Countertransference can influence your attitude—becoming overly protective, or reject-
ing, or generally relating to the client subjectively (Gehart, 2010). Although these reactions
are understandable and, at times, unavoidable, it is essential to anticipate countertransfer-
ence and to have a set of tools readily available for managing it in order to be effective
with students and families (Kilpatrick, Kilpatrick, Jr., & Callaway, 2000; Nichols, 2010).
Table 17.1 contains a list of prevention and intervention strategies for the school-based
mental health practitioner regarding countertransference.
Striving for self-awareness, working to minimize and process countertransference, and
making a commitment to continue working towards balance will serve you well as you
undertake the responsibilities associated with helping families in crisis and conflict.
School counselors and school psychologists alike have felt a sense of anxiety or fear
around working with families, and may feel tempted to retreat into the familiarity of indi-
vidual work with students. Traditionally, the field of counseling has separated individual
Table 17.1 Ten Strategies for Practitioners to Increase Self-Awareness
1. Acknowledge and accept that countertransference is bound to arise.

2. Reflect on your own family of origin, specifically in terms of communication and conflict
styles, and the role and expression of emotions.
3. Examine your own preferences during times of conflict or crisis—e.g., do you feel more ener-
gized during conflict, or do you avoid it and attempt to make peace?
4. Engage in your own personal therapy.
5. Strive towards balance—for example, if you have to be “right” in an argument, work towards
allowing for multiple perspectives.
6. Consider your own relationship history, including the impact of divorce, breakups, and other
types of endings.
7. Trust that being reflective about your own life will aid in preventing the interference of your
issues with students and families.
8. When countertransference does arise, do not panic! Seek consultation to mitigate overwhelm-
ing feelings.
9. Avoid self-disclosure in the midst of countertransference. Instead of sharing your personal
responses or feelings with the family, take time to engage in self-reflection or process your
feelings with someone else.
10. Accept that you do not have to be “perfect” in this work.
psychology from family therapy, with the former focusing on intrapsychic forces and the
latter on dynamics that are located externally (Nichols, 2010). Individual therapy has
embraced a linear approach to counseling that assumes “A caused B.” This individual
approach was strongly supported by the modernistic culture of the 20th century that saw
the individual as the basic building block of society (Becvar & Becvar, 2009). The individu-
alistic perspective suggests that the individual can be understood in isolation, outside of a
larger context; or, in terms of working with families, that conflict within a family can be
assigned to an individual rather than to the larger family, cultural, and ecological contexts
(Sayger et al., 2000).
School-Based Consultation in Family Conflict and Crisis

One of the primary roles that the school-based mental health practitioner is likely to
adopt when there is conflict or crisis within the family system is that of consultant. An
indirect service, consultation is one of the many functions ascribed to school counselors
and school psychologists. Because direct service (e.g., individual or group counseling) is
time-consuming, the indirect service approach of consultation is considered to be an effec-
tive use of the school-based mental health practitioner’s time. By helping a teacher or par-
ent/caregiver resolve an issue with a student, the school-based mental health practitioner
benefits not only the student, but also the overall performance of the teacher or effective-
ness of the parent/caregiver. Consultation and counseling have some philosophical and
practical similarities, but they also differ in some important ways that should feel clear to
all parties involved.
At times the school-based mental health practitioner may actually engage in family
therapy techniques when assisting families in crisis, and some of these will be presented in
the prevention and intervention applications throughout this chapter. In the big picture,
however, the school counselor or school psychologist functions more in the role of consul-
tant, attempting to improve communication, teach skills, enhance objectivity, and increase
internal and external resources. Because the student exists within the family system and
the school system, and crises at school affect the climate at home, the school-based mental
health practitioner may engage in consultation with family members as well as school
personnel.
In the context of crisis, consultation has both a preventive and remedial focus. The
consultant functions as a supplementary ego for the members of the consultative system,
helping both consultee and client to gain perspective, tools, and resources for resolving
the current problem and preventing future, similar problems. The consultant must possess
a clear understanding of her/his role, and communicate the nature of the role to the con-
sultee (Caplan & Caplan, 1993). Otherwise, parents/caregivers and teachers can become
overly reliant on the services of the school-based mental health practitioner, and may seek
therapeutic services for issues that are beyond the scope of practice of the consultant.
Family Therapy-Based Interventions for Conflict and Crisis

Current approaches to family therapy tend to be inclusive and relational in nature. Regard-
less of the setting, the mental health practitioner is always working with more than the
individual, because the individual does not exist within a vacuum. A systems approach to
counseling suggests that the individual can be understood only within context and in rela-
tion to others. This perspective challenges the mental health practitioner to acknowledge
ecological influences upon the family system—influences that may contribute to family
crisis. From a systemic perspective, then, “A causes B” is replaced with an emphasis on
relationships, patterns of interaction that create relational dynamics, and mutual respon-
sibility for behaviors and outcomes (Sayger et al., 2000).
Conflict within a family system is a complex interplay between the home, community,
school, and cultural milieu. The ecological perspective originally developed by Bronfen-
brenner (1979) incorporates the various contexts that influence individual development;
when applied to the family, these contexts—such as culture, gender, race/ethnicity, class,
generation, government, and so on—represent factors that shape the family and either
support or hinder its functioning. Current thinking not only emphasizes the context of the
family itself, but also takes into account the role and impact of these larger, external forces
on the health of the family (Sayger & Horne, 2000; Sheridan & Gutkin, 2000). Privilege,
power, and oppression are social forces that influence individual and family themes (Gior-
dano & McGoldrick, 2005; Johnson, 2006; McIntosh, 1998). The school-based mental
health practitioner is called upon to develop an ongoing awareness of how the external
influences of privilege, power, and oppression may contribute to the current crisis affect-
ing a family system. These social constructs represent realities in which some benefit while
others are placed at a disadvantage. The benefits of privilege are usually not “earned,” but
bestowed upon those in the dominant categories (e.g., White, male, young, Christian, het-
erosexual, able-bodied, wealthy, etc.). Part of the task of working with students and their
families contextually involves understanding the roles of power, privilege, and oppression
in their lives and listening for these relational themes (Giordano & McGoldrick, 2005;
Johnson, 2006; McIntosh, 1998).
Family Systems Theories and Intervention. Family systems theory posits the individual
in relation to and interaction with the environment. A script exists for each family that
informs the members about rules and roles regarding behavior, boundaries, and commu-
nication. When any change occurs, the script must be revised and the entire family system
also changes (Blevins, 1994). Homeostasis (often used interchangeably with balance) is a
term that appears frequently in family systems theory. It is common for individuals and
systems to resist change, and there is a natural tendency towards the familiar, even when
what is familiar is dysfunctional or unhealthy. Individuals and families will seek homeo-
stasis, or a return to balance, especially in times of conflict or crisis. It is essential for the
school-based practitioner to recognize the powerful pull towards homeostasis; those who
work with families must not judge resistance to change. At the same time, they should
strive to help the family develop healthier ways of interacting and recognize areas of resil-
ience within the family structure (Haley, 2007; Nichols, 2010; Sayger & Horne, 2000).
There are many names associated with the development of family systems theories—far
too many to present in this chapter. We have chosen three well-known theorists, Murray
Bowen, Salvador Minuchin, and Virginia Satir, whose work has contributed to the body
of knowledge regarding effective family counseling and therapy. The three classic family
systems perspectives reviewed here provide theoretical stances that emphasize the family as
a living, breathing system, view conflict within a context, and allow for ecological consid-
erations and opportunities for advocacy in an effort to bring about systemic healing. Their
key concepts are particularly useful when addressing family crisis and conflict.
Natural Systems Theory. Bowenian theory conceptualizes the family from a multigen-
erational perspective, including those who are no longer alive but whose personalities and
characteristics continue to influence the behaviors of present family members. Family sys-
tem patterns are transmitted from one generation to the next, and individuals adopt family
roles that may have belonged to people they never knew. Examples of intergenerational
transmission of the family system might include ineffective communication or parenting
skills, norms about culture, gender roles, and relationship dynamics between and among
members. The primary tension that exists within families is the push between connection
and individuality, togetherness and autonomy. The needs of individual family members
may be in conflict with the needs of the family unit, or they may contribute to the health
of the family as a whole (Goldenberg & Goldenberg, 2008).
Key Concepts. A primary concept in Bowenian theory is differentiation. Characterized
by an individual’s ability to successfully connect to others while maintaining an appropri-
ate level of independence, differentiation of self is the balance between individuality and
togetherness that also leads to harmony between thoughts and feelings. A differentiated
person maintains healthy levels of emotional involvement to and investment in the fam-
ily while simultaneously attending to the self. In contrast, fusion refers to the inability to
separate self from others. Fusion often includes discord between thoughts and feelings,
automatic emotional reactivity, and failure to evolve out of roles assumed within the fam-
ily of origin. Fused families generate anxiety out of high levels of involvement and depen-
dence. They are also more likely to experience emotional cutoff, where a family member
physically moves away or emotionally disconnects from the family in order to escape the
detrimental effects of fusion. In a family where one child committed suicide, for example,
the parents may resist allowing the surviving sibling to have personal freedom or leave
home for college, insisting instead that the family needs outweigh the individual’s goal
of autonomy. In this case, the child may respond by reducing interaction and intimacy
with the parents or even by running away from home. Triangulation also occurs more in
families where differentiation is low. Triangulation involves two family members mov-
ing towards balance by bringing a third member into the dynamic. While the intention
behind triangulation is often to reduce anxiety, it can sometimes increase the experience
of anxiety. Conversely, differentiated families tolerate and allow for conflict and growth
to occur, and support the development of independence for family members, trusting that
commitment to the family will not be damaged along the way (Becvar & Becvar, 2009;
Goldenberg & Goldenberg, 2008; Nichols, 2010).
Applications. The genogram is a specific tool that emerged from Bowenian theory and
has been used and expanded by others. A genogram represents family history for multiple
generations, and addresses relational issues and patterns such as triangulation, cutoff,
and conflict. Similar to a traditional family tree, a genogram is a graphic diagram of
the family, representing each individual by a symbol with information about important
family milestones (i.e., birth, death, marriage, divorce). Unlike a family tree, a genogram
includes additional information about relationships, like fusion or cutoffs, between fam-
ily members. These relationship dynamics are illustrated through the use of lines drawn
between individual family members. Finally, genograms often recognize the influence of
social, cultural, and psychological influences on the family by including information about
substance abuse or child abuse, religion or race, and mental illness. The genogram is a tool
that can be used by the practitioner to uncover and understand patterns in order to work
more effectively with the family; this tool can also be used directly with a family in crisis, to
help them see relationship dynamics, multigenerational influences, and cultural and eco-
logical forces (Becvar & Becvar, 2009; Eppler & Weir, 2009; Gehart, 2010; Goldenberg &
Goldenberg, 2008; McGoldrick, Gerson, & Shellenberger, 1999; Nichols, 2010). School-
based practitioners should be aware that the process of doing a genogram in a family that
includes adoption may bring up complicated and complex feelings related to unresolved
grief or anxiety because of how the family has or has not integrated the adoption into its
overall structure; on the other hand, it can offer a clearer sense of identity and belonging
for the adoptee and other family members.
Structural Theory. This systems theory is primarily associated with the work of Salvador
Minuchin and, as the name implies, focuses on the structure of the family and specifically
on boundaries, hierarchies, and subsystems within the family unit. As with all systems
approaches, structural theory focuses on family context and the family as an integrated
whole rather than on each individual (Goldenberg & Goldenberg, 2008). The assumption
is that changing the organizational structure of the family will result in behavioral change
among individual family members. Healthy families are open and flexible, able to modify
their structure in response to change; on the other hand, unhealthy families have hidden
or unspoken rules and a structure that does not easily adapt in the face of crisis or change.
“Structural” refers to the ways in which the subsystems (e.g., the couple, the parental unit,
the siblings, the individual) interact, the habits and patterns embodied in communication,
the assignment and maintenance of roles, and the way in which the family arrives at bal-
ance or homeostasis (Goldenberg & Goldenberg, 2008).
Key Concepts. Families engage in a process of negotiation and accommodation. Nego-
tiation refers to the compromise that can take place as roles and subsystems change;
accommodation is a process of adjustment to the needs of others and of the larger system.
In healthy families, negotiation and accommodation are fluid processes that allow for
adaptation to change (Becvar & Becvar, 2009). When couples develop strong methods of
communication, they are more likely to succeed in a new subsystem as parents, and then to
be able to teach skills to the children in their sibling subsystems. When couples have initial
dysfunctional patterns or develop dysfunction as parents, these patterns will be transmit-
ted to the children as well (Becvar & Becvar, 2009; Gehart, 2010; Goldenberg & Golden-
berg, 2008). Beyond subsystems that develop based on position within the family, other
subsystems also emerge in response to the assignment of roles or tasks (e.g., taking care of
the family pets, babysitting younger siblings, paying bills, doing household projects) that
must be completed; thus, members of a family may belong to more than one subsystem
(Goldenberg & Goldenberg, 2008).
There are inherent hierarchies within family subsystems that imply power and determine
roles. In a well-functioning family, the parent subsystem would hold power and guide the
sibling subsystem. Part of the work of structural therapy is uncovering and understanding
family hierarchies in order to identify the subsystems and define the roles and responsibili-
ties of each. Inevitably, subsystems will respond to power differences by forming alliances,
which can become coalitions in which several family members align against a particular
family member (Goldenberg & Goldenberg, 2008). In a family where one parent has had
an affair, for example, children may align with the other parent.
Another element of structural theory, according to Minuchin, is boundaries, implicit or
explicit rules that should be clearly defined between and among subsystems (Goldenberg
& Goldenberg, 2008). Boundaries should be flexible in nature, in response to ecological
and developmental influences within a family system. When boundaries within a family
are overly rigid, individuals tend to have autonomy but may be disconnected from the
family as a unit. When boundaries are diffuse, family members have trouble differentiating
and may become overly involved and unable to clearly define roles and responsibilities.
The most well-known term for this is enmeshment, which implies excessive investment,
along with overactive accommodation and negotiation—in these cases, family members
do not have an accurate sense of what is “too much” involvement with one another
(Becvar & Becvar, 2009). The goal is to develop clear boundaries, which are permeable,
open, and adaptable. What defines a “healthy” boundary is, of course, unique to the cul-
tural background and influences of the family (Becvar & Becvar, 2009).
Applications. The school-based practitioner can assist families with the process of nego-
tiation and accommodation. The practitioner’s goal is to help the family understand these
dynamics and rebalance itself in relation to internal and ecological influences. Tools that
the school-based practitioner can use include building positive alliances within the family,
helping members to examine the nature of boundaries and hierarchies, mapping family
structures to shed light on current dynamics, and enacting family themes in an effort to
gain insight and learn new skills.
Another technique is unbalancing, in which the counselor or psychologist adopts one
of the typical roles in the family so that other family members will be forced to push
towards homeostasis by taking on a different role (Gehart, 2010). In a single-parent fam-
ily, a conflict might exist when the parent wishes for the student to stay home to watch
younger children, while the student would like to join a sports team. Unbalancing in this
case may include the practitioner assuming a heightened or exaggerated version of the
parent’s stance that paradoxically forces the parent to move out of an extreme position
and consider alternatives. These interventions highlight the way in which roles shift during
life transitions and crises and additional skills in negotiation and accommodation must be
learned (Gehart, 2010; Goldenberg & Goldenberg, 2008).
The Human Validation Process Model. Virginia Satir was another central figure in the
development of family therapy and family systems theory. Satir’s approach shares sev-
eral concepts with that of Carl Rogers’s (1961) person-centered theory (described ahead),
including the belief that each individual has an innate desire to be whole, healthy, and
authentic, and the internal resources necessary for growth. This is a positive and optimistic
approach, focusing on the development and enhancement of self-esteem and awareness,
with the goal of expressing emotion and communicating with congruence and genuine-
ness (Gehart, 2010; Goldenberg & Goldenberg, 2008; Satir & Bitter, 2000). Satir (1983)
argued that congruence can be taught, and that the practitioner’s role is to help others
communicate more intentionally and authentically. The premise of this theory is not about
treating “symptoms,” but about effecting change at core levels to increase self-awareness
and move towards wholeness (Goldenberg & Goldenberg, 2008; Satir, 1983).
Key Concepts. When families are stuck in dysfunctional patterns, their communication
is ineffective, indirect, and even inappropriate. One of Satir’s primary contributions that
can be of use to the school-based practitioner is a method of assessing family communi-
cation patterns using five possible styles or stances. These are defined as follows: 1. The
placater is overly agreeable, a “people-pleaser” who denies having needs. 2. The blamer
is always right, insisting that others are wrong. 3. The super-reasonable person is distant,
disconnected, inflexible, and controlled. 4. The irrelevant individual is unable to connect
with others or to assert a clear position about anything. 5. The congruent communicator
is authentic, appropriate, and clear in her or his messages to others. The first four styles
are ineffective and result from the fear of taking the risk of being rejected by another
family member. Underneath these positions are feelings of loneliness, worthlessness, and
vulnerability. The last style defines functionality within any given family. Examining the
family system in the context of these communication styles, the counselor or psychologist
can help members to identify their roles and move closer towards the healthy position of
congruent communicator. The goal is to improve communication and increase congru-
ence, thus improving family relationships and enhancing self-esteem (Becvar & Becvar,
2009; Gehart, 2010; Goldenberg & Goldenberg, 2008; Satir & Bitter, 2000). A prevention
strategy could be inviting families to attend an educational workshop wherein the school-
based practitioner presents the five stances, asks participants to assess their current stance,
and offers suggestions for achieving congruent communication.
Applications. When families function well, members validate and support one another.
During a crisis, the family may revert to “survival mode,” in which communication occurs
from within the first four styles as the family seeks homeostasis and is forced to reorganize
in some way. The school-based practitioner guides the family through the change, model-
ing congruence (Becvar & Becvar, 2009; Gehart, 2010; Satir & Bitter, 2000). Sometimes,
children will manifest a “problem” that is actually reflective of an issue within the parental
subsystem; in a family where gender norms are traditional, an elementary school-age boy
may be excessively competitive, alienating peers and being referred for counseling services.
In such cases, the practitioner’s task is to uncover and identify dysfunctional patterns,
encourage emotional awareness, and improve communication so that the system becomes
more open and able to face and adapt to change (Becvar & Becvar, 2009). Children will
seek role models outside of the family system when role models do not exist within the
system (Satir & Bitter, 2000); as a school counselor or school psychologist, you might
become one of those role models for a student.
A Developmental Lens and Crisis

In addition to ecological influences, students or families may experience a crisis that is the
result of developmental transitions within the family. The family life cycle stages depict the
developmental progress of an individual and family, beginning with single adulthood, fol-
lowed by entering into a partnership/marriage and having children; then the family is con-
sidered in the context of the ages of the children, from the early years through adolescence
and into the launching stage; finally, this framework examines families in the retirement
stage, when the system changes again as the family both expands (i.e., with grandchildren)
and faces death and loss (Becvar & Becvar, 2009; Carter & McGoldrick, 2005; Golden-
berg & Goldenberg, 2008; Nichols, 2010; Sayger et al., 2000). School-based practitioners
need to be aware that crisis within a family may be an indication of the family’s inability
to negotiate a developmental milestone related to one or more of the family life cycle
stages. Each stage of development will impact each family member in differing ways,
whether the response is one of grief, resistance, or excitement. Within this lens, crisis can
be viewed as developmentally normal and appropriate. As one member within the family
system changes, it is only natural that the changes will impact the system as a whole, and
that other members of the family will have to adapt and change (Becvar & Becvar, 2009).
Erikson’s (1963) theory of psychosocial development can be applied to the family system
as well as the individual. Counselors and psychologists who are familiar with the psychoso-
cial stages and tasks of development can use this information to understand developmental
issues and corresponding crises for students of various ages and their family members.
For example, while identity issues are paramount for adolescents, some students may find
themselves “stuck” in an earlier stage (e.g., the preschool or early childhood stages of
autonomy versus shame/doubt or initiative versus guilt) and thus unable to grapple with
identity. At the same time, younger parents might be grappling with the task of intimacy
versus isolation; or, grandparents who are primary caregivers might be facing the stage of
later life, involving the tension between integrity versus despair. The school-based prac-
titioner can work to prevent conflict by offering empathy-building skills for families to
become more aware of the needs and challenges of different developmental stages. This
could be accomplished by hosting a “Grandparents’ Day” at school to promote awareness
of and respect for multigenerational experience.
Individual Theoretical Perspectives on Conflict and Crisis

Attachment Theory: Secure Attachments Promote Resilience Amid Conflict. Attachment
theory, developed by John Bowlby, Mary Ainsworth, Mary Main, and others, offers some
interesting possibilities for school-based mental health practitioners working with families
in conflict or crisis. Attachment theory proposes that the formation of attachments with
primary caregivers is an essential requirement for healthy development in the individual.
When the basic nurturing needs of the baby are met by the primary caregiver(s), the baby
learns to trust that her needs will be met and forms what is known as a secure attach-
ment. If, on the other hand, the primary caregiver is withholding, inconsistent, abusive, or
unavailable, the baby’s development in the area of attachment will be impaired or delayed
(Bowlby, 1973, 1982; Goldenberg & Goldenberg, 2008). Ainsworth, Blehar, Waters, and
Wall (1978) identified dysfunctional attachment patterns as ambivalent-insecure attach-
ment, characterized by high levels of anxiety as well as resistance, and avoidant-insecure
attachment, in which the child shows low levels of responsiveness to others. Main and
Solomon’s (1990) research added the style of disorganized-disoriented attachment, a lack
of coherent or consistent response to others that may result from abuse by the primary
caregiver (Goldenberg & Goldenberg, 2008).
Applications. Attachment styles have an impact on behavior as the child grows and
develops, and shape the child’s approach to conflict and response to crisis. The nature
of attachment bonds in a family has multigenerational implications: those raising the
child(ren) may, themselves, have impaired attachment based on their early childhood expe-
riences, which influences the way in which they parent their child(ren) and the formation
of attachment bonds in the child(ren) (Baptist, Thompson, Norton, Hardy, & Link, 2012;
Goldenberg & Goldenberg, 2008; Nichols, 2010). A parent who is the survivor of child
abuse, for example, may not understand the difference between abuse and appropriate
discipline, which will invariably mean that the primary attachment bond will be wounded
without intervention. The school-based practitioner can use attachment theory as a way
to conceptualize the responses of family members to conflict and crisis, understanding that
individuals with impaired attachment will not have the same level of resilience or internal
strength for handling the difficulty and may need more support and tools for learning how
to resolve a conflict or crisis.
Psychoanalytic Theory: How Defense Mechanisms Influence Coping Skills. As men-
tioned earlier, the psychoanalytic concept of transference is useful within the consultative
paradigm, and the notion of countertransference can be useful for the school-based mental
health practitioner in terms of self-awareness. There are also some practical ways in which
psychoanalytical concepts can be woven into family systems work. A key Freudian concept
that may play a role in family crisis or conflict is defense mechanisms, which are coping
devices (though not always the most productive) that individuals use to manage painful or
stressful experiences (Corey, 2012; Novie, 2007). Common ego defenses such as denial,
projection, and rationalization represent (usually) unconscious methods for keeping pain-
ful information out of conscious awareness.
Applications. The school-based mental health practitioner who is aware of the powerful
role that defense mechanisms may play during a conflict or crisis can use that informa-
tion to understand the seemingly irrational responses family members may have, and to
assist them in becoming conscious of current maladaptive patterns in order to replace
these with more functional reactions. This is no easy task! Defense mechanisms lie deep
within the unconscious and represent “knee-jerk” responses to adversity. When faced with
the prospect of moving, for example, parents may report that their middle schooler has
begun to have “tantrums” that were common in childhood; this is an example of regres-
sion, in which the child has reverted to an earlier stage in order to cope with the change.
The school counselor or school psychologist can work with the family, or with the child,
to process the underlying feelings and fears associated with the move and help the child
to develop new coping skills. In some cases, it may be that the school counselor or school
psychologist is the only one who recognizes defense mechanisms within a family, or that
the child/adolescent sees these patterns but the adults are unaware of them.
Gestalt Theory: Contact Boundaries and Unfinished Business in Conflict Resolution.
Another conceptual paradigm that relates to defenses during conflict is the Gestalt notion
of contact boundaries, which are fluid in healthy relationships and impaired in one or
more ways in disturbed relationships or during periods of distress. Tactics for avoiding
contact and discomfort include confluence (blurring of boundaries), deflection (diffusing
contact through humor), introjection (internalizing others’ beliefs), projection (disowning
a quality and attributing it to someone or something else), resistance (blocking contact),
and retroflection (a form of self-rejection). The Gestalt term unfinished business refers to
the unexpressed feelings that interfere with contact, cause problems, and hinder aware-
ness of the moment; this past material must be faced and dealt with in order to move
through impasses and achieve authentic expression. The goals of Gestalt therapy include
self-awareness and the development of internal means of support (Corey, 2012; Golden-
berg & Goldenberg, 2008; Haley, 2007).
Applications. A school-based practitioner coming from a Gestalt framework would
pose “what” and “how” rather than “why” questions. In an individualized education plan
(IEP) meeting, a family dealing with the crisis of a recent learning disability diagnosis may
be inclined to ask the student questions such as, “Why aren’t you doing your homework?”
The Gestalt-minded practitioner can mitigate the situation by asking “what” and “how”
questions like, “What happens when you sit down to do your homework?” Additional
tools include facing unfinished business through the empty chair technique, becoming
your feeling, or exaggeration exercises intended to bring symptoms to life so that they
can be released (Corey, 2012; Haley, 2007; Sayger & Horne, 2000). Unfinished business
connected to grief, for example, may be expressed through the use of the empty chair. A
student who has a deployed family member may “place” war in an empty chair in order
to freely express emotions.
Person-Centered Theory: How Empathy Creates Space for Healing. A fundamental
assumption in Rogerian person-centered therapy is that, given the appropriate therapeutic
environment, an individual can experience and work through feelings that were denied
or distorted and become inner-directed and self-actualized. The core conditions form the
basis for Rogerian counseling, including: congruence, characterized by the qualities of
genuineness, authenticity, and integration—that is, there is an agreement between what is
felt and what is communicated; empathy, which involves entering the client’s private world
“as if” it were your own, and reflecting an understanding of that experience without add-
ing from your own frame of reference; and unconditional positive regard, described as the
expression of nonjudgmental, unrestricted warmth or regard (Corey, 2012; Rogers, 1961).
Applications. School-based practitioners can and should use person-centered theory in
their own stance towards the student and family members, demonstrating genuineness,
empathy, and a nonjudgmental attitude; in addition, they can help family members learn
how to show empathy towards one another and how to come from another person’s per-
spective, even in times of tension and struggle (Corey, 2012; Hazler, 2007; Thayer, 2000).
In the case of teenage pregnancy, for example, it may be especially challenging for family
members to practice the core conditions and to see the viewpoint of the pregnant teen.
Besides working directly with a family in crisis over pregnancy, the school-based practi-
tioner can design classroom workshops aimed at raising awareness among students about
the emotional stress and strain associated with teenage parenthood from both the teen
mother’s and teen father’s (an often overlooked population) perspectives.
Cognitive-Behavioral Techniques: Thought-Stopping and Reframing to Diffuse Conflict.
The cognitive-behavioral therapy (CBT) branch of psychotherapy has been popular for many
years among school psychologists and school counselors, because of its brief and direct
nature and the concrete skills for problem solving. These modalities have contributed
much to the field of parent education and skills training (Becvar & Becvar, 2009; Golden-
berg & Goldenberg, 2008). People who work in schools are often short on time and have
heavy caseloads. CBT is effective in helping design a practical intervention reinforced with
homework.
Applications. With regard to conflict and crisis, numerous CBT techniques have rel-
evance for families. A primary tool of CBT is examining faulty or absolute thinking to help
families gain an understanding of current schemas that operate within their family system,
and how these either support or undermine healthy functioning. During times of conflict
and crisis, patterns of exaggeration and minimization often drive interactions, and abso-
lute thinking is common. CBT theorists argue that it is easier to increase positive behavior
than decrease negative behavior, so treatment plans focus on teaching new behaviors and
reinforcing productive ones. Given the assumption that all behavior is learned, it follows
that behavior can be “unlearned,” changed, or modified (Becvar & Becvar, 2009; Corey,
2012).
Specific techniques for families in crisis include: reinforcement (rewarding desired
behavior), shaping (gradual increase of desired behavior), thought-stopping (maladaptive
thought patterns are recognized and replaced), affirmations (positive self-statements to
reinforce new beliefs), contracting (verbal or written agreements between family members
or between the family and the practitioner), and time-out (a structured break when a mal-
adaptive behavior emerges). The family can work together to support behavior change in
each member. The school-based practitioner can model effective communication, encour-
age development of new behaviors through role-play exercises, and decrease stress through
relaxation techniques. These interventions help the family to capitalize on its strengths and
learn new coping skills together (Becvar & Becvar, 2009; Corey, 2012; Goldenberg &
Goldenberg, 2008; Horne & Sayger, 2000; Nichols, 2010; Sayger & Horne, 2000).
Solution-Focused Brief Therapy (SFBT): What’s Already Working? In SFBT, another
extremely popular approach for school-based mental health practitioners, the focus is on
seeing or finding the solution to the problem rather than focusing on understanding the
problem itself. A “problem” is really a person’s best attempt at coping with a current situ-
ation. Phrases like, “If it works, don’t fix it,” are common in SFBT. Labeling is damaging; a
child who has been labeled “hyperactive” will be redefined as “spirited” in a SFBT context
(Corey, 2012; Goldenberg & Goldenberg, 2008; Nichols, 2010).
Applications. One of the main principles is to look for exceptions to the “problem,”
or times when it has not been a problem (Becvar & Becvar, 2009; Corey, 2012; Gehart,
2010; Goldenberg & Goldenberg, 2008). For example, if a student is out of his seat for
20 minutes out of a 30-minute class, a traditional approach would be to determine why
he was out of his seat or engage in behavior modification; an SFBT approach would be to
focus on the 10 minutes when he is in his seat and look for ways to extend that time. This
paradigm shift is a relief in times of crisis, when the involved parties may be able to see
only the problem.
Traditional SFBT counselors use the miracle question, which involves asking the cli-
ent to imagine life without the “problem.” This technique involves a series of questions,
beginning with the suggestion that a miracle took place overnight and the problem is now
gone. Then the counselor asks the client to describe how he would be different, and how
others might respond differently to him. The purpose is to generate momentum towards
resolving the problem. Another traditional technique is scaling questions to help a client
see how much control she has over a feeling or behavior, and then to move towards more
control. In addition, this theory emphasizes a “1-down” approach, which can be mod-
eled by the school counselor or school psychologist and taught to family members. In the
1-down approach, power is de-emphasized and the practitioner asserts that the family is
the expert on whatever issue they are facing. This strategy can help to stimulate a sense of
empowerment. Modeling that one does not need to be “right” or “perfect” is a powerful
tool during conflict, when individuals can become attached to knowing what is best for
themselves and for others. SFBT is a positive approach that can feel like a reprieve to a
family in crisis (Becvar & Becvar, 2009; Corey, 2012; Gehart, 2010; Homrich & Horne,
2000; Nichols, 2010).
Narrative Therapy: “Restorying” the Crisis. Narrative therapy overlaps with SFBT in
several ways, such as resistance to labeling, and the search for exceptions to the problem.
Many school-based practitioners have not been trained in narrative approaches, though
this modality has significant applications for families in crisis. The narrative approach
purports that each of us designs a story about ourselves. The story we build influences
our use of language and how we interpret our experience. Our stories shape who we are,
how we present to others, and how we see ourselves, and they can be affirming or limit-
ing. Although there are always multiple interpretations for any experience, it is common
for individuals to become “stuck” in a narrative. Families also design stories about them-
selves, which serve similar purposes (Goldenberg & Goldenberg, 2008).
The narrative approach argues that, instead of teaching clients to “reframe” their prob-
lems (as is done with CBT), helping them to construct a “new story” will mean that
the need for thought-stopping techniques fades away as clients learn to live within the
new narrative. Narrative therapy encourages the client to look at the current story more
expansively in order to find alternate or additional stories (Corey, 2012; Goldenberg &
Goldenberg, 2008). This approach is effective cross-culturally, because it encourages the
inclusion of cultural narratives and recognizes the oppressive impact of the dominant nar-
rative with regard to marginalized groups. When working with clients or families affected
by internalized racism or internalized homophobia, narrative techniques can be especially
effective (Becvar & Becvar, 2009; Goldenberg & Goldenberg, 2008).
Applications. Externalizing is one of the primary tools in the narrative approach. Exter-
nalizing means finding a way to “join” with the client “against” the “problem” (Corey,
2012; Goldenberg & Goldenberg, 2008). An example of this would be saying, “How can
we work together to get a hold on this tardiness thing?” This technique helps the student
feel heard and lessens potential resistance, because the student is no longer “the problem”
but someone outside of the problem with potential agency to conquer it. Externalizing
can also help the family discover unique outcomes (similar to exceptions), or times when
they triumphed over a problem. This can result in the emergence of new, more flexible and
healthy narratives and the reauthoring of the family story, which is then reinforced by the
acknowledgment and confirmation of others. A tool that the school-based practitioner can
use is letter writing, which involves designing a written narrative of the story that the fam-
ily had at the beginning of the work and a record of the process of transformation and the
resulting new narrative (Becvar & Becvar, 2009; Corey, 2012; Gehart, 2010; Goldenberg
& Goldenberg, 2008; Nichols, 2010).
Conclusion
Research indicates that when school counselors and school psychologists are prepared to
do family and systemic work, their levels of confidence and role clarity grow (Bryan &
Griffin, 2010). School is increasingly a primary place for mental health services for vari-
ous reasons, including limited access to affordable health care (Burns et al., 1995; Power
et al., 2005). This provides school-based practitioners with a golden opportunity to work
directly with students and their families in potentially powerful ways. Families continue to
become more complex in structure in the 21st century and to confront the layers of inter-
generational family history, along with social, cultural, and ecological realities. They will
continue to face both expected and unexpected conflicts and crises that may be short-lived
or enduring. The self-aware school counselor or school psychologist has much to offer to
families in times of need, equipped with prevention and intervention tools and techniques
from a wide array of theoretical positions. School-based practitioners can use the sug-
gestions offered in this chapter to help families build on existing strengths, ease pain and
suffering, and develop new methods for handling inevitable times of conflict and crisis.
REFERENCES
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psycho-
logical study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum Associates.
Anderson, S. A., & Nuttall, P. E. (1987). Parent communication training across three stages of chil-
drearing. Family Relations, 36, 40–44.
Baptist, J. A., Thompson, D. E., Norton, A. M., Hardy, N. R., & Link, C. D. (2012). The effects of
the intergenerational transmission of family emotional processes on conflict styles: The moderat-
ing role of attachment. The American Journal of Family Therapy, 40, 56–73. doi:10.1080/0192
6187.2011.575030
Becvar, D. S., & Becvar, R. J. (2009). Family therapy: A systemic integration (7th ed.). Boston: Allyn
& Bacon.
Blevins, W. (1994). Your family your self. Oakland, CA: New Harbinger.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation, anxiety, and anger. New York: Basic Books.
——— (1982). Attachment and loss: Vol. 1. Attachment (2nd ed.). New York: Basic Books.
Branje, S. J. T., van Doorn, M., van der Valk, I., & Meeus, W. (2009). Parent-adolescent conflicts,
conflict resolution types, and adolescent adjustment. Journal of Applied Developmental Psychol-
ogy, 30, 195–204. doi:10.1016/j.appdev.2008.12.004
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design.
Brotman, L. M., Calzada, E., Huang, K., Kingston, S., Dawson-McClure, S., Dimitra Kamboukos,
D., . . . Petkova, E. (2011). Promoting effective parenting practices and preventing child behav-
ior problems in school among ethnically diverse families from underserved, urban communities.
Child Development, 82(1), 258–276. doi:10.1111/j.1467–8624.2010.01554.x
Brotman, L. M., Kingston, S., Bat-Chava, Y., Calzada, E. J., & Caldwell, M. (2008). Training school
personnel to facilitate a family intervention to prevent conduct problems. Early Education and
Bryan, J. A., & Griffin, D. (2010). A multidimensional study of school-family-community partner-
ship involvement: School, school counselor, and training factors. Professional School Counseling,
14(1), 75–86.
Burns, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, D., Farmer, E. M. Z., & Erkanli, A.
(1995). Children’s mental health service use across service sectors. Health Affairs, 14(3), 147–159.
Caplan, G., & Caplan, R. B. (1993). Mental health consultation and collaboration. San Francisco:
Jossey-Bass.
Carter, B., & McGoldrick, M. (2005). Overview. In B. Carter & M. McGoldrick, The expanded
family life cycle: Individual, family, and social perspectives (pp. 1–26). New York: Allyn & Bacon.
Centers for Disease Control and Prevention. (2010). Teen drivers: Fact sheet. Retrieved from http://
www.cdc.gov/motorvehiclesafety/teen_drivers/teendrivers_factsheet.html
Chow, W., Law, S., Andermann, L., Yang, J., Leszcz, M., Wong, J. & Sadavoy, J. (2010). Multi-
family psycho-education group for assertive community treatment clients and families of cultur-
ally diverse background: A pilot study. Community Mental Health, 46, 364–371.
Corey, G. (2012). Theory and practice of counseling and psychotherapy (9th ed.). Belmont, CA:
Brooks/Cole.
Dishion, T. J., Shaw, D. S., Connell, A., Gardner, F., Weaver, C., & Wilson, M. (2008). The Family
Check-Up with high-risk indigent families: Preventing problem behavior by increasing parents’
positive behavior support in early childhood. Child Development, 79, 1395–1414.
Eppler, C., & Weir, S. (2009). Family assessment in K-12 settings: Understanding family systems to
provide effective, collaborative services. Psychology in the Schools, 46(6), 501–514. doi:10.1002/
pits.20393
Erikson, E. (1963). Childhood and society (2nd ed.). New York: Norton Press.
Faber, A., & Mazlish, E. (1980). How to talk so kids listen & listen so kids will talk. New York:
HarperCollins.
Fiske, A. P. (2002). Socio-moral emotions motivate action to sustain relationships. Self and Identity,
1, 169–175.
Fristad, M. A., Gavazzi, S. M., Centolella, D., & Soldano, K. (1996). Psychoeducation: An intervention
strategy for families of children with mood disorders. Contemporary Family Therapy, 18, 371–383.
Garcia-Preto, N. (2005). Transformation of the family system during adolescence. In B. Carter &
(3rd ed., pp. 274–286). Boston: Allyn and Bacon.
Gehart, D. (2010). Mastering competencies in family therapy: A practical approach to theories and
clinical case documentation. Belmont, CA: Brooks/Cole.
Giordano, J., & McGoldrick, M. (2005). Families of European origin: An overview. In M. McGold-
rick, J. Giordano, & N. Garcia-Preto, Ethnicity and family therapy (3rd ed., pp. 501–519). New
Goldenberg, H., & Goldenberg, I. (2008). Family therapy: An overview (7th ed.). Belmont, CA:
Brooks/Cole.
Haley, M. (2007). Gestalt theory. In D. Capuzzi & D. R. Gross, Counseling and psychotherapy:
Theories and interventions (4th ed., pp. 216–242). Upper Saddle River, NJ: Pearson.
Hazler, R. J. (2007). Person-centered theory. In D. Capuzzi & D. R. Gross, Counseling and psy-
chotherapy: Theories and interventions (4th ed., pp. 189–215). Upper Saddle River, NJ: Pearson.
Herrenkohl, T. I., Kosterman, R., Hawkins, J. D., & Mason, W. A. (2009). Effects of growth in
family conflict in adolescence on adult depressive symptoms: Mediating and moderating effects
of stress and school bonding. Journal of Adolescent Health, 44, 146–152. doi:10.1016/j.jado-
health.2008.07.005
Homrich, A. M., & Horne, A. M. (2000). Brief family therapy. In A. M. Horne, Family counseling
and therapy (3rd ed., pp. 243–271). Belmont, CA: Wadsworth.
Horne, A. M. (2000). Introduction. In A. M. Horne, Family counseling and therapy (3rd ed., pp.
1–11). Belmont, CA: Wadsworth.
Horne, A. M., & Sayger, T. V. (2000). Behavioral approaches to couple and family therapy. In A. M.
Horne, Family counseling and therapy (3rd ed., pp. 454–488). Belmont, CA: Wadsworth.
Johnson, A. (2006). Privilege, power, and difference (2nd ed.). New York: McGraw Hill.
Johnson, S. M., & Greenman, P. S. (2006). The path to a secure bond: Emotionally focused couples
therapy. Journal of Clinical Psychology, 62(5), 597–609.
Kilpatrick, A. C., Kilpatrick, Jr., E. G., & Callaway, J. T. (2000). Object relations family therapy. In
A. M. Horne, Family counseling and therapy (3rd ed., pp. 300–329). Belmont, CA: Wadsworth.
Kristjánsson, K. (2003). On the very idea of “negative emotions.” Journal for the Theory of Social
Behavior, 33(4), 351–364.
Main, M., & Solomon, J. (1990). Procedures for identifying disorganized/disoriented infants during
the Ainsworth Strange Situation. In M. Greenberg, D. Cicchetti, & M. Cummings (Eds.), Attach-
ment in the pre-school years (pp. 121–160). Chicago: University of Chicago Press.
McGoldrick, M., Gerson, R., & Shellenberger, S. (1999). Genograms: Assessment and intervention
(2nd ed.). New York: W. W. Norton.
McIntosh, P. (1998). White privilege: Unpacking the invisible knapsack. In M. McGoldrick (Ed.),
Revisioning family therapy: Race, culture, and gender in clinical practice (pp. 147–152). New
McKinney, C., & Renk, K. (2011). A multivariate model of parent-adolescent relationship vari-
ables in early adolescence. Child Psychiatry and Human Development, 42, 442–462. doi:10.1007/
s10578–011–0228–3
Mennin, D., & Farach, F. (2007). Emotion and evolving treatments for adult psychopathology.
Clinical Psychology: Science and Practice, 14(4), 329–352.
Missotten, L. C., Luyckx, K., Branje, S., Vanhalst, J., & Goossens, L. (2011). Identity styles and
conflict resolution styles: Associations in mother-adolescent dyads. Journal of Youth and Adoles-
cence, 40, 972–982. doi:10.1007/s10964–010–9607–5
Nichols, M. (2010). Family therapy: Concepts and methods (9th ed.). Boston: Allyn & Bacon.
Novie, G. J. (2007). Psychoanalytic theory. In D. Capuzzi & D. R. Gross, Counseling and psycho-
therapy: Theories and interventions (4th ed., pp. 74–97). Upper Saddle River, NJ: Pearson.
Paylo, M. J. (2011). Preparing school counseling students to aid families: Integrating a family sys-
tems perspective. The Family Journal: Counseling and Therapy for Couples and Families, 19(2),
140–146. doi:10.1177/1066480710397130
Power, T. J., Eiraldi, R. B., Clarke, A. T., Mazzuca, L. B., & Krain, A. L. (2005). Improving men-
tal health service utilization for children and adolescents. School Psychology Quarterly, 20(2),
187–205.
Reid, M. J., Webster-Stratton, C., & Baydar, N. (2004). Halting the development of conduct prob-
lems in Head Start children: The effects of parent training. Journal of Clinical Child & Adolescent
Riesch, S. K., Gray, J., Hoeffs, M., Keenan, T., Ertl, T., & Mathison, K. (2002). Conflict and con-
flict resolution: Parent and young teen perceptions. Journal of Pediatric Health Care, 17, 22–31.
doi:10.1067/mph.2003.24
Rogers, C. (1961). On becoming a person. Boston: Houghton Mifflin.
Rowell, L. L. (2005). Collaborative action research and school counselors. Professional School
Counseling, 9(1), 28–36.
Satir, V. (1983). Conjoint family therapy. Palo Alto, CA: Science and Behavior Books.
Satir, V. M., & Bitter, J. R. (2000). The therapist and family therapy: Satir’s Human Validation
Process Model. In A. M. Horne, Family counseling and therapy (3rd ed., pp. 62–101). Belmont,
CA: Wadsworth.
Sayger, T. V., Honrich, A. M., & Horne, A. M. (2000). Working from a family focus: The histori-
cal context of family development and family systems. In A. M. Horne, Family counseling and
therapy (3rd ed., pp. 12–40). Belmont, CA: Wadsworth.
Sayger, T. V., & Horne, A. M. (2000). Common elements in family therapy theory and strategies.
In A. M. Horne, Family counseling and therapy (3rd ed., pp. 41–61). Belmont, CA: Wadsworth.
Sheridan, S. M., & Gutkin, T. B. (2000). The ecology of school psychology: Examining and changing
our paradigm for the 21st Century. School Psychology Review, 29(4), 485–502.
Thayer, L. (2000). Toward a person-centered approach to family therapy. In A. M. Horne, Family
counseling and therapy (3rd ed., pp. 330–365). Belmont, CA: Wadsworth.
Tugade, M., & Fredrickson, B. (2007). Regulation of positive emotions: Emotion regulation strate-
gies that promote resilience. Journal of Happiness Studies, 8, 311–333.
United States Department of Education, Office of Educational Research and Improvement. (1999).
Learning skills of peace through every day conflicts: Practical activities and resources for families,
teachers and other caregivers. Columbus, OH: Ohio Commission on Dispute Resolution and
Conflict Management.
Van Ryzin, M. J., Stormshak, E. A., & Dishion, T. J. (2011). Engaging parents in the family check-up
in middle school: Longitudinal effects on family conflict and problem behavior through the high
school transition. Journal of Adolescent Health. doi:10.1016/j.jadohealth.2011.10.255
Wilmot, W., & Hocker, J. (2010). Interpersonal conflict (8th ed.). New York: McGraw-Hill.
18 Rape and Sexual Assault
Virginia L. Schiefelbein
& Jonathan Sandoval
Often termed “The Silent Epidemic,” rape is an unfortunately common occurrence in con-
temporary America (Ullman & Knight, 1993) and, unfortunately, among secondary school
students. A nationwide survey found that 7.5% of high school students had been physi-
cally forced to have sexual intercourse (Eaton, et al., 2008). Around 11% of high school
girls in two different studies reported a history of being forced to have sex (Eaton et al.,
2010; Young, Grey, & Boyd, 2009). A reasonable estimate is that between 7 and 16% of
children and adolescents experience forced sexual intercourse before age 18 (Miller, Mon-
son, & Norton, 1995). Rape, as well as other forms of sexual assault and harassment, is
clearly a major problem in this society and others (e.g., Choquet, Darves-Bornoz, Ledoux,
Manfredi, & Hassler, 1997), but there is no clear consensus on its causes, the best way
to prevent it, or even how to define it. Nevertheless, in this chapter we will present our
current state of understanding about this crime and the crisis it creates for young victims.
For the purposes of this chapter, we will focus on nonconsensual sexual contact between
an adolescent and someone of similar age or older; because of differences in legal, causal,
and prevention issues, we will not address sexual contact between adults and younger chil-
dren nor between members of the same family (incest). Many of these issues are covered
in the chapter on maltreatment. In addition, most of this chapter refers to a heterosexual
context in which the male is the offender and the female is the victim, although male rape
and same-sex assaults do occur.
Consistent with the majority of writing on this topic, we use the term “victim” in this
chapter regardless of whether the assaulted person survived. A few authors use the term
“survivor” for those who are not killed during the assault and “victim” only for those
who are murdered.
This chapter first addresses some background information about sexual assault, includ-
ing prevalence, terms, and a review of risk factors and protective factors for both poten-
tial victims and potential rapists. The second part of the chapter discusses postassault
counseling: reactions to sexual assault; counseling responses; and approaches to use with
individuals, groups, victims from specific populations, and the victim’s significant others.
The third part of the chapter covers sexual assault prevention; first comes a discussion of a
number of theories of the causes of sexual assault, and then the following section addresses
sexual assault prevention strategies, including theoretical implications, research findings,
and general classes of prevention programs.
Background Information
Defining the Problem: Definitions, Prevalence, and Costs

The actual prevalence of rape and other sexual assaults is difficult to estimate. Different
researchers report very different statistics on the prevalence of rape and sexual assault.
Rape and Sexual Assault 335
Some of this difference derives from variations in definition; another issue is how the
prevalence is measured.
Definition Issues. The legal definition of rape would be a convenient standard, but dif-
ferent law enforcement agencies operate under different definitions of “rape.” A definition
used by the FBI is “carnal knowledge of a female forcibly and against her will” (Koss,
1983, p. 89). Different states define rape differently, and the FBI keeps no national statis-
tics on rape. For example, the broad definition used by the state of Ohio includes “vagi-
nal intercourse between male and female, and anal intercourse, fellatio, and cunnilingus
between persons regardless of sex . . . ” via force, threat of force, or administering drugs
or intoxicants to prevent resistance (Harney & Muehlenhard, 1991, p. 3). While many
of the acts in Ohio’s law are also illegal elsewhere, they are not always legally defined as
rape in a particular jurisdiction. Most researchers define rape as some variation of sexual
intercourse against one’s will, which involves force or threat of force. Some researchers
also specify the use of Ohio’s definition of sexual intercourse: “[p]enetration, however
slight” (e.g., Koss & Dinero, 1988, p. 138).
The term “sexual assault” includes rape, but also includes other nonconsensual sexual
activities and is thus a more general term. The acts included may range from rape and
attempted rape to “sexual behavior such as fondling or kissing . . . after the use of men-
acing verbal pressure, the misuse of authority, threats of harm, or actual physical force”
(Hanson & Gidycz, 1993, pp. 1047–1048). Estimates of the prevalence of sexual assault
will necessarily be larger than estimates of the prevalence of rape. Consistent with other
studies, Young, Grey, and Boyd (2009) determined prevalence rates of peer sexual assaults
to be 26% for 7th- to 12th-grade boys and 51% for girls in a southeastern Michigan
school district, with school the most common (44% of incidents) location for peer sexual
victimization. “We found that approximately 50% of high school girls reported being
assaulted, with one-fourth of high school girls experienced less invasive forms of violence
(e.g., forced kissing, making out, being fondled) and the other fourth experienced invasive
forms of assault, including rape, attempted rape, and forced to perform fellatio by peers”
(pp. 1080–1081). Half the girls and 13% of the boys reported being somewhat or very
upset by the experiences reported (Young et al., 2009).
“Sexual harassment” is a closely related term that overlaps with the definition of sexual
assault. There are many definitions of sexual harassment, but a basic definition is “delib-
erate and/or repeated sexual or sex-based behavior that is not welcome, not asked for,
and not returned” (Webb, 1995, p. 12). At one end of the spectrum, sexual harassment
can include such behaviors as leering, the display of offensive photographs or cartoons,
and sexual jokes or remarks (Webb, 1995, p. 14); it ranges up through “nasty, personal-
ized graffiti on bathroom walls; . . . bras snapped and body parts groped; and outright
physical assault and attempted rape” (Stein, 1995, p. 21). The boundary between sexual
assault and sexual harassment is hazy, but physical contact, however minor, makes the
distinction of when harassment also becomes sexual assault. Both are crimes under the
law. The American Association of University Women (2001) reports that 60% of high
school students report that harassment in school occurs often or occasionally. In addi-
tion, the majority of teenagers work part-time at some point during high school in retail,
restaurant service, or other settings; both males and females report sexual harassment on
the job. In their study, Fineran and Gruber (2009) found that 52% of their sample of 260
White, suburban, New England high school girls reported being sexually harassed at work
during the past year.
Statutory rape is also a crime but also underreported. Statutory rape generally refers
to an offense that occurs when an individual of any age has consensual sexual relations
with an individual below the age to legally consent. The statutory age of consent varies
from state to state, making estimates of prevalence difficult. In some states the definition
336 Virginia L. Schiefelbein & Jonathan Sandoval
specifies that the perpetrator must be a number of years older than the minor. Based on
cases reported to law enforcement in 21 states between 1996 and 2000, 95% of statutory
rape victims were female, 60% were age 14 or 15, the median age difference between male
offenders and female victims was 6 years, and 30% of the offenders were boyfriends or
girlfriends and another 60% were acquaintances (Troup-Leasure & Snyder, 2005). These
were cases serious enough to be reported; how many were not reported is unknown.
Since the definition excludes forcible sexual intercourse, it is difficult to evaluate how
commonly statutory rape precipitates a crisis response. At the same time, statutory rape
is a situation that can result in an adolescent becoming pregnant, and stunting the educa-
tional, economic, and psychological development of the victim (Hines & Finkelhor, 2007).
The data related to the age discrepancy between perpetrator and victim suggest that many
older men are seducing high school age girls; some predation occurs online. Wolak, Fin-
kelhor, Mitchell, and Ybarra (2010) estimate that 7% of statutory rape crimes initiate on
the Internet.
Other common terms in the sexual assault literature refer to a distinction based on the
previous relationship between the rapist and victim. “Stranger rape” unambiguously refers
to the lack of any prior relationship. “Acquaintance rape” has various meanings, but
generally the term “acquaintance” refers to “an individual known to the victim in some
capacity: they could be friends, dates, lovers, former lovers or spouses, coworkers, neigh-
bors, and so forth” (Lonsway, 1996, p. 230), although the term generally does not include
incest, assaults by persons in authority, marital rape, or child abuse (Warshaw, 1988).
Stranger rape, contrary to the common stereotype, is generally considered to be much
less common than acquaintance rape. According to a 1990 study by Kilpatrick and Best,
75% of victims knew their attackers; a high-end estimate is that acquaintance rapes con-
stitute 80–90% of all rapes (Warshaw, 1988). At least one study contradicted this finding
and found that less than half of all the sexual assault victims—but 64% of adolescent
victims—seeking help at a Memphis-area rape crisis center were attacked by a “date/
acquaintance” (Muram, Hostetler, Jones, & Speck, 1995).
Prevalence Issues. Prevalence estimates are affected not only by varying definitions and
what type of rape (stranger vs. acquaintance) is counted, but also by the method used to
obtain reports. Using rapes reported to police, for example, would give a much lower
estimate than using anonymous surveys. According to Calhoun and Atkeson (1991), “the
majority of sexual assaults are never reported. A large-scale national probability survey,
for instance, found that 84% of sexual assaults had not been reported” (p. 2). Using police
reports to compare states would also be problematic; since the definition of “rape” varies
between states, the number of acts meeting the legal definition will also vary even if actual
occurrences were identical.
Another alternative is retrospective self-report. Problems with this procedure include
the inaccuracy of memory, the need for literacy, concerns about privacy, and the wording
of questions. Nevertheless, this method has yielded higher estimates than police reports.
A few prospective studies have been done with small populations. Prospective studies
can be precise in definition and measurement, but expensive to conduct. In a prospective
study in rural Appalachia of 112 adolescent girls from age 12 to 27, 8% had experienced
stranger or older family friend rape or incest, 23% reported being victims of unwanted
sexual abuse by dates/boyfriends, and 10% reported experiencing some other form of sex-
ual assault (Vicary, Klingaman, & Harkness, 1995). In France, for grades 8–12, estimates
for rape were 9% for girls and .6% for boys (Choquet et al.,1997). Although statistics on
sexual assault of males are harder to come by, men and boys can also be victims of sexual
assault. In one Memphis-area study, 9% of sexual assault victims seeking help at a rape
crisis center were male (Muram et al., 1995).
Another commonly studied method of estimating the prevalence of rape is men’s self-
reported willingness to sexually assault if they would not be caught. Depending on the
exact question asked, over 20% of the men in one study reported some future likelihood
of raping (Denmare, Briere, & Lips, 1988), whereas in another study 60% indicated a
willingness to “force a female to do something she didn’t really want to do” and/or “rape”
(Briere & Malamuth, 1983).
Since it is difficult to determine the exact prevalence of rape, it is difficult to quantify its
social costs. For those rapes that are reported to police, there are obvious financial costs
in the legal and (sometimes) correctional systems. The victim’s family bears other financial
costs; medical exams, legal fees, and counseling are examples. However, rape also has
emotional costs for victims and for society as a whole. Some of the impacts on rape victims
include anxiety, depression, poor social adjustment, sexual dysfunction, somatic symp-
toms, blame, and humiliation (Harney & Muehlenhard, 1991). In addition to the victim’s
suffering, Harney and Muehlenhard point out that “[a]ll women who live in a society with
a high prevalence of rape are affected by it” (p. 14). Often, women restrict their activities
in an attempt to avoid becoming a victim (Gordon & Riger, 1989).
Risk Factors and Protective Factors

This section discusses factors correlated with increased or decreased probability of becom-
ing a victim or perpetrator of sexual assault. While correlation does not equal causation,
some of these factors would logically serve as causes or as the focus for prevention.
Potential Victims
One of the most commonly known risk factors for rape is gender—specifically, being
female. As mentioned previously, only a small fraction of sexual assault victims are male
(Finkelhor, Ormrod, Turner, & Hamby, 2005).
Age is another risk factor. During adolescence, the risk of rape increases with age
(Wolitzky-Taylor et al., 2008). In a study by Masho and Ahmed (2007), 78% of the
females participating indicated that their first assault occurred before 18 with a mean age
of 14. A national survey by Smith et al. (2000), similarly, found that victims’ ages at the
time they were raped broke down as follows: 25% were under 10; 37% were 11–17; 25%
were 18–24; and the remainder were 25 or older. Thus, age appears to be a rather potent
risk factor.
Race does not appear to be a risk factor, when family structure (e.g., living with two
biological parents) and socioeconomic class (e.g., income, parent education) are taken into
account (Elwood et al., 2011). Instead, environmental factors associated with poverty put
young women at risk. For example, among low-income high school students, those living
in nontraditional households (living with one parent, grandparent, or another relative or
nonrelative) were more likely to report a history of forced sexual intercourse compared to
those living with both parents (Freeman & Temple, 2010).
While age and gender are important risk factors, changing them is not a feasible
prevention strategy. One preventable risk factor is alcohol consumption. Norris (1994)
cites several findings relating alcohol to sexual assault, including that drinking women
are “considered more sexually disinhibited and available by both men and women,”
more likely to be victims of completed (as opposed to attempted) rape, and less able to
“make judgments about sexual assault” compared with sober women (p. 200). Impulsiv-
ity, aggressiveness, and poor decision making often accompany excessive alcohol use (Le,
Behnken, Markham, & Temple, 2011). This relationship between alcohol and rape is
fairly intuitive; a woman who has been drinking may have impaired judgment, appear to
be an easy mark, or be less able to physically resist an assault. Muram, Hostetler, Jones,
and Speck (1995) warn that substance use is a particular concern for female adolescents,
who tend “to be more often . . . under the influence of alcohol or drugs at the time of
assault” relative to adult women (p. 375).
Alcohol is not only a risk factor for an initial sexual assault, but also a mediator for
suicidality following an assault in high school girls (Le et al., 2011). Alcohol use is a mal-
adaptive coping strategy that results in a high likelihood of suicidal behavior, both in rape
victims and in those with no history of assault.
A history of dating violence may also be related to forced sexual intercourse (Alleyne,
Coleman-Cowger, Crown, Gibbons, & Vines (2011). Dating violence is the perpetuation
or threat of an act of violence between one member of a dating couple and the other.
Prevalence rate estimates among adolescents, for both male and female perpetrators and
victims across the spectrum of behaviors, range from 9% to 46% (Glass et al., 2003). In a
large national survey of 12- to 17-year-olds, examining serious dating violence, defined as
physical assault, sexual assault, and drug/alcohol-facilitated rape, Wolitzky-Taylor et al.
(2008) obtained a prevalence figure of 2.7% for girls and .6% for boys. These figures are
lower than other studies because of the larger age span, which included many nondating
teens. Acceptance of violence may lead to acquaintance sexual assault.
Scott, Lefley, and Hicks (1993) reviewed several “factors [which] may increase the vul-
nerability of some women to sexual assault,” including a history of psychiatric treatment,
mental retardation, mental illness, prior sexual assault, being a tourist or visitor, and being
homeless (pp. 133–134). Some of these factors, such as being homeless or unfamiliar with
the area, seem to be more related to stranger rape than to the more common acquaintance
rape. Others, such as mental illness or mental retardation, or having low self-control,
might make a woman appear vulnerable to either a stranger or acquaintance. It must be
remembered, however, that only 49% of victims who were studied displayed one or more
of the foregoing risk factors (Scott, Lefley, & Hicks, 1993). Wolitzky-Taylor et al. (2008)
found that the presence of posttraumatic stress disorder (PTSD) and a major depressive
episode were associated with dating violence after controlling for relevant demographic
variables.
Prior sexual assault is also an important risk factor. In their study using the National
Survey of Adolescents, Elwood et al. (2011) discovered that 12.5% of adolescent victims
reported a new rape. This study and others examining predictors of revictimization iden-
tified PTSD as the strongest correlate of new rape (Elwood et al., 2011), suggesting the
need for effective initial treatment. Other predictors were family drug problems and prior
child sexual abuse.
Some risk factors may be endemic to the school environment. Going to schools where
there is exposure to motivated offenders, such as associating with delinquent peers and
self-reported criminal behavior, increases risk, while going to schools where there is
strong attachment to parents, teachers, and peers decreases it (Tillyer, Wilcox, & Gia-
lopsos, 2010).
Protective Factors
The converse of each of the foregoing risk factors (e.g., being male, being outside the
age ranges discussed, abstaining from alcohol, etc.) probably serves as a protective
factor. Ullman and Knight (1993) found that forceful resistance methods, “such as fight-
ing, screaming, and fleeing/pushing the offender away,” also serve a protective function,
at least in reducing the severity of sexual abuse once an attack has begun (p. 35).
This effectiveness holds regardless of the relationship between the offender and victim
(i.e., strangers or acquaintances) and whether a weapon is present, “[although women
who fought back forcefully when a weapon was present experienced more physical
injury” (Ullman & Knight, 1993, p. 35). Bloom (1996), after reviewing a similar study
by Zoucha-Jensen and Coyne (1993), also concluded “persons threatened with rape
would probably be well advised to use physical resistance, forceful verbal resistance,
or fleeing” (p. 142).
Potential Rapists
Other research focuses on potential rapists. For lack of a better criterion, many of these
studies use gender (male) as the screening variable. One of the most commonly cited risk
factors for sexual aggression is holding beliefs or attitudes that are “rape supportive.” Bri-
ere and Malamuth (1983), for example, found that men who admitted they might rape or
“forc[e] a female to do something she didn’t really want to do” scored significantly higher
than other men in the following belief and attitude categories: “[1] Victims are respon-
sible for their rapes, [2] Rape reports are manipulations, [3] Male dominance is justified,
[4] Adversarial sexual beliefs, [5] Women enjoy sexual violence, and [6] Acceptance of domes-
tic violence” (pp. 318–319). In a study of middle adolescent boys and girls, boys indicated
it was acceptable to force sex on a girl in one or more situations, such as “She is wearing
revealing/sexy clothing,” “She agrees to go home with him,” or “She lets him touch and
kiss her above the waist.” Girls were much less likely to agree to such myths (Davis, Peck,
& Storment, 1993). Mallet and Herbé (2011) found similar beliefs in a French sample,
but noted that over time and experience, adolescents found forced sex to be somewhat less
acceptable. This risk factor of attitude certainly makes sense; feeling that sexual assault is
justified correlates with committing such acts.
Psychological variables also seem logical, in that an antisocial or hostile person is more
likely to commit aggressive acts. Langevin et al. (1988) mention that an antisocial per-
sonality is one of the “clinically important features common to sadists and other sexually
aggressive men” (p. 164). Similarly, Koss and Dinero (1988) report that “highly sexually
aggressive men were typified by greater hostility toward women” (p. 144).
The potential perpetrator’s sexual experience is a less intuitive risk factor. Briere and
Malamuth (1983) found that men indicating willingness to rape or use force gave higher
self-ratings of “perceptions of relative sexual experience” but did not differ from other
men on “sex life rating, importance of sex, relationships with women, . . . or sexual
inhibitions” (p. 321). In other words, the men who claimed that they would be willing
to use force in a sexual context also claimed to be more experienced, on average, than
men who were not willing to use force. Koss and Dinero’s (1988) results concur, showing
that highly sexually aggressive men “were more likely to have become sexually active
at an earlier age and to report more childhood sexual experiences both forced and vol-
untary” (p. 144).
Several other characteristics may serve as risk factors for becoming a rapist. Langevin
et al. (1988) found sexually aggressive men to be characterized by alcoholism, illegal drug
use, a criminal record, and aggressive and alcoholic parents. Another factor identified by
Koss and Dinero (1988) was the use of violent and degrading pornography; however, Bri-
ere and Malamuth (1983) did not find that the “use of pornography” held any predictive
value for their sample.
Few protective factors have been noted in the literature. The converse of the risk factors
(e.g., being female, not holding rape-supportive attitudes, sexual inexperience, etc.) prob-
ably serves a protective function in making an individual less prone to rape.
Postassault Crisis Counseling
Crisis Reactions of Victims

It is important that care providers recognize that sexual assault is a crisis situation. Termed
rape trauma syndrome, “the initial phase lasts for days to weeks, during which the victim
experiences disbelief, anxiety, fear, emotional lability, and guilt followed by a reorganiza-
tion phase that lasts for months to years during which the victim goes through periods
of adjustment, integration and recovery. Part of rape trauma syndrome is post-traumatic
stress disorder, which occurs in up to 80% of rape victims” (Kaufman & Committee on
Adolescence, 2008, p. 464). The first stage, and thus the one we are most concerned with
in crisis counseling in schools, is the acute or disorganization phase; it may last several
weeks after the assault (Ellis, 1983). There are both physical and emotional components
to this acute phase.
Physical reactions in the acute phase include the direct physical results of the assault,
such as injury, as well as somatic manifestations of emotional trauma. Examples of physi-
cal reactions include: soreness and bruising; reproductive disorders such as infection, pain,
discharge, or sexually transmitted diseases (STDs); reactions to medication administered
to prevent pregnancy; stomachache, headache, and muscle tension; fatigue or exhaustion;
changes in appetite or in how food tastes; and sleep disturbances.
Emotionally, the acute stage of rape trauma syndrome includes “overwhelming fear
and a sense of helplessness, shame, guilt or self-blame, and lack of control” (Weinstein &
Rosen, 1988, p. 205). Other emotional reactions may include anger, humiliation, revenge,
hysteria, a lack of affect, and lowered self-esteem (Kaufman & Committee on Adoles-
cence, 2008). Note that both extremes—hysteria and a complete lack of affect—are pos-
sible. This relates to two general styles the victim may exhibit, described by Burgess and
Holmstrom (1974); the “expressed style” means that the victim appears upset and visibly
emotional, whereas the “controlled style” means that the victim appears calm or con-
trolled but is actually in denial. It is important for care providers to remember that calm-
ness does not necessarily mean that there is no underlying trauma.
Goals of Crisis Counseling

Since crisis counseling is generally short-term, it has a narrower set of goals than long-term
counseling does. In crisis counseling with a sexual assault victim, “the therapist works
to reduce the victim’s emotional distress, enhance her coping strategies, and prevent the
development of more serious psychopathology” (Calhoun & Atkeson, 1991, p. 39). It is
also important to believe the victim. Believing the victim goes beyond simply acknowledg-
ing that she was assaulted (i.e., not making up her story). The counselor must believe “her
story, that she did her best to prevent the assault and that she utilised all her resources”
(Ben-Zvi & Horsfall, 1985, p. 351).
In addition, crisis counseling in a medical setting, such as an emergency room, should
include giving the victim information about medical procedures (Weinstein & Rosen,
1988, pp. 208–209). Two areas on which to focus in crisis counseling are restoring the
victim’s sense of control and dealing with concerns about pregnancy and disease.
Restoring a Sense of Control. Recall that many of the emotional components of rape
trauma syndrome relate to a lack of a feeling of control. Lack of control is itself a symp-
tom, but other symptoms, such as fearfulness and helplessness, are obviously related to
this feeling. For many, if not all, victims of sexual assault, control is a central issue. Thus,
“[t]he immediate goal of counseling clients who have experienced sexual assault is to help
them reestablish a sense of control over themselves and their environment” (Weinstein &
Rosen, 1988, p. 207).
One of the most important implications of the victim’s need for control is that the
crisis . . . counselor needs to refrain from taking over decision making or performing
tasks of which the client is capable. Such actions can foster dependence and increase
feelings of lack of control . . . Small tasks such as finding the money for and making [a]
telephone call themselves reenforce [sic.] the feeling of regaining of control. (Weinstein
& Rosen, 1988, p. 209)
In giving the victim these tasks, the counselor must consider the victim’s current emotional
state; different victims will be capable of different tasks, but it is important to give the victim
as much control and choice as she is capable of handling. It is also important, however, not to
go to the opposite extreme and expect the victim to immediately resume normal functioning.
As Weinstein and Rosen (1988) point out, victims of sexual assault “need permission to feel
disoriented and to give themselves time to regain their sense of control” (p. 208).
The victim’s control over her own body may be an especially important facet of regain-
ing control. Some victims will want physical contact—to be hugged or have their hand
held—but others will wish to avoid such contact, so it is a good idea to ask before touching
her and to follow her lead; this is also a good plan for the victim’s friends and family. If
the victim undergoes a pelvic examination, the doctor should allow her to be in control of
it as much as possible (Kaplan & Holmes, 1999).
Addressing Concerns About Pregnancy and Disease. One of the most immediate con-
cerns is the possibility of pregnancy. Rape results in pregnancy about 2–3% of the time
(MacDonald, 1971; McDermott, 1979). Therefore, the crisis counselor must discuss test-
ing and treatment options with the victim. Guidelines for pediatricians state that emer-
gency contraception should be offered to female sexual assault victims if reported within
120 hours of the assault (Kaufman & Committee on Adolescence, 2008).
Sexually transmitted diseases are another concern that requires medical intervention
and must be dealt with promptly. When discussing these issues, victims “can be expected
to be very anxious and apprehensive” (Weinstein & Rosen, 1988, p. 210). A crisis coun-
selor should not dismiss these concerns, but should provide support for the victim in deal-
ing with them.
Components of Crisis Counseling

Setting. Many of the components of crisis counseling do not change across settings. How-
ever, there are a few points to bear in mind for particular settings.
If a victim telephones immediately after a sexual assault, the first priority is to determine
whether she is still in danger and/or needs urgent medical care and to remedy these situ-
ations. Weinstein and Rosen (1988) also suggest speaking clearly, precisely, and calmly;
offering reassurances that help is available; giving the victim simple tasks to do; remaining
on the line until help arrives, if possible; and “inform[ing] the victim that washing, brush-
ing one’s teeth, drinking, or eating destroys necessary evidence” (p. 208). This warning can
even extend to washing one’s hands, since blood or other tissue may be on them or under
the fingernails. If there is any possibility that the victim may want to later prosecute her
assailant, time is of the essence in obtaining medical care; useful physical evidence can be
recovered for only 48 to 72 hours after the assault (Kaplan & Holmes, 1999).
A victim may also have advocacy needs if the police are present, either at a crime scene
or in a medical setting. In particular, “the dynamics of the interview, the criminal process,
and the person’s choices about it should be clearly explained” (Weinstein & Rosen, 1988,
p. 211). Some of the jargon commonly used by police, such as “alleged rape,” may suggest
to the victim that she is not being believed; this language should be avoided (Weinstein &
Rosen, 1988).
Some of the concerns discussed in relation to medical settings also apply to schools. In
particular, the victim should be informed of any limits to confidentiality due to mandatory
reporting laws for school personnel. Privacy can also be a concern in a school setting, but
sensitive topics such as sexual assault demand that as much privacy as possible be avail-
able to the victim.
Information About the Physical Examination. Counseling sexual assault victims often
involves providing them with information on medical procedures, but the counselor may
or may not be familiar with medical procedures. Lehmann (1991) provides a detailed
account of what occurs, from the collection of forensic evidence, to the evaluation and
photography of visible trauma.
With the exception of pregnancy testing, the medical procedures performed on sexual
assault victims “are essentially the same for males as for females” (Weinstein & Rosen,
1988, p. 220). For most male victims, “this is [their] first such invasive physical examina-
tion . . . and is therefore likely to add to their trauma” (Weinstein & Rosen, 1988, p. 220).
This is a point for medical personnel, counselors, and caretakers to keep in mind.
General Guidelines for Sexual Assault Crisis Counseling

This section is a summary of the basics of crisis counseling with victims of sexual assault.
There are several models available, based on various counseling approaches. What follows
is a synthesis of several works, mainly Burgess and Holmstrom (1979a, 1979b), Burgess,
Groth, Holmstrom, and Sgroi (1978), and Calhoun and Atkeson’s (1991) excellent discus-
sion of crisis intervention with sexual assault victims.
The first step in crisis counseling, as in all counseling, is to connect with the client—in this
case, the sexual assault victim. As Weinstein and Rosen (1988) state, “[t]he development of
a supportive and trusting counselor/client relationship is essential” (p. 209). Establishing
trust and a secure, supportive atmosphere with someone who is in crisis may not be easy,
but it is necessary. Calhoun and Atkeson (1991) summarize the important points:
Both verbal and nonverbal strategies must be used to convey understanding and
acceptance of the victim’s recent experiences. It is important to listen attentively to the
victim and show sensitivity and respect for her as a person. Emotional support should
include realistic reassurance and a sense of optimism or expectation for recovery in
relation to the assault and its impact on the victim. (p. 40)
The general idea is to convey empathy and support for the victim so that she can feel
secure enough to talk about her feelings, concerns, and problems. The building of a thera-
peutic relationship will—or should—continue throughout the counseling sessions, but it
is important to establish at least some initial rapport. Although establishing rapport is
important, time pressures also place priority on medical attention. Many rape victims have
injuries that must be attended promptly.
Once these issues are dealt with, several sources (e.g., Burgess et al., 1978; Calhoun
& Atkeson, 1991; Weinstein & Rosen, 1988) refer to assisting the victim in obtain-
ing or “mobilizing” social support. Victims can use the support of their friends, their
families, and other community resources to build self-confidence and begin returning
to a normal lifestyle (Burgess et al., 1978). Crisis counseling should include preparing
the victim to enlist these resources. With friends and family, how the victim confides in
them can determine whether their response is supportive; crisis counseling may involve
anything from discussing different approaches with the victim to actual notification
on her behalf. In addition, friends and family members need to be given “information
on what reactions to expect in the victim and themselves and ways in which they can
facilitate recovery,” such as expressing positive regard for the victim, encouraging emo-
tional expression, validating the victim’s feelings, and providing reassurance (Calhoun
& Atkeson, 1991, pp. 42–43).
Beyond these basic steps, different victims will have different issues. Many victims will
need help dealing with fears or phobias related to the assault (Burgess et al.,1978). Some
other possible issues mentioned by Calhoun and Atkeson (1991) include encouraging the
victim to express her emotions and talk about her experience; exploring whether and how
she might decrease her daily responsibilities for a short while; exploring ways to increase
her feelings of personal security and safety; and discussing potential problems with inti-
macy and sexual functioning (pp. 40–43).
Since crisis counseling tends to be short in duration, it focuses on the days and weeks
to come. As part of this, sexual assault victims should be given information, preferably
written, on common reactions to sexual assault (e.g., rape trauma syndrome) so that she
know what to expect (Calhoun & Atkeson, 1991). In addition to emotional inoculation
and anticipatory guidance, she needs to have coping strategies ready to deal with her
difficulties. Helping her to cope successfully with likely problematic situations increases
self-confidence and feelings of control; examples of coping strategies include deep breath-
ing, muscle relaxation, and breaking down difficult situations and tasks into smaller steps
(Calhoun & Atkeson, 1991).
Follow-Up/Referral
The last step in crisis counseling is to arrange for some sort of follow-up, either with
the person providing the crisis counseling or with another person or agency. Relatively
few rape victims, however, actually keep follow-up appointments; therefore, Calhoun and
Atkeson (1991) recommend getting permission to later telephone the victim and giving her
the counselor’s name and phone number. If the victim refuses follow-up contact, it is per-
missible to gently encourage her to continue counseling, but her wishes must be respected.
At the very least, however, she should be given the phone number(s) of a local rape crisis
center and/or other community counseling agencies so that she can seek follow-up care
herself if and when she chooses to do so.
In referring a sexual assault victim to another counselor or agency, it is important to be
sure that she does not feel she is being abandoned.
Long-Term Reactions
Although the focus of this book is on crisis counseling, the long-term reactions to sexual
assault are still relevant. This is partly so that the counselor can explain to the victim
what to expect and can make informed decisions regarding referral. Long-term reactions
to sexual assault depend on individual factors, such as age/development, coping skills,
and circumstances of the assault, even more than crisis reactions do (Weinstein & Rosen,
1988). Bearing this in mind, some reactions are relatively common among sexual assault
victims. These reactions—physical, emotional, behavioral, and economic—constitute the
long-term or reorganization phase of rape trauma syndrome and may last months or years
after the assault (Burgess & Holmstrom, 1979a).
Long-term physical reactions include pregnancy or STDs resulting from the assault;
sleeping disturbances, such as a need for frequent sleep, difficulty falling asleep, and night-
mares. Other physical reactions are changes in eating patterns, particularly overeating or
inability to eat; and various symptoms of stress, such as digestive difficulties, headaches,
and heart palpitations (Weinstein & Rosen, 1988).
Emotional reactions are some of the most common difficulties victims face after sexual
assault. Many female victims have trouble with trust in male-female relationships (Wein-
stein & Rosen, 1988, p. 206). Fear and anxiety are also common. Victims may have sexual
fears and/or various phobias, including fear of being alone, of going outside, of men who
have some resemblance to the assailant, or global fear. Depression, another common reac-
tion, affected 72% of rape victims in a study by Nadelson, Notman, Zackson, and Gor-
nick (1982). Other emotional reactions include difficulty in relating positively to men; a
loss of privacy; and distrust of one’s judgment, particularly in regard to safety (Weinstein
& Rosen, 1988, p. 206).
Victims of sexual assault also often exhibit behavioral reactions, many of which are
related to the emotional reactions. These reactions include changes in lifestyle and general
upset in normal living patterns. Specific examples include: absenteeism or withdrawal
from school; sexual acting out, such as promiscuity or prostitution; suicidal tendencies;
and drug and/or alcohol use.
Counseling: Individual or Group?

There is quite a bit of debate in the research literature about whether individual or group
therapy is generally more appropriate in counseling victims of sexual assault. Both types
of therapy have advantages and drawbacks. It seems sensible to let the victim’s preference
and particular issues serve as a guide. Victims who want to share their story with many
people or who want validation from others who have “been there” may do better in a
group; those who want more privacy may do better with individual counseling, at least at
first. In addition, logistical factors may preclude, or at least hinder, group therapy; many
existing support groups are restricted by age or to females only. Finally, some victims may
benefit from both types of therapy.
Individual Approaches
Individual counseling may be the best approach for victims who want more personalized
attention, who do not feel they can face a group, or who do not have access to support
groups for some reason. Some cultures attach a strong feeling of shame to sexual assault,
and victims from these cultures may also prefer to speak to a counselor one-on-one.
Many sexual assault victims exhibit symptoms of depression. If the victim has severely
reduced her activity level, it may help her to first increase her activity level and then
increase specific activities in which she finds pleasure or a sense of mastery (Calhoun &
Atkeson, 1991). Other recommended strategies for treatment include: Frank and Stewart’s
(1983) cognitive behavior therapy program; biofeedback with anxiety-related symptoms
(Weinstein & Rosen, 1988); systematic desensitization; flooding; stress inoculation train-
ing (Cormier & Cormier, 1998); and assertion training.
The counselor plays different roles for victims with different needs. Burgess and Hol-
mstrom (1974) studied how rape victims “wished to utilize the supportive role of the
counselor” (p. 201) during follow-up counseling. They categorize the primary requests
of those victims who accepted telephone counseling as: confirmation of concern, ventila-
tion, clarification, and advice. Victims in the “confirmation of concern” category, mostly
children and adolescents, tend to be rather guarded and volunteer little information. In
response the counselor might ask questions and comment on positive steps the victim
took. Victims who want ventilation, on the other hand, feel burdened and generally talk
spontaneously about their experience and their feelings. The counselor’s role with these
victims is to give the victim freedom to speak, let her know it was all right to talk about
her fears, and provide perspective as needed. Victims seeking clarification also talk freely,
but want help in “sort[ing] out the conflicting thoughts and feelings and to actively work
on settling the crisis”; with these victims, the counselor follows the victim’s verbal lead
(Burgess & Holmstrom, 1974, p. 201). Finally, the fourth group of victims wants advice on
questions such as legal issues, whom to confide in, family conflicts surrounding the assault,
and sexuality issues. Here the counselor’s role is to give “[d]irection and guidance in terms
of information and alternative from which to choose . . . so the victim could make a deci-
sion” (Burgess & Holmstrom, 1974, p. 201).
Danielson et al. (2010) report an evaluation of a multicomponent family therapy inter-
vention for adolescent sexual assault victims. The aim is to reduce the risk of substance
abuse and PTSD following a rape. Components include providing education about sexual
assault, counseling and treatment goals, building effective coping skills, improving family
communication, explicitly addressing issues related to substance abuse, addressing issues
related to PTSD, building skills for healthy dating and sexual decision making, and provid-
ing education regarding the risk for revictimization.
Group Approaches
Group therapy is not appropriate for all victims of sexual assault, but it may be useful
for many. Some groups restrict membership by age, gender, and/or type of assault (incest,
childhood sexual abuse, rape, etc.), so one must find or create a group with an appropriate
makeup and a meeting time that fits one’s schedule. A member of a therapy group must
also be willing to share at least some information about her experience with others.
Group therapy is generally considered effective for sexual assault survivors. “Various
group interventions have been found to be effective in decreasing symptoms, especially
phobic and anxiety responses of assault survivors who do not have a major personality
disorder or other psychopathology” (Weinstein & Rosen, 1988, p. 212). Particular ben-
efits of group therapy include being able to tell one’s story to others who are likely to be
sympathetic, and receiving validation from others who have “been there.” As Weinstein
and Rosen (1988) point out, “[t]he sharing of the assault incident with others who have
had similar experiences and feelings is often therapeutic” in and of itself (p. 212). Being a
member of a group can also give the sexual assault victim a feeling of belonging. “Children
and young adolescents who have experienced sexual assault feel somewhat isolated from
their peers. . . . [and a therapy] group provides a place of almost guaranteed acceptance
and understanding” (Weinstein & Rosen, 1988, p. 214). Groups may be especially appro-
priate for adolescents because adolescence “involves a shift from reliance on family to
self-reliance and increased peer orientation” (Berliner & MacQuivey, 1983, p. 106), but
sexual assault or abuse can isolate an adolescent from her usual peer group.
Counseling Concerns With Specific Populations
Children and Young Adolescents

Many of the reactions to sexual assault discussed earlier are typical of children and young
adolescents as well as adults. However, there are some special concerns to be aware of
with these victims. First, very young children are not likely to deeply understand what has
happened to them. The counselor must answer their questions with age-appropriate and
sexual knowledge–appropriate information (Weinstein & Rosen, 1988). Second, children
will usually be unable to verbally discuss the incident. Play therapy, particularly using
dolls and drawing, can be helpful. A third concern with young children is that they may
exhibit separation anxiety. One way to deal with separation anxiety is to discuss it with
the parents and make sure that they are not reinforcing the behavior by supervising their
child overly closely or severely restricting the child’s activities (Weinstein & Rosen, 1988).
A few additional concerns apply to both children and adolescents. One is medical inter-
vention (Weinstein & Rosen, 1988). The importance of preparation and support during
the medical examination was discussed earlier in reference to sexual assault victims in
general; one would expect it to be even more important for a child. “With the sexually
inactive child or adolescent the entire medical intervention needs special preparation if it
is not to become another frightening assault” (Weinstein & Rosen, 1988, p. 214). The
counselor may help the child know what to expect and may help the parents understand
how to prepare, support, and advocate for their child; the counselor can also help the child
deal with her feelings after the medical examination.
The other concern, which applies to both children and adolescents, is that the victim
may refuse to return to school (Weinstein & Rosen, 1988). This, like separation anxiety,
is understandable for a short period, but can create further difficulties if it is prolonged.
If it continues for more than a week, Burgess and Holmstrom (1979a, 1979b) suggest
considering that it may be symptomatic of a phobic reaction. The return to school is some-
times eased if the counselor, with approval from the child’s parents, encourages the child’s
teacher(s) and close friends to visit or telephone and helps them communicate acceptance
and understanding to the child (Weinstein & Rosen, 1988).
Racial and Ethnic Considerations

In addition to the usual need for cultural sensitivity in any counseling, working with
sexual assault victims from diverse cultures involves an awareness of how each victim’s
culture and family view sexual assault issues. White and Black victims show no difference
in severity of reactions or recovery rate but Asian victims suffer more trauma (Calhoun &
Atkeson, 1991). One would also expect that victims who have recently moved to the area,
whose primary language is not locally common, or who feel they “stand out” in terms of
race, ethnicity, or religion are likely to feel particularly isolated and may have additional
difficulties in dealing with the assault. In addition, Ben-Zvi and Horsfall (1985) point out
that some “traditional” cultures highly value virginity and that this can add to the distress
of a victim from these cultures. The same may be true of some devoutly religious families.
The difficulty the counselor faces in dealing with these cultural issues is to try to reassure
the victim of her worth without discounting her culture and belief system—a fine line to
walk. In some cases, it may be useful to consult with community members with a back-
ground similar to the victim’s or to help an individual victim find a support group that has
other members who share her beliefs or experiences. Finally, keep in mind that some victims
may be helped by participating in healing ceremonies from their religion or culture. If the vic-
tim expresses an interest in these, the counselor could help her locate community resources.
Male Victims
Although there are some differences, male victims’ reactions to sexual assault are similar
in many ways to those of female victims. According to Calhoun and Atkeson (1991),
“Goyer and Eddleman (1984) identified posttraumatic stress symptoms in 13 male sex-
ual assault victims . . . [including] fear, generalized anxiety, depression, suicidal ideation,
sleep disturbances, nightmares, anger, and sexual dysfunctions” (p. 114). These are all
common reactions among female sexual assault victims as well, as discussed earlier.
Weinstein and Rosen (1988), similarly, cite Burgess and Holmstrom (1974) in point-
ing out that the symptoms, fears, and emotions male victims experience as counseling
progresses are the same as those of female victims (pp. 219–220). Also recall that male
victims, like female victims, often find the medical examination traumatic (Weinstein &
Rosen, 1988, p. 220).
One of the major differences with male victims is that they have usually been assaulted
by an assailant of the same sex. Thus, male victims “frequently worry about the implica-
tions . . . for their sexual identity or that others may view a rape as predisposing them to
homosexuality” (Calhoun & Atkeson, 1991, p. 114), and their families may have the same
worries (Weinstein & Rosen, 1988). These worries contribute to male victims’ sense of
shame and unwillingness to report the assault. Weinstein and Rosen recommend reassur-
ing the male victim that these are myths. In the case of a young child, the counselor would
need to reassure the parents as well.
Other difficulties for male victims derive from societal pressures. Men feel they are
expected to be able to defend themselves, which is one reason male victims hesitate to
report sexual assaults (Weinstein & Rosen, 1988). They also feel that they are expected
to appear masculine, and hence may worry that they were selected as a victim because
they appeared “feminine.” Finally, men in our society tend to expect themselves to be
strong and in control. Many male victims “react badly to the loss of control and sense
of helplessness experienced during sexual assault . . . [and therefore] may tend to with-
draw, deny the experience, avoid reminders of it, or even become amnesic” (Calhoun &
Atkeson, 1991, p. 114). Counseling a male sexual assault victim could include discussing
gender roles and stereotypes in American society and in his family and helping him assess
how realistic they are. As with any sexual assault victim, another part of his recovery is
to help the male victim reduce his self-blame and place the responsibility for the assault
on the perpetrator.
Victims with Disabilities

Part of the trouble sexual assault victims with disabilities face is simply in trying to get the
help they need. For example, local rape crisis centers may lack teletypewriters (TTYs), mak-
ing it impossible for deaf or hearing-impaired victims to call them, and there is also a general
lack of sexual assault information available in Braille or audio formats for blind victims to
access. In addition, a deaf adolescent may fear that if she tells another deaf person that word
of the assault will spread through the generally tightly knit deaf community. Victims who
have difficulty with mobility may also be reluctant to report an assault because of “[p]revious
negative experiences with hospitals and social service agencies which were not accessible or
sensitive to their needs” (Ryerson, 1984, p. B19). Therefore, the first step in assisting victims
with disabilities is to make sure that information and resources are available.
Adolescent victims with disabilities often face another set of difficulties, which has to do
with sexuality and sex education. Disabled teens “often do not receive adequate informa-
tion about their sexuality at home or in school” (Ryerson, 1984, p. B19), and thus may
not have clear knowledge about consent and sexual assault. This lack of knowledge makes
them more vulnerable to sexual assault, and probably also heightens their level of crisis
and confusion after an assault. These adolescents may need additional help with sexuality
issues and self-blame in postassault counseling (Andrews & Veronen, 1993).
Weinstein and Rosen (1988) sum up the other concerns specific to disabled sexual
assault victims as follows:
Those with disabilities who have created a relatively independent life-style may have
major setbacks because of the fear reactions common to postassault victims (especially
fears of being alone). Significant others or caretakers may feel highly responsible for
not being effective. Society often identifies people with physical disabilities as child-
like and may foster dependency behaviors after this crisis. Those with disabilities
are often thought of as not being sexual. Thus, counselors may neglect the negative
sexual outcomes of the rape trauma. These problems and any special medical dif-
ficulties may be exacerbated by the sexual assault and are important for counselors
to consider. (p. 219)
Counselors should be alert for these problems when dealing with victims who have dis-
abilities and be prepared to help the victims regain their independence and deal with issues
of sexuality and sexual dysfunction.
Victims Who Are Homosexual

While there is little available information on counseling homosexual victims of sexual
assault, a few concerns can be noted. One is that in a study by Waterman, Dawson, and
Bologna (1989), both lesbians and gay men “who were victims of forced sex believed
that it would be significantly more difficult to get counseling than did those who were
not sexually victimized . . . [but] individuals who were not victims of forced sex did not
view counseling as particularly easy to get” (p. 123). One reason for this is that programs
that assist rape victims may not recognize a need to serve the gay community or may not
publicize their services for homosexuals (Waterman et al., 1989, p. 123). Another point to
consider is that many homosexual victims may not feel comfortable in counseling groups
primarily made up of heterosexuals. Lesbians dealing with relationship violence may feel
isolated if the rest of the group members are focusing on issues regarding men; perhaps
even more isolating would be for a gay man to be in a group of heterosexual male victims,
since (as noted previously) the other group members are likely to be worried about their
own sexual identity/orientation and may therefore come across as homophobic.
Approaches With Significant Others

Although most of the services offered after a sexual assault focus on the victim—and
rightly so—other people in the victim’s life may also need assistance. Parents and friends
may have difficulty dealing with the assault and with the victim’s healing process. Particu-
lar issues must be considered in counseling each of these groups.
Victim’s Parents. Burgess and Holmstrom (1979a, 1979b) found that parents whose
adolescent was sexually assaulted went through an acute disorganization phase and a
long-term phase of reorganization in reaction to their son’s or daughter’s experience. The
victim’s parents experience their child’s assault as a crisis, albeit a qualitatively different
crisis than the victim experiences.
Mann (1981) interviewed teenage sexual assault victims and their parents and found
many qualitative differences in parents’ and victims’ concerns and reactions. Half of the
parents, particularly those whose child had been physically injured, had continued fears
for the safety of their child. Seventy percent expressed anger at the assailant and sought
some form of revenge. Surprisingly, 41% of the parents directly blamed their child for the
rape, especially if conflict was present in the family prior to the assault. The majority of
parents were concerned about future emotional and sexual adjustment and about preg-
nancy and STDs.
In contrast, teenagers complained about increasing communication difficulties with
parents following the rape. Their concerns were about parental overprotectiveness, restric-
tiveness, and anger. They were also concerned about rejection from their parents. In addi-
tion adolescents had worries related to body image and peer reactions to the rape.
Counseling can help parents deal with their reactions to their child’s sexual assault.
Simply allowing them to express their feelings may be of some assistance. Schmidt (1981)
found that families who ask questions and express their feelings at the emergency room
feel more comfortable later with the victim at home. One could speculate answering par-
ents’ questions and letting the parents express their feelings later, in counseling, might have
a similar benefit. Counselors may also need to teach some parents anger management and
communication skills to help them express their emotions and needs in a more productive
manner.
Another facet of counseling parents is to help them understand the myths and realities
of sexual assault. Schmidt (1981) suggests that parents tend to blame the victim at first
because of the parents’ perception of rape as a sexual, rather than a violent, crime. Helping
them understand rape as a violent, power-based crime may help parents to reduce their
focus on the sexual aspects of the assault and to decrease the blame they assign their child;
this could help them reopen communication with their child.
Mann (1981) developed several guidelines for counselors working with adolescent
sexual assault victims and their families. Two of these are: to use separate interviews in
identifying the victim’s and parents’ concerns; and to help parents to accept and support
the victim’s separate feelings and needs. One way to assist parents in dealing with the vic-
tim’s reactions is to educate them about typical reactions to sexual assault, rape trauma
syndrome, etc. If the parents know what to expect, they may have an easier time under-
standing and supporting the victim’s behavior.
Finally, counselors should be ready to explain to parents what to expect from the vic-
tim’s therapy and recovery. Logistical considerations, the victim’s use of her assertiveness
training in parent-child arguments, new expressions of anger, and the social aspects of
therapy groups may all discourage parents from continuing their child’s counseling (Ber-
liner & MacQuivey, 1983). Counselors can warn parents that these problems may arise.
“If some of the likely reactions or problems can be anticipated, parents can be helped to
see the rationale for allowing the girls the time and place to work out all the different feel-
ings that go with being victimized” (Berliner & MacQuivey, 1983, p. 115). Encouraging
the parents to give their child the time and professional assistance she needs would benefit
the child—and thus, indirectly, the parents—in the long run.
Victim’s Boyfriend or Girlfriend. Sexual assault, not surprisingly, strongly impacts the
victim’s boyfriend or girlfriend. Calhoun and Atkeson (1991) summarize the partner’s
experience:
Not only must the partner cope with the victim’s psychological distress and emotional
needs, but he must also deal with his own reactions to the assault. Although reactions
are variable, descriptive studies have found partners to exhibit shock, rage, self-blame,
concern for the victim, and emotional distress immediately following sexual assault
(Holmstrom & Burgess, 1979). Longitudinal studies of partner reaction indicate that
the psychological distress (e.g., fear, anxiety, and depression) experienced by part-
ners may be long term in nature and last for at least 1 year following sexual assault
(Veronen, Saunders, & Resnick, 1988). (pp. 117–118)
While experiencing his own emotional distress, the victim’s partner may also feel torn in
trying to balance his emotional needs with those of the victim. Counseling significant oth-
ers can help them express and understand their feeling as well as understand what their
partner may be going through. The victim and her partner may be unable to provide suf-
ficient support for each other, and couples often avoid even discussing the sexual assault
or its effects (Calhoun & Atkeson, 1991, p. 118).
Victim’s Friends. Counseling for the friends of sexual assault victims is often overlooked,
although they are often the first to learn of an assault (Hanson, Resnick, Saunders, Kil-
patrick, & Best, 1999). Friends of victims may not typically seek out counseling, but those
who serve as primary supports for the victim may need some assistance in dealing with
their own reactions.
It is likely that very close friends of a sexual assault victim experience many of the same
emotional impacts as victims’ partners, including shock, rage, concern, long-term depres-
sion, anxiety, and fear (see passage from Calhoun & Atkeson, 1991). Female friends in
particular may fear for their own safety.
While some victims and their friends may wish to speak to a counselor together, a vic-
tim’s friends will most likely seek help individually. It may be useful to give them written
information on sexual assault and its effects so that they better understand what the victim
is going through. Friends who fear for their own safety can probably benefit from attend-
ing self-defense or assertiveness-training classes, possibly with the victim. Some friends
may also need assistance in setting boundaries with the victim so that the friend does not
become overwhelmed.
Sexual Assault Prevention: Theory and Practice
Theories of Causation
In order to address how to prevent sexual assault, it is first necessary to consider its causes.
There are several broad classes of theories.
Victim Theories. A review of the available literature reveals no support for academic
theories focusing mainly on the victim as the cause of rape. However, this view may be
common among the general population. Recall that in 41% of the cases of adolescent
sexual assault in Mann’s (1981) study, parents of the victim directly blamed their child for
the rape. Victim blame is also common among young people. Several studies have found
that adolescents tend to blame the sexual assault victim for the assault (Davis et al., 1993).
For example, Goodchilds and Zellman (1984) report that “across a number of vignettes
presented to adolescents, one third of the responsibility for coercive sex was attributed
to the nonconsenting girl” (p. 145). In Cowan and Campbell’s (1995) survey of 453 high
school students on the causes of rape, boys gave the highest mean responses to “female
precipitation” items (pp. 147–148). These results are particularly disconcerting given the
potency of rape-supportive attitudes as a risk factor for becoming a rapist.
Rapist Theories. Several theories focus mainly on the individual rapist as the cause of
rape. Evolutionary theory, as the name suggests, postulates “some genetic underpinnings,
although these underpinnings could be quite indirect” for male behaviors resulting in rape
(Ellis, 1989, p. 43). Without going into the details of natural selection, the basic idea is that
“rape may have a selective advantage because, when it leads to procreation, the rapist’s
genes are propagated” (Renfrew, 1997, p. 207).
Psychopathology models focus on problems with rapists’ neurological development. For
example, Hucker, Langevin, Dickey, and Handy (1988) showed that the Luria Nebraska
Neuropsychological Test Battery finds a relatively high level of impairment in sexually
aggressive men and moderate levels in sadists as compared to controls. Langevin et al.
(1988) conclude that “the right temporal lobe is somehow more implicated in sexual
aggression than are other areas of the brain” (p. 170).
Social learning theory, on the other hand, suggests that certain men rape because they
learn to do so by observing models—either in person or via media such as pornography.
Evidence for this theory includes Koss and Dinero’s (1988) finding that severe forms of
sexual aggression correlate with “involvement in peer groups that reinforce highly sexual-
ized views of women” (p. 144). Additionally, some of the risk factors discussed previously,
such as having aggressive parents and (learned) rape-supportive attitudes, are consistent
with social learning theory.
Context Theories. Context theories are those that emphasize the influence of the societal
context. Although they focus on the rapist to some extent, they emphasize society as a
whole rather than interactions between individuals. Two such theories are feminist theory
and cultural spillover theory.
Feminist theory “considers rape to be the result of long and deep-rooted social traditions
in which males have dominated nearly all important political and economic activities”
(Ellis, 1989, p. 10). In other words, feminist theory says that rape is the result of long-
standing inequality between the sexes. Some cross-cultural evidence from studies of tribal
societies supports this theory in that rape is less common in societies with gender equality
(Marshall & Barbaree, 1990).
The other context theory, cultural spillover theory, focuses on a different aspect of soci-
ety. According to this theory,
cultural support for rape may not be limited to beliefs and attitudes that directly con-
done rape . . . the more a society tends to endorse the use of physical force to attain
socially approved ends . . . , the greater the likelihood that this legitimation of force
will be generalized to other spheres of life where force is less socially approved, such
as the family and relations between the sexes. (Baron & Straus, 1989, p. 147)
Integrated Theories. Marshall and Barbaree (1990) have posited an integrated theory of
the etiology of sexual offending. They identify four types of factors: biological influences,
childhood experiences, sociocultural context, and transitory situational factors. Many
individual risk factors are examined within each of these domains; this level of interaction
is summarized in Figure 18.1.
Additionally, Marshall and Barbaree (1990) explain how these factors interact with
each other to produce rape:
Biological inheritance confers upon males a ready capacity to sexually aggress which
must be overcome by appropriate training to instill social inhibitions toward such
behavior. Variations in hormonal functioning may make this task more or less dif-
ficult. Poor parenting . . . typically fails to instill these constraints and may even serve
to facilitate the fusion of sex and aggression rather than separate these two tendencies.
Sociocultural attitudes may negatively interact with poor parenting to enhance the
likelihood of sexual offending, if these cultural beliefs express traditional patriarchal
views. The young male whose childhood experiences have ill-prepared him for a pro-
social life may readily accept these views to bolster his sense of masculinity. If such a
male gets intoxicated or angry or feels stressed, and he finds himself in circumstances
where he is not known or thinks he can get away with offending, then such a male
is likely to sexually offend depending upon whether he is aroused at the time or not.
(pp. 270–271)
BIOLOGICAL FACTORS loneliness CHILDHOOD EXPERIENCES
stress & anxiety social

puberty species-specific inadequacy
“eliciting stimuli” genetic Incapability of
hormones decreased appropriate sociosexual
propensity love/intimacy
behavior
poor
socialization resentment
lack of
and hostility lack of
critical period identification
violent parenting style confidence
for learning combining sex facilitates with parent
about sex and and aggression aggression
social learning
aggression
need to prove
brain insensitivity & lack of constraints masculinity
connections
imagery in masturbation
parent
RAPE characteristics
alcohol disinhibition of lack of detection
sexual aggression social norms
hostility
male dominance in society
prior sexual
alienating and arousal
dehumanizing of interpersonal
women violence in society
tolerance social learning
low chance permissive (reward violence)
of detection instructions
war negative attitude
anonymity pornography toward women media
stress and images
large cities
anxiety
TRANSITORY SITUATIONAL FACTORS SOCIOCULTURAL CONTEXT
Figure 18.1 Summary of Marshall/Barbaree (1990) integrated theory of the etiology of sexual offending.
Finkelhor (1984) developed a multicausal theory to explain the occurrence of child sexual
abuse, under which four conditions must be met for abuse to occur: the desire to sexually
abuse a child; undermining of the perpetrator’s internal inhibitions; undermining of the
perpetrator’s social inhibitions (such as the fear of punishment); and the ability of the
perpetrator to “undermine or overcome his or her chosen victim’s capacity to avoid or
resist” (p. 73). Russell (1984) theorizes that these are also preconditions for the sexual
assault of women and suggests factors that could predispose men to want to sexually assault:
biological influences, childhood sexual abuse, gender role socialization, mass media influ-
ence, and pornography. Russell (1984) has produced an alternative integrative theory.
The factors examined by Marshall and Barbaree (1990) could interact to produce each
of the four conditions set forth by Russell (1984), as shown in Figure 18.2.
The drawback of this hybrid is taking two very broad theories and producing an even
broader theory, making it difficult to choose a specific target for prevention. However, sexual
assault may be caused by a wide array of factors working together. The availability of many
targets for preventive programs, although it increases the difficulty of choosing a focus, may
actually be a benefit that allows communities to tailor programs to their resources and needs.
Prevention of Sexual Assault

Implications of the Theories. Although no true victim-focused theories were available in
the literature, the implications of this approach seem obvious. This type of program would
target female audiences of high school to college age and focus on how to avoid becoming
a victim. For example, given that alcohol consumption is a risk factor, such programs might
recommend against consuming alcohol in “unsafe” situations. Self-defense programs could
also fall into this category, since resistance prevents the completion of attempted rape.
Rapist-focused theories suggest a very different audience and content. It is difficult to
see evolutionary or psychopathology models recommending much in the way of primary
prevention; they would more likely focus on screenings to find men likely to commit
sexual assault and creating secondary prevention programs for them. Social learning
RAPE
transitory
biological childhood sociocultural
situational
influences experiences context
factors
undermining of undermining of victim’s inability

desire to
rape
+ internal + social + to effectively =
inhibitions inhibitions resist
Figure 18.2 Hybrid of Marshall/Barbaree (1990) and Russell (1984) showing preconditions and
four factors leading to rape.
theory, on the other hand, would suggest changing how sexual relationships are pre-
sented in the media, eliminating at least violent pornography, and providing nonviolent
models of relationships by focusing primary prevention efforts on parents and teachers.
Context theories would suggest changing the sociocultural context. Feminist theory
focuses on creating equality between men and women in all spheres of life, including politi-
cal and economic. Cultural spillover theory emphasizes the need to decrease legitimized
violence, by, for example, limiting media portrayals of violence, outlawing corporal pun-
ishment, and abolishing the death penalty. Programs based on these two theories would
consist largely of convincing the general population to believe the theory and to work on
social and legal change.
The integrated theories imply the need for comprehensive prevention programming.
Marshall and Barbaree (1990), in particular, present such a complex suite of interacting
factors that prevention programs would have to target multiple areas—for example, com-
munity parenting classes to decrease the number of boys exposed to poor parenting, legal or
other changes to decrease violence, feminist programming to improve the status of women,
and so on. Russell (1984) presents more of a chain of events; this implies that only one link
of the chain needs to be broken. Although it might be difficult to address men’s desire to
sexually assault, programs could focus on strengthening moral values (i.e., increase inter-
nal inhibitions) or making reporting easier and punishments harsher (i.e., increase social
inhibitions) or creating self-defense classes and other safety education (i.e., increasing the
probability of effective resistance).
Many possible rape prevention strategies are available; Fischhoff, Furby, and Morgan
(1987) documented 1,140 possibilities. However, each of the most common strategies
involving education and self-defense, when consistently used, was estimated by groups of
men, women, and self-defense experts to reduce the risk of sexual assault by half (Furby,
Fischhoff, & Morgan, 1989).
Classes of Programs. Rape prevention programs can be divided into four broad classes.
These are environmental control, victim control, self-empowerment, and social change
strategies. In practice, not all programs fit neatly in these categories, but these labels
describe the emphases of most programs.
The first type of program focuses on environmental control. Lonsway (1996) refers to
this as what “rape prevention has historically involved” and lists possible components:
“shearing bushes, installing lights and alarm systems, or teaching women self-defense”
(p. 230). For example, a project on one college campus involved improving campus light-
ing and installing signs to notify pedestrians and bicyclists of pathways with good lighting.
These programs increase feelings of safety, and it is probably one of the strategies with the
lowest financial cost over the long term. The problem with this approach is that it targets
stranger rape, which is much less common than acquaintance rape. Thus, the feelings of
safety it generates might be a false sense of security. Additionally, the benefits of these
measures, with the exception of self-defense training, affect safety only in the immediate
area. Although we have no objection to such measures as part of a larger program, the fear
is that some communities and campuses might provide this type of environmental control
without doing anything to address acquaintance rape.
Victim control programs are those that assume the cause of rape is victim behavior, a
theory that has received little support (Corcoran, 1992). These programs warn potential
victims of risky behavior such as drinking, walking alone at night, and acting hesitant.
Victim control has the same main benefit as environmental control: feelings of safety (at
least as long as one avoids “risky” behavior). However, Corcoran (1992) points out the
high costs of such an approach, including victim blame, further restriction of women’s
activities, and a lack of effectiveness in decreasing sexual assaults.
Self-empowerment, on the other hand, attempts “to provide women with more options
and to strengthen their ability to resist and avoid rape” by providing information, self-
defense training, assertiveness and communication training, etc. (Corcoran, 1992, p. 135).
One of the strengths of this type of program is that the effects are mobile; women can carry
these skills with them. It is also much less restrictive than victim control. Problems with
this strategy include victim blame, the lack of 100% effectiveness of resistance, and the
possible danger of displacing sexual assaults onto more vulnerable women as rapists seek
out new targets (Corcoran, 1992).
Social change, the final class of programs, parallels the context theories described earlier.
One example is the set of school reforms recommended by Enke and Sudderth (1991).
They urge schools to address peer relationships in current programs on sexual coercion; to
encourage egalitarianism; to teach communication and body awareness; to avoid reward-
ing gender-stereotyped behavior; to encourage cooperation and participation rather than
competition; and to teach a more holistic conception of sexuality. Feminist approaches
would also fall into this change category. The advantages of social change include possible
effectiveness (e.g., the aforementioned success of gender role discussions) and applicability
to a wide audience. The drawbacks include the amount of time needed to change society
and the difficulty of eliciting action after the program is over. Also, this perspective “does
not provide specific rape avoidance or self-protection strategies” for individuals (Corco-
ran, 1992, p. 136).
Designing Rape Prevention Programs

The design of a rape prevention program will, of course, depend on the philosophy or
theory behind it. Since we believe that rape is caused by numerous factors and their inter-
actions with multiple levels, we favor prevention programs with multiple components.
Another advantage to multifaceted programs is that different components are likely to
appeal to—and affect—different people, so having multiple components increases the
potential audience.
Recall that we view the causes of sexual assault via a hybrid of Marshall and Barba-
ree’s (1990) and Russell’s (1984) theories, as shown in Figure 18.2. It is difficult for pri-
mary prevention efforts to target biological factors or childhood experiences, except that
childhood experiences could be influenced by providing parenting classes and by direct-
ing efforts at the prevention of child abuse (a topic found in other chapters). Situational
factors are also difficult to control in practice, although some educational efforts can
be directed there. For example, alcohol consumption is a potent enough risk factor that
women should be made aware of its effects on sexual assault risks; however, care must be
taken to avoid blaming victims who consume alcohol or excusing the behavior of offend-
ers who consume alcohol or attempt to intoxicate their victims. Sociocultural factors, then,
are probably the most logical targets for prevention, although this does not mean that they
are the easiest to change.
There are four levels on which to examine sociocultural factors: perpetrator desire, perpe-
trator internal inhibitions, social inhibitions, and victim resistance. It is difficult to address
perpetrator desire except as how the media and pornography portray sex and aggression as
connected with love and enjoyment; this might be more effectively addressed by legislation
or short-term publicity campaigns than by ongoing programs. Programs can successfully
address internal inhibitions on a sociocultural level by discussing rape myths; interactive
drama is generally considered effective, but videotapes are also commonly used. Social inhi-
bitions are generally addressed governmentally (i.e., via the courts and correctional system),
but can also be addressed by increasing a potential perpetrator’s fear of being caught in the
first place. One way is to provide victim support services and to make it as easy as possible
for victims to report sexual assault and get legal help. Finally, victims’ ability to resist can
be increased by commonly used means such as self-defense training.
Although crisis and advocacy services are not really primary prevention, they are impor-
tant elements in a comprehensive program. First, one hopes that they mitigate whatever
impacts of sexual assault may have. Providing support for victims of sexual assault also
creates an environment in which rape is not accepted and victims are not blamed or stig-
matized—a possible model under social learning theory. Providing these services may not
always be feasible in a school-based program, but students can be made aware of com-
munity resources that do provide them.
An additional consideration is that programs may cause distress in participants who are
victims or friends of victims. Therefore, we recommend against making such programs
and rape-education presentations mandatory. While making them completely voluntary
would probably result in a rather small audience, there should at least be some unobtru-
sive option available for students who wish to opt out. One could argue that the students
who most need the program are also likely to excuse themselves, but we believe it is more
important to have an escape available for victims who need it. We also agree with Heppner,
Humphrey, Hillenbrand-Gunn, and DeBord’s(1995) decision to have counselors available
at rape prevention presentations.
Evidence-Based Programs. A number of rape prevention programs have been developed,
implemented, and evaluated for college students. Program evaluation research indicates
that rape prevention programs work, to at least some extent. In their meta-analysis of 69
college rape prevention programs, Anderson and Whiston (2005) found the largest impact
to be on rape knowledge and on rape attitudes. There was a small impact on behavioral
intentions, rape-related attitudes, and the incidence of sexual assault, but no significant
impact on rape empathy or rape awareness. The authors state, “Our results suggest that
sexual assault education interventions for college students tend to be more effective when
they are longer, presented by professionals, and include content addressing risk reduction,
gender-role socialization, or provision of information and discussion of myths and facts
about sexual assault. In addition, there was support for both mixed- and single-gender
programming; however, single-gender programming may tentatively be more helpful in
some circumstances for women (Anderson & Whiston, 2005, p. 385).
Programs have been developed for middle school and high school students. Some pro-
grams focus on dating violence (Avery-Leaf, Cascardi, O’Leary, & Cano, 1997; Elias-
Lambert, Black, & Sharma, 2010) and some explicitly on sexual assault (Fay & Medway,
2006). Fay and Medway’s (2006) program addressing acquaintance rape, for example,
adapted a program designed for college students for use with younger students. The 2-day
curriculum was designed to help students: 1) to understand acquaintance rape and its
frequency, rape laws, and the relation of rape to violence and coercion; 2) to explore feel-
ings about acquaintance rape, and discuss teasing, honesty in dating, decision making,
aggression, submission, and assertion; 3) to learn about the cultural forces contributing
to the frequency and social acceptance of acquaintance rape, such as traditional gender
stereotypes, media violence, and cultural norms and myths; 4) to learn about the role of
inconsistent verbal and nonverbal communication (i.e., mixed messages), and learn how to
communicate wants and desires clearly; and 5) to identify rape prevention strategies and
learn about local sources of victim support. As with other programs the main outcomes
examined in their study were changes in factual knowledge. Comprehensive programs for
this age group still need development and study.
There are several cautions, however, in trying to evaluate a rape prevention model.
While attitude change is a common criterion, Heppner, Humphrey, Hillenbrand-Gunn, and
DeBord (1995) showed that it may rebound after the program; thus, either programs must
be repeated frequently or another measure should be used. Behavioral outcomes are, of
course, ideal, and Hanson and Gidycz’s (1993) use of actual sexual assault rates is again a
model for other programs; where participants cannot be followed, however, attitude change
immediately after a presentation may be the only short-term measure available. A decrease in
the rates of sexual assault is the ultimate goal, but this can be seen only over the long term;
ideally, it should be measured by methods such as retrospective questionnaires, since police
reports represent only a fraction of sexual assaults. An additional evaluation consideration is
that an increase in reports to police agencies and support services may represent an increased
willingness for victims to seek assistance rather than an increase in the number of victims.
Finally, rape prevention educators should be alert for unintended effects. Some of these
may be positive; for example, self-defense training can provide a good form of exercise and
might increase physical health measures, or attitude change to decrease rape-supportive
attitudes could conceivably impact attitudes on and reporting of domestic violence. Some
impacts, however, may not be positive. For example, victim control programs may lead
women to restrict their activities. Programs may lead to increased levels of fear, although
including self-empowerment components may ameliorate this concern. In addition, pro-
grams may cause distress in participants who are victims or friends of victims; this has
already been discussed.
Conclusions
Sexual assault is a crime that is far too common in the United States at present. When
sexual assaults occur, it is important that counseling be available to the victim, her parents,
her romantic partner, and her friends. Specific concerns and various modes and strate-
gies for counseling and prevention have been discussed, and the schools are places where
efforts should be launched.
There does not seem to be any one simple cause of sexual assault. There are many causal
influences described by many theories. However, there is good evidence that sexual assault
can be prevented through the use of various programs. Program evaluations offer some
consensus on what components should be included, particularly discussion of rape myths
and gender roles. The most important components of a comprehensive program are victim
support services, education that facilitates internal and social inhibitions for potential rap-
ists, and resistance (i.e., self-defense) training for potential victims. With effort the silent
epidemic of rape and sexual assault can be quelled.
REFERENCES
Alleyne, B., Coleman-Cowger, V. H., Crown, L., Gibbons, M. A., & Vines, L. N. (2011). The effects
of dating violence, substance use and risky sexual behavior among a diverse sample of Illinois
youth. Journal of Adolescence, 34(1), 11–18. doi:10.1016/j.adolescence.2010.03.006
American Association of University Women Educational Foundation. (2001). Hostile hallways: Bul-
lying, teasing, and sexual harassment in school. Washington, DC: Author.
Anderson, L. A., & Whiston, S. C. (2005). Sexual assault education programs: A metaanalytic
examination of their effectiveness. Psychology of Women Quarterly, 29, 374–388.
Andrews, A. B., & Veronen, L. J. (1993). Sexual assault and people with disabilities. Journal of
Social Work & Human Sexuality, 8, 137–159.
Avery-Leaf, S., Cascardi, M., O’Leary, K. D., & Cano, M. A. (1997). Efficacy of a dating violence
prevention program on attitudes justifying aggression. Journal of Adolescent Health, 21, 11–17.
Baron, L., & Straus, M. A. (1989). Four theories of rape in American society: A state-level analysis.
New Haven, CT: Yale University Press.
Ben-Zvi, R., & Horsfall, E. (1985). Adolescent rape: The role of rape crisis counseling. International
Journal of Adolescent Medicine and Health, 1, 343–356.
Berliner, L., & MacQuivey, K. (1983). A therapy group for female adolescent victims of sexual
abuse. In M. Rosenbaum (Ed)., Handbook of short-term therapy groups (pp. 101–116). New
York: McGraw-Hill.
Bloom, M. (1996). Primary prevention practices. Thousand Oaks, CA: SAGE.
Briere, J., & Malamuth, N. M. (1983). Self-reported likelihood of sexually aggressive behavior:
Attitudinal versus sexual explanations. Journal of Research in Personality, 17(3), 315–323.
Burgess, A. W., Groth, A. N., Holmstrom, L. L., & Sgroi, S. M. (1978). Sexual assault of children
and adolescents. Lexington, MA: Lexington Books.
Burgess, A. W., & Holmstrom, L. L. (1974). Crisis and counseling requests of rape victims. Nursing
Research, 23(3), 196–202.
——— (1979a). Rape: Crisis and recovery. Bowie, MD: Brady.
——— (1979b). Rape: Sexual disruption and recovery. American Journal of Orthopsychiatry, 49,
648–657.
Calhoun, K. S., & Atkeson, B. M. (1991). Treatment of rape victims: Facilitating psychosocial
adjustment. New York: Pergamon Press.
Choquet, M., Darves-Bornoz, J., Ledoux, S., Manfredi, R., & Hassler, C. (1997). Self-reported
health and behavioral problems among adolescent victims of rape in France: Results of a cross-
sectional survey. Child Abuse & Neglect, 21, 823–832.
Corcoran, C. B. (1992). From victim control to social change: A feminist perspective on campus rape
prevention programs. In J. C. Chrisler & D. Howard (Eds.), New directions in feminist psychol-
ogy: Practice, theory, and research (pp. 130–140). New York: Springer.
Cormier, S., & Cormier, B. (1998). Interviewing strategies for helpers: Fundamental skills and cogni-
tive behavioral interventions. Pacific Grove, CA: Brooks/Cole.
Cowan, G., & Campbell, R. R. (1995). Rape causal attitudes among adolescents. The Journal of
Sex Research, 32, 145–153.
Danielson, C. K., McCart, M. R., de Arellano, M. A., Macdonald, A., Doherty, L. S., & Resnick,
H. S. (2010). Risk reduction for substance use and trauma-related psychopathology in adoles-
cent sexual assault victims: Findings from an open trial. Child Maltreatment, 15(3), 261–268.
doi:10.1177/1077559510367939
Davis, T. C., Peck, G. Q., & Storment, J. M. (1993). Acquaintance rape and the high school student.
Journal of Adolescent Health, 14, 220–224.
Denmare, D., Briere, J., & Lips, H. M. (1988). Violent pornography and self-reported likelihood of
sexual aggression. Journal of Research in Personality, 22, 140–153.
Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., . . . Wechsler, H. (2010). Youth
risk behavior surveillance—United States, 2009. MMWR Surveillance Summaries, 59, 1–142.
——— (2008). Youth risk behavior surveillance—United States, 2007. Retrieved from http://www.
cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm
Elias-Lambert, N., Black, B., & Sharma, Y. (2010). Middle school youth: Satisfaction with and
responses to a dating violence and sexual assault prevention program. Journal of School Violence,
9(2), 136–153. doi:10.1080/15388220903585887
Ellis, E. M. (1983). A review of empirical rape research: Victim reactions and response to treatment.
Clinical Psychology Review, 3, 473–490.
Ellis, L. (1989). Theories of rape: Inquiries into the causes of sexual aggression. New York: Hemi-
sphere. doi: 10.1080/14681810600836414
Elwood, L. S., Smith, D. W., Resnick, H. S., Gudmundsdottir, B., Amstadter, A. B., Hanson, R.
F., . . . Kilpatrick, D. G. (2011). Predictors of rape: Findings from the national survey of adoles-
cents. Journal of Traumatic Stress, 24(2), 166–173. doi:10.1002/jts.20624
Enke, L. E., & Sudderth, L. K. (1991). Educational reforms. In E. Grauerholz & M. A. Koralewski
(Eds.), Sexual coercion: A sourcebook on its nature, causes, and prevention (pp. 149–159). Lex-
ington, MA: Lexington Books.
Fay, K. E., & Medway, F. J. (2006). An acquaintance rape education program for students transition-
ing to high school. Sex Education, 6, 223–236. doi: 10.1080/14681810600836414
Fineran, S., & Gruber, J. E. (2009). Youth at work: Adolescent employment and sexual harassment.
Child Abuse & Neglect, 33(8), 550–559. doi:10.1016/j.chiabu.2009.01.001
Finkelhor, D. (1984). Child sexual abuse: New theory and research. New York: Free Press.
Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. L. (2005). The victimization of children and youth:
A comprehensive, national survey. Child Maltreatment, 10, 5–25. doi:10.1177/1077559504271287
Fischhoff, B., Furby, L., & Morgan, M. (1987). Rape prevention: A typology of strategies. Journal
of Interpersonal Violence, 2, 292–308.
Frank, E., & Stewart, B. D. (1983). Treatment of depressed rape victims: An approach to stress-
induced symptomatology. In P. J. Clayton & J. E. Barrett (Eds.), Treatment of depression: Old
controversies and new approaches (pp. 307–330). New York: Raven Press.
Freeman, D. H., & Temple, J. R. (2010). Social factors associated with history of sexual assault
among ethnically diverse adolescents. Journal of Family Violence, 25(3), 349–356. doi:10.1007/
s10896–009–9296–6
Furby, L., Fischhoff, B., & Morgan, M. (1989). Judged effectiveness of common rape prevention and
self-defense strategies. Journal of Interpersonal Violence, 4, 44–64.
Glass, N., Fredland, N., Campbell, J., Yonas, M., Sharps, P., & Kub, J. (2003). Adolescent dating
violence: Prevalence, risk factors, health outcomes, and implications for clinical practice. Journal
of Obstetric, Gynecological, & Neonatal Nursing, 32, 227–238.
Goodchilds, J. D., & Zellman, G. L. (1984). Sexual signaling and sexual aggression in adolescent
relationships. In N. M. Malamuth & E. Donnerstein (Eds.), Pornography and sexual aggression
(pp. 233–243). New York: Academic Press.
Gordon, M. T., and Riger, S. (1989). The female fear. New York: Free Press.
Goyer, P., & Eddleman, H. (1984). Same sex rape of nonincarcerated men. American Journal of
Hanson, K. A., & Gidycz, C. A. (1993). Evaluation of a sexual assault prevention program. Journal
of Counseling and Clinical Psychology, 61, 1046–1052.
Hanson, R. F., Resnick, H. S., Saunders, B. E., Kilpatrick, D. G., & Best, C. (1999). Factors related
to the reporting of childhood rape. Child Abuse & Neglect, 23, 559–569.
Harney, P. A., & Muehlenhard, C. L. (1991). Rape. In E. Grauerholz & M. A. Koralewski (Eds.),
Sexual coercion: A sourcebook on its nature, causes, and prevention (pp. 3–15). Lexington, MA:
Lexington Books.
Heppner, M. J., Humphrey, C. F., Hillenbrand-Gunn, T. L., & DeBord, K. A. (1995). The differential
effects of rape prevention programming on attitudes, behavior, and knowledge. Journal of Coun-
seling Psychology, 42, 508–518.
Hines, D. A., & Finkelhor, D. (2007). Statutory sex crime relationships between juveniles and adults:
A review of social scientific research. Aggression and Violent Behavior, 12, 300–314.
Holmstrom, L. L., & Burgess, A. W. (1979). Rape: The husband’s and boyfriend’s initial reactions.
The Family Coordinator, 28, 321–330.
Hucker, S., Langevin, R., Dickey, R., & Handy, L. (1988). Cerebral damage and dysfunction in sexu-
ally aggressive men. Annals of Sex Research. 1, 33–47.
Kaplan, D., & Holmes, M. M. (1999). Clinical management of rape in adolescent girls. Patient
Care, 33, 42–56.
Kaufman, M., & Committee on Adolescence. (2008). Care of the adolescent sexual assault victim.
Pediatrics, 122(2), 462–470. doi:10.1542/peds.2008–1581
Kilpatrick, D. G., Best, C. L., Saunders, B. E., & Veronen, L. J. (1988). Rape in marriage and in
dating relationships. How bad is it for mental health? In R. A. Prentky & V. L. Quinsey (Eds.),
Human sexual aggression: Current perspectives (pp. 335–344). Annals of the New York Academy
of Sciences, Vol. 528. New York: New York Academy of Sciences.
Kilpatrick, D. G., Veronen, L. J., & Best, C. L. (1985). Factors predicting psychological distress among
rape victims. In C. R. Figley (Ed.), Trauma and its wake (pp.113–141). New York: Brunner/Mazel.
Koss, M. P. (1983). The scope of rape: Implications for the clinical treatment of victims. Clinical
Koss, M. P., & Dinero, T. E. (1988). Predictors of sexual aggression among a national sample of
male college students. In R. A. Prentky & V. L. Quinsey (Eds.), Human sexual aggression: Current
perspectives (pp. 133–147). Annals of the New York Academy of Sciences, Vol. 528. New York:
New York Academy of Sciences.
Langevin, R., Bain, J., Wortzman, G., Hucker, S., Dickey, R., & Wright, P. (1988). Sexual sadism:
Brain, blood, and behavior. In R. A. Prentky & V. L. Quinsey (Eds.), Human sexual aggression:
Current perspectives (pp. 163–171). Annals of the New York Academy of Sciences, Vol. 528. New
York: New York Academy of Sciences.
Le, Y. L., Behnken, M. P., Markham, C. M., & Temple, J. R. (2011). Alcohol use as a potential
mediator of forced sexual intercourse and suicidality among African American, Caucasian, and
Hispanic high school girls. Journal of Adolescent Health, 49(4), 437–439. doi:10.1016/j.jado-
health.2011.01.003
Ledray, L. E. (1986). Recovering from rape. New York: Henry Hill.
Lehmann, D. (1991). Sexual assault. In M. L. Pernoll (Ed.), Current obstetric & gynecologic diag-
nosis & treatment (7th ed., pp. 1142–1147). Norwalk, CT: Appleton & Lange.
Lonsway, K. A. (1996). Preventing acquaintance rape through education: What do we know? Psy-
chology of Women Quarterly, 20(2), 229–265.
MacDonald, J. M. (1971). Rape offenders and their victims. Springfield, IL: Charles C. Thomas.
Mallet, P., & Herbé, D. (2011). Does knowledge about sexuality prevent adolescents from developing
rape-supportive beliefs? Journal of Sex Research, 48(4), 372–380. doi:10.1080/00224491003794048
Mann, E. M. (1981). Self-reported stresses of adolescent rape victims. Journal of Adolescent Health
Care, 2, 29–33.
Marshall, W. L., & Barbaree, H. E. (1990). An integrated theory of the etiology of sexual offending.
In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theo-
ries, and treatment of the offender (pp. 257–275). New York: Plenum Press.
Masho, S. W., & Ahmed, G. (2007). Age at sexual assault and posttraumatic stress disorder among
women: Prevalence, correlates, and implications for treatment. Journal of Women’s Health, 16,
262– 271. doi:10.1089/jwh.2006.M076
McDermott, M. J. (1979). Rape victimization in 26 American cities. Washington, DC: U.S. Depart-
ment of Justice, Law Enforcement Assistance Administration, National Criminal Justice Informa-
tion Statistics Service.
Miller, B. C., Monson, B. H., & Norton, M. C. (1995). The effects of forced sexual intercourse on
white female adolescents. Child Abuse & Neglect, 19(10), 1289–1310.
Morelli, P. H. (1981, March). Comparison of the psychological recovery of black and white victims
of rape. Paper presented at the meeting of the Association for Women in Psychology, Boston, MA.
Muram, D., Hostetler, B. R., Jones, C. E., & Speck, P. M. (1995). Adolescent victims of sexual
assault. Journal of Adolescent Health, 17(6), 372–375.
Nadelson, C. C., Notman, M. T., Zackson, H., & Gornick, J. (1982). A follow-up study of rape
victims. American Journal of Psychiatry, 139, 1266–1270.
Norris, J. (1994). Alcohol and female sexuality: A look at expectancies and risks. Alcohol Health
and Research World, 18(3), 197–201.
Renfrew, J. W. (1997). Aggression and its causes: A biopsychological approach. New York: Oxford
University Press.
Ruch, L. O., & Chandler, S. M. (1983). Sexual assault trauma during the acute phase: An explor-
atory model and multivariate analysis. Journal of Health and Social Behavior, 24, 174–185.
Russell, D. E. (1984). Sexual exploitation. Beverly Hills, CA: SAGE.
Ryerson, E. (1984). Adolescents with disabilities and acquaintance rape. In Alternatives to Fear
(Ed.), This is it, Teen acquaintance rape information and prevention activities for groups (pp.
30–38). Seattle, WA: Alternatives to Fear.
Schmidt, A. M. (1981). Adolescent female rape victims: Special considerations. Psychosocial Nurs-
ing and Mental Health Services, 19, 17–19.
Scott, C. S., Lefley, H. P., & Hicks, D. (1993). Potential risk factors for rape in three ethnic groups.
Community Mental Health Journal, 29(2), 133–141.
Smith, D. W., Letourneau, E. J., Saunders, B. E., Kilpatrick, D. G., Resnick, H. S., & Best, C. L.
(2000). Delay in disclosure of childhood rape: Results from a national survey. Child Abuse &
Neglect, 24, 273–287.
Stein, N. (1995). The definition of sexual harassment applies to schools. In K. L. Swisher (Ed.), What
is sexual harassment? (pp. 19–24). San Diego, CA: Greenhaven Press.
Tillyer, M. S., Wilcox, P., & Gialopsos, B. M. (2010). Adolescent school-based sexual victimization:
Exploring the role of opportunity in a gender-specific multilevel analysis. Journal of Criminal
Justice, 38(5), 1071–1081. doi:10.1016/j.jcrimjus.2010.07.010
Troup-Leasure, K., & Snyder, H. N. (2005). Statutory rape known to law enforcement. Juvenile
Justice Bulletin No. NCJ208803. Washington, DC: Office of Juvenile Justice & Delinquency Pre-
vention. Retrieved from www.ncjrs.gov/pdffiles1/ojjdp/208803.pdf
Ullman, S. E., & Knight, R. A. (1993). The efficacy of women’s resistance strategies in rape situa-
tions. Psychology of Women Quarterly, 17, 23–38.
Veronen, L. J., Saunders, B. E., & Resnick, H. S. (1988, November). Partner reactions to rape.
Paper presented at the meeting of the Association for the Advancement of Behavioral Therapy,
New York.
Vicary, J. R., Klingaman, L. R., & Harkness, W. L. (1995). Risk factors associated with date rape
and sexual assault of adolescent girls. Journal of Adolescence, 18, 289–306.
Warshaw, R. (1988). I never called it rape. New York: Harper & Row.
Waterman, C. K., Dawson, L. J., & Bologna, M. J. (1989). Sexual coercion in gay male and les-
bian relationships: Predictors and implications for support services. The Journal of Sex Research,
26(1), 118–124.
Webb, S. L. (1995). Sexual harassment should be defined broadly. In K. L. Swisher (Ed.), What is
sexual harassment? (pp. 10–18). San Diego, CA: Greenhaven Press.
Weinstein, E., & Rosen, E. (1988). Sexuality counseling: Issues and implications. Pacific Grove, CA:
Brooks/Cole.
Weisz, A., & Black, B. (2009). Relationships should not hurt: Programs that reach out to youth to
reduce dating violence and sexual assault. New York: Columbia University Press.
Wolak, J., Finkelhor, D., Mitchell, K. J., & Ybarra, M. L. (2010). Online “predators” and their
victims: Myths, realities, and implications for prevention and treatment. Psychology of Violence,
1(S), 13–35. doi:10.1037/2152–0828.1.S
Wolitzky-Taylor, K. B., Ruggiero, K. J., Danielson, C. K., Resnick, H. S., Hanson, R. F., Smith,
D. W., . . . Kilpatrick, D. G. (2008). Prevalence and correlates of dating violence in a national
sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 47(7),
755–762. doi:10.1097/CHI.0b013e318172ef5f
Young, A. M., Grey, M., & Boyd, C. J. (2009). Adolescents’ experiences of sexual assault by peers:
Prevalence and nature of victimization occurring within and outside of school. Journal of Youth
and Adolescence, 38(8), 1072–1083. doi:10.1007/s10964–008–9363-y
Zoucha-Jensen, J. M., & Coyne, A. (1993). The effects of resistance strategies on rape. American
Journal of Public Health, 83, 1633–1634.
19 Nonsuicidal Self-Injury
David N. Miller
Introduction
Nonsuicidal self-injury (NSSI) refers to an intentional, self-effected, socially unaccept-
able form of deliberate bodily harm in the absence of suicidal intent (Miller & Brock,
2010; Walsh, 2006). A puzzling, disturbing, and to many an inexplicable behavior, NSSI is
prevalent in all cultures and across all socioeconomic levels (Lieberman & Poland, 2006;
Nock, 2009). Although the first recorded account of NSSI occurred over 2,400 years ago
(Favazza, 1998), it has only been in recent decades that it has been recognized as a serious
mental health problem, particularly among young people. The most common form of NSSI
appears to be skin cutting (Klonsky & Muehlenkamp, 2007), and those individuals who
engage in it typically cut on their forearms, although it is not restricted to that area (Nixon
& Heath, 2009a). NSSI may also take other forms, including severe skin scratching, pick-
ing at wounds, burning, or inserting objects into the body (D’Onofrio, 2007). Previously
referred to by a number of descriptors, the term nonsuicidal self-injury, or NSSI, is currently
the most widely used and accepted designation and will therefore be the term used through-
out this chapter. Use of the term “self-mutilation,” previously the most common descriptor
for this condition (Lieberman & Poland, 2006), has been discouraged given that it is “too
extreme, pejorative, and ultimately inaccurate” (Miller & Brock, 2010, p. 1).
There are several misconceptions about NSSI. For example, some individuals confuse it
with suicidal behavior, while others assume that its primary purpose is to gain attention
from or to manipulate others. Many mental health professionals mistakenly view NSSI
as being synonymous with borderline personality disorder, even though this diagnosis
is not appropriate for the majority of youth who engage in NSSI (Walsh, 2006). NSSI
also should not be confused with what is commonly referred to as self-injurious behavior
(SIB), which is often associated with children and adolescents with severe developmental
disabilities, such as autism. Similarly, NSSI should not be confused with Lesch-Nyhan
Disease (a genetic disorder resulting in involuntary muscle movements, cerebral palsy, and
the frequent self-mutilation of body tissue) or Body Integrity Identity Disorder (character-
ized by the strong desire to amputate healthy limbs). Finally, NSSI should be distinguished
from culturally sanctioned forms of body modification, such as body piercings or tattoos
(Miller & Brock, 2010).
Although NSSI may appear at any age, it is frequently associated with adolescence
because it typically emerges during that developmental period (Nixon & Heath, 2009a).
Consequently, it has become a major concern among adults who work with young people,
particularly school personnel. Indeed, school has emerged as the primary place in which
youth who engage in NSSI first come to the attention of others and therefore is the set-
ting in which an effective response to this problem can often begin (D’Onofrio, 2007;
Lieberman, Toste, & Heath, 2009). Schools are typically the primary treatment setting
Nonsuicidal Self-Injury 363
for children’s general mental health problems (Miller, 2011), and it is likely that school
personnel will be asked to take on a more active role in the identification, assessment, and
treatment of youth with NSSI in the future (Miller & Brock, 2010). It is therefore imper-
ative that school personnel, particularly school-based mental health professionals such
as school psychologists, school counselors, and school social workers, develop greater
knowledge and skills regarding the effective assessment and treatment of NSSI.
Effectively responding to and treating NSSI is critical, as without intervention it may
persist for years or even decades. Moreover, the presence of NSSI increases the risk for
developing a variety of other mental health and school adjustment problems (D’Onofrio,
2007). As a result, school-based mental health professionals are being increasingly called
upon to effectively assess and respond to NSSI, as well as to consult with teachers, other
school practitioners, and parents regarding this troubling problem (Lieberman et al., 2009;
Lieberman & Poland, 2006; Miller & Brock, 2010). Unfortunately, many school-based
professionals, including high school teachers (Heath, Toste, & Beetham, 2006; Heath,
Toste, Sornberger, & Wagner, 2011) and school psychologists (Miller & Jome, 2010), fre-
quently perceive themselves as being inadequately trained to effectively respond to NSSI.
This situation is made even more difficult by the fact that the behaviors associated with
NSSI are often perceived by school personnel as shocking, repulsive, and horrifying (Heath
et al., 2011; Walsh, 2006). Students who engage in NSSI often evoke powerful emotions
and cognitions in adults, including confusion, fear, anger, and disgust. These reactions often
result in some adults distancing themselves from being present and responsive to students
in need of assistance (D’Onofrio, 2007; Walsh, 2006). Further complicating this situation is
the fact that NSSI can appear to be “contagious,” potentially running through various peer
groups, grade levels, and schools (Lieberman & Poland, 2006). Moreover, research suggests
that many adolescents who engage in NSSI are often unwilling to access school-based sup-
port services (Heath, Baxter, Toste, & McLouth, 2010), a condition that, in the context of
similar findings among suicidal youth, has been described as help negation (Rudd, Joiner,
& Rajab, 1995). Consequently, effectively identifying, assessing, and intervening with stu-
dents engaging in NSSI frequently present school personnel with significant challenges.
Prevalence
In part because the professional literature on NSSI is relatively new and still emerging,
there has been much inconsistency and wide variability in the methodology designed to
study it and therefore in its reported prevalence rates (Miller & Brock, 2010). For exam-
ple, prevalence rates in youth community samples have been reported to be as low as 4%
(Briere & Gil, 1998) and as high as 48% (Lloyd-Richardson, Perrine, Dierker, & Kelley,
2007). Even higher prevalence rates have been reported among clinical samples (Nock &
Prinstein, 2004). When examining prevalence rates, a number of methodological issues
need to be considered, including definition, measurement, setting, and sample selection
(Heath, Schaub, Holly, & Nixon, 2009; Miller & Brock, 2010). Each of these issues is
discussed briefly ahead.
Definitional Issues
Many studies examining the prevalence of NSSI have used a definition that includes any
form of self-inflicted injury, including self-poisoning, jumping from heights, skin picking,
and drug overdose. In contrast, some other studies have limited the behavioral definition
of NSSI to skin cutting and fail to include other pertinent behaviors, such as burning,
self-hitting, and other behaviors that may be more common in males than females (Heath
364 David N. Miller
et al., 2009). Consequently, how NSSI is conceptualized and defined in various studies will
inevitably lead to highly variable prevalence reports.
Measurement Issues
Adding to the difficulty of accurately defining the prevalence rate of NSSI in youth is the con-
fusion that may result by how it is measured. For example, some of the behavioral checklists
used to determine prevalence rates include a variety of self-injurious behaviors, while others
are more open-ended and rely on more subjective judgments about what should or should
not be considered a self-injurious behavior (Miller & Brock, 2010). For example, Ross and
Heath (2002) asked 440 high school students if they had ever hurt themselves on purpose.
Although 21% reported doing so at least once, a follow-up interview with these students
revealed that only 14% of them met the criteria for NSSI developed by the authors.
An additional measurement issue in calculating prevalence rates is the time frame and
frequency variables used for criterion purposes (Miller & Brock, 2010). For example,
some studies have examined lifetime prevalence of NSSI, while others have examined
single occurrences. Still others may use time lines that may include how frequently the
individual has engaged in NSSI in the last year, in the last 6 months, or in the last month
(Heath et al., 2009). The way NSSI is measured affects its reported prevalence rate.
Setting Issues
In calculating prevalence rates for youth with NSSI, it is important to know whether partici-
pants in studies were drawn from clinical or community samples. Clinical samples include
inpatient hospitals, outpatient clinics, emergency rooms, and a host of other health and
mental health agencies. Community samples generally include schools and other nonclinical
settings. In general, there are several studies to date that have examined the prevalence of
NSSI in young adults in clinical settings, a few studies examining young adults in community
settings, a limited number of studies involving adolescents in clinical settings, and only a few
studies involving adolescents in community settings, such as schools (Heath et al., 2009).
Research on NSSI, like other mental health problems, has consistently found prevalence
rates to be higher in clinical settings than in community settings (Heath et al., 2009).
Sample Selection Issues

The sample selection procedures used in studies can also affect the reported prevalence rate
of NSSI. For example, different prevalence rates are found for samples of young adoles-
cents compared to older adolescents and young adults. In addition, there are fewer studies
that examine the prevalence of NSSI in adolescents as compared to young adults, and the
majority of studies in clinical settings have included larger numbers of females than males
(Heath et al., 2009).
Tentative Conclusions About the Prevalence of NSSI in School-Age Populations

Despite these various methodological problems, research is emerging that is painting a
clearer picture of the prevalence of NSSI in school-age youth. For example, studies that
have examined the occurrence of NSSI in high school–aged youth indicate that 15 to 20%
have reported engaging in NSSI at least once (Laye-Gindhu & Schonert-Reichl, 2005;
Muehlenkamp & Gutierrez, 2007; Nixon, Cloutier, & Aggarwal, 2002; Ross & Heath,
2002). Given that most of these studies employed clinical rather than community samples,
however, these figures likely overestimate the prevalence rate of NSSI in typical school-
age populations. For example, in their study of 440 high school students, Ross and Heath
(2002) found that 14% reported engaging in NSSI. Some other tentative conclusions
regarding prevalence rates across various demographic categories are described ahead.
Age
Most studies suggest that the majority of youth who engage in NSSI begin to do so between
the ages of 13 and 15 (Muehlenkamp & Gutierrez, 2007; Ross & Heath, 2002; Sourander
et al., 2006). There is some evidence, however, that a significant proportion of youth begin
engaging in NSSI earlier (Heath et al., 2009). Ross and Heath (2002), for example, found
that 25% of the students who reported engaging in NSSI in their study reported first
engaging in it prior to age 12.
Gender
Studies involving clinic-based samples have consistently found that females outnumber
males by a considerable margin, especially in comparison to community samples. These
significant gender differences appear largely due to two variables. First, females in general
appear more prone to seek help than males. Second, many clinical studies have included
participants who engaged in a wide range of self-harm behaviors, including drug overdose
and the inappropriate ingestion of medications without suicidal intent—behaviors that
have been found to occur more often in females than in males (Heath et al., 2009; Rodham,
Hawton, & Evans, 2004). Although some recent studies have focused to a greater extent
on males who exhibit NSSI (e.g., Muehlenkamp & Gutierrez, 2007), most of the research
on prevalence rates to date has focused on clinical samples of young adult females. Con-
sequently, there is a lack of reliable epidemiological data providing a clear understanding
of the prevalence of NSSI among children and adolescents generally, including the ratio of
males to females. Although it appears likely that the number of adolescent females who
engage in NSSI outnumbers the amount of adolescent males who do so, research suggests
that the level of these differences has perhaps been exaggerated (Heath et al., 2009).
Geography, Ethnicity, and Sexual Orientation

Current research suggests there is little variation in the behavior of youth who engage in
NSSI across urban or suburban areas (Heath et al., 2009). Further, there are currently too
few studies in non-Western cultures to make any definitive conclusions about the preva-
lence of NSSI among youth in other countries. In the United States, higher suicide rates have
consistently been reported in the Western states and Alaska (Miller, 2011), although it is
unclear if the prevalence of NSSI follows a similar pattern. There have been some ethnic dif-
ferences reported in community sample studies, with Caucasian youth found to be more likely
to engage in NSSI than African American youth (Muehlenkamp & Gutierrez, 2004, 2007;
Whitlock, Eckenrode, & Silverman, 2006). In regards to sexual orientation, there are some
indications that NSSI may occur more frequently in individuals who are gay, lesbian, or con-
flicted about their sexual orientation (Gratz, 2006; Heath et al., 2009; Whitlock et al., 2006).
Is the Prevalence of NSSI in Youth Increasing?

Although reports in the media frequently suggest that NSSI is increasing among young
people, there is currently no empirical evidence that this is the case (Miller & Brock,
366 David N. Miller
2010). In fact, it may be that the increased media exposure given to NSSI has fueled this
belief. This perception may also have been strengthened by studies conducted in the United
Kingdom on NSSI, which often employ a much broader definition of it that includes all
nonfatal aspects of self-inflicted harm (e.g., drug overdose, suicide attempts). It is also pos-
sible that rates of NSSI appear to be increasing because of an increased willingness among
youth to disclose the fact that they engage in it (Lieberman et al., 2009). A recent study
examining college student populations would support this last hypothesis (Whitlock, Eels,
Cummings, & Purington, 2009). Although there is some debate as to whether the reported
increase in the prevalence of NSSI among youth is one of actual occurrence, increased dis-
closure, or a combination of the two (Lieberman et al., 2009), it is clear that more young
people engaging in NSSI are coming to the attention of adults, including school personnel.
Causes and Associated Conditions
Causes of NSSI
There is no single cause of NSSI, and no one variable that can reliably predict whether a
child or adolescent will ultimately engage in self-injury. Psychiatric problems and disor-
ders typically result from complex interactions of genetic predispositions, environmental
variables, and individual vulnerabilities, and NSSI is no exception. Many theoretical
models have been proposed to explain the causes of self-injury, although many of these
(e.g., psychodynamic models) lack empirical support. Research is increasingly suggest-
ing that a functional approach may provide the clearest explanation of the development
and maintenance of self-injury (Miller & Brock, 2010). A functional approach assumes
that behaviors are determined by their immediate antecedents and consequences, and
that NSSI is maintained by several reinforcement processes. These may include intrap-
ersonal negative reinforcement (i.e., NSSI decreases or distracts from aversive thoughts
or feelings), intrapersonal positive reinforcement (i.e., NSSI generates desired feelings or
stimulation), interpersonal positive reinforcement (i.e., NSSI facilitates help-seeking), or
interpersonal negative reinforcement (i.e., NSSI facilitates escape from undesired social
situations) (Nock, 2009).
In providing an evidence-based overview of the nature and function of self-injury, Nock
(2009) suggests that (a) NSSI functions as a means for regulating an individual’s emo-
tional/cognitive experiences as well as communicating with or influencing others; (b) the
risk for NSSI is increased by the presence of distal risk factors (e.g., childhood abuse) that
contribute to the development of problems which affect regulation and interpersonal com-
munication; and (c) several more specific variables (e.g., social modeling) explain why
some individuals specifically use NSSI to serve these functions. Walsh (2006) provides a
biopsychosocial model of NSSI, in which its development is viewed as a complex interac-
tion between biological, environmental, cognitive, affective, and behavioral dimensions. It
may also be useful to consider NSSI in a wider social context, including differing socioeco-
nomic circumstances that may affect its development, as well as potential power inequities
and the wider social and cultural meanings of self-injury (Chandler, Myers, & Platt, 2011).
Conditions Associated With NSSI

NSSI is associated with a variety of psychiatric disorders, although most of the studies to
date have not differentiated between NSSI and suicidal self-injury. For example, a recent
review of the empirical literature on this topic found that only 15 published studies spe-
cifically examined NSSI and associated psychiatric conditions in adolescent populations
(Lofthouse, Muehlenkamp, & Adler, 2009). Within inpatient samples, NSSI was found
to be most frequently comorbid with depression, followed by suicidal behavior, anxiety,
substance abuse, eating disorders, and problems with anger and hostility, respectively. In
community samples, NSSI was most frequently associated with suicidal behavior, depres-
sion, substance abuse, hostility/anger, and anxiety (Lofthouse et al., 2009). Although other
psychiatric disorders (e.g., borderline personality disorder) and experiences (e.g., trauma,
maltreatment) are commonly associated with NSSI (D’Onofrio, 2007), research suggests
that their relationship may be less direct and less significant than previously believed (Loft-
house et al., 2009).
The presence of one or more of these psychiatric disorders or problems may place youth
at heightened risk for the development of NSSI. In many cases, however, NSSI may precede
rather than follow particular psychiatric problems. Consequently, school personnel should
be cautious in making particular assumptions about these disorders in terms of whether
they contribute to or result from NSSI (Miller & Brock, 2010).
Differentiating NSSI From Suicidal Behavior

The relationship between NSSI and suicidal behavior is complex and nuanced (Jacobson
& Gould, 2007; Klonsky & Muehlenkamp, 2007). Suicidal behavior has a high rate of
comorbidity with NSSI, and individuals who engage in NSSI are at increased risk for
suicide. Joiner (2005, 2009), for example, has suggested that engaging in NSSI may essen-
tially serve as “practice” for engaging in other potentially lethal behaviors such as suicide
by desensitizing individuals to pain and habituating them to violence. That said, many
people who engage in NSSI are not suicidal, and the functions of NSSI and suicide are
frequently quite different (Miller, 2011). Indeed, NSSI is typically counterintentional to
suicide, in the sense that the suicidal individual typically wants to end all feelings while
the individual who engages in self-injury typically does so to feel better (D’Onofrio, 2007;
Favazza, 1998).
Nevertheless, engaging in NSSI clearly places individuals at risk for a variety of suicidal
behaviors, including suicidal ideation and suicide attempts (Jacobson & Gould, 2007).
In particular, research suggests that people who engage in self-injury are more likely to
attempt suicide if they report being repulsed by life, if they exhibit greater apathy and self-
criticism, if they have fewer connections to family members, and if they report less fear
about suicide (Muehlenkamp & Gutierrez, 2004, 2007). Differentiating suicidal behavior
from NSSI can be a challenge; for more information on this topic, the reader is referred to
Miller (2011), Miller and Brock (2010), and Walsh (2006).
NSSI: A Comprehensive Approach to School-Based Prevention and Intervention

In attempting to provide effective prevention and intervention services in schools for youth
who may be exhibiting NSSI, a public health approach is recommended (Miller & Brock,
2010). A central characteristic of a public health approach is its emphasis on prevention
and early intervention with entire populations rather than individuals (Doll & Cummings,
2008). A public health approach in schools can perhaps best be conceptualized using a
three-tiered model of prevention and intervention (Shinn & Walker, 2010). These three
overlapping tiers represent a continuum of interventions that increase in intensity to meet
individual student needs (Sugai, 2007).
The three tiers include intervention strategies at the universal level (i.e., all students
in a particular population are recipients of interventions designed to prevent particular
problems), the selected level (i.e., interventions designed for students at risk for developing
368 David N. Miller
particular problems), and the tertiary level (i.e., interventions designed for students who are
already exhibiting problem behavior and for whom interventions at the previous two tiers
were not sufficient). A public health approach utilizing a three-tier model of prevention
and intervention has been increasingly viewed as a recommended approach to educational
practice (Merrell, Ervin, & Gimpel Peacock, 2012; Miller & Sawka-Miller, 2008; Yssel-
dyke et al., 2006). It has been advocated for a variety of problems in schools, including
academic concerns (Ikeda, Paine, & Elliott, 2010), child poverty (Miller & Sawka-Miller,
2009), antisocial behavior and school violence (Furlong, Jones, Lilles, & Derzon, 2010;
Sprague & Walker, 2010), bullying and peer harassment (Espelage & Swearer, 2010),
and depression, suicidal behavior, and other internalizing problems (Merrell & Gueldner,
2010; Seeley, Rohde, & Bracken Jones, 2010), including NSSI (Miller & Brock, 2010).
When implementing the three-tier model, interventions at the selected and tertiary levels
will often be similar and may frequently overlap (Merrell & Gueldner, 2010). For the pur-
poses of the present chapter, we will first consider universal prevention strategies (tier one)
for NSSI, followed by generally recommended intervention strategies (tiers two and three).
School-Based Prevention of NSSI: Universal Strategies

Miller and Brock (2010) suggest that school personnel consider implementing three types
of universal strategies: teaching students and school personnel about NSSI; and where to
go for help; confronting and correcting myths and misunderstandings about NSSI, and
promoting student strengths and resiliency. Each of these areas is described briefly ahead.
Teaching Students and School Personnel About NSSI and Where to Go for Help
A recommended universal strategy is to provide information to all students and school
staff members in a given population (e.g., entire school, entire school district) about NSSI,
including where to go for help. For example, there should be one or more designated indi-
viduals at the school to whom school personnel and students should report if they suspect
that someone may be exhibiting self-injury. These individuals should be mental health pro-
fessionals (e.g., school psychologist, school counselor, school social worker) who are at the
school on a regular basis. Many teachers and other members of the school staff may find it
difficult to understand NSSI, and when discussing it with school personnel it may arouse
greater negative emotions (e.g., fear, disgust) rather than more positive, helpful ones (e.g.,
sympathy). It is therefore incumbent upon the individuals providing this information to
do so in way that will ultimately lead to greater understanding and empathy for students
who engage in self-injury.
Although medical (e.g., school nurse) and mental health professionals in the school should
be integrally involved with the assessment and treatment of students exhibiting NSSI, other
school staff members (e.g., teachers, principals, librarians, coaches, bus drivers, cafeteria
workers, etc.) may be among the first adults in the school to recognize the behavior (Lieber-
man et al., 2009). For example, students who engage in NSSI might first report it to a trusted
teacher rather than the school nurse or a school-based mental health professional. Conse-
quently, even though teachers and related school personnel will most likely not be involved
in the assessment or treatment of NSSI, it is still important that they receive information
regarding possible warning signs for self-injury, as well as suggestions for what to do and
what to avoid when confronted by a student engaging in it (Lieberman et al., 2009).
All school personnel should be aware of possible warning signs for NSSI. Some possible
warning signs include: (a) frequent or unexplained scars, cuts, burns, or bruises; (b) use of
clothing to conceal wounds that may appear on the arms, thighs, or abdomen (e.g., wearing
long-sleeve shirts during warm weather); (c) evidence of self-injury in work samples, jour-
nals, or art projects; (d) secretive behaviors, such as spending extended time in the student
restroom or isolated areas of the school campus; (e) evidence of high risk-taking behaviors;
(f) evidence of eating disorder or substance abuse; (g) possible history of maltreatment and
abuse; and (h) general signs of depression, social isolation, and/or disconnection (Lieber-
man & Poland, 2006; Lieberman et al., 2009). Unfortunately, it is not currently clear as to
which of the foregoing possible risk factors, or which combination of them, best predict
which individuals will likely engage in or are engaging in NSSI. Moreover, some students
may exhibit several of these risk factors but may not be engaging in self-injury.
Correcting Common Myths and Misunderstandings About NSSI

All students and school personnel should be made aware of the many myths and mis-
conceptions that surround NSSI. This information should be clearly communicated to
students and school personnel on a regular (i.e., annual) basis. Examples of some myths
and misconceptions regarding NSSI include the following: (a) all youth who engage in
self-injury are suicidal; (b) self-decoration (e.g., tattooing) is a form of self-injury; (c) all
youth who engage in self-injury have been physically or sexually abused; (d) all youth who
engage in self-injury are “crazy” and need to be hospitalized; (e) youth who self-injure do
so only to get attention or to manipulate others into getting what they want; and (f) youth
who engage in self-injury present a danger to others as well as themselves (Kanan, Finger,
& Plog, 2008; Lieberman & Poland, 2006).
Promoting Student Strengths and Resiliency

A universal approach to NSSI in schools should be concerned with not only preventing
NSSI whenever possible, but also promoting student strengths, competencies, and healthy
living skills (Miller & Brock, 2010). Although students at risk for engaging in NSSI could
potentially benefit from universal programs designed to foster mental health and wellness,
it is clear that all students, regardless of whether they are at risk for particular problems,
could benefit as well. Such programs would be strengthened by incorporating findings
from the professional literature in health promotion (Nastasi, 2004) and the emerging field
of positive psychology (Snyder & Lopez, 2007), particularly as these areas are applied to
schools (Gilman, Huebner, & Furlong, 2009). For example, given that youth who engage
in NSSI frequently experience a high degree of negative emotions and thoughts, teaching
students skills for engaging in healthier, more positive emotions (Fredrickson & Joiner,
2002) and cognitions (Wingate et al., 2006) could be beneficial. Moreover, because youth
who engage in NSSI frequently report high levels of social isolation (Walsh, 2006), devel-
oping programs designed to enhance students’ levels of perceived social support (Demaray
& Malecki, 2002) and school connectedness (Appleton, Christenson, & Furlong, 2008)
may promote their sense of belonging, a potentially important variable for reducing NSSI
(Miller & Brock, 2010).
Focusing on other areas to promote student strengths and competencies may be benefi-
cial for youth with NSSI as well. For example, because individuals who engage in NSSI
often exhibit emotional volatility, teaching students to develop greater emotional regu-
lation skills could be beneficial (Buckley & Saarni, 2009). In addition, given the high
levels of negative affect and cognitive distortions often present among youth engaging
in NSSI, interventions for the promotion of hope (Lopez, Rose, Robinson, Marques, &
Pais-Ribeiro, 2009), optimism (Boman, Furlong, Shochet, Lilles, & Jones, 2009), and life
satisfaction (Suldo, Huebner, Friedrich, & Gilman, 2009) might prove useful as well.
370 David N. Miller
Although universal strategies may be potentially useful in preventing the development of
NSSI in some students, there are currently no empirical studies that have definitively dem-
onstrated this outcome (Miller & Brock, 2010). Many of these strategies have, however,
been recommended as being useful in the prevention of other related problems, such as
youth suicidal behavior (Miller, 2011), and could prove useful for the prevention of NSSI
as well (Miller & Brock, 2010). In particular, it appears that having strong connections to
school is an important variable for promoting mental health generally, and may be useful
for preventing NSSI. For example, one study found that adolescents were less likely to
harm themselves either through NSSI or suicidal behavior if they attended schools where
they felt safe, had close friendship ties with peers in schools, and perceived themselves as
being members of a tightly knit school community (Bearman & Moody, 2004). School
personnel can promote greater student-school connectedness in a number of ways, such as
enhancing students’ academic competence or encouraging their participation in structured
extracurricular activities such as athletic teams, school clubs, school-sponsored plays, and/
or the school band (Miller & Brock, 2010).
Promoting student mental health and wellness (Miller, Gilman, & Martens, 2008;
Nastasi, 2004) by focusing on increasing students’ competencies rather than merely
decreasing students’ problems (Doll & Cummings, 2008) is strongly aligned with a pub-
lic health model of prevention and intervention (Miller, Nickerson, & Jimerson, 2009;
Nastasi, 2004). For some students, however, universal programs designed to prevent
problems and promote competencies will not be sufficient. For those students who begin
to engage in self-destructive behavior such as NSSI, immediate and effective interven-
tion is required. Some recommended steps for working with these students in schools
are described ahead.
Crisis Counseling and Intervention: Initially Responding to Students with NSSI

The initial response to the student who is exhibiting NSSI will frequently be a strong pre-
dictor of whether subsequent treatment is effective (Walsh, 2006). In particular, a skillful
initial response can gain the confidence of the student and is more likely to lead to cor-
rectly identifying the unique features of the student’s self-injury. Conversely, mishandling
the initial response to NSSI can result in unintended negative consequences. For example,
a student may be mistakenly identified as suicidal, possibly resulting in unnecessary hos-
pitalization (Walsh, 2006).
An effective initial response to a student exhibiting NSSI is also important for develop-
ing a positive and therapeutic alliance with the student (Nafisi & Stanley, 2007), which
is critical if effective intervention is to occur. Unfortunately, developing a positive alliance
with students engaging in NSSI is frequently difficult to accomplish. For example, students
who engage in NSSI are often concerned about how their self-injury will be perceived by
others (Nixon & Heath, 2009a), which may in turn affect the degree to which they will
honestly self-disclose their situation and confide in school personnel. This problem is com-
pounded by research indicating that school personnel such as teachers are often perplexed
and disturbed by NSSI, and that they frequently feel ill-prepared to respond to it ade-
quately (Heath et al., 2006, 2011). School psychologists have reported similar perceptions
of inadequate training in response to NSSI (Miller & Jome, 2010), and even experienced
mental health and medical professionals report self-injury to be among the most difficult
and upsetting behaviors they encounter in their work (Connors, 2000; Dieter, Nicholls,
& Pearlman, 2000). Many professionals who have attempted to work with individuals
engaging in NSSI have reported high levels of disgust in conjunction with a sense of help-
lessness regarding what to do to help (D’Onofrio, 2007; Walsh, 2006).
To counteract these tendencies, it is especially important that school-based mental health
professionals—those individuals in the schools who will most likely provide therapeutic
interventions—be cognizant of certain issues when working with students engaging in
NSSI. Several of these issues are discussed ahead, along with some suggestions and recom-
mendations for school personnel working with self-injurious youth. These recommenda-
tions come largely from Walsh (2006), who has extensive clinical experience working with
people who engage in self-injury, including adolescent and young adult populations.
Avoid Underreacting and Overreacting to NSSI

It is first essential that practitioners neither underreact nor overreact to NSSI (Walsh,
2006). If a professional underreacts to a student with NSSI and does not respond to the
situation with sufficient urgency, it will likely communicate to students that their problems
are not being taken seriously. Such behavior will also likely undermine any trust or alli-
ance that may be created between the school professional and the student. Overreacting to
NSSI—in the form of reacting to it with shock, disgust, horror, or excessive concern—can
be equally problematic. As noted by Walsh (2006), “conveying shock, followed by recoil
and retreat, is destructive to self-injurers. Too many have encountered multiple losses and
rejections in their lives and do not need additional abandonment experiences” (p. 76).
Unfortunately, some adult reactions may be extreme and unhelpful. For example, Walsh
(2006, p. 76) noted a situation in which a father’s initial reaction to his daughter’s cutting
and burning herself was to call her “a stupid idiot,” later adding that “if you’re going to
do that sick kind of behavior, you can get out of here and into a mental hospital right now!
You know and I know you’re just doing it for attention! Get out of my sight!” It should
come as no surprise that such a response is extremely unhelpful and counterproductive.
Communicate in a Low-Key, Dispassionate Manner

Instead of either underreacting of overreacting to a case of NSSI, it is recommended that
school personnel interact with students who engage in self-injury in a calm, dispassionate,
low-key manner (Walsh, 2006), focusing on listening to the student’s perspective regard-
ing his/her problems and emotional well-being (Nixon & Heath, 2009a). Being able to
listen effectively to youth and their concerns often is a critical variable in determining
whether treatment will be successful. In fact, Walsh (2006) has stated that “the secret to
understanding and treating self-injury is first and foremost developing the ability to really
listen” (p. xiv).
Emotionally charged reactions to NSSI are generally counterproductive. First, emo-
tional responses, regardless of whether they are supportive or condemning, may result
in shame or embarrassment for the self-injurious youth. Emotional reactions by adults
may also result in making the self-injuring person less likely to communicate about his/
her behavior in the future. In addition, in many cases highly emotional reactions by adults
may inadvertently reinforce the behavior, making it more likely to occur in the future. This
reinforcement may occur because nurturing, overly solicitous responses may be highly
gratifying for youth engaging in NSSI, particularly among those who have been neglected,
rejected, or abused. Condemnation and recoil reactions among adults may also be para-
doxically reinforcing, particularly for youth who receive a high degree of satisfaction and
gratification in provoking strong reactions from adults (Walsh, 2006).
Achieving some sort of equanimity may take some practice on the part of the school
mental health professional, but it has two significant advantages in working with youth
who self-injure. First, it does not involve adding even more affect to an already emotionally
372 David N. Miller
charged situation. Second, it does not inadvertently reinforce a behavior that the school
professional wants to decline and hopes to cease (Walsh, 2006).
Be Nonjudgmental and Compassionate

Youth who engage in self-injury frequently encounter harsh and pejorative judgments
about their NSSI, and are also highly aware that many if not most adults will find their
behavior to be bizarre and inexplicable. If an adult from their school responds to them
with nonjudgmental compassion, it can often be immediately reassuring and relieving
(Walsh, 2006). Communicating to youth engaging in NSSI in this manner will increase the
probability that the youth will self-disclose honestly about their problems and concerns.
Walsh (2006) provides a useful distinction between providing students with compassion—
which is recommended—and providing concern and support—which is not. The main dif-
ference between the two “is subtle in tone. Concern and support suggest a certain amount
of affective intensity, a yearning to be of assistance, and a desire to quickly protect and
intervene. Compassion is more about acceptance, about being with the client in a neutral,
nonjudgmental way with no immediate expectations for change” (Walsh, 2006, p. 78).
An example of this nonjudgmental, compassionate approach—which is both difficult to
describe and achieve—is provided here by Walsh (2006, p. 78):
Therapist: It’s good to hear those details about your life. Could we move now toward
discussing why you came?
Client: (looking embarrassed) Well, I cut myself all the time. . .
Therapist: (low-key demeanor, compassionate tone) How often do you do it?
Client: Almost every day.
Therapist: That is quite frequent. [not minimizing] Where do you tend to cut yourself?
[respectful curiosity]
Client: (even more embarrassed) Everywhere, I guess.
Therapist: I see. Do you have favorite body areas to cut? [respectful curiosity]
Client: Yeah, my arms and legs.
Therapist: Okay. Is it one of the most effective ways you have to deal with your feelings?
Client: (enthusiastically) Definitely!
Therapist: Well, it’s no wonder you do it so often then, is it? [non-judgmental]
Client: Thanks for understanding. Most people think I’m a jerk or a nut.
Convey Respect and Curiosity

Kettlewell (1999), who engaged in self-injury herself for years, has suggested that another
way to helpfully respond to an individual who self-injures is to communicate with that
person in a manner characterized by “respectful curiosity.” According to Walsh (2006),
“Curiosity conveys an attitude of wanting to know more about the problem rather than
wanting the problem to go away quickly. To be helpful, curiosity has to be tempered and
respectful. Interest that comes across as prurient or thrill seeking is aversive (or too rein-
forcing) for most self-injurers” (p. 77).
Use the Student’s Own Descriptive Language Strategically

Most youth who engage in NSSI use behaviorally descriptive language when they speak
about it, referring to it as “cutting, “carving,” “burning,” “scratching,” or some other
descriptor. When school-based mental health professionals work with these students, it
is often helpful for them to employ the same descriptive language as the students do.
Doing so has several distinct advantages. First, using the client’s own terminology can
be viewed as a joining strategy. It also demonstrates respect for the client, and can there-
fore assist in forming a therapeutic alliance (Walsh, 2006). As noted by Walsh (2006),
the implicit message from the therapist is, “I am giving respectful attention to your view
of this and using your own language in discussing it” (p. 73). Mirroring the language
of the student also is a preliminary step in entering the client’s “psychological space”
(Walsh, 2006, p. 73). Using the youth’s own language can therefore be useful for entering
the client’s psychological space, and demonstrates empathy on the part of the therapist
(Walsh, 2006).
There are times, however, when using the terminology employed by self-injuring youth
is ill-advised. According to Walsh (2006), these exceptions involve two kinds of language:
the “minimizing” and the “ultrasubjective” (Walsh, 2006, p. 73). Language of minimaliza-
tion is said to occur when an individual is engaging in significant self-harm to his or her
body, but the individual’s language does not accurately reflect the level of damage inflicted.
Walsh (2006), for example, described working with a female client who was covered with
extensive and permanent scars on both of her arms. When this individual first met with
a therapist, however, she described her significant self-injury as “picking” and “scratch-
ing”—language that clearly minimized the level and extent of her NSSI.
Another problem may occur when youth engaging in NSSI refer to the behavior in an
ultrasubjective manner. According to Walsh (2006), this most commonly occurs when
working with individuals who may be psychotic. For example, an individual may speak
of his or her self-injury as a manifestation of “evil spirits” or some other fictitious entity.
This kind of language problem will be much less likely to occur than minimization, given
that most individuals engaging in NSSI do not suffer from a delusional disorder, such as
schizophrenia.
Avoid “Contracts” and Convey Limits of Confidentiality

A common mistake that some professionals make when they first encounter an individual
engaging in NSSI is to make what is considered to be a “contract” with the individual to
not engage in self-injury (Miller & Brock, 2010). This practice is problematic because
engaging in NSSI is often the best emotion-regulation technique individuals with this prob-
lem have devised, and asking these individuals to give it up can be both unrealistic and
invalidating (Walsh, 2007). Students may view such “contracts” as implicit condemnation
of their behavior, which will likely have negative effects on the relationship between the
student and the school-based mental health professional. A more effective strategy would
involve teaching the student new and more effective skills in emotional regulation rather
than “forbidding” NSSI (Walsh, 2007).
The issue of contracts also applies to youth exhibiting suicidal behavior, and examining
the issue in that context may be useful. Similar to safety contracts for NSSI, “safety” or
“no-suicide” contracts are verbal or written agreements between an adult professional and
an individual at risk for suicide. Suicidal individuals are presented with such contracts,
and often asked to sign them, in the hope that it will improve intervention compliance
and decrease the probability of suicidal behavior (Miller & Eckert, 2009). Although “no-
suicide” contracts have been widely used, particularly in outpatient settings (Berman et al.,
2006), their use has been criticized on the grounds that they provide professionals with
a false sense of security and decrease clinical vigilance (Goin, 2003). For example, Jobes
(2003) has pointed out that “safety contracts are neither contractual nor do they ensure
genuine safety, because they tend to emphasize what patients won’t do versus what they
374 David N. Miller
will do” (p. 3). A literature review of no-suicide contracts with suicidal individuals found
no support for their use (Rudd, Mandrusiak, & Joiner, 2006), and led the authors to
propose the use of commitment to treatment statements as an alternative. School-based
mental health professionals are encouraged to adopt similar practices when working with
students engaging in NSSI (Miller & Brock, 2010).
Manage and Prevent Possible Contagion

A sequence of events in which an individual engages in NSSI and is then imitated by others
in the individual’s environment is referred to as contagion (Lieberman et al., 2009). Social
contagion, such as the rapid spreading of NSSI among students, appears to be an emerg-
ing problem in some schools. In these situations, multiple students who know each other
engage in self-injury within short periods of time (Lieberman et al., 2009). These students
often appear to be communicating frequently about NSSI, essentially triggering the behav-
ior in each other (Walsh, 2006). In some situations the contagion may be immediate and
direct, with students injuring themselves in the presence of other students. These students
may share the same tools or implements of self-injury, and may even assist injuring one
another (Walsh, 2006).
Young people may trigger self-injury in each other for a variety of reasons, including:
(a) the behavior produces feelings of cohesiveness and group bonding; (b) the behavior has
powerful communication aspects; (c) the behavior may be perceived by others as outra-
geous and provocative; and (d) the behavior may also be inadvertently reinforced by adults
(Walsh, 2006). To address these issues, Walsh (2006) recommends that school personnel
consider implementing three interventions to minimize possible contagion effects, includ-
ing reducing communication about NSSI among students, effectively managing students
who openly display the scars or wounds that resulted from their self-injury, and employing
individual rather than group counseling procedures for youth with NSSI. Each of these
areas is discussed in more detail ahead.
Reduce Communication About NSSI

Students speaking to each other about their NSSI may create a triggering effect. Young
people may sometimes even compete with each other to produce more or grislier methods
of self-harm (Walsh, 2006). One strategy that might be useful to counteract this situation
and decrease the probability of contagion is for school staff to explain to students that
communicating (i.e., talking, emailing, texting) about NSSI has a negative effect on peers
by making self-harm more likely. Many students engage in self-injury with little or no
remorse, but feel guilty if their behavior negatively affects their friends. Making appeals
to youth in this situation can be effective. Some students, however, will not respond to
this strategy, especially if they feel no remorse if they trigger NSSI in their peers (Walsh,
2006). Moreover, it would seem that some would be reinforced for this behavior by having
it emulated by friends.
Manage Students Who Exhibit Scars or Wounds

Some students who engage in self-injury may openly exhibit their wounds and scars. View-
ing wounds or scars can be troubling to other students in the school, and may serve as
a triggering device for vulnerable students at risk for NSSI (Walsh, 2006). When work-
ing with a student who exhibits his/her wounds and/or scars, Walsh (2006) recommends
meeting with the student privately and making a direct request to the student that he/she
cover the scars or wounds with clothing, jewelry, a bandana, or some other means while
at school. Simply covering the wounds with a bandage is not acceptable, because it will be
obvious to other students that wounds are underneath.
In many cases, students will be responsive to this direct request. For those students who
are not responsive, the next step should be to contact the student’s parents and work with
them to ensure their child is complying with the school’s request. In some instances, fami-
lies may be asked to provide extra sets of clothing that can be stored at school if and when
a student’s attire is inappropriate. In the most extreme cases, students may need to be sent
home (Walsh, 2006). It should be understood, however, that doing so may reinforce the
student if he/she desires to escape the school environment.
Use Individual Rather Than Group Counseling

Placing students who self-injure together in groups for purposes of counseling can often
backfire; rather than being therapeutic, providing group counseling may also provide
greater opportunities for peer modeling and contagion. School-based professionals provid-
ing therapeutic interventions for students in schools are therefore encouraged to provide
individual counseling services to self-injurers (Walsh, 2006).
Providing effective treatment for self-injury will often involve multiple components,
including contingency management strategies, replacement skills training, body image
work, possible exposure treatment, psychopharmacological intervention, and family
interventions (Walsh, 2006, 2007). Cognitive-behavioral therapy is also typically recom-
mended, and one cognitive-behavioral approach that has significant promise for the treat-
ment of NSSI is dialectical behavior therapy.
Dialectical Behavior Therapy: A Potentially Useful Counseling Approach

Dialectical behavior therapy, otherwise known as DBT, is a cognitive-behavioral therapy
for complex and difficult to treat mental health problems. DBT is a relatively new thera-
peutic approach, and is considered a “third wave” behavior therapy (Hayes, Follette,
& Linehan, 2004). “First wave” behavior therapies emphasized the application of basic
behavioral principles to clinical problems. “Second wave” behavior therapies added a cog-
nitive component by attempting to eliminate or replace irrational thoughts among clients
exhibiting cognitive distortions. In contrast, third-wave behavior therapies emphasize two
fundamental and related concepts: acceptance and mindfulness (Greco & Hayes, 2008;
Hayes et al., 2004).
DBT focuses on both the acceptance of problems and changing them—ideas that appear
contradictory. As noted by O’Brien, Larson, and Murrell (2008), however, “the goal of
these techniques is not to change problematic thoughts or emotions, but rather to accept
them for what they are—just private experiences, not literal truth. In this view, acceptance
is accompanied by change, but the change is of a different sort than that seen in tradi-
tional cognitive-behavioral therapies” (p. 16). Specifically, while in traditional cognitive-
behavioral therapy individuals are challenged to change the content of their thoughts,
in DBT the therapist assists the individual to change the relationship to their thoughts
(Linehan, 1993). In other words, clients receiving DBT are taught that their thoughts are
just that and nothing more, and that one need not take such thoughts seriously or become
overly attached to their value or accuracy. By accepting their thoughts and not getting
overly attached to them, or trying to change them through traditional cognitive-behavioral
techniques such as cognitive restructuring, change can occur. The careful balance between
acceptance and change is the central dialectic in DBT (O’Brien et al., 2008).
376 David N. Miller
In addition to acceptance, the other central element of DBT is an emphasis on mind-
fulness. Mindfulness involves “paying attention in a particular way; on purpose, in the
present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). Behaving mindfully
therefore entails being present and nonjudgmental even in those situations and moments
that are unpleasant and painful (O’Brien et al., 2008). Engaging in mindfulness requires
three different but interrelated components: observing, describing, and participating.
More specifically, “observing entails watching one’s own thoughts, feelings, and behav-
iors without trying to change them; describing refers to the labeling of thoughts, feel-
ings, and behaviors without judgment; and participating requires complete involvement in
the present moment, without self-consciousness” (O’Brien et al., 2008, p. 21). Practicing
mindfulness is fairly simple in theory but often extremely difficult to execute (Miller &
Nickerson, 2007). With ongoing practice, however, individuals can improve their ability
to be mindful. Although the application of mindfulness procedures for addressing mental
health problems such as NSSI has a relatively recent history (Greco & Hayes, 2008), Bud-
dhists have been practicing mindfulness for over 2,500 years (Kabat-Zinn, 2003).
Originally developed by Linehan (1993), DBT grew out of failed attempts to apply
standard cognitive-behavioral therapy protocols to chronically suicidal adult clients with
comorbid borderline personality disorder (Dimeff & Linehan, 2001). It has subsequently
been modified to treat a host of other mental health problems characterized by emotional
dysregulation, including NSSI (Nock, Teper, & Hollander, 2007). DBT therapists work-
ing with students engaging in NSSI should first work with them to commit to treatment,
then focus on the main skills taught to students during DBT sessions, including mindful-
ness, emotional regulation, interpersonal effectiveness, and distress tolerance (Nock et al.,
2007). Although DBT therapy for adults is often recommended to occur for at least a year,
a version of DBT developed for adolescents is significantly more brief and can be com-
pleted within a 16-week period (Miller, Rathus, & Linehan, 2007).
Some school-based mental health professionals may be familiar with DBT, but most are
unlikely to have the necessary knowledge and skills to administer it effectively. Moreover,
professionals who are more familiar and comfortable with traditional cognitive-behavioral
techniques, such as cognitive restructuring and the disputation of irrational thoughts and
beliefs, may (at least initially) find the “mental shift” necessary to fully understand DBT
difficult (Merrell, 2008). School-based mental health professionals interested in learn-
ing more about DBT are encouraged to review other sources, including Linehan (1993),
Callahan (2008), and especially Miller, Rathus, and Linehan (2007). Readers interested
in more information on the treatment of NSSI generally, including DBT, are encouraged
to review D’Onofrio (2007), Walsh, (2006), Nixon and Heath (2009b), and Miller and
Brock (2010).
Conclusion
Although it is not a new phenomenon, nonsuicidal self-injury among youth is receiving
greater attention than ever before, and the number of young people exhibiting this behav-
ior is increasingly coming to the attention of school personnel. Unfortunately, many in
schools find NSSI difficult to comprehend, and perceive themselves as not being adequately
trained to effectively respond to it. Consequently, NSSI presents significant challenges to
school personnel, particularly school-based mental health professionals providing crisis
prevention and intervention services. A public health approach to NSSI, emphasizing both
prevention and intervention, is recommended for school-based practice. As professionals
working in schools learn more about this often disturbing condition, it is hoped they will
be better equipped to provide more effective services for youth engaging in NSSI.
REFERENCES
Appleton, J. J., Christenson, S. L., & Furlong, M. J. (2008). Student engagement with school:
Critical conceptual and methodological issues of the construct. Psychology in the Schools, 45,
369–386.
Bearman, P., & Moody, J. (2004). Suicide and friendships among American adolescents. American
Journal of Public Health, 94, 89–95.
Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). Adolescent suicide: Assessment and inter-
vention (2nd ed.). Washington, DC: American Psychological Association.
Boman, P., Furlong, M. J., Shochet, I., Lilles, E., & Jones, C. (2009). Optimism and the school con-
text. In R. Gilman, E. S. Huebner, & M. J. Furlong (Eds.), Handbook of positive psychology in
schools (pp. 51–64). New York: Routledge.
Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples: Prevalence,
correlates, and functions. American Journal of Orthopsychiatry, 64, 609–620.
Buckley, M., & Saarni, C. (2009). Emotion regulation. In R. Gilman, E. S. Huebner, & M. J. Furlong
(Eds.), Handbook of positive psychology in schools (pp. 107–118). New York: Routledge.
Callahan, C. (2008). Dialectical behavior therapy: Children and adolescents. Eau Claire, WI: Pesi.
Chandler, A., Myers, F., & Platt, S. (2011). The construction of self-injury in the clinical literature:
A sociological exploration. Suicide and Life-Threatening Behavior, 41, 98–109.
Connors, R. E. (2000). Self-injury: Psychotherapy with people who engage in self-inflicted violence.
Northvale, NJ: Jason Aronson.
Demaray, M. K., & Malecki, C. K. (2002). The relationship between perceived social support and
maladjustment for students at risk. Psychology in the Schools, 39, 305–316.
Dieter, P. J., Nicholls, S. S., & Pearlman, L. A. (2000). Self-injury and self-capacities: Assisting an
individual in crisis. Journal of Clinical Psychology, 56, 1173–1191.
Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California
Doll, B., & Cummings, J. A. (Eds.). (2008). Transforming school mental health services. Thousand
Oaks, CA: Corwin Press.
D’Onofrio, A. A. (2007). Adolescent self-injury: A comprehensive guide for counselors and health
care professionals. New York: Springer.
Espelage, D. L., & Swearer, S. M. (2010). Bullying and peer harassment. In M. R. Shinn & H. M.
Walker (Eds.), Interventions for achievement and behavior problems in a three-tier model includ-
ing RTI (pp. 729–748). Bethesda, MD: National Association of School Psychologists.
Favazza, A. (1996). Bodies under siege: Self-mutilation and body modification in culture and psy-
chiatry (2nd ed.). Baltimore, MD: Johns Hopkins University Press.
——— (1998). The coming of age of self-mutilation. The Journal of Nervous and Mental Disease,
186, 259–268.
Fredrickson, B. L., & Joiner, T. (2002). Positive emotions trigger upward spirals toward emotional
well-being. Psychological Science, 13, 172–175.
Furlong, M. J., Jones, C., Lilles, E., & Derzon, J. (2010). Think smart, stay safe: Aligning elements
within a multilevel approach to school violence prevention. In M. R. Shinn & H. M. Walker
(Eds.), Interventions for achievement and behavior problems in a three-tier model including RTI
(pp. 313–336). Bethesda, MD: National Association of School Psychologists.
Gilman, R., Huebner, E. S., & Furlong, M. J. (Eds.). (2009). Handbook of positive psychology in
schools. New York: Routledge.
Goin, M. (2003). The “suicide prevention contract”: Dangerous myth. Psychiatric News, 18, 3.
Gratz, K. L. (2006). Risk factors for deliberate self-harm among female college students: The role
and interaction of child maltreatment, emotional inexpressivity, and affect intensity/reactivity.
Greco, L. A., & Hayes, S. C. (Eds.). (2008). Acceptance and mindfulness treatments for children and
adolescents: A practitioner’s guide. Oakland, CA: New Harbinger Press.
Hayes, S. C., Follette, V. M., & Linehan, M. M. (Eds.). (2004). Mindfulness and acceptance: Expand-
ing the cognitive-behavioral tradition. New York: Guilford.
378 David N. Miller
Heath, N. L., Baxter, A. L., Toste, J. R., & McLouth, R. (2010). Adolescents’ willingness to accept school-
based support for nonsuicidal self-injury. Canadian Journal of School Psychology, 25, 260–276.
Heath, N. L., Schaub, K., Holly, S., & Nixon, M. K. (2009). Self-injury today: Review of population
and clinical studies in adolescents. In M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The
essential guide to assessment and intervention (pp. 9–27). New York: Routledge.
Heath, N. L., Toste, J. R., & Beetham, E. (2006). “I am not well-equipped”: High school teachers’
perceptions of self-injury. Canadian Journal of School Psychology, 21, 73–92.
Heath, N. L., Toste, J. R., Sornberger, M. J., & Wagner, C. (2011). Teachers’ perceptions of non-
suicidal self-injury in the schools. School Mental Health, 3, 35–43.
Ikeda, M. J., Paine, S. C., & Elliott, J. L. (2010). Supporting response to intervention (RTI) at school,
district, and state levels. In M. R. Shinn & H. M. Walker (Eds.), Interventions for achievement
and behavior problems in a three-tier model including RTI (pp. 27–45). Bethesda, MD: National
Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-
injurious behavior among adolescents: A critical review of the literature. Archives of Suicide
Research, 11, 129–147.
Jobes, D. A. (2003). Manual for the collaborative assessment and management of suicidality—
Revised (CAMS-R). Unpublished manuscript.
Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
——— (2009). Suicide prevention in schools as viewed through the interpersonal- psychological
theory of suicidal behavior. School Psychology Review, 38, 244–248.
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life.
New York: Hyperion.
——— (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psy-
chology: Science and Practice, 10, 144–156.
Kanan, L. M., Finger, J., & Plog, A. E. (2008). Self-injury and youth: Best practices for school inter-
vention. School Psychology Forum, 2, 67–79.
Kettlewell, C. K. (1999). Skin game. New York: St. Martin’s Griffin.
Klonsky, E. D., & Muehlenkamp, J. J. (2007). Self-injury: A research review for the practitioner.
Journal of Clinical Psychology: In Session, 63, 1045–1056.
Laye-Gindhu, A., & Schonert-Reichl, K. A. (2005). Non-suicidal self-harm among community ado-
lescents: Understanding the “whats” and “whys” of self-harm. Journal of Youth and Adolescence,
34, 447–456.
Lieberman, R., & Poland, S. (2006). Self-mutilation. In G. G. Bear & K. M. Minke (Eds.), Children’s
needs III: Development, prevention, and intervention (pp. 965–976). Bethesda, MD: National
Lieberman, R. A., Toste, J. R., & Heath, N. L. (2009). Non-suicidal self-injury in the schools: Pre-
vention and intervention. In M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The essential
guide to assessment and intervention (pp. 195–215). New York: Routledge.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New
York: Guilford.
Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and func-
tions of non-suicidal self-injury in a community sample of adolescents. Psychological Medicine,
37, 1183–1192.
Lofthouse, N., Muehlenkamp, J. J., & Adler, R. (2009). Non-suicidal self-injury and co- occurrence.
In M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The essential guide to assessment and
intervention (pp. 29–41). New York: Routledge.
Lopez, S. J., Rose, S., Robinson, C., Marques, S. C., & Pais-Ribeiro, J. (2009). Measuring and
programming hope in schoolchildren. In R. Gilman, E. S. Huebner, & M. J. Furlong (Eds.), Hand-
book of positive psychology in schools (pp. 37–50). New York: Routledge.
Merrell, K. W. (2008). Helping students overcome depression and anxiety: A practical guide (2nd
ed.). New York: Guilford.
Merrell, K. W., Ervin, R. A., & Gimpel Peacock, G. A. (2012). School psychology for the 21st cen-
tury: Foundations and practices (2nd ed.). New York: Guilford.
Merrell, K. W., & Gueldner, B. A. (2010). Preventive interventions for students with internalizing
disorders: Effective strategies for promoting mental health in schools. In M. R. Shinn & H. M.
Walker (Eds.), Interventions for achievement and behavior problems in a three-tier model includ-
ing RTI (pp. 799–824). Bethesda, MD: National Association of School Psychologists.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal
adolescents. New York: Guilford.
Miller, D. N. (2011). Child and adolescent suicidal behavior: School-based prevention, assessment,
and intervention. New York: Guilford.
Miller, D. N., & Brock, S. E. (2010). Identifying, assessing, and treating self-injury at school. New
York: Springer.
Miller, D. N., & Eckert, T. L. (2009). Youth suicidal behavior: An introduction and overview. School
Psychology Review, 38, 153–167.
Miller, D. N., Gilman, R., & Martens, M. P. (2008). Wellness promotion in the schools: Enhancing
students’ mental and physical health. Psychology in the Schools, 45, 5–15.
Miller, D. N., & Jome, L. M. (2010). School psychologists and the secret illness: Perceived knowl-
edge, role preferences, and training needs in the prevention and treatment of internalizing disor-
ders. School Psychology International, 31, 509–520.
Miller, D. N., & Nickerson, A. B. (2007). Changing the past, present, and future: Potential applica-
tions of positive psychology in school-based psychotherapy with children and youth. Journal of
Applied School Psychology, 24, 147–162.
Miller, D. N., Nickerson, A. B., & Jimerson, S. R. (2009). Positive psychology and school-based
interventions. In R. Gilman, E. S. Huebner, & M. Furlong (Eds.), Handbook of positive psychol-
ogy in schools (pp. 293–304). New York: Routledge.
Miller, D. N., & Sawka-Miller, K. D. (2008). The practice of school psychology in the 21st century:
Reflections and recommendations. In D. Molina (Ed.), School psychology: 21st century issues and
challenges (pp. 1–11). New York: Nova Science.
Miller, D. N., & Sawka-Miller, K. D. (2009). A school-based preferential option for the poor: Child
poverty, social justice, and a public health approach to intervention. In J. K. Levine (Ed.), Low
incomes: Social, health, and educational impacts (pp. 31–56). New York: Nova Science.
Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self- inju-
rious behavior and suicide attempts in a sample of adolescents. Suicide and Life-Threatening
Behavior, 34, 12–23.
——— (2007). Risk for suicide attempts among adolescents who engage in non-suicidal self-injury.
Archives of Suicide Research, 11, 69–82.
Muehlenkamp, J. J., Walsh, B. W., & McDade, M. (2010). Preventing non-suicidal self-injury in
adolescents: The signs of self-injury program. Journal of Youth and Adolescence, 39, 306–314.
Nafisi, N., & Stanley, B. (2007). Developing and maintaining a therapeutic alliance with self- injuring
patients. Journal of Clinical Psychology: In Session, 63, 1069–1079.
Nastasi, B. K. (2004). Meeting the challenges of the future: Integrating public health and public edu-
cation for mental health promotion. Journal of Educational and Psychological Consultation, 15,
295–312.
Nixon, M. K., Cloutier, P. F., & Aggarwal, S. (2002). Affect regulation and addictive aspects of
repetitive self-injury in hospitalized adolescents. Journal of the American Academy of Child &
Adolescent Psychiatry, 41, 1333–1341.
Nixon, M. K., & Heath, N. L. (2009a). Introduction to non-suicidal self-injury in adolescents. In
M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The essential guide to assessment and
intervention (pp. 1–6). New York: Routledge.
Nixon, M. K., & Heath, N. L. (Eds.). (2009b). Self-injury in youth: The essential guide to assessment
and intervention. New York: Routledge.
Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and functions of
self-injury. Current Directions in Psychological Science, 18, 78–83.
——— (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339–363.
Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative
behavior. Journal of Consulting and Clinical Psychology, 72, 885–890.
380 David N. Miller
Nock, M. K., Prinstein, M. J., & Sterba, S. K. (2009). Revealing the form and function of self- inju-
rious thoughts and behaviors: A real-time ecological assessment study among adolescents and
young adults. Journal of Abnormal Psychology, 118, 816–827.
Nock, M. K., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among ado-
lescents. Journal of Clinical Psychology: In Session, 63, 1081–1089.
O’Brien, K. M., Larson, C. M., & Murrell, A. R. (2008). Third-wave behavior therapies for children
and adolescents: Progress, challenges, and future directions. In L. A. Gresco & S. C. Hayes (Eds.),
Acceptance and mindfulness treatments for children and adolescents: A practitioner’s guide (pp.
15–35). Oakland, CA: New Harbinger.
Robins, C. J., Schmidt, H., & Linehan, M. M. (2004). Dialectical behavior therapy: Synthesizing
radical acceptance and skillful means. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.),
Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 30–44). New
York: Guilford.
Rodham, K., Hawton, K., & Evans, E. (2004). Reasons for deliberate self-harm: Comparison of
self-poisoners and self-cutters in a community sample of adolescents. Journal of the American
Academy of Child and Adolescent Psychiatry, 43, 80–87.
Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community sample of
adolescents. Journal of Youth and Adolescence, 31, 67–77.
Rudd, M. D., Joiner, T. E., & Rajab, M. H. (1995). Help negation after acute suicidal crisis. Journal
of Consulting and Clinical Psychology, 63, 499–503.
Rudd, M. D., Mandrusiak, M., & Joiner, T. E. (2006). The case against no-suicide contracts: The
commitment to treatment statement as a practice alternative. Journal of Clinical Psychology, 62,
243–251.
Seeley, J. R., Rohde, P., & Bracken Jones, L. (2010). School-based prevention and intervention
for depression and suicidal behavior. In M. R. Shinn & H. M. Walker (Eds.), Interventions for
achievement and behavior problems in a three-tier model including RTI (pp. 363–396). Bethesda,
Simeon, D., & Favazza, A. (2001). Self-injurious behaviors: Phenomenology and assessment. In D.
Simeon & E. Hollander (Eds.), Self-injurious behaviors: Assessment and treatment. (pp. 1–28).
Washington, DC: American Psychiatric.
Snyder, C. R., & Lopez, S. J. (2007). Positive psychology: The scientific and practical exploration of
human strengths. Thousand Oaks, CA: SAGE.
Sourander, A., Aromaa, A., Pihalkoski, L., Haavisto, A., Rautava, P., Helenius, H., & Sillanspaa, M.
(2006). Early predictors of deliberate self-harm among adolescents: A prospective follow-up study
from age 3 to 15. Journal of Affective Disorders, 93, 87–96.
Sprague, J. R., & Walker, H. M. (2010). Building safe and healthy schools to promote student suc-
cess: Critical issues, current challenges, and promising approaches. In M. R. Shinn & H. M. Walker
(Eds.), Interventions for achievement and behavior problems in a three-tier model including RTI
(pp. 225–257). Bethesda, MD: National Association of School Psychologists.
Sugai, G. (2007). Promoting behavioral competence in schools: A commentary on exemplary prac-
tices. Psychology in the Schools, 44, 113–118.
Suldo, S. M., Huebner, E. S., Friedrich, A. A., & Gilman, R. (2009). Life satisfaction. In R. Gilman,
E. S. Huebner, & M. J. Furlong (Eds.), Handbook of positive psychology in schools (pp. 27–35).
New York: Routledge.
Wagner, E. E., Rathus, J. H., & Miller, A. L. (2006). Mindfulness in dialectical behavior therapy
(DBT) for adolescents. In R. A. Baer (Ed.), Mindfulness-based treatment approaches: Clinician’s
guide to evidence-base and applications (pp. 167–189). San Diego, CA: Elsevier.
Walsh, B. W. (2006). Treating self-injury: A practical guide. New York: Guilford.
——— (2007). Clinical assessment of self-injury: A practical guide. Journal of Clinical Psychology:
In Session, 63, 1057–1068.
Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population.
Pediatrics, 117, 1939–1948.
Whitlock, J. L., Eels, G., Cummings, N., & Purington, A. (2009). Non-suicidal self-injury on college
campuses: Mental health provider assessment of prevalence and need. Journal of College Student
Psychotherapy, 23, 172–183.
Wingate, L. R., Burns, A. B., Gordon, K. H., Perez, M., Walker, R. L., Williams, F. M., . . . Joiner,
T. E. (2006). Suicide and positive cognitions: Positive psychology applied to the understanding and
treatment of suicidal behavior. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and
therapy (pp. 261–283). Washington, DC: American Psychological Association.
Woodberry, K. A., Roy, R., & Indik, J. (2008). Dialectical behavior therapy for adolescents with bor-
derline features. In L. A. Greco & S. C. Hayes (Eds.), Acceptance and mindfulness treatments for
children and adolescents: A practitioner’s guide (pp. 115–138). Oakland, CA: New Harbinger Press.
Ysseldyke, J., Burns, M., Dawson, M., Kelly, B., Morrison, D., Ortiz, S., . . . Telzrow, C. (2006).
School psychology: A blueprint for training and practice III. Bethesda, MD: National Association
of School Psychologists.
Index
abstinence-only programs 298–9 advocate, teen pregnancy role of 306–7

academic failure: bullying and 87; crisis from 51; age: divorce risk factors by 71–2; grief
NASP model addressing 49; parent perception responses typical by 130–1; NSSI and 365;
of 49; patterns of 48; perception of 49–52; rape and 337
rates of 48; student perception of 50–2; aggressive victims 90–1
teacher perception of 49–50 Ainsworth, Mary 110, 326
acceptance, in grief 133 alcohol consumption: rape and 337–8; suicide
ACLU see American Civil Liberties Union and 248
acquaintance rape 336 altar building 144
acts of violence: accounting for students and ambivalent-insecure attachment 327
staff during 220; campus visitors and 213–14; American Academy of Child and Adolescent
CPTED for 215; crisis prevention for 213–16; Psychiatry 203
crisis response box for 219; crowd control American Civil Liberties Union (ACLU) 290
for 220; emergency communications for 219; Americans with Disabilities Act 173, 176
emergency evacuations for 219–20; emergency anger, from grief 132, 133
procedures for 219; employee and student anonymous self-reporting 92
identification and 214; law enforcement anticipated life transitions 5, 11
involvement in 220–1; parent involvement anticipatory guidance 14
in response to 224; preparing for 218–21; antidepressant medication, suicide and 249
psychological triage responding to 222–3; Anxiety and Depression Association of America
publicity of 212; referral planning for 221, (ADAA) 47
223–4; responding to 221–4; reuniting students appraisal-focused coping 4
with parents during 220; school climate ARC framework 116–18
for preventing 214–15; school frequency of art and play therapy: for grief 145–6; for illness
212–13; school security for 215–16; self- 162–3
referral for response to 224; stereotypes and ASAP see Adolescent Suicide Awareness Program
217; student discipline and 213; students asthma 154
identified for potential 216–18; treating victims at-risk students, early intervention for 59
of 224; warning sign response for 217–18; Attachment, Self-Regulation, and Competency
warning signs identified for 216–17 see ARC framework
ADAA see Anxiety and Depression Association attachment theory: child maltreatment and
of America 108–9, 116–17; divorce and 72; early
ADAPT program 192 caregiving system essential to 108; for family
ADHD see attention deficit hyperactivity disorder system conflict and crisis 326–7
administrative support, for school safety/crisis attention deficit hyperactivity disorder (ADHD)
response team 23 248–9
adolescents; see also teen pregnancy: divorce attributions, destructive 54–5
and 69, 75; family system conflict and crisis avoidant-insecure attachment 327
with 314–16; intergenerational change of
315; moving considerations with 203–4; as background knowledge, for school crisis
rape and sexual assault victims 345–6 response 20–2
Adolescent Suicide Awareness Program (ASAP) Back Off Bully Program 95
253 bargaining, in grief 133
adults; see also parents: divorce impact on 69; behavioral regulation, child maltreatment and
grief processing for 129 110–11
384 Index
bibliotherapy 146; moving help with 206 Child Abuse Prevention and Treatment Act
bisexual youth 276; see also lesbian, gay, (CAPTA) 106
bisexual, transgender and questioning youth Childhood and Society (Erikson) 1
blame 9–10 childhood traumatic grief (CTG) 135
Bowen, Murray 322–3 child maltreatment: ARC framework for
Bowenian theory 322–3 116–18; attachment theory and 108–9,
Bowlby, John 326 116–17; behavioral regulation and 110–11;
bullies 88–9; identification methods for 92–3 biological effects of 109; causes of 112–13;
Bully Busters Program 95 cognitive processing interference of 111;
bully courts 96–7 competence for 118; crisis counseling
bully-focused interventions, for bullying 97–9 guidelines for 115–16; crisis intervention
bullying; see also cyber bullying: academic for 115–18; dissociation and 109–10;
failure and 87; bullies in 88–9; bully-focused ecological interventions for 115; emotional
interventions for 97–9; bully-victims in maltreatment in 107; emotional regulation
90–1; bystanders in 91–2; class meetings disturbed by 109; group intervention for
for 96; counseling interventions for 97–8; 118; home visitation programs for 114–15;
crisis intervention for 95–9; curriculum for neglect in 107; parent education for 113–14;
preventing 94–5; definition of 85; ecological physical abuse in 106; primary crisis
model and 88; explanations of 87–8; prevention for 113–15; protective factors
gender and 89; groups at-risk in 88–92; in 112–13; psychological abuse in 107; as
identification methods for 92–3; illness and psychological crisis 107–11; risk factors
157, 165–6; incidence and prevalence of 86; in 112; self-concept impacted by 111; self-
legislation addressing 99–100; method of regulation for 117–18; sexual abuse in 106–7
shared concern for 96; personal and social children; see also deployed parents, children
costs of 86–7; PIC for 98; problem of 85–7; with; incarcerated parents, children with;
reporting boxes for 93–4; restorative justice moving, children and; parents; students:
for 95–6; school crisis response programs adaptive tasks for 8; with cancer 154; in
for 93–5; SFT for 98–9; social-cognitive crisis 1; crisis prevention for sexual abuse of
interventions for 97; social-cognitive theory 114; cultural identification of 32; diversity
and 87–8; social learning theory and 87; statistics on 31; divorce as hazard for 67–8;
student advice for 94; support groups for divorce reactions of 68–9; divorce resolution
99; telephone hotlines for 93–4; topicality of 72; dying 140; early intervention in
of 85; victim-focused interventions for 97–9; development of 57; funerals and 142; grief
victim-inclusive approaches to 95–7; victims statistics with 128; grief support for 142–3;
of 90, 92–3 illness causing stress with 156; illness risk
Bully Proofing Program 95 factors for 155–6; incarcerated parent
bully-victims 90–1 risks for 184–6; magical thinking of 129;
bystanders, in bullying 91–2 marital conflict as risk for 69–70; parents
with disabilities and status variables of 179;
Campion, M. J. 176 parents with disabilities identification of
campus visitors, acts of violence and 213–14 at-risk 180–1; parents with disabilities with
cancer, children with 154; see also illness at-risk 174–9; as rape and sexual assault
CAPD see Center for Assessment and Policy victims 345–6; Steward’s Matrix of child’s
Development appraisal of experience of illness 158–9,
Caplan, Gerald 1–2, 3 163–4; of teen mothers 293–4
CAPTA see Child Abuse Prevention and Children Act of 1989 176
Treatment Act Children of Handicapped Parents: Research
caregiver: disaster training for 236; and Clinical Perspectives (Thurman) 174
reunification 26 Children’s Institute 58
case manager, teen pregnancy role of 306 chronic illness 153, 161; see also illness
CBT see cognitive behavioral theory civilian children, moving and 200–1
CCI see classroom-based crisis intervention class meetings, for bullying 96
CD see conduct disorder classroom-based crisis intervention (CCI): for
CDC see Centers for Disease Control and disasters 237; for school crises 55–7
Prevention Coconut Grove nightclub fire 1
Center for Assessment and Policy Development cognitive behavioral theory (CBT): for disasters
(CAPD) 306 238; for family system conflict and crisis
Centers for Disease Control and Prevention 328–9; for grief 135; for illness 161–2;
(CDC) 229 suicide model in 244–5, 246
Index 385
cognitive processing, child maltreatment communication and 36–7; for NSSI 370–6;
interfering with 111 PIC for 98; principles of 8–10; for rape
Columbia University, TeenScreen Program at 253 and sexual assault 340–5; rape and sexual
Columbine High School 2 assault victims and individual 344–5; social
Comer model 58–9 status and 35–6; sociolinguistic issues for 36;
“coming out” process, for LGBTQ youth 270 solution-focused 98–9, 162
communication: emergency 26, 219; illness and crisis intervention; see also classroom-
modes of 161; styles of 36; well-functioning based crisis intervention; individual crisis
families and healthy 318 intervention: for bullying 95–9; for child
competence, for child maltreatment 118 maltreatment 115–18; cultural implications
complex trauma 107–11, 116; see also child for 38–40; culturally sensitive protocols for
maltreatment 42–4; for deployed parents 193; disaster
complicated grief 129 preparation with levels of mental health
conduct disorder (CD) 272 232; for family system 319–26; grief and
confidentiality: group intervention and 77; school-wide 147; group 40; history of theory
illness and 161 for 1–2; for incarcerated parents 187–8;
conflict; see also family system conflict interpreters working with 41–2; language
and crisis: crisis compared to 316–17; issues in 40–2; for LGBTQ youth at various
interpersonal styles of 316 school levels 280–1; moving and individual
consultation 15; for school crises 59–60 207–8; for parents with disabilities 181–2;
contact boundaries 328 plans developed for 25–7; preparedness
contextual models, for LGBTQ youth protocols for 26–7; prevention programs
development 269–70 for 14–15; principles of 10–12; procedural
coping: defense mechanisms influencing 327; guidelines for 27–8; school crises using early
domains of 4; with illness 159–60 57, 59; services provided for 28; triage in 222
counseling see crisis counseling crisis prevention: for acts of violence 213–16;
counselors: behavior principles for 13; in crisis child maltreatment and primary 113–15; for
12–13; teen pregnancy role of 302–4 child sexual abuse 114; cultural implications
countertransference: family system conflict and for 43–4; with deployed parents 189–93;
crisis recognizing 320–1; grief management for divorce 72–4; for grief 147–8; for illness
of 136–7 165–6; for LGBTQ youth 277–83; moving
crime prevention through environmental design and 204–9; parents with disabilities and 181;
(CPTED) 215 programs for 14–15; school crises programs
crisis; see also family system conflict and crisis: with 57–9
from academic failure 51; anticipated life crisis responders 33–4
transitions and 5; child maltreatment as crisis response box 26; for acts of violence 219
psychological 107–11; children in 1; conflict Crisis Response Planning Committee (CRPC) 23
compared to 316–17; counselor in 12–13; crisis victim identification 27–8
culture and 32–4; culture and perception crowd control, for acts of violence 220
of 34; definition of 3–4, 9; dispositional CRPC see Crisis Response Planning Committee
4–5, 11; drills for 26; exercises for 26; CTG see childhood traumatic grief
maturational/developmental 6–7, 11; migrant Cuento therapy 40
families experience with 31; psychiatric culture: attitudes and beliefs of dominant
emergencies and 7–8, 11; psychopathology 32–3; children identification with 32;
reflected in 7, 11; rape and sexual assault communications styles and 36; concept of
victims reacting to 340; in school entry 46–7; 32; crisis and 32–4; crisis counseling and
traumatic stress and 5–6, 11; types of 4–8; implications of 35–8; crisis counseling
well-functioning families and 317–19 attitudes by 40; crisis intervention and
crisis counseling: bully interventions with 97–8; implications of 38–40; crisis intervention
child maltreatment guidelines for 115–16; protocols sensitive to 42–4; crisis
communications styles for 36; cultural perception and 34; crisis prevention and
attitudes towards 40; cultural implications 43–4; crisis responder and 33–4; denial
for 35–8; denial and 37–8; developmental variations by 37–8; dimensions of 33;
issues in 15–16; for divorce 74–5; dress and dress and 36; emotional expression and 37;
36; emotional expression and 37; goals of 8; food and 39; gifts and 39; multicultural
for grief 143–7; for illness 160–5; LGBTQ counseling 34; music and 39; nonverbal
youth preparation for professionals in 266–7; communication and 36–7; problem solving
LGBTQ youth suggestions for 282–3; for and 39; religion and 38–9; shamanic 38–9;
moving 207–9; multicultural 34; nonverbal social status and 35–6; social support
386 Index
networks and 38; sociolinguistic issues with psychological trauma from 234–5; threat
36; traumatic event reactions and 35 perceptions of 234; traumatic stress warning
cyber bullying; see also bullying: bully-victims signs for 234–5
in 91; bystanders in 92; definition of 86; disease prevention 166
gender and 89; incidence and prevalence of disenfranchised grief 141–2
86; victims of 90 disorganized-disoriented attachment 327
dispositional crises 4–5, 11
DABDA see denial, anger, bargaining, dissociation, child maltreatment and 109–10
depression, acceptance district-level crisis response team 24–5
dating violence 338, 356; see also sexual divorce; see also family system conflict and
assault crisis; marital conflict: adolescents and 69,
DBT see dialectical behavior therapy 75; adult impact of 69; age risk factors in
death; see also suicide: children nearing 140; 71–2; attachment theory and 72; children
of deployed parents 193; in family system and hazard of 67–8; children resolution
137–40; friend 140–1; grandparent 139; of of 72; children’s reactions to 68–9; crisis
parents 137–8; pet 139–40; of sibling 138–9; counseling for 74–5; crisis prevention for
sudden compared to prolonged 141; teacher 72–4; elementary school age reactions to
140; unfinished business with 144 68–9, 75; gender risk factors in 71; group
death anxiety 136, 148 intervention for 76–80; parent programs
debriefing 13 for 74; preschoolers and 68, 75; school
defense mechanisms 327 administrative policy changes with 73;
delegating authority 13 schools offering continuity during 67;
denial 9; crisis counseling and cultural statistics on 66; teacher assistance for 73–4
variations with 37–8; from grief 132–3 DoE see Department of Education
denial, anger, bargaining, depression, dress, culture and 36
acceptance (DABDA) 151 drills, for crisis 26
Department of Education (DoE) 22
deployed parents, children with: ADAPT Early Warning, Timely Response: A Guide to
program for 192; crisis intervention for Safe Schools 216
193; crisis prevention with 189–93; death ecological interventions, for child maltreatment
and 193; injury and disabilities with 115
193; prevalence of 188–9; prevention ecological model, bullying and 88
during deployment for 190–2; prevention educational workshops and programs 14
postdeployment for 192–3; prevention prior Educator’s Guide to the Military Child During
to deployment for 190; resilience from 189; Deployment 190–2
reunion issues for 192–3; trauma experienced EMDR see eye-movement desensitization and
by 188 reprocessing
depression, from grief 133 emergency communications 26; for acts of
destructive attributions 54–5 violence 219
developmental crises see maturational/ emergency evacuations, for acts of violence
developmental crises 219–20
developmental disabilities 52 emergency procedures, for acts of violence 219
dialectical behavior therapy (DBT) 375–6 emotional cutoff 323
differentiation 323 emotional expression 37
disabilities see parents with disabilities; emotional hazards 3
students with disabilities emotional inoculation 14
disabled sexual assault victims 347–8 emotional maltreatment 107
disasters: caregiver training for 236; CBT for emotional regulation, child maltreatment
238; CCI for 237; combined 229; ICI for disturbing 109
237–8; ICS preparation for 230–1; industrial emotion-focused coping 4
229; informational documents for 236; employee identification 214
mental health crisis intervention preparation Environmental Protection Agency (EPA) 229
for 232, 235–8; natural 229; NIMS Erikson, Erik 1
preparation for 230; PFA for 236–7; physical ethnicity: LGBTQ youth issues with 275–6;
and psychological safety planning for 231; NSSI and 365; of rape and sexual assault
PREPaRE program preparation for 230–8; victims 346; suicide and 243
responding to 233–8; safety perceptions for evacuations, emergency 219–20
234; student and staff resiliency promoted exercises, for crisis 26
for 232–3; student exposure to 234; student existential theory, grief and 136
Index 387
eye contact 37 gestures 37
eye-movement desensitization and reprocessing gifts, culturally appropriate 39
(EMDR) 238 GLAAD see Gay and Lesbian Alliance Against
Defamation
Families and Schools Together (FAST) 187–8 GLBT National Help Center 290
family dinner 144–5 GLSEN see Gay, Lesbian and Straight
family system; see also well-functioning Education Network
families: boundaries in 324; Bowenian theory grandparent death 139
for 322–3; crisis intervention for 319–26; grief: acceptance in 133; adult processing
death in 137–40; ecological lens on 319; of 129; advantages and disadvantages of
Minuchin theory for 323–5; negotiation 128–9; age-typical responses to 130–1; anger
in 324; Satir theory for 325–6; theories of from 132, 133; art and play therapy for
322–6 145–6; bargaining in 133; causes of 128;
family system conflict and crisis; see also CBT for 135; children statistics with 128;
divorce; well-functioning families: children support for 142–3; complicated
adolescents and 314–16; attachment 129; countertransference management for
theory for 326–7; CBT for 328–9; 136–7; crisis counseling for 143–7; crisis
conflict compared to crisis for 316–17; prevention for 147–8; DABDA approach to
countertransference recognition for 320–1; 151; from death in family system 137–40;
developmental transitions crisis 326; Gestalt denial from 132–3; depression from
theory for 327–8; intervention for 319–26; 133; in developmental context 129–35;
narrative therapy for 329; psychoanalytic disenfranchised 141–2; of dying children
theory for 327; Rogerian person-centered 140; elementary school age responses to
theory for 328; school-based mental health 130–1; existential theory and 136; from
practitioner consultation for 321; self- friend death 140–1; Gestalt theory and
awareness increased for 320–1; SFBT for 136; from grandparent death 139; group
329–30; therapy-based interventions for intervention for 146–7; high school response
321–6; 21st century issues for 317 to 131; infant responses to 130; Kübler-
FAST see Families and Schools Together Ross’s five stages of 132–3; middle school
father involvement, for teen pregnancy 297–8 response to 131; models of 132–5; mourning
Federal Emergency Management Agency compared to melancholia with 132; from
(FEMA) 22, 229 parent death 137–8; from pet death 139–40;
Feifel, Herman 147 preschooler responses to 130; rituals in
FEMA see Federal Emergency Management 143–5; Rogerian person-centered theory for
Agency 135–6; school-wide crisis intervention for
Feminist theory, on rape 351 147; from sibling death 138–9; from sudden
Finance/Administration Section Chief 24 compared to prolonged death 141; from
food 39 teacher death 140; teen pregnancy and 304;
Freud, Sigmund 132, 327 time capsules for 145; transitional objects for
friend death 140–1 145; unfinished business in 144; Worden’s
Fukushima Daiichi nuclear disaster 229 tasks of mourning for 133–5
funerals, children and 142 group intervention 40; for child maltreatment
118; confidentiality and 77; content
Gay, Lesbian and Straight Education Network determinations for 78–9; for divorce
(GLSEN) 273–4, 280, 290 76–80; for grief 146–7; heterogeneity of 77;
Gay and Lesbian Alliance Against Defamation interviews for 77–8; for LGBTQ youth 281–2;
(GLAAD) 290 for moving 208–9; parent participation in
Gay-Straight Alliances (GSAs) 273, 280, 290 79–80; peer 164; for rape and sexual assault
gay youth see lesbian, gay, bisexual, victims 345; referral assessment for 78–9;
transgender and questioning youth structure of 77; teacher participation in 80
gender: bullying and 89; cyber bullying and 89; GSAs see Gay-Straight Alliances
divorce risk factors by 71; NSSI and 365;
potential rapists and 339; rape and 337; rape hazards 3, 67–8
and sexual assault victims differences with healthy communication, well-functioning
346–7; suicide and 243 families and 318
gender identity disorder 265–6, 277 heteronormativity 278
genogram 323 heterosexism 267–8, 278
Gestalt theory: family system conflict and crisis holding environment 67
and 327–8; grief and 136 homeless, moving risk with 202
388 Index
homelessness, LGBTQ youth and 275 infants, grief responses of 130
home visitation programs, for child informational documents, for disasters 236
maltreatment 114–15 injuries: deployed parents returning with 193;
homophobia 268, 278 physical 154–5; prevention of 166
homosexuality; see also lesbian, gay, bisexual, Internet resources, for school crisis response 22
transgender and questioning youth: interpreters, crisis intervention working with
classifying 265; terminology for 267–8 41–2
hotline, telephone 93–4 intervention see crisis intervention
HPA see hypothalamic-pituitary-adrenal axis interviews, for group intervention 77–8
Human Rights Campaign (HRC) 290 It Gets Better Project 290
Hurricane Katrina 2; moving caused by 200–1
hypothalamic-pituitary-adrenal axis (HPA) 109 Klein, Donald C. 3
Kübler-Ross, Elisabeth 132–3, 176
ICI see individual crisis intervention Kübler-Ross’s five stages of grief 132–3
ICS see Incident Command System
IDEIA see Individuals with Disabilities Lambda Legal Defense and Education Fund
Education Improvement Act of 2004 290
identification, employee and student 214 language, crisis intervention issues with 40–2
IEPs see individual educational plans law enforcement involvement, for acts of
illness: art and play therapy for 162–3; bullying violence 220–1
and 157, 165–6; CBT techniques for 161–2; learning disabilities 52–3
children at risk for 155–6; child stress from legislation, on bullying 99–100
156; chronic 153, 161; communication Lennon, John 146
modes with 161; confidentiality and 161; lesbian, gay, bisexual, transgender and
coping with 159–60; crisis counseling questioning youth (LGBTQ youth) 249;
for 160–5; crisis prevention for 165–6; bisexual youth issues 276; “coming out”
disease prevention and 166; magnitude of process for 270; contemporary research on
problem with 153–5; parental stress from 264–5; contextual models for development
155–6; peer alienation from 157; peer group of 269–70; crisis counseling professionals
intervention for 164; psychological impact of preparations for 266–7; crisis counseling
157–8; psychological screening for 165; QoL suggestions for 282–3; crisis intervention
outcomes in 156–8; school impact of 158; at various school levels for 280–1; crisis
school transitioning with 164; SFT for 162; prevention for 277–83; developmental
sibling stress from 156; special education perspective on 267–71; ethnicity issues with
services with 164; Steward’s Matrix of child’s 275–6; GLSEN report findings on 273–4;
appraisal of experiencing 158–9, 163–4; group intervention for 281–2; homelessness
student absence and rates of 154–5, 158; and 275; identity transformation issues for
summer camps and 165 267; laws promoting rights of 273, 277;
impulsive action 13 mythical and reality issues facing 266;
incarcerated parents, children with: crisis NSSI and 365; parent reaction to 270–1;
intervention for 187–8; FAST program prevalence of 264; psychiatric classification
dealing with 187–8; implications of 183–4; issues with 265–6; as rape and sexual assault
modeling and social learning theories with victims 348; resilience among 271; resources
185; prevalence of 183; protective factors for 290; risks among 271–5; school-based
with 186–7; stigma and labeling theories mental health practitioners assisting 278–81,
with 185; strain theories with 185; trauma 290; school dropout and 275; school issues
theories with 185; visitation issues with 184 facing 265; sexual orientation development
Incident Commander 23 for 268–70; sexual risk-taking in 274–5;
Incident Command System (ICS): disaster stage models for development of 269;
preparation of 230–1; responsibilities and subgroup issues for 275–7; substance abuse
resources for 25–6; roles and responsibilities risk in 274; suicide risk in 274; terminology
in 23–4; for school crisis response 19, 23 for 267–8; transgender youth issues 276–7;
individual crisis intervention (ICI) 237–8 victimization of 272–3
individual educational plans (IEPs) 203 LGBTQ youth see lesbian, gay, bisexual,
Individualism dimension 33 transgender and questioning youth
Individuals with Disabilities Education Life Skills Training program (LST) 97, 301–2
Improvement Act of 2004 (IDEIA) 164 life transitions, anticipated 5
Indulgence Versus Restraint dimension 33 Lindemann, Erich 1, 3
industrial disasters 229 literature review 20
Index 389
Logistics Section Chief 24 narrative counseling 55
Long-Term Orientation dimension 33 narrative therapy 329
LST see Life Skills Training program National Association of School Psychologists
(NASP) 46, 215, 221; academic failure
McCartney, Paul 146 addressed in model of 49; curriculum of 21;
Main, Mary 326 Internet resources of 22; workshops of 20–1
maltreatment see child maltreatment National Campaign to Prevent Teen and
marital conflict; see also divorce; family system Unplanned Pregnancy 299
conflict and crisis: children at risk from National Child Traumatic Stress Network
69–70; frequency of 71; risk factors linked to (NCTSN) 22
style of 70–1; severity of 70 National Day to Prevent Teen Pregnancy 305
marital separation 66 National Incident Management System (NIMS)
Masculinity Versus Femininity dimension 33 21, 219; for disaster preparation 230
maturational/developmental crises 6–7, 11 natural disasters 229
MDT see multidisciplinary team natural systems theory 322–3
media relations 26 NCTSN see National Child Traumatic Stress
melancholia, mourning compared to 132 Network
Memorial Wall 147, 152 neglect 107
mental health, teen pregnancy and 295–6 NFP see Nurse Family Partnership
mental health crisis intervention, disasters and NIMS see National Incident Management
232, 235–8 System
method of shared concern 96 9/11 attacks 2
Meyer, Adolph 2 nonsuicidal self-injury (NSSI): age and 365;
Migrant Education Program 202 causes of 366; compassion without judgment
migrant families: crises experienced by 31; for 372; conditions associated with 366–7;
moving risks for 202; poverty and 31–2 crisis counseling for 370–6; DBT for 375–6;
military see deployed parents definitional issues with 363–4; ethnicity
military dependents, moving and 199–200 and 365; gender and 365; LGBTQ youth
Minuchin, Salvador 322–5 and 365; manage exhibition of 374–5;
Minuchin theory 323–5 misconceptions of 362, 369; overreacting to
miracle question 329 371; prevalence of 363–6; respectful curiosity
modeling and social learning theories, with for 373; safety contract issues with 373–4;
incarcerated parents 185 at school 362–3; school-based prevention
mourning; see also grief: melancholia compared of 368–70; social contagion of 374; student
to 132; Worden’s tasks of 133–5 resilience promoted to prevent 369–70;
moving, children and: adolescent considerations students taught about 368–9; suicide
with 203–4; anticipatory guidance for 204–5; differentiated from 367; terminology usage
bibliotherapy for 206; civilian children and with 372–3; underreacting to 371
200–1; crisis counseling for 207–9; crisis nonverbal communication 36–7
prevention activities for 204–9; extent of no-suicide contract 255–6
problem for 199; group intervention for NSSI see nonsuicidal self-injury
208–9; high risk groups in 201–2; homeless Nurse Family Partnership (NFP) 114–15
risks with 202; Hurricane Katrina causing
200–1; individual crisis interventions for ODD see oppositional defiant disorder
207–8; middle childhood considerations with Olweus Bullying Prevention Program 95
203; migrant family risks with 202; military Operation Military Kids 191
dependents and 199–200; poverty risks with Operations Section Chief 23–4
202; preschooler considerations with 202–3; oppositional defiant disorder (ODD) 272
school assistance with 205–7; separation in
198; stress and 198; support groups for 208–9; Parent-Child Interaction Therapy (PCIT)
teachers assisting new students in 206–7 113–14
MS see multiple sclerosis parents; see also children; deployed parents,
MST see multisystemic therapy children with; family system conflict and
multicultural counseling 34 crisis; incarcerated parents, children with;
multidisciplinary team (MDT) 179–80 teen pregnancy; well-functioning families:
multiple sclerosis (MS) 177 academic failure perceptions of 49; acts
multisystemic therapy (MST) 257 of violence, reuniting students with 220;
music, culturally appropriate 39 acts of violence response involving 224;
music therapy 146 bullies relationships with 89; bully-victims
390 Index
relationships with 91; child maltreatment psychological education in 235–6; social
education for 113–14; death of 137–8; support considerations in 235; workshops of
divorce programs for 74; group intervention 20–1
participation of 79–80; illness causing stress preschoolers: divorce and 68, 75; grief
in 155–6; LGBTQ youth reaction of 270–1; responses of 130; moving considerations
rape and sexual assault victim services for with 202–3
348–9; suicide assessment contacting 256; prevention see crisis prevention
suicide “home plan” for 251; suicide of 257; Primary Mental Health Project 58
teen pregnancy risks in background of 296; problem-focused coping 4, 39
victims of bullying relationships with 90 problem solving 10; culture and 39; school
Parents, Families and Friends of Lesbians and crises and skills for 55
Gays (PFLAG) 290 Project SOAR 252–3
parents with disabilities: at-risk children Promoting Alternative Thinking Strategies
identification for 180–1; at-risk children (PATHS) 97
of 174–9; child status variables for 179; Promoting Issues in Common (PIC) 98
chronicity of 177–8; crisis intervention for protective factors, in child maltreatment 112–13
181–2; crisis prevention and 181; family provocative victims 90–1
status variables for 179; involved processes psychiatric emergencies 7–8, 11
for 178; MDT for 179–80; needs of 173; psychoanalytic theory, for family system 327
prevalence of 174; school services for 179–81; psychological abuse, in child maltreatment 107
severity of disability for 177; significance psychological disequilibrium 1, 3
of disability variables for 176–9; social psychological education 235–6
acceptance for 178–9; stability of 177; time psychological first aid (PFA) 12; for disasters
significance of onset of disability for 175–6; 236–7
types and conditions of 173–4; visibility of psychological screening, for illness 165
disability issues for 178 psychological triage 222–3
PATHS see Promoting Alternative Thinking psychopathology, crises reflecting 7, 11
Strategies psychosis suicide 245, 247
PCIT see Parent-Child Interaction Therapy psychotherapy 238
peer alienation, from illness 157 PTSD see posttraumatic stress disorder
peer group intervention, for illness 164 publicity, of acts of violence 212
peer nominations 92–3
peer pressure 305 quality of life (QoL) 156–8
peer support, for suicide prevention 251–2 queer 267–8; see also lesbian, gay, bisexual,
personality disintegration 245, 247 transgender and questioning youth
personal space 37 questioning youth see lesbian, gay, bisexual,
person-centered theory see Rogerian person- transgender and questioning youth
centered theory
pet death 139–40 rape; see also sexual assault: acquaintance
PFA see psychological first aid 336; age and 337; alcohol consumption and
PFLAG see Parents, Families and Friends of 337–8; causation theories for 350–1; context
Lesbians and Gays theories on 351; crisis counseling for 340–5;
physical abuse 106 definition issues with 335; Feminist theory
physical injuries 154–5 on 351; gender and 337; integrated theories
PIC see Promoting Issues in Common on 351–3; potential victims of 337–8;
Pikas, Anatol 96 pregnancy concerns with 341; prevalence
Planning Section Chief 24 issues with 336–7; prevention program
play therapy see art and play therapy classes for 354–5; prevention program design
posttraumatic stress disorder (PTSD) 2, 135, 188 for 355–7; protective factors for 338–9; self-
postvention, for suicide 258–9 empowerment preventing 355; statutory 305,
poverty: migrant families and 31–2; moving 335–6; stranger 336; terminology with 334
risks with 202; teen pregnancy and 296 rape and sexual assault victims: adolescents as
Power Distance dimension 33 345–6; advocacy needs of 341–2; boyfriend
pregnancy, rape and 341; see also teen pregnancy or girlfriend of 349–50; causation theories
pregnancy brain 292 on 350; children as 345–6; crisis reactions of
preparation 13 340; with disabilities 347–8; ethnicity of 346;
PREPaRE program 221; curriculum of follow-up for 343; friends of 350; gender
21; disaster preparation with 230–8; differences with 346–7; group intervention
effectiveness of 238; evaluation of 21–2; for 345; individual counseling for 344–5;
Index 391
LGBTQ youth as 348; long-term reactions addressed for 54–5; early crisis intervention
of 343–4; parent services for 348–9; physical for 57, 59; emotional support for 54–5;
examination information for 342; sense of example of 56–7; instructional approaches
control restoration for 340–1; victim control for 57; intervention for 53–7; problem
programs for 354 solving skills for 55; school-based team for
rape trauma syndrome 340 24; students with disabilities and 52–3
rapists: causation theories on 350–1; potential school crisis counseling, for suicide 250–9;
339; prevention theories focusing on 353–4 primary prevention (Tier 1) 251–3;
referral planning, for acts of violence 221, 223–4 secondary prevention (Tier 2) 253–7; tertiary
regional-level crisis response team 25 prevention (Tier 3) 257–9
Rehabilitation Act of 1973 164 school crisis response: background knowledge
religion, culture and 38–9 for 20–2; for bullying 93–5; ICS for 19, 23;
reporting boxes, for bullying 93–4 Internet resources for 22; literature review
research 15 for 20; preparing for 19–28; team building
resilience 4; from deployed parents 189; of for 22–5; training programs for 20–2
LGBTQ youth 271; NSSI prevention by school dropout, LGBTQ youth and 275
promoting student 369–70; of students and school entry: crises prevalent in 46–7;
staff in disaster preparation 232–3 intervention for 48; school refusal behavior
respectful curiosity, for NSSI 373 in 46–7; school refusal types and dynamics
respiratory diseases 154 in 47
restorative justice 95–6 school failure see academic failure
reuniting students with parents during acts of school refusal: behavior 46–7; intervention for
violence 220 48; types and dynamics of 47
rituals, in grief 143–5 School Safety Checkbook 213
Rogerian person-centered theory: for family school safety/crisis response team; see also acts
system conflict and crisis 328; for grief 135–6 of violence: administrative support for 23;
Rogers, Carl 13, 135–6, 325, 328 building 22–5; characteristics of effective
214; district-level 24–5; regional-level 25;
safety contracts, NSSI and 373–4 roles and responsibilities in 23–4; school-
safety resource officers (SROs) 215 based 24
sandtray 145–6 school security, for acts of violence 215–16
Satir, Virginia 322, 325–6 screening programs 14–15
Satir theory 325–6 secondary triage 223
scaling questions 329 Second-Step program 218
SCARE see Student Created Aggression secure attachment 327
Replacement Education SEL see social and emotional learning
schools: acts of violence frequency in 212–13; selective serotonin reuptake inhibitors (SSRIs)
divorce and administrative policy changes of 249
73; divorce and continuity from 67; grief and self-awareness, family system conflict and crisis
crisis intervention throughout 147; illness and 320–1
impact on 158; illness transitioning back self-concept 10–11; child maltreatment impact
to 164; LGBTQ youth crisis intervention at on 111; modification of 55
various levels of 280–1; LGBTQ youth issues self-empowerment, for rape prevention 355
at 265; moving assistance of 205–7; NSSI at self-esteem, of students with disabilities 53
362–3; parents with disabilities services from self-homicide 247
179–81; suicide programs in 252–3 self-referral, for acts of violence response 224
school-based mental health practitioners: self-regulation, for child maltreatment 117–18
conflict compared to crisis for 316–17; self-reliance 11
family system conflict and crisis consultation Selye, Hans 2
with 321; LGTBQ youth and 278–81, 290; separation see marital separation
teen pregnancy and 302–7 September 11 see 9/11 attacks
school-based prevention of NSSI 368–70 sexual abuse: in child maltreatment 106–7;
school climate 58–9; acts of violence prevention crisis prevention programs for 114
with 214–15; discipline established in 213 sexual assault 34; see also rape; rape and sexual
school crises; see also acts of violence: at-risk assault victims; background information on
student early intervention for 59; CCI for 334–7; causation theories for 350–1; context
55–7; consultation for 59–60; cooperative theories on 351; crisis counseling for 340–5;
climate preventing 58–9; crisis prevention definition issues with 335–6; integrated
programs for 57–9; destructive attributions theories on 351–3; potential victims of 337–8;
392 Index
prevalence issues with 336–7; prevention of student evacuation and assembly 26, 219–20
353–5; protective factors for 338–9 students; see also children: academic failure
sexual education programs 298–9 perception of 50–2; acts of violence,
sexual harassment 335 reuniting parents with 220; acts of violence
sexually transmitted infections (STIs) 299 and discipline of 213; bullying advice
sexual minority youth 267–8; see also lesbian, for 94; disaster exposure of 234; disaster
gay, bisexual, transgender and questioning preparation fostering resiliency of 232–3;
youth disasters and psychological trauma of
Sexual Orientation Counselor Competency 234–5; early intervention for at-risk 59;
Scale (SOCCS) 279 identification for 214; illness and absence
sexual orientation development, for LGBTQ rates of 154–5, 158; NSSI issues taught
youth 268–70 to 368–9; NSSI prevention by promoting
sexual risk-taking, in LGBTQ youth 274–5 resilience of 369–70; teachers assisting
SFBT see solution-focused brief therapy moving and new 206–7; violent potential
SFT see solution-focused therapy identified in 216–18
shamanic culture 38–9 students with disabilities: developmental
shared concern, method of 96 disabilities 52; learning disabilities 52–3;
sibling: death 138–9; illness causing stress with school crises and 52–3; self-esteem of 53;
156 social skills of 53
Signs of Suicide (SOS) 253 substance abuse, LGBTQ youth risk of 274
SOCCS see Sexual Orientation Counselor suicide: ADHD and 248–9; alcohol and
Competency Scale 248; antidepressant medication and 249;
social and emotional learning (SEL) 252 assessment and identification questions
social-cognitive theory 87–8; bullying for 254–5; CBT model of 244–5, 246;
interventions based on 97 definition of 244; environmental risk factors
social learning theory 87 for 247–8; ethnicity and 243; gender and
social status 35–6 243; hospitalization after assessment for
social support network 10; by culture 38; 256–7; intervention procedures for 254–6;
PREPaRE program considerations for 235 LGBTQ youth and 249; LGBTQ youth
sociolinguistic issues 36 risk of 274; nomenclature for behaviors of
“SOFAR” Guide 192 244–5; no-suicide contract 255–6; NSSI
solution-focused brief therapy (SFBT) 329–30 differentiated from 367; outpatient treatment
solution-focused therapy (SFT): for bullying after assessment of 257; parent contact after
98–9; for illness 162 assessment for 256; parent “home plan”
SOS see Signs of Suicide for 251; parents committing 257; peer
special education: illness services with 164; support for prevention of 251–2; postvention
suicide risks for 250 for 258–9; prevalence of 242–3; primary
SROs see safety resource officers prevention (Tier 1) for 251–3; protective
SSRIs see selective serotonin reuptake inhibitors factors for 250; psychological risk factors for
stage models, for LGBTQ youth development 248–9; school crisis counseling for 250–9;
269 school-wide programs for 252–3; secondary
statutory rape 305, 335–6 prevention (Tier 2) for 253–7; special
stereotypes, acts of violence and 217 education risks of 250; teachers committing
Steward’s Matrix of child’s appraisal of 257; tertiary prevention (Tier 3) for 257–9;
experience of illness 158–9, 163–4 types of 245, 247; warning signs and triggers
stigma and labeling theories, with incarcerated of 253–4; in youth 242–3
parents 185 summer camps, and illness 165
STIs see sexually transmitted infections supplementary ego 321
strain theories, with incarcerated parents 185 support groups; see also group intervention;
stranger rape 336 social support network: for bullying 99; for
Strange Situation procedure 110 moving 208–9
stress 2; disasters and warning signs for survivor guilt 138–9
traumatic 234–5; illness causing child and
sibling 156; illness causing parental 155–6; Taking Charge program 302
moving causing 198; traumatic 5–6, 11 Targeting Bullying Program 95
structural theory 323–5 tattling 93
student accounting 26; in acts of violence 220 TBI see traumatic brain injury
Student Created Aggression Replacement teachers: academic failure perceptions of
Education (SCARE) 218 49–50; death of 140; divorce assistance from
Index 393
73–4; group intervention participation of 80; transgender youth 276–7; see also lesbian, gay,
moving students assisted by 206–7; suicide of bisexual, transgender and questioning youth
257; teen pregnancy roles of 304–6 transitional objects, for grief 145
team see school safety/crisis response team trauma theories, with incarcerated parents 185
Teen Father Academy (TFA) 301 traumatic brain injury (TBI) 188
teen fathers 293; paternity rights issues for 307; traumatic events, culture and reaction to 35
programs assisting 301 traumatic stress 5–6, 11
teen mothers: children of 293–4; graduation Trevor Project 290
rates of 300; programs reducing negative triage: in crisis intervention 222; definition of
outcomes for 299–301; risks of 292–3 221; psychological 222–3; secondary 223
teen pregnancy: advocate role in 306–7; case triangulation 323
manager role in 306; counselor role in
302–4; father involvement for 297–8; grief Uncertainty Avoidance dimension 33
and loss with 304; LST programs for 301–2; unfinished business 328; in grief 144
mental health risks in 295–6; misinformation
problems with 305; negative outcomes of victim-focused interventions, for bullying 97–9
292–4; parent background risks for 296; victim-inclusive approaches, to bullying 95–7
perspective risks on 297; poverty and 296; victims; see also rape and sexual assault
prevalence of 291; prevention programs for victims: of bullying 90, 92–3; LGBTQ youth
298–9; protective factors for 297–8; repeat as 272–3; of violence 224
pregnancy with 296; risk factors with 294–7; violence see acts of violence
school-based mental health practitioner roles visitors see campus visitors, acts of violence and
in 302–7; social costs of 291–2; teachers role visitor sign-in 27
in 304–6; universal programs for 302 vulnerability, personal 234
TeenScreen Program, Columbia University 253
telephone hotlines, for bullying 93–4 well-functioning families: characteristics of
TFA see Teen Father Academy 317–18; creating 318–19; crisis and 317–19;
Threat Assessment in School: A Guide to healthy communication in 318
Managing Threatening Situations and to White House Conference on the Handicapped
Creating Safe School Climates 216 of 1977 176
Thurman, S. Kenneth 174 Who’s Fit to Be a Parent? (Campion) 176
time capsules, for grief 145 Worden, J. W. 133
touching 37 Worden’s tasks of mourning 133–5
training programs, for school crisis response
20–2 Youth Development Model 302

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Crisis Counseling, Intervention,

and Prevention in the Schools

Persons interested in developing handbooks or textbooks in school consultation should

Dr. Sylvia Rosenfield Rebecca Novack

1 Conceptualizations and Principles of Crisis Counseling,

2 Preparing for the School Crisis Response 19

3 Considering Culture in Crisis Work 31

4 School Entry, School Failure, and the Discovery

5 Divorce: Crisis Intervention and Prevention with Children

6 Bullying: Students Hurting Students 85

7 Child Maltreatment 106

8 Helping Children Cope With Grief 128

9 Illness: A Crisis for Children 153

10 Children of the Disabled, Incarcerated, or Deployed 173

12 Acts of Violence 212

13 Preparing for and Responding to Disasters 229

15 Lesbian, Gay, Bisexual, Transgender, and Questioning

16 Adolescent Pregnancy and Parenthood 291

17 Conflict and Crisis Within the Family System 314

18 Rape and Sexual Assault 334

19 Nonsuicidal Self-Injury 362

Stephen E. Brock, PhD, NCSP

Jeff Cook, PhD

Katherine Hadley Cornell, PsyD

John M. Davis, PhD

Colette L. Ingraham, PhD, NCSP

Mari Griffiths Irvin, PhD

David N. Miller, PhD

Juliana Raskauskas, PhD

Jonathan Sandoval, PhD, ABPP

Rev. Virginia L. Schiefelbein, PhD, BCC

Amy N. Scott, PhD

Suzy R. Thomas, PhD

Oanh K. Tran, PhD

A History of Crisis Intervention Theory

Anticipated Life Transitions

Crises Reflecting Psychopathology

Crisis Counseling and Intervention

Crisis Counseling Goals

Generic Counseling Principles

1. Begin counseling immediately. By definition, a crisis is a time when a child is in danger

Generic Crisis Intervention Principles

Crisis Type Goals General Intervention

1. Dispositional crises Confront reality • Provide information—educate

The Counselor in Crisis

Actions Goals Examples of Skill

Preparing to deliver To have both intellectual Entering the setting

Educational Workshops and Programs

Anticipatory Guidance and Emotional Inoculation

Developmental Issues in Crisis Counseling

(Thinkers) (Doers) (Getters) (Payers)

Medical Support Service Branch

General Staff Mental Health Support Branch

Obtaining Background Knowledge

Adapted from NASP (2011).

Building Crisis Response Teams

Obtaining Administrative Support

Defining Crisis Response Roles and Responsibilities

Defining Crisis Response Teams

Developing Crisis Response Plans

Designating ICS Responsibilities and Identifying Resources

Crisis Preparedness Protocols

Developing Crisis Response Procedural Guidelines