Psychoeducational implications and vulnerability to relapse can be lessened with effective reintegration planning and implementation. Currently, there is a dearth of information regarding effective school reintegration and PTSD (Cook-Cottone, 2000). Consequently, the proposed reintegration model outlined below is informed by current knowledge related to school reintegration following serious medical conditions (i.e., cancer) and psychiatric placement, as well as proposed PTSD guidelines (Cook-Co(tone, 2000). Current models embrace an ecological approach to understanding the status and needs (Prevatt, Heifer, & Lowe, 2000; Shields & Heron, 1995; Worchel-Prevatt et al., 1998). In these models, the child's current functional capacity (including symptom manifestation and coping ability) is considered within the context of the network of individual and ecological stressors germane to the reintegration transition. The proposed school reintegration model is intended for children whose traumatic experience and consequent symptomatic expression result in absence from school and clinical need for supported reintegration. A child suffering with a less severe symptom expression may require less restrictive services. Therefore, reintegration services should be based on need.
Step 1: Establishing the relationship. The therapeutic and supportive relationship is key to successful school reintegration (Pullis, 1998). The school psychologist can act as educational consultant, or liaison, between the three subsystems--home, school, and hospital or inpatient setting (Prevatt et al., 2000; Rynard et al., 1998; Shields & Heron, 1995). Armstrong, Blumberg, and Toledano (1999) found, when working with children with cancer, smooth school transitions were facilitated by: shared literature, multispecialty child conferences, cross disciplinary workshops, school personnel visits to the hospital setting, and continuing professional-to-professional consultation. In addition, a proposed program for reentry with runaways emphasized the importance of prereentry initial contact, as well as ongoing support (Rohr & James, 1994). If a pretrauma relationship does not exist, the school psychologist may want to collaborate with psychiatrist(s) and/or psychologist(s) working with the student prior to reentry. The school psychologist will need to obtain mutual releases of information, consider joint sessions, and setup ongoing consultation.
Step 2: PTSD recovery education. Current models recommend educating the family, school personnel, and the child as part of the reintegration process (Prevatt et al., 2000). Topics important for review include: the recovery process, relapse prevention, coping skills and relaxation, epicycles in healing (Johnson, 1998), the stress and possible symptomatic consequences of school reentry (Gaensbauer, Chatoor, Drell, Siegel, & Zeanah, 1995), and the importance of self-monitoring. It is important to note that peer education is not currently included as part of the PTSD reintegration protocol. In cancer research, the long-term benefits of peer education programs have not been demonstrated and some important considerations have not been addressed such as possible iatrogenic effects and costs to already overburdened instructional time (Prevatt et al., 2000).
Step 3: Individualized plan development. The individualized plan for reintegration should be based on an assessment of the child and family's needs (Prevatt et al., 2000). Plans should identify needs, goals, and treatment guidelines, and include a calendar of appointments and schedules, a list of names and phone numbers, and a plan for meetings and conferences (Prevatt et al., 2000). It may become necessary to include a goal of providing safety within the context of appropriate boundaries. This might include setting firm limits about office visits, describing and modeling appropriate behaviors, and reminding the student that learning good boundaries is part of healing (Rosenbloom & Williams, 1999). A crucial component of the individualized plan is inclusion of preventative sessions addressing anniversaries, high stress circumstances, or crisis (Ernsperger, 1998; Rosenbloom & Williams, 1999). These sessions should be scheduled, on identified dates, before reintegration is attempted. This can contribute to feelings of security and competence, as well as model appropriate preparing for vulnerable periods (Rosenbloom & Williams, 1999).
Step 4: Facilitated integration. The goal at this stage is toward independence and regular, full-day attendance. Clinical decisions should be made regarding length of the initial school visit and the process of extending the school visit to a full day. It is important to consider factors such as: inpatient status, length of time absent from school, premorbid functioning data, level of support among peers and family, the student's wishes, self-regulatory skills, and mental health status. In this stage the reintegration plan is implemented.
Step 5: Independent integration. Step 5 represents the ultimate goal of a successful reintegration plan, independent functioning. Throughout the process, the focus is on movement toward independence and self-monitoring (Ernsperger, 1998). As the student gains independence, the school psychologist should discuss pruning back, or fading, supports. Child study team and parent contacts are often used to monitor success. Though not addressed in this review, prevention efforts (e.g., school emergency response plan and teams, and relaxation and coping training) may increase resiliency for children who are at-risk (Pynoos et al., 1999), as well as those who have been traumatized, yet are asymptomatic (i.e., delayed onset; Herman, 1992; Johnson, 1998).
- Cook-Cottone, Catherine; Childhood Posttraumatic Stress Disorder: Diagnosis, Treatment, and School Reintegration; School Psychology Review, 2004, Vol. 33 Issue 1, p127-139
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #8
The preceding section contained information
regarding managing school reintegration for child disaster survivors with PTSD. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are five steps in a successful school reintegration plan? Record the letter of the correct answer