PDACK129.pdf - USAID

==- y FOR - SAFETX-AND -- .. -. -. - HOPE

Final Report, October 2005 - May 2007

Grant Number: 294-G-00-05-00222-00 Grant Award: $526,500

Prepared for USAID by: JDC Middle East Program

Project Parlners Center for Development in Primary Health Care (CDPHC)

Israel Center for Treatment of Psychotrauma, Herzog Hospital (ICTP)

June 2007

Table of Contents

Page Number 1. Introduction

2. Accomplishments I

2.1 General 2

2.2. Primary Heallh Care 3

2.3. Assessment of Bereaved Families 4

2.4. Clinical Skills Training Course 6

2.5. Research - Assessmenl of CHERISHmodel 8

3. Cooperation 9

4. Problems encountered and remedia1 actions 11

'w 5. Conclusions/Lessons Learned 12

6. Appendices

A. Primary Health Care, Orientation Protocol (English, Arabic)

B. Primary Health Care, Mental Health Professional Forms (Arabic, Hebrew)

C. Primary Health Care, Research Batteries -Clinic and Home interviews

(Arabic, Hebrew)

D. Bereaved Families, Study Protocol

E. Bereaved Families, Research Batteries (Arabic, Hebrew)

F. Clinical Skills Training, Course Description

G. Clinical Skills Training. Arabic Worksheets

H. Clinical Skills Training, Article in Arabic

1. Clinical Skills Training, Articles Hebrew Worksheets (Separate Document)

J. Clinical Skills Training, Feedback from course participants

1. Introduction

This report covers the activities undertaken by CHERISH through the grant awarded by the US Conflict Management and Mitigation program (administered through USAID West BanWGaza) in the period October 2005- May 2007. The main achievement has been the actual implementation of all planned project components. This despite the not unsubstantial barriers on the ground, some of which required adapting andlor curtailing certain aspects of the implementation, but none of which deterred the partners and professionals involved from the ultimate goal

Project CHERISH was initiated in 2003, at the height of the second Intifada, to provide a much-needed response to the trauma experienced by children and youth born into an intractable conflict. Together with the American Jewish Joint Distribution Committee (JDC), the lead organizations in this initiative are the Center for Development in Primary Health Care (CDPHC) and the Israel Center for Treatment in Psychotrauma (ICTP).

bv The CHERISH partners recognized the need to build professional capacity and infrastructure for meeting psychotrauma needs within the Palestinian and Israeli communities. They understood that this would be a long-term undertaking; involving raising awareness, changing preconceptions and promoting cooperation between a range of medical, psychosocial and educational community services, and dedicated CHERISH to this undertaking.

In its first year, the CHERISH initiative undertook activities to learn about the needs and to consider the feasibility of joint activities in this field. Activities included: mapping the trauma services available in both societies; holding a three-day workshop for 26 professionals involved in trauma assessment and treatment and convening a steering committee. Out of these activities grew a vision to create an ecologic framework to reach out to children and families through existing community services. A workplan was developed to support this vision through activities to identify children and families most in need and develop responses within community settings, from school, to their doctor's clinic, to community centers. Defying a steadily worsening political and security situation, from its inception, CHERISH was undertaken as a cooperative activity, providing professionals with the opportunity to work together and to learn about each other and to develop an evidence-base for understanding how assessments and interventions can be relevant across cultures and in different environments.

In September 2005, the US Conflict Management and Mitigation grant (administered through USAID West BanWGaza) enabled the CHERISH partners to take the next steps in reaching the vision. Th~ough the grant, three intervention components were launched - the Primary Health Care Intervention: an assessment of the psychosocial needs of Bereaved Families, and a Clinical Skills Training Course in cognitive behavioral therapy for front-line professionals. A fourth evaluation component aimed to look at the added value of conducting this project as a cooperative endeavor.

Despite many roadblocks (literal and figurative) along the way, CHERISH has successhlly achieved many of the professional goals it set out for itself in this period. In recognition of these achievements, the partners have managed to secure additional funding to ensure wider

impact in both communities. In this upcoming phase, the partners plan to build on the knowledge and experience gained under the CMM grant and prepare the models for dissemination and replication through the preparation of manuals and case books.

In terms of the cooperative goals where the roadblocks and challenges were even greater, CHERISH accomplishments are even more significant. In the period of the grant, CHERISH brought together 100 Palestinian and Israeli psychosocial professionals in its various components. Cooperation takes place at all levels of the project: from joint planning of initiatives, to cultural and linguistic adaptation of materials, to participation in joint workshops. Participants overcame both personal and communal reservations regarding cooperative activities, as they labored to find a language that could build bridges and lead to common understandings. As the qualitative and quantitative data fiom the pilot stages comes in, the professionals have been comparing their experiences in implementing the activities in different communities, and discussing the cultural, societal and environmental differences that shaped their experiences.

Accomplishments

2.1. General Over the course of the grant period, relationships were developed with Israeli and Palestinian psychosocial organizations:

Ard El Atfal (Primary care clinics in Hebron and Jenin) Clalit Health Services (Children's Health clinic in Lod) Koby Mandel Foundation (NGO assisting bereaved Israeli families) Ramallah Treatment Center (Psychosocial services, including trauma treatment) Shoham Center (Community Center serving the RamleILod area) Terre des Hommes (Psychosocial service programs in Hebron and Jenin) UNRWA (Mental health services)

Active involvement of over 100 Israeli and Palestinian professionals in various CHERISH components

At least 60 meetings of the various working groups (not including ongoing phone and e- mail communication between meetings). Implementation of professional activities in the field Two seminars for Palestinian and Israeli professionals Translation and cultural adaptation (including testing) of materials for each project component (questionnaires, articles, worksheets).

2.2. Primary Health Care 1nitial:ive The Bio-psycho-social Model Implemented in Primary Health Care Settings (CHERISH- PHC) program seeks to create a dialogue and improve collaboration between primary care and mental health services. This is accomplished through the placement of a mental health professional (MHP) in primary care clinics whose role is to raise awareness and

psychosocial professionals began meeting with families. Professionals spend two days per week in each clinic. Children in need of longer-term care were referred to TDH clinics.

Several differences were noted in the implementation in the different communities that have implications for replication. In the Israeli clinics, the majority of referrals came from the physicians, while in the Palestinian clinics, the majority came from nurses, or were self- referred, but not the physicians. In further work with Palestinian clinics, more thought will need to be dedicated to gaining the physicians' cooperation. In Israeli clinics, the role of the nurses will be analyzed to see if there is further potential for working with them as in the Palestinian clinics. The "self referral" possibility in the Palestinian clinic may speak to the greater informality of the Palestinian clinics, where patients are treated on a first-come-first serve basis, rather than scheduled appointments. According to reports fkom the psychosocial professionals, quite a few families approached them directly upon learning that they were available. The "self referral" option could be tested in the Israeli clinics in the next phase.

PHC Research The purpose of the study was to assess the effectiveness of the SDQ as a screening tool for psychosocial symptoms that can be used in both Israeli and Palestinian primary care clinics. The 24-question tool is completed by parents, and assesses several categories of psychosocial issues: Emotional Symptoms, Conduct problems, Hyperactivity and inattention, Peer problems, and prosocial behavior.

Chart 1 : Total Psychosocial

100% Difficulties (n=320)

80%

60%

40%

20%

0%

normal (low borderline abnormal (high risk) (moderate risk) risk)

Over the implementation period, 225 Israeli families and 320 Palestinian families completed the SDQ in the clinic waiting rooms. A higher proportion of the parents in the Palestinian community reported higher levels of psychosocial distress among their children than Israeli parents. Within the Palestinian community, there were also significant differences between Jenin and Hebron, with parent in Jenin reporting higher levels of distress among their children. Given the similar socioeconomic situation of the two Palestinian communities, some of these differences may be related to different levels of exposure to traumatic events,

@ but this will have to be explored fh-ther. The data indicates that the SDQ can be useful as a screening tool in both communities, and this will further validated with in-depth evaluation of selected families. An analysis of the findings of the SDQ as a screening tool will be complete by August 2007.

2.3. Assessment of Bereaved Families 1 The purpose of the assessment has been to identify the psychosocial needs of families that have lost a child as a result of the conflict. While local organizations and government bodies provide financial and other assistance immediately after the tragedy, there is no systematic assessment of the family's long-term needs. The assessment took a holistic approach to bereaved families, taking into account their material and emotional positions. Please see Appendix D for the full study protocol. Forty families were included in this assessment - twenty Israeli and twenty Palestinian. Based on analysis of the assessment by the professionals on this team, each family is offered a personalized intervention program to meet their needs.

The professionals involved in the assessment spent the first ten months developing the tools for the assessment, testing them for cultural relevancy in both communities, and accurately translating them into Arabic and Hebrew. This stage was extremely time and resource intensive. Once the questionnaires and research design were finalized, the study was submitted for approval to the ethics (Helsinki) committees responsible for ICTP and CDPHC respectively. Recruitment of families also proved challenging; ICTP and CDPHC worked closely with NGOs that provide support to bereaved families, and trained interviewers contacted families that met the study criteria by phone to explain the project and obtain their agreement to participate in the assessment.

The assessment tools include individual batteries for each family member - parents, young children (completed by parents), children aged 8-1 1, adolescents, and adult children living at home (see Appendix E, list of questionnaires, and batteries in Hebrew and Arabic). Four Israeli and four Palestinian psychology students were trained to conduct the interviews, and were supervised by the psychologists from ICTP and CDPHC. The training and supervision was critical because in-depth interviews, such as the one conducted, can lead to renewed distress to the family members as they recount their traumatic loss and to distress of the interviewers themselves.

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Families were eligible to be included in the assessment if a child under the age of 17 died as a consequence of the conflict between 2001 and 2003. Family interviews took between four and six hours each. Interviewers sometimes made several visits to each family to complete the process.

The bereaved families component is in many ways the most difficult to conduct jointly; it deals with the most tragic outcomes of the conflict on both sides. This fact impacted the implementation in that there was no way of avoiding the details of specific traumas, and the charged terminology that these narratives raised.

Since many terms are used by one community, but are sensitive, and even painful to the other, the team agreed that the versions of the narratives shared in the meetings and included in the report should be adapted with an eye to language that will be sensitive to the other. The original versions of the interviews have been retained as part of the documentation of each community, and may be shared at a later date, when team members feel ready to read them.

b v Findings A framework for summarizing the family questionnaires and interviews was developed. including both the qualitative (psychopathology and coping measures) and quantitative (family narrative and interviewer impressions) aspects of assessment. In analyzing the questionnaires, one cannot deny the uniqueness of each families' experience. however several patterns do emerge, such as gender differences (between mothers and fathers) that cut across other variables. A 1 1 1 report. including a statistical analysis of the data. will be completed by August 2007.

The team developed an algorithm to analyze the family profiles to serve as the basis for creating an intervention plan based on the family needs. Algorithms for deciding on interventions include:

o Parents - Do one or both parents have psychopathologies (PTSD, grief, depression) o Older children (12+) - Are they highly functionally impaired (more than three

domains)? Do they have full PTSD? Severe grief? o Younger children (ages 8-12) - Do they exhibit severe anxiety? Severe functional

impairment? o Very young children (ages 2 % -8) - IS SDQ highly clinical?

Intervention The project is following-up on the assessments and offering the family guidance, intervention and referral. Intervention options can be for individual family members, couples or for the family as a unit. The analysis is cognizant of the need to be careful not to over-treat, and some families may only need guidance/advice,

In development of the intervention plan, treatment options in both communities are considered carefully, as where feasible, families will be referred to community-based services. The services in the West Bank are not as developed as they are in Israel, and some interventions may also not be culturally appropriate. Where necessary, interventions are offered through CHERISH. Professional training and adaptation of intervention modules are undertaken as needed.

CHERISH will be following-up with all these families to assess the impact of the interventions, to ensure that ongoing issues are addressed.

While the assessment data were analyzed on a basic level for the purposes of the clinical intervention, a more in-depth analysis of the quantitative and qualitative data will be carried out to better understand the process of grief that a family experiences following the loss of a child.

2.4. Clinical Skills Training Course In its original mapping of trauma services, the CHERISH partners found that in both societies there was a shortage of community-based professionals trained in skills specific to treating children with trauma. Cognitive Behavioral Therapy (CBT) is an accepted treatment

and emotional symptoms of trauma. j Traditionally, CBT has been provided by masters degree psychologists, but recent literature has shown that with proper supervision, other professionals, including social workers and counselors, can successfully learn and implement these skills in the community. The goal of this component was to develop a training module for these "front line" profes~ionals who are in daily contact with children, in schools, community centers and medical clinics. A brief course description is included as Appendix F.

' f ie 80-hour course includes three main components: theoretical background clinical skill demonstration

practice (with the group and through home exercises)

Originally, the course was planned to be carried out for Israeli and Palestinian professionals jointly. However, the situation on the ground made this untenable. Therefore, parallel courses were planned. An unexpected benefit of this, was that it enabled increasing the total number of people who were trained. The Israeli course was taught by two experienced trainers from ICTP: Gafnit Aghassy and Ehud Rahat. Since there were no experienced CBT trainers in the Palestinian community, Ismaeel Hamoud, a psychologist specially recruited by CDPHC, received intense on-going training prior to and throughout the course. This training involved weekly four-hour meetings over a 9 month period.

In addition to training the trainer, another major investment was the preparation of course materials (training manual, background articles and theoretical materials, worksheets, etc).

I Materials were translated and culturally adapted for this purpose (see Appendices G-I).

I The Israeli course was held in the Shoharn Community Center. Participants received continuing education credits for the course, and

the community center provided the classroom at no cost. The Palestinian course was held at CDPHC in Ramailah and participants received a certificate at the end.

One of the criteria for recruitment of course participants was securing a commitment from their place of work to allow them time to conduct CBT therapy with their clients. This is critical in ensuring that the participating professionals will hone their newly acquired skills and that children and families actually have more access to the treatment. In general, most agencies made this commitment wholeheartedly.

The Israeli participants were recruited from the Ramle Lod area, and include professionals from the central region of Israel. The Palestinian course included professionals from Ramallah, Hebron, Jenin and Nablus. The 47 professionals (23 Palestinian and 24 Israeli) came from social service agencies and NGOs. All trainees were vetted by USAID.

The course offered an opportunity to train professionals involved in other CHERISH components, thereby increasing the impact of those components and enabling coordination between components. Professionals involved in both the PHC and Bereaved Families participated in this course, which gave them a fuller understanding of the CHERISH model, and of the needs for trauma and grief services.

Feedback from participants in the Palestinian course was overwhelmingly positive (Appendix J). The teaching method, which is more experiential than lecture-based, was new to most of the students and especially appreciated. While theoretical knowledge was emphasized, through readings and course discussions, the actual skills are acquired through demonstration and group practice, considered the "best-practice" training methodology.

Feedback from the Israeli course was also very positive (Appendix J). They also appreciated the integration of frontal teaching with group practice. Many of the participants felt that the course gave them a good basis to begin working in CBT, but would need at least close supervision, if not additional training, to become effective practitioners themselves.

Following the 80-hour training module, participants were offered an additional 20 hours of clinical supervision. This supervision is carried out in small groups, enabling participants to share experiences and learn from one another. Over 80% of the course participants are taking part in the supervision sessions.

In order to make the clinical supervision more effective, the course directors developed a protocol for presenting cases during supervision that includes assessment; verbatims of therapy sessions and summaries. At the end of the supervision period, CHERlSH will have documentation on the treatment experiences for the course participants. The pedagogic value of this material is unmatched and CHERISH will use it in developing a casebook on trauma treatment in the region, which can be of practical value for other therapists in working with traumatized patients.

Two joint workshops were held for the clinical skills training course participants. The

b u purpose of these workshops were to enable the Palestinian and Israeli participants to meet each other and share experiences. This was particularly important as the training course itself was run separately in each community. The first workshop held in December 2006 was entitled "Treatment of Trauma Exposed Children: The F a i q Tale Model" and facilitated by Dr. Ricky Greenwald a visiting American psychologist. The second workshop held in March 2007, was entitled "Case Studies: Learning from our Experience" was facilitated by Dr. Yoram Yovell and presented a model for documenting case studies.

2.5. Research - Assessment of CHERISH model This goal of the research activity is to examine the CHERISH action as a unique case of partnership in service development for children and to examine issues that cut across the different activities and can contribute to theoretical and practical understanding for future cooperation in relevant areas. The topics of the research include:

1 . The development process of CHERISH, the roles played by the partners,

b organizational/professional challenges and facilitating factors.

2. Integration and interface between new initiatives and the existing systems in each

country

3. Intervening with children through different systems: school, family, medical facility

etc in each country

4. Cultural issues in intervention and service development

5. Benefits and risks /prices of the bi-country implementation

6. Palestinians and Israelis working together on the results of the ongoing conflict

7. The impact of the CHERISH process on action on practice in relevant professional

areas including impact on leaders and wider circles.

Over the course of the project, a team of Palestinian and lsraeli researchers conducted 35 interviews and focus groups with CHERISH participants and beneficiaries. and analyzed documentation from the projects, including meeting summaries, reports and data analysis. The findings of the research are currently being analyzed, and will be presented in a final report in July 2007.

3. Cooperation

The most unique aspect of CHERlSH, is its design as a cooperative project. The ~rocess of working together and creating broad partnerships is just as important as into the professional m. The cooperative design enabled the professionals to confront their own traumas through the eyes of the other, providing important insights into trauma work itself. .

Throughout implementation, but particularly during the first six months of implementation, efforts were dedicated to encouraging professional dialogue including:

Ensuring that all participants and organizations feel "ownership" of what was being done.

k Harmonizing the cultural relevance of assessment, intervention, training and research aspects. Enhancing understanding of the realities each side is facing. Enhancing common understanding of latest development in the field.

Issues requiring resolution were not t ) ~ i c a l of those normally present in a professional project. For example, the applied research (evidence-based) approach taken in implementing the interventions, required receiving informed consent from those people participating. As such, the partners had to discussthe implications of presenting the assessment to parent that have lost a child as the result of the conflict as a joint initiative (family bereavement component).

4. Problems encountered and remedial actions

Implementation Strategy The original plan called for implementing the professional elements in organizations that could ensure system-wide impact. However, following the Hamas victory in the Palestinian elections (January 2006), and in consultation with USAID, the groundwork invested in developing relations with the Palestinian ministries of health and education had to be put on hold. In response to the new circumstances, the partners developed alternate strategies and undertook to identifl and develop relationships with implementing agencies that are non- governmental, are interested in being involved in a cooperative venture. can maintain professional standards, and have the capacity for further dissemination at the conclusion of the formal prqject initiative.

New Organizations/New Professionals To ensure broad base of participation and reach, the partners expended a great deal of energy in reaching out to and involving a wide-range of organizations and professionals. Given the limitations listed above, the partners spent significant time identifying, meeting and screening potential implementing agencies and/or professionals. Once identified it was necessary to dedicate additional time to orientation and confidence-building in working together.

Given the changing situation as well as the growth of activities, there was also a fairly high turnover of professionals - staff, consultants, implementing organizations. This too entailed time to orient new professionals to the CHERISH concept both professionally and cooperatively.

Terminology Since all participants are living within the context of the conflict themselves. the meanings of terns used by one side or the other needed to be discussed and resolved before moving ahead at various junctures in the project. These discussions were difficult for all those who took part. This was exceptionally true in the assessment of bereaved families, when the narratives of those most hurt by the conflict were shared. As a rule, narratives are meant to accurately reflect the stories (and the pain) of the families as they tell in their own words and we want to ensure this voice is heard. The team had to consider the question of how to share the essence of the narrative within the team, while being sensitive to the other.

The team agreed that the versions of the narratives shared in the meetings and included in the report should be adapted with an eye to language that will be sensitive to the other. The question of whether presenting material in the edited versions makes it context andlor value neutral. This was felt not to be an issue at this time as we are all well-versed in the situation and know what we are talking about.

Meetings Joint meetings are one of the greatest challenges of cooperative projects in the current situation. The CHERISH team worked closely with the USAID/West Bank-Gaza office to facilitate permits, and are gratel l for the services provided in this area. without which project development would have been even further curtailed. Nevertheless, travel became very restricted at various points during the project. Practically, this meant that meetings and even a joint workshop, had to be postponed at the last moment.

During the more difficult times, lines of communication remained opened though telephone and e-mail contact. Implementation was slowed because of this, but never ceased completely. To facilitate future meetings, the partners have secured funds from a private foumdation to purchase videoconferencing equipment for ofices in Jerusalem and Ramallah.

b This technology will enable virtual meetings, without completely losing the added value of "face to face" interaction.

5. Conclusions/Lessons Learned In taking stock of CHERISH'S accomplishments over the past 18 months, the outcomes are overwhelmingly encouraging. In addition, it provided important lessons and insights to both the trauma field and for considering health cooperation in conflict situations.

1. It proved possible to conduct a cooperative project on one of the tragic consequences of the conflict. Given the focus on psycho-trauma, the conflict was always at the heart of project. This raised personal, professional and practical dilemmas throughout. The web of personal, professional and organizational dedication present at all levels in this project enabled the participants to overcome these dilemmas.

2. CHERISH demonstrates that it is possible to maintain the highest professional standards and ensure cultural relevance. This was accomplished by jointly discussing what the standards are and how to go about adapting them for the different contexts, implementing in-situ, and jointly evaluating outcomes.

3. Small projects can use limited resources efficiently to make a broader impact. In the scale of responding to the psycho-trauma needs in both communities, CHERISH is a relatively small initiative. However, by focusing on developing community-based interventions and capacity-building, CHERISH, has created an infrastructure that will last long after the project itself ends.

4. The benefit of framing the project in relatively independent, but interactive. modules proved beneficial in working in a highly unstable environment. The relative independence of the components enabled differential implementation, to adapt to specific politicallsecurity circumstances that affected one component but not others, thus ensuring that the project was not forced to come to a complete halt at any point in time. The interactivity enabled sharing knowledge and information between components, so that if a component was slowed down due to the environment, it could quickly move ahead when

L it was possible.

5. Achieving true system-wide impact is a long-term undertaking with few shortcuts. In the current project-based funding environment, it is difficult to ensure funding for the long- term vision. Dedicated initiatives such as CHERISH, are able to plan staged implementation strategies able to overcome the challenges posed by project-based hnding cycles. The CMM grant enabled implementation of key activities for capacity building that were only possible due to the groundwork that preceded it, and will have long-term impact through the activities to come.

6. In undertaking to cooperate by choice at a time when the conflict was being waged around them, project partners and participants, demonstrate that their professional identity, enables them to break out of the seemingly never-ending cycle of violence, offering succor to their own communities and hope for the future of the region.

(English, Arabic)

A Biopsychocial Model Implemented in Primary Health Care Settings

CHERISH-PHC

Orientation Protocol

Cherish is a partnership of The Center for Development in Primary Health Care/ A1 Quds University The Israel Center for the Treatment of Psychotrauma The JDC-Middle East Program (JDC-Israel, Myers-JDC-Brookdale Institute, AJJDC), Ashalim

The Biopsychosocial Model lmplemented in Primary Health Care Settings developed and implemented by The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical Center)

lmplementa tion in coopera tion with: Clalit Health Services Terre des Hommes/Ard El Atfal

,p-54+, I. =s- yUSAID & , $ FROM THE AMERICAN PEOPLE

Table of Contents

I. Introduction to CHERISH Ecological model

II. Introduction to PHC model

I l l . The role of mental health profession.al in a collaborative setting

IV. The PHC program

V. Revfew of procedures and documentation

VI. Problems and overcoming them

VU+- i Working with famllles

Appendices: . a. .. Z[?

1 1. Clinic Forms . . . .

1. Introduction to CHERISH Ecologjcal model I CHERISH is an umbrella initiative under which a network of activities work across institutions and within families and communities, both an a local and an international level, to create an ecological model of child and family centered resources.

An Ecological Model

The overall objective of CHERISH is to develop community-based psychotrauma activities that address unmet needs among Palestinian and Israeli children and families, while creating opportunities for cooperation within an environment of GO-existence.

Since 2002, CHERISH has been working to develop a network of culturally relevant community-based services aimed at identifying, assessing and treating Palestinian and Israeli children suffering from psychotrauma, as well promoting coping mechanisms and resilience in both communities. Activities integrate service development, professional training and research to increase capacity for addressing trauma in both societies.

The Bio-psycho-social Madel Impldrmented in Primary Health Care Settings (CHERISH- PHC) program seeks to create a dialogue and improve collaboration between primary care and mental health services. This is accomplished through the placement of a mental health professional (m) in primary care clinics whose role is to raise awareness and understanding of primary health clinic staff to mental health issues and their connection to physical health. The learning process is multi-directional, and also raises the awareness of the concerns.

II. Introduction to Bio-psycho-soclal Model Definitions: In 1980, George Engel, an internal medicine specialist articulated the biopsychosocial approach and rendered a visual representation that illustrates this comprehensive view. To understand illness , the clinician must attend to the biological contributors as we1 as the person, the clinician-patient interaction, the family, the social setting, and how these factors may be connected in the creation of symptoms (Family

I Oriented Primary Care, Second edition, 2005.p. 3 Spinger, New York.

. , . ' t ' Benefits h,B-.: b#:

i j cost effective for the health system. Children with psychosocid problems have up to 200% more compIaints regarding physicalhealth issues, and utilize more health servicef. Only 5% of these chiidren are identified by the mental health service sys tm I2

-+ New nzorbidity in pediatrics- in primary care this reflects the fact that children and adolescents suffer from disorders related to psychosocial factors ( family problems, poverty, violence, neglect, etc.)

+ The primary care physician sees large numbers of children and adolescents together with their parents.

-, Since there is less stigma in discussing issues with a family physician than with mental 1 health service providers (and greater accessibility of the primary health services), the

potential for identifying psychosocial issues is greater in primary health settings.

J- The primary focus of healthcare is th,e.patient in the c a n m of thefQmily.

4 The patient, family and clinicia re pafimtrs in h r d & c a ~

-+ The famil y-oriented clinician leflzct!a on how he or she is part of the i r e ~ n e n r s y s r e m m

Developing skillsfor family-oriented primary care:

Level I: Minirnd contact: farnilies are dealt with for practical or legal reasons. One-way communication prevails.

Level 2: Information and c o l l a b t j ~ n : . communicate information clearly to patients and families. Elicit questions and areas of concern, and generate mutually agreed-upon action plans.

Level 3: Feelinas and Support: demonstrate empathic listening and elicit expressions of feelings and concerns from patients and families. Normalize feelings and emotional

I reactions to illness.

Level 4: Pnrnary. fanulv8eS the relationship between the illness problem and the family dynamics. If the problem is not complex or long-standing, work with the family to achieve change. If the problem is entrenched of family counseling is not effective, make a referral and educate the family and therapist &but

1 4 what to expect.

Level 5: Medical family thera~y 0 Medical famiIy therapy 4 intensive spscialty care delivered by professionals wi.th advanced psychotherapy training. Prrmary care physicians should collaborate closely on those patients with whom they have active

i J involvement.

' ~ o s t e ~ o E : Primary Care Pediatrics and &ld Psychopathology: A review of diagnostic, tmament anrl referral ractices. Pediatrics, Dee. 1986, vol. 78(6)

Costeiia et a!: Service utilization and psychiatric d i r p s i s in pediatric primary care: the role of he gataktcptu. Pdatrics. Sbpt. 1988. VoI. 82 (30: 435-441)

Mental Health Professionals (MHP) Working in Primary Health Care clinics. The setting similarities and differences with mental health services.

-t The language: medical vs "psychotherapeutic"

-t The paradigm: biomedical vs psychotherapeutic

-t Professional style: action oriented, advice giving vs process oriented, avoids advice

-t Standard session time: 5-10 min vs 45-50 min

-t Demand for services: around the clock vs scheduled sessions except emergencies

-t Medications: frequent vs less or none

-t Use of individual and family history: basic vs extensive

-t At risk for : somatic vs. Psychosocial explanation

b Ill. The role of Mental Health Professional in a collaborative setting

Work with the Medical Staff - Through observations, modeling and informal discussions a collaborative relation is developed which focuses on raising awareness, honing assessment/identification skills and providing information on treatment options with regard to psychosocial issues to the physician and other clinic staff.

-t It should be made clear to the primary health staff (physicians, nurses, administrative) that the MHP is available for consultation by phone on days when they are not physically present in the clinic. This is significant because the primary care staff needs to learn that the role of the MHP is flexible.

-t The MHP requests to sit in on physician consultations, at the outset just observing, as a relationship of trust develops, the MHP may model questions to ask and offer observations after the family has left. (For more detailed steps, see work stages, page #)

-t Regular updating of the physicians regarding the children referred to the MHP, enables the physician to be part of the treatment, in contrast to the approach that refers the patient

Ir to outside factors and the resultant loss of contact.

-t Regular meetings with the physicians should be scheduled, during which their different needs to receive information on the subjects they encounter during their everyday work in the clinic are raised

-t Honing psychosocial assessment skills - As the physician's limited time must be taken into consideration, this does not refer to structured interviews, but rather the types of questions to ask the mother during the check-up of the child, how to ask them, what replies should inform him of problems, and how to encourage the parents to trust the doctor and share issues/problems that are no1 purely medical. (please provide sample questions).

-t Provision of information for the treatment/follow-up of common psychosocial problems - For example, in cases of enuresis or attention deficit disorder the doctors are provided with guidelines (do we have?) how to perform the follow-up, what to check, what to ask, what to look at. In cases of attention deficit disorder that entailed pharmaceutical treatment, the doctors receive instructions from a psychiatrist about the treatment prescribed.

4 In order to enhance the sensitivity of the doctors to psychosocial problems and to promote their awareness, a series of lectures is planned in accordance with the doctors' requests and according to the needs perceived by the MHP. These lectures include subjects such as children at risk, the sick child and the family life cycle, eating disorders, attention deficit disorders, normative emotional development and dangerous behaviors.

Intervention with Families

4 Intake stage - Once a child is identified by the physician and referred to the MHP, the MHP conducts an intake with the child and histher parents (preferably both). This could take one or two meetings. After the intake, a decision is taken by the MHP and the physician regarding the appropriate course of treatment and where it should be implemented. This decision is guided by the understanding that the program does not intend to transform the primary healh clinic into a mini-depot for mental health care, so as not to impair its ability to accept new children. The idea is to make as much use as possible of services that exist in the community (social services, educational- psychological, etc). The treatment remains in the framework of the clinic only if the services in the community are unavailable andlor inaccessible.

Treatment - Short-term treatments (6 sessions) may be offered in the clinic. These may be individual, family-oriented, or pharmaceutical (mainly for children with attention deficit disorder). The treatment must be provided with the cooperation of the PHP.

a The Mediated Community Part

4 After the intake process and the determination of the assessment, the extent to which the community could help in the treatment is determined. With some families, it may be clear that the family or the child has an earlier relationship with services in the community (social services, educational etc). Then it is important to share information and work in cooperation. In other families, the MHP will be the first to identify the problem and then will consider which other services (with the parents agreement) could be involved.

4 It is important to emphasize that the MHP's is expected to mediate between the factors in the community, and to provide guidance or follow-up, even if the child is referred to treatment in outside services. Frequently, it is necessary to involve the school system. As such, the MHP serves as a case manager, the one individual overseeing interventions in various settings.

IV. The PHC program

CHERISH - PHC Flowchart

Referral \/?

Primaly Goals for Ently:

Study of population characteristics. Learning about medical and paramedical staff. Understanding the community system involved in the lives of the children and their families.

Functions of MHP in the PHC model:

The MHP will receive an orientation and on-going supervision in the biopsychosocial model through the CHERISH-PHC program. The MHP will work together with the clinic staff through joint meetings held in the physicians' offices during the clinic's office hours, and by working along with the physicians at their request. The MHP will be in contact with other psychosocial treatment services in the community to inform them of the fact that slhe is working at the clinic, and promote a sense of collaboration. Using the referral form, doctors will refer children (and their families) with symptoms of psycho-social distress for consultation with the MHP. Children who are referred, together with their families, will undergo the intake process (up to two sessions), at the end of which the staff will determine how the intervention should proceed. Treatment process: family therapy, individual therapy, psychiatric treatment, workshops for families - as needed.

3. Work Stages

Familiarization with the Medical Staff (Time Frame: Weeks 1&2)

-, The work of mental health professionals in primary care clinics has the potential to arouse negative feelings in the clinic staff. These feelings could include suspicion of strangers, anxiety due to the upcoming change, insecurity due to the unfamiliar issue and what is required of them, and contempt of the ability of the 'collaboration' staff to help and to effect a change. The nature of the team's work depends on ability of the clinic staff to overcome these feelings and to cooperate in the development of skills that permit the identification of psychosocial problems in children. This is a new issue for the physician and others, and it is necessary to devote much work in the effort to diminish their tension. The main message to transmit is that they are not being tested and that the quality of their work is not being judged. It is necessary to convince them that you are interested in expanding their ability in a different direction - to develop a new mode of thinking that will directly help them develop their relationships with children and families and that will provide a solution for those children whose problems do not necessarily lie in the medical direction.

4 In the first stage, in order to achieve cooperation and reduce suspicion and anxiety among clinic staff, the mental health professional is simply present in the clinic and makes no declarations and assumes no special assignments. The mental health professional is present in the physician's room, in the nurse's room and in the waiting room. The mental health professional watches the staff at work and transmits the message that it is important for them to learn the work at the clinic and to identify with the difficult work conditions and their burdens.

-, Over the course of the process, when the relationship is formed and the suspicion lessened, it is possible to introduce the terms of identification. The main message is that you do not expect for the medical staff to perform perfect professional diagnosis but that they can refer phenomena or difficulties that do not appear to be purely medical to the mental health professional. In addition, if the parents clearly and explicitly refer to issues related to the psychosocial realm the doctors can refer them to the mental health professional a Familiarization with the work arrangements, atmosphere and communication in the clinic. (Time Frame: Weeks 1&2)

4 This stage is also performed through the presence of the mental health professional in the clinic. It is necessary to come to know the administrative staff, the procedure for making appointments, and the procedures for referral to specialists.

4 The mental health professional must have a dedicated, private place to meet with parents and children and so achieve the state in which the doctors and the administrative staff recognize the mental health professional an integral part of the team.

Development and implementation of the combined work.

+ As mentioned above, the work of the team for the incorporation of mental health care in a orimarv care clinic is based on cooveration with the medical staff and on the ~hvsician's . . degree of willingness and ability to develop skills to identify psychosocial problems in children, and recognize that there are professionals to whom s h e can refer them.

4 In order to facilitate the referral process, a special referral form is available (see Clinic Forms). As the doctors in the clinic are very busy and see about 12 children per hour on an average work day (5 min. appointments), the referral form is very simple and not be burdensome for the physician to complete.

It is very important to 'recruit' the nurse to the process, as they are very dominant figures in the clinic and are more likely to see the work with a system-wide perspective.

Data collection via questionnaires (see also research protocol) The interviewers will be specially trained to enroll families into the project and will learn how to complete the questionnaires.

The interviewer will approach every family with children aged 3-16 coming to the clinic, will explain the project to them and attempt to enlist their participation. After signing the consent forms, participating families will receive questionnaires to be completed (Demographics. SDQ - for parent and child, consanguinity). If the family has trouble filling out the forms, the interviewer can help them as necessary. The interviewer must ascertain that the questionnaires were properly completed, and if there are any answers missing they must ask the family to fill in the missing information wherever possible. The interview will tally up the SDQ questionnaire, and if the results are higher than the cut-off point, will inform the attending doctor and the mental health professional (registration procedure). At the end of each day, the interviewer will confirm the child's identifying details (name, identity number, telephone, etc.) with the clinic's filing system. The questionnaires will be locked up for storage at the clinic until the data has been entered into the computer. Data from the questionnaires will be entered into the computer via intake screens designed using Access software. Follow-up full interview will be conducted with selected families. The research assistant will also put together a additional data on patients in the clinic's catchment area to compare with the information collected from the study participants.

V. Review of procedures and documentation SDQ questionnaire Physician referral MHP Intake by MHP (including genogram) Follow-up MHP Feedback to physician Referral to community services

VI. Problems and overcoming them (role-playing) acceptance by staff acceptance by families - stigma identifying the clinic "contact" person (usually not MD) Back-up for trouble-shooting - procedures, who to contact

VII. Working with families (role-playing) Intake and Genogram - how to fill out Case studies - who to work in clinic, who to refer out

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Materials for Psychosocial Professionals (A)

Contents: Follow-up form for families invited to meet with the MHP- completed by physician

SDQ - children aged 11-16 MHP Intake Form

Genogram Follow-up form for refening Physician

Cherish is a parfnership of. The Center for Development in Primary Health Caret Al Quds University The Israel Center for the Treatment of Psychotrauma The JDC-Middle East Program (JDC-Israel, Myers-JDC-Brookdale Institute, AJJDC), Ashalim

The Biopsychosocial Model Implemented in Prima y Health Care Settings developed and implemented by: The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical Center)

Implementation in cooperation with: Clalit Health Services Terre des HommestArd El Atfal

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Cherish is a partnership of: The Center for Development in Primary Health Carel Al Quds University The Israel Center for the Treatment of Psychotrauma The JDC-Middle East Program (JDC-Israel, Myers-JDC.Brookdale Institute, AJJDC), Ashalim

The Bio~sychosocial Model Implemented in Primary Health Care Senings developed and irnpkrnenied by. The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical center)

lrnplementation in cooperation with: Clalit Health Services Terre des HornrnesfArd El Atfal

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Contents: Summary form (list o f people approached in clinic)

Consent form (parents and children) Demographics form

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Cherish is a parlnership 06 The Center for Development in Primary Health Care/ Al Quds University The Israel Center for the Treatment of Psychotrauma The JDC-Middle East Program (JDC-Israel, Myers-JDC-Brookdale Institute, AJJDC), Ashalim

The Biopsychosocial ~Wodel lmplemented in Primary Health Care Settings developed and implemented by: The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical Center)

Implementation in cooperation with: Clalit Health Services Terre des Hornrnes/Ard El Atfal

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Cherish is a partnership of: The Center for Development in Primary Health Care1 Al Quds University The Israel Center for the Treatment of Psychotrauma The JDC-Middle East Program (JDC-Israel, Myers-JDC-Brookdale Institute, AJJDC), Ashalim

The Biopsychosocial Model lmplemented in Primary Health Care Settings developed and implemented by: The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical Center)

Implementation in cooperation with: Clalit Health Services Terre des HommeslArd El Atfal


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Cherish is a partnemhip of: The Center for Development in Primary Health Carel Al Quds University The Israel Center for the Treatment of Psychotrauma The JDC-Middle East Program (JDC-Israel, Myers-JDC-Brookdale Institute, AJJDC), Ashalim

The Biopsychosocial Model Implemented in Primary Health Care Settings developed and implemented by: The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical Center)

lmplemenlation in cooperation with: Clalit Health Services Terre des HommesIArd El Atfal

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The Biopsychosocial Model Implemented in Primary Health Care Settings developed and implemented by. The Lady Sarah Cohen Unit for Family Centered Therapy and Healthcare (Schneider Children's Medical Center)

Implementation in cooperation with: Clalit Health Services Terra des HommesIArd El Atfal

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) g uLLm~n nL E mc,o E) E-9 uum~n 2) I-E uiLm~n I) qn GULU uuLLm (ST) uu' cucum LN,iLn cnLxiun.j (our. umcc NUU)

PHC - Parents

: 3 p5n

-/??a1 1i1ulu7is 51 Vuip .7uniu1u uii3u iinv lnx5 ,n7v1u 5ru n ~ n ~ u 5 niu7sina ni7ul 5v an7vl l5a5

- / n i .lnnua wiina 15anx 15 ;IY-TII;I IT a1y2 nn7m ir7x3 l n i n ;iziua mirl lxnnv (3-0) isona nu

.14 ulim niuln iniu luniuiua uii'u5 on71 a3ul 52

i l52 nnu nun i u u5 551 .O

nus ' in / nins iu u i l v l nus . I

jnnn 'rn l u i l v l nlnus 4-2 .2

7lnn nun> I inil i u u i l m nlnus 5 .3

~uniuiua uii7ua >Y n7ui10 IN nlui nini5n 19 ila 0 1 2 3 (23)

l i v vninn ar i 5 1 ~ ~ nvl'la iu n5us ,7unluiua u1i1Ha nu vinn nllln 0 1 2 3 (24)

;invu , x u , O Y ~ ,ins nvn ,5vn5) -aniuiua ~ i i ~ u a 15 i ~ r i a w ~ nAuo1 nvna ('731

0 1 2 3 (25)

(nii7;ln 25 nip's1 ,aura ,5vn5) ‘uniuiua uiilua 15 i ~ r i a v ~ ni-r3s n l l l l n n?ln 0 1 2 3 (26)

7 ~ n i ~ i u a uii7ua nu vy1ia5 i u 1275 ,zivn5 u5 n-0‘1 0 1 2 3 (27)

7uni~ iua uii-ua nu 15 P~-I~JTBV ninipn i u D~VIX ,ni?iVusn ~1n3a11 n707~ 0 1 2 3 (28)

7uniuiu;l uii3wan l i v n i;l5n ii1r5 nn5ra u5 0 1 2 3 (29)

nuiwn ni11V~02 nins azia nsnnvav IN lWlu nns 15 v3 0 1 2 3 (30) - i r 2 o n3vlun n/pni~n i u nlpnnn nvn o 1 2 3 1 (31)

) (n?nx ~s51 azau win5 nhlion x5 IN ni135 n5i1' loin ,9v135) n 7 v ~ i niap nvn 0 1 2 3 1 (32)

..n ,mmip 15 i1a7 u5 ,5vn5) alvnnnn ti5 i9nu5 17niipn i u 17ni1nn 1Vx1 nwlia ! (n~3i -1~ n3?n i u n"157 ,j7uiv1~ 0 1 2 3 (33)

jlru'11 1~ n11v5 nwvp 111 iva 0 1 2 3 (34)

nu1 nilirisna 15 i7a i u m i ~ n lo in nvn 0 1 2 3 (35)

i l lw, ninil lo in nvn ,p720 urn] 7n npiz ,5vn5) ailna 5~ i n 7 nI71iy ;l/n17a ('721 n5i5 alsin (I 1 2 3 ( (31)

1

(nnx naiwn ?a??) ?5'~5 nnii7i p75u ni7um n h o lnr an, i v n l v i inn nins 1 n7viin 3-1 2

(nnx naiwn -s7pa) ? a h ni7u2 i5na

PHC -Parents

PHC -Parents

RDI (only parent has experienced trauma) nx i n 1 1x1 ,n~> ,olugwn nrlaq >> 11~~2 x7p !IN' .O~UDWD,>W dlYt'ivn lz i rn ar 115,~w

. ' . , ,,

5% om,nna o " y ~ l w l nwna ,nl11 aalua hn , ~ n n , ~ w ~ , n r q z n -)Inn uDwna . . . , , ; , :: , ,

7> nw71 , a ~ n p 7nN ugwnn ,n~nnx .mn1w ugwna T>W mona n ~ ' ~ > ~ a ~ h i i , a ~ , : =' , . . .

' 1 I , , ,

.n;l l i~~n 7n11 n~xah 'wonan~ 'qqn ,nln+inn

.21YY W'hln ~5 'IN .O .1

.21YY 'IN .1

.nto ~ N Y > >D' '11,~1 ln tn >> 2 1 ~ ~ 'IN .Z

.nNt TIN* 3 1 ~ 'I'NW 7 Y >>)31N 1N 21YY 'IN . 3

.)1>~'3> W'hTD N> 'IN .O . 3

.y?linnn OlNT1n ini' 'n3w31w w in 'IN .1

.DCI~ nvi>wn tin ntii i 'INW no 53 "n >Y v n ~ > ru?2i13 .z i i n h l i 3 ~ 3 'INW wmn 'IN . 3

L'T UNO Uu3Ul dLlC <I<LL 6CC C'0'11 UUNKLLU NI C'OU <Grin cl(KU1 CLLL C<mL!'i

u~uIi

CNUKnLU LLcU' OCC\ NL tmd NUL C<AWt UU C'L' IrCt DYlUl ~Jdi

U~~U~GL(.C UNO '<LL cncm c~id mrrLuu q cK,nu NI NLUL <L ucoui UNO C<LL ULU~L

1'7 UNO 'CLL N' 660 ULudb GcL'U CCLt UCHU' LU'GU' UC'dU'tm'CU' NL CLL'ui-CNCfCr

9.1 UNO t<LL CN~ <UcGLL UUL NL ULULU UfiU6tU'U CU"L K<'U ULN Cam <KLLL NUKU NL

I

q C( <N q <N COLU

I q C( <N <N CLILU IN UNO 'QL uu~ uu<u dmu NL c6'6u m< NLO ALE N<LL~ uu u'u r'cl CWUI

muL! CULL udl NL ~K'U ULG'O <umL <'<ci auu'ur'(l CNLU; u~u[i-

S'T UNO '<LL ~CL u<'L LGLN' ULLCE C<~UL NL UU<U dmui UNO C<LL nit< I(,,' uiCm NL

uu udu r'cl cmu; u~ul;-

VrC UNCi<<lL ULLU ULLU C<U< KGh NL KOLO 1UCL a< NLO N<di

q CL a<N a<N COLU

CL D<N <NCntU

q C\ <N q <N COLU

<UULCi ICCIl UNLCU LC[: NL NLGCuO dmc' CG<<U' ~LvX!' NU6 CL ULNIULN CCCL dmLU'

(ad ~VCOLU

1'1 UNO '<LL e~e ani~c CUNLCU dmu c<mu' cu u'mu 6g< u,u qhcKnNcLrntu ur NG~

-

CUI KO CG,lrU,,

((LIL,~ mrca IL,LIO UII,~ XILIIT,~ rtq. XIG, m4 UXIL'~' irmr,,o ~L*~G,IT /r4 rr,xluo crGm,u

oLI~LuA(~GuA<K~L(~(~ nLNiIT/n(to-L(,,uL/iL~a c/uiCI(-uciauuc/~I~~~

surneii pamauadxa seq ply3 J! Lluo) IS^

T'L NM UNL C~KLU UNO '<LL ULIU N'LLKIO dm'o NUL'O.

Kumruu NLO mr~c CKLIL 4UiO)i uu uru rr5i c~lui uddi KUU4U' ULIANL <CL <<N URCUU C('< CL <N <Cl< U'U <nG< KriKUL' NL <U'<LG'I'ULBNL

2'9 UNO '<LL KL N' GCO U~LGU cu run1 uua w<o rctd uoL KNLC~ NL cmucul uaL

wuli cd~~u: uu MU rrct wut

mUN N"U1 6<cL Cc cCiCl NLUL NL CI 'm<UL NLUL <UdW NUL, NCN WU'

1'9 UNO CNUL ~<LL CNLG~ UUL icmru cc NCCI L<L ntc' UNO mad6 6qt CNIG~ UN'CO' NI

UU UrU rrC1 Nu1 Uldi

2.5 UNO c4.L ICU C4'C!LNK<L! CU CCGU 6< UiRUL MOLd CGkClU U'C'U CCmU'i

E'PUNO CQL N' 560 KGU cn<~i,i'~ CG~L<LU UGUUU NL nLLL~a,u~iu NL mwi ~<'uI CLL'L~

uu UIL' rrcl mud u~uli-

z P UNO i<LL cum6 'm'LIu gu<uuu' ri'utu'o uuim'o NL nuL,loi

fiUbUlLUiU 69LL i Uu CrU rrCl CXIUl ~l~li-

mN1L6l COKlKL' UULCLU LURLCU 4 CCL~ C'U U~GL' URCL(U CU ULN UUrLLL NL mCLCU NULU

LLuG~o' NL UL~G'O IU NU iUi UNO C<LL LNU NI mu6 N<'ULU cril UCNU' 'LC NL mu T'C UNO GLL HI GKO U'U I[L NL mu~~cm'o NUCCO~N'~~ C~L~C' U~UU LC'O' UCIO'

Uu<<O NLULfi\'LUlr UNO U'U 61 <UKC mC1Ui UU UrU rrCl CNlUi ~Uli-

5.f UNO 14.1 UC'L N' 660 ~LLC URGUU I?,[~KL' ULCN <UN~L' NL Y~U (6,,' UUIOLU'

S'Z NO L<LL Nc 660 Ulud6 6186 C<CNL KKrzU NULi UU UrU rrcl CNiUl ~ddi-

uu ur u rrci CWUI ~iuli-

cL <N 0 ON cntu

PHC -Parents

I nilon n'lnnl n'rn iawLn a l a'rn~u,o'I TY nmta I N n73a OYD 'N o ~ a .d nlul n'l n'l 13

? ~ I W I I N vrei I N o - n ! I n ~ u a n'l n'l 13 ?awp auSr= I N a'lnn l i tv ~ T D W I N OYD 'N o ~ a .e 1

I nrua n+ n'r 13 ? n s u n ~ ovs , N o ~ a . i I

I nrua n'l n'r 13 ?al l 'ap nun n13on mlnn n~n"IxS -rv nzmn o v ~ 'N o ~ a . I

1 I ' I n'r 1, ?,7-1~7 < n > l nmion n h v o l+?v an931 ouo #N o ~ a .n I

PHC - Parents

Scheeringa (only if child has experienced trauma) I I I 7 I

nqnuo'r N? ?>J ?unw? on81 nnlnn 'lu ?rn I N u17'~il > Y >NWI i r n n~f in n ~ a 81

nrnuo? N? >>3 ? u n 4 ~ > w 7 1 a>'> 8 u ~ a o n3fib> lna ~ N ; I 82 !

aaina uai>w in1>3 , ( o ' ~ ~ w N > D ) "nnirln n7r1a1' alln n 3 - h ~ ~ a ~ i ~ n ~ a ?11w wninn unwa I ? N ~ I B 3 1

__I_

13

13

13

I 13

/ 13 1 o'nuo) 1 N? >% ] ? n a p i w ~ n inl8 a n n l n ~ n TIDTI? awpnn f i a n ~ i i ( E3 (

o'nuo?

nnnvo>

nnnv5j?

nanvo>

13 i

N>>?J nnnuo>

N> 333

N> >>I

N> >>I

N? >>I

. o ' ~ i n nlno u?w) ?in13 inur a n I ? ~ J a a ~ n a ? i r n fima u1imx;1 rxn D N ~

( I > ~ A > l n l f i ~ DIN^ 717n

?n71p i w ~ n l n ~ ~ n w n ,>#a n ~ a

?0?1p i w ~ n l n n m nlnol a101 in11 nmi -boa vnwa r ~ n n ~ a

?>#a13 i w ~ n nwai nlno a ~ i a fi"a ON^

?- r1nu~ 117 DIW'I ilorn II'N ~ ' N J Y I ~ ~ N ~ ) r ~ n 1'1 fins ona

El

C4 -

C5

C6

C7


SOC Adolescent version it'runl 78 olx'r~a'r (SOC) a1YUIfi71N II?NW

SIN p x 5 wpmn 71n .nIiwn nlriiw9n 7 w, n5uw 535 .imn 5w 0'11w 0177x5 mon"nan nl5tiw 5w ni7o ~'135 I pn ,75 n i n ' ~ n n n in 1 mso5 nnnn o,5'nn ON .ni,>ix,pn nl3iwnnln 7- 1 1 ~ W N J ,Inliwn nN nNV3niI mson 51a'y3 )nu ninN wmn nnu ON ,nisun nN 5ia'Yl 1pn ,75 ninwnn 7 moo5 nnnn o'5'nn ON .ni9on nn 5 1 ~ ~ 3 .7353 nnN n ~ i w n \no ~ > N W 535.7 IN -15 7nw~in ,s 5~ i n i x n3iipn nisun nN

? ~ U ' T I i n n nnNw nwnw O,W>N 5w niJn>nna nynsinw izty3 n i p ON^

6 5 4 n i p 71an

!0,7Y,l n n u a om3 15 l'il ~ , W J Y 7y o ~ n 7 6 5 4 3 2

0'7y,i n n v n 1,n 55 33 1'n ~5 71~a 0,1112 OVY'I n i ivn

!nnin ~5 n i i ~ 3 f , 5 ~ o,on,,naw nwnn 75 w'w n i p aNn 7 6 5

nipini o > n W n i ~ i i p o'n'y:, oys qN 1N

) ? n l M m yri. i+i i3in N> 3rnx nnNw nwnn 75 w'w 3117 oNn (6 I


! ) n i ~ w'~in5 ~5 7 w n n"nw niwnn 7> w'w rn1p ONn 19

7 6 5 4 3 2 1 nipini o~n>y> n n n p o'nw> ,

I ' 6 5 4 3 2 I u71117i1 nN 'n'Ni 'nnn~n IN 'nntJn

1131~1 on's U')")YT) n i 3 x ~ n ~

( mi' ui'n ''"2 liiyn r m ~ on1 u>im> niynwn nl in ~ N W nwnn 7> w 7 D N ~ 112 1 7 6 5 4 3 2 1

I

nipini D ~ ' Y > nil l ip o>nv> DY9 7 N 1N

PHC - Home Interviews - Adolescents

2~ .niri? 7 2w 021~3 wnnw, IIN IIW . n ~ 7nwnnZ1 72w nnswnn nN 7no,snZ nlon,,nn niNm n12nwn .7 - I 1 nlirp3 p i NZI n79o 5 i n I nnNw n3wn

-nnl!J :,,3 N,n 522 7-1-13 7!Jw nwnnn nwp 3 7 ~ 3 ,193 mniy Innswn T W N ~ (5 : nt I n n s

7 6 5 4 3 2 1 '-1nr2 ?>nn nwp ),,)Y 7 ~ n n

nnswn3 71-13 nnswm Zl23n1

: 7 3 72 n ~ i ~ oi,n ?Y 7Zw nnswnn Zw o,,nl (3

7 6 5 4 3 2 1 1'n N!J O,-IY'I n ~ i u n i,n

IN n n u n 1 K ~ I o'~Y, 71ND 0,7173

10 71~3 n ~ 7 n ~ , n 7 , ~ nisr:, 213, 71i117n3 7Zw nnswan -17ny n v n 1 1 7 ~ 3 (7 !D,It!J

7 6 5 4 3 2 1 nnswnn ~ v - Y nn >w~n 72 ),N

71-13 ,in* T,JIY> n,n,

a


7 6 5 4 3 2 1 31 nn3 TY )IN 5532 nn5 nim5 nu o>n"p

: 75 o'nii, nnswnl 7,i'pgn niloal nww nnNw 0'1x7~1 (10


BDI ( if adolescent has experienced trauma) , . , , ,

n~ i n 1 pn I ~ N V ,olu~wn T I Y I ~ >,3 1 1 ~ ~ 1 N ~ P N I N : . ~ ~ u ~ ~ I . , ,

>w;n~xia.$jj( j i ~ n . ' n r . ' ~ ~ > ~ w , _ . I

8. . , ~. .:. . ) , i , L.,'

9913 b ~ n n n a o r 1 v l ~ w ~ nwam -1n1'1 allu? nxyi T m n i w + ,il~lq?q' i inn 'u~&nn . . ,

, ... . . , .. , . "' .: ,:; 75 O~N-II & l l p l 5 n ~ u ~ n n ,nln O N .n,niw u ' ~ w n a ' ~ ~ > l u ,;onA--nu . , >li'~a-:qpa dl _ . . E,

, , . t ~ a ~ ~ ~ r n ~ n ~ ~ aIxta,,=dni n${?,i ,oLnu~nn . ~ Y Y W,> l t2 N> ,IN .O .1

.3lYY ,IN .I

.ntn n~x>>i3, 7 1 1 , ~ i )ntn >J ~ I Y Y ,IN .Z

. n ~ t nnw5 >I>, ,SNW TY >>DIN IN ~ I Y Y n3 ,IN . 3

.-r,ny> vn,3 -rni,nl wtwn N> ,IN .O .Z

.-r,n~n 7 3 0 wNI,a ,IN .1

.msr> nn> ' 5 ],NW wn )IN .Z

.i%-~wn> o,>is, N> o,i3iilwi niipn ivn in -r'nYnw w,nn ,IN .3

.-r,nnn mi, ,nrv nN D W N ~ I N i p l o N> ,IN .o .6

. i l y ~ ,n"nwn 'nYY ,s>> ,nijp'l i n r ,JN .i

.,,ni~nvn >> 7 3 0 ,DYY ,933 ,niip,l ')N .Z

.npw o,yin o'i3-rn 53 >Y ~ Y Y nN o,wNn ,IN . 3

PHC - Home Interviews -Adolescents

FI ( if adolescent has experienced trauma)

uun N> >>>I ?(inla 11 ynxn inn nlw11-r jaw

al 'n1 1 alunl i 1 urn 1 N > ~ J I ( ,J wn anx) n n l n 'onn nu rrlnn;l> inln nnwpn;l nxa .3 1 I 11 a11 ?(imi~n nu i-tnoa? inlm 1'1 ;nu?

uun N> >>>I ?n~q-rln~> -yln n19!>'us1 qnnwa? in!' 7'1 awq oxa .7

Q

i 1 ~ n 1 i17'nl a7'n1 ,n8~wSx-lml onon'l , W ~ I J ~ ) [ ~ n o a > inl8 ;lull anx nxa .a 71xn a m a11 an ?(onno I N > I ~ I J > X 1113 ns7n1n nu

i17'n3 71xn a11

i17'nl 71xn a m

i 1 ~ n 1 i 1 ~ n 1 UUn

UUn

a11

a7'nl a11

an

a7801 nn

N? >>>I

N> ??>I

,nlila-w >nlm) 1in7ni1 i n i l n nu i 'onm ox2 .4

?(ay#ni~ [II>U nwlnn inl ' ,oo l - i

,J wn anx) angwnn nu n80n'l in^' nmwpn;l oxa .5

?(innsun nu i-moa'l inlu i> awp


.aipw an> onn l nlwai win> N'II IIW

Jrn rawnwJ nlgrn nr819ra nrwrnn "r


CDI nmlnnna n l a u ~ ~ w a l ' l ? n ~ llnlillml 1Inrw.m nN mnnw uown? nN l n l ,1137

D,DY~ nnn I~YY 'IN

In rn53 ~ I Y Y 'IN

1 7 U 3 D'l2f i l m nN nW1Y 'IN . 3

1702 N> ~ ' 1 2 7 nmn nww 'JN

-1703 N> >)>a nww 'IN El

) ~ ~ > J Y ~ ' I N .5

D,DY~ nxn ~1 'IN

0'DYdJ Y l 'IN

Children 12 and under that have experienced Trarrrna

D'WIN DY nlV> 121N 'IN .12

D'WIN DY nvn5 IN N> 'IN D ~ D Y ~ min

D'WIN DY niw> nrn N> 'hx 'IN

07lTt> 73 3Wp a>'> >3 .I6

w > a 1 i n

11V '7 JW' 'IN

>~JN> pwn '> 1 ' ~ own 211 .18

>DN> pwn ' 5 J'N o'n'nn n l i a

l l V '7 >31N 'IN 17

Children 12 and under that have experienced Traunle

Children I2 and under that have experienced Trauma

FI

( r i N n nrp 1 N:, 1 in:,:, in), ,:, nwp .1 (

1 7 i N n I nrp I N:, 1 nnswnn ,n ov mi, 17 . 3 1

I I I

( T i N n 1 nrp N:, I o,nn,:,n rnEt ni,i:,,vs1 nins y-mwn ,IN .4 )

f i N n

1 m a I nrp N:, 1 ,> 'IIDNW 0,717 7n1, n w i y ,IN .6 1

nrp

I I I

N:, o,ilnn ov in), 11 ,IN .2

f i ~ n N:, nrp O,WI~Y ini' h p n a N .7

Children 12 and under that have experierzced Traunaa

Pynoos Children

4 - nmn 7 i ~ n

n ~ l i ~ 1

n3-m 7)Nn

n ~ n 7 i ~ n

I

0

>>22

N:,

n ~ n 3 ~ , I ~ I Y

nvn3 n , ~ u n n7,m n,liln

nmn

:,> 23 I uyn I n i m OY ni>n> ibO N 1 N>I %I> i ~ w ) n > n ~ ~ i ,IN 7

3

nmn

il31il

nmn

n17n

. ~ n n 7ngn VNW 0, i l -r~ IN nl3DD inti ,IN

7 i ~ n

N> nu3n VN

:o

n3-m uyn N:, .nipw an> o~iiwpw

n3-m n ~ n l nmn u YD . n > n ~ IN nnnw w,>in> ,> nwp

n3-m >:,>I

2

n7,n3 n>111v 1

I 2

,::I: a7,n3 n>1i1,3 n7)nl n)1i1)1

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n3-r uyn

1

UYD

UYD

n37n - r ? ~ n

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.orip 1 n3-m

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n )~ i l n .VYJ IN ~ Y Y wuin5, ,> nwg 11

I

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nmn

nmn

I N -1n9n , > ~ 7 i n ,IN mpw a n n~ ,> i w n inwnw~

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vyn

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,> niiliyw mpw no >w nilinn IN nilwnn ,> w, .nYll N> ' lNW3 Dl wi t11

.DYII IN DY13 ,"iuipi1 w'>in 'IN

n m n

n1-n ilmn v YD

nmn n-r)n> n31n v YD

n n i ~ n

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N:, 143 ,

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3

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n x i l

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inwnw~ IN pln W Y ~ ~ n i w VNW >wn> ,rn>p> >ax ,>N

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TI YYDN3 n>inii iYnn )>NW IN n f i ,~~ : , '> nwp

. , n n w ~ ~ in nipw nnn p>nw w i n ,IN n3-m

ilmn

nl-ln

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.wmn m i p Ynwa

12

13

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.mpw nnn n ,~iwn o'p>n i i x > ,> nwp

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.mpw nn nN a n nN ' 5 i m n inwnw~ 9111 niptn niwinn ,> w,

n31a

16

17

Assessment of Families Who Have Undergone the Traumatic Loss of a Child Study Protocol

The Israel-Palestinian conflict has taken a heavy toll in human lives in recent years. From September 2000 to July, 2006, terrorist incidents have accounted for the deaths of 1,059 civilians and soldiers, of whom 129 were under the age of 18. The scale of the fatalities forces many families to deal with the traumatic loss of someone close to them. Most people respond to such loss with normal and adaptive mourning (Pngerson, 2004). though others may exhibit more severe and more complicated grief that could lead to emotional and health-

t related problems (Prigerson &Jacobs, 2001; Prigerson et al, 1997).

Complicated grief describes people who experience a sense of constant grief (Prigerson, 2004). A large part of the mental torment of such people derives from their psychological protest against the reality of loss, and their unwillingness to adapt their lives to a reality in which the loved one is absent. The experience is characterized by feelings of bitterness and emptiness, by constant longing for the person lost, by a wish to reverse reality, by a lack of hope of achieving any satisfaction in the future, and by the difficulty of finding any purpose or meaning in life without the deceased. Recuning intrusive thoughts about the absence of the deceased and the attendant sorrow hamper the ability to concentrate and live the present.

Frequently, there is significant difficulty in forging new relationships, and in getting involved in activities that provide satisfaction. All these lead to social isolation and a deterioration in family, work and academic functioning (Solomon, 2006). It is important to note that such responses are normal in the case of loss, and appear in the early stages of the mourning process. In most cases, one can see a gradual reduction in the intensity of the reactions and a rise in the ability to accept the loss. The difference between complicated grief and an adaptive

b gnef response depends particularly on its chronicity and intensity. Furthermore, by contrast with the normal grief response, complicated grief predicts negative results, like impairment of quality of life, morbid tendencies (depression and suicidal thoughts), and impaired health (high blood pressure, sleep problems, and unhealthy behaviors like smoking or alcohol consumption) (Prigerson & Maciejewski, 2005).

In light of studies showing symptoms of pathological grief as constituting a discrete syndrome (Horowitz et al, 1997; Prigerson, Macijeweski et a], 1995). clinicians and researchers have begun, over the last decade, to attempt the formulation of a diagnosis of Complicated Grief. This diagnosis describes a symptomatic pattern - like depression disturbances, anxiety and post-traumatic disturbance - that is distinct from other responses to loss (Prigerson &Jacobs, 2001).

Criterion A of the diagnosis relates to separation stress, and includes at least three of the following four symptoms: ongoing yearning or desire for the deceased; intrusive thoughts about the deceased and his or her absence; searching for the deceased; and a strong feelingof loneliness.

Criterion B relates to traumatic stress, and includes at least four of the following eight symptoms, with a frequency of several times a day, or at a high level of stress:

a) Difficulty accepting the death; b) World-view is undermined (feeling of security; trust in others; control); c) Feeling of detachment and distance from other close persons, or a feeling of

numbness or lack of affective response towards them; d) Feeling of lack of meaning in life without the deceased; e) Lack of hope about the possibility of achieving any satisfaction in the future

without the deceased; f) Strong feelings of bitterness or initability since the death; g) Appearance of physical or behavioral symptoms associated with those

experienced by the deceased; h) Feeling of unease about moving on with one's life.

The symptoms should persist for at least six months, and be accompanied by a significant deterioration in functioning in family, social, professional and other relevant situations (Neimeyer, Prigerson & Davies, 2002; Solomon, 2006).

0

The literature on children who have experienced loss presents a slightly different picture from that of adults, and relates to "traumatic grief in childhood"; that is, the presence of post- traumatic symptoms which influence the normal mourning process in children (Layne et al, 2001). The emphasis is on a subjective exposure to death which is experienced as traumatic for the child; in other words: involving a strong subjective feeling of horror and helplessness. It should be pointed out that the intention here is not necessarily to death as a result of an objective, traumatic and sudden incident. While in the complicated grief of adults the trauma is the product of lost relations in the context of attachment and self-regulation, for children the trauma is the product of feelings of horror and fear, which are connected to the nature of the death and to death itself (Cohen & Mannarino et al, 2002).

The main objectives of mourning in childhood are to come to terms with the reality of the loss, to experience the pain of the loss, to adjust successfully to an environment and a new sense of self-identity in which the deceased is absent, to transform the relations with the deceased from the present to a memory, to find meaning in the death, and to have the II;) presence and constant support of another adult (Worden, 1996; Wolfelt, 1996). Success in achieving these objectives depends on the process of working through memories and feelings connected with the deceased and the interaction with him or her, as well as deal in^ with the - pain of loss. The child has positive memories of the deceased, thus the memory and the work of processing is not a matter of pain or horror alone. Furthermore, in a normal process of mourning, the child is able to establish a sense of the ongoing presence of the deceased, a presence that is able to provide comfort for the loss (Brown & Goodman, 2005).

In the case of traumatic grief in childhood, the post-traumatic symptoms, and in particular intrusive memories, interfere with the success of the mourning process. Intrusive memories are aroused in response to three kinds of reminders: those that recall the trauma (places, smells and voices that remind the child of the circumstances of the death); those that recall the loss and the deceased him- or herself; and those that recall changes as a consequence of the death (moving house, changes in life style, who wakes me up in the morning?, and so on). These intrusive memories produce physiological arousal and a sense of horror and helplessness, which the child copes with through a strategy of avoidance and restriction of his or her responses. The avoidance reduces the possibility of exposure, and the restriction

reduces the experience of pain. These symptoms exact a heavy price in the mourning process. The child will refuse to experience the pain and try to process memories connected to his or her relations with the deceased that would allow assimilation of the deceased as part of his or her personal identity. He will have difficulty forming new significant relationships, partly out of fear of further loss (Nader, 1997; Cohen & Mannarino et al, 2002).

The literature on the subject of complicated grief suggests that factors of resilience and risk may predict the adjustment to loss. One controversial risk factor is the suddenness and the circumstances of the death. Some studies found this factor to be a clear predictor of low adjustment and complicated grief (Jacobs, 1993; Parkes & Weiss, 1983; Barry, Kasl & Prigerson, 2001). Other researchers, by contrast, did not find that the factors of suddenness or the circumstances of the death were predictors of complicated grief, and suggested that the severity of the symptoms of the grief response is connected to the closeness to the deceased and the relationship with him or her (Goodenough et a1 2004; McLatchey and Vonk, 2005). Thus, studies that examined grief responses after traumatic events (terrorist incidents, road

b accidents, war and disasters) found that the closeness to the deceased is the clearest predictor of complicated grief (Pivar & Prigerson, 2004).

This last assumption is connected to the theory that regards complicated gnef as a disturbance associated with impaired attachment (Bowlby, 1980; Prigerson & Vandenveker, 2005). and in a study that found a relationship between complicated grief in adulthood and a history of separation anxiety (Vandenveker et al, 2006), and abuse and neglect in childhood (Silverman, Johnson & Prigerson, 2001). Similarly, a dependent relationship with the deceased, in which the deceased fills the need of the subject's self-approval or affirmation could be a predictor of complicated grief in the individual (Bonnano et al, 2002). Again, Prigerson & Vandenveker (2005) see the focus of the criteria for the diagnosis of complicated grief in the relations between the individual and the deceased, and in the importance of the loss of those relations for the grieving individual. It can be seen that the individual's system of relations have a significant impact on his or her response to mourning. This is also clear in the findings that testify to the importance of support systems for the adaptive adjustment to loss (Vanderweker & Prigerson, 2004).

The family is the natural available source of support for the individual. Death in the family has an impact on the individuals within the family, but also on the family as a system that must go through a process of reorganization. The response of a particular individual in the family - regardless of whether the response is adaptive or maladaptive - influences other family members and relations within the family as a whole. There is therefore a need to understand mourning within the family from the perspective of the family as an interactive system (Walsh and McGoldrick, 1990).

Previous studies have dealt with the relationships of the subject in mourning, but they focused on understanding the pattern of his or her personal connections and relationship with the deceased, and not on his or her presently active system of relations that could be a source of support or even pressure in the context of loss. Understanding family processes and patterns of functioning can contribute greatly to a deeper understanding of the individual's adjustment to loss, and to the development of complicated grief. It should be remembered that some of the symptoms described in the context of complicated grief relate to the connection with others. That is how the feeling of dissociation and distancing from others is described, and a decrease in affective responsiveness, a strong feeling of loneliness, a loss of trust and even imtability and nervousness which find expression in the systems of relations

themselves. It would appear that these symptoms should be understood not only in reference to the inner world of mourning, but also in reference to existing interactions that could - - encourage or inhibit the development of such symptoms.

Studies have shown that family variables can predict the grief response. Family functioning has been found to predict two of the components of traumatic grief: traumatic distress and separation distress (Goodenough et al 2004). The clinical literature describes necessary family tasks for adjustment to loss, and emphasizes the importance of family sharing and communication, and the reorganization of the family system in all its various roles, on the basis of the interrelationships within it and the relations between the family and the outside world (Walsh & McGoldrick, 1990). Neimeyer et al(2002) conceptualize the process of adjustment to loss within the family a little differently, describing it as dependent on the ability to redefine the actual situation (i.e. to accept the death), and to rebuild a meaningful life. In their view, a clearer picture of this process requires an understanding of the interactive family processes of the search for and attribution of meaning.

The degree of cohesiveness and sharing in this process is an important factor in adjustment, certainly in a situation in which the cohesiveness also involves individuation. For example, the greater the discrepancy in personal significance given to linking objects - items that oncc belonged to or which serve as distinct reminders of the deceased - the greater the potential for misunderstanding within the family and for difficulties in the mourning process (Davies, 1987). An "open" family system. with clear patterns of communication, in which the individual can feel that he or she can communicate a significant part of his or her inner world and even intense emotional reactions, offers a better possibility of adjustment (Bowen, 1990). One may understand from this that the trauma of childhood mourning is significantly dependent on the parent's reactions. Hyperarousal and increasing demands on the parent can produce initability and anger and an attendant reduction in parenting competence (Nader, 1997). The parent's avoidance will lead to less patience and support for the child who shows grief symptoms, causing avoidance in the child as well. The parent's over-identification with the child's pain and his or her own loss of strength may blur the family boundaries and cause an inversion of roles, and an attendant message to the child that 'the world is not safe' (Cohen & Mannarino et al, 2002).

In the event of the loss of a child, special attention must be given to the role of the couplehood or marital relationship. The death of a child is a double blow for the parent. The experience of losing part of the self represents a deep and painful narcissistic blow. Furthermore, the damage to parental omnipotence and the attendant feelings of guilt produce a sense of loss of competence and power (Klass, 1988). The difference between losing a child and losing a parent has been described by parents in this way: "When your parent dies you lose your past; when your child dies you lose your future" (Klass, 1988, p.14). There are gender differences in the response to grief. The response of men is characterized by withdrawal, by a reduction of emotional responsiveness, and by expressions of anger and loss of control. Women exhibit feelings of guilt and depression. The gap between the responses can lead to a feeling of distancing or detachment: the husband feels helpless in the face of his wife's reaction, while she, on the other hand, feels that she has lost her main source of support. A wider gap between the couple predicts difficulties of adjustment (Walsh & McGoldrick. 1990).

The present study will focus on several objectives in the framework of the family perspective and systemic understanding of the mourning process:

1. Identification of the psychological, social and practical needs of families that have lost a child to terrorism.

2. Deepening and extending the knowledge of how families cope with the loss of a child in a violent incident of a security-related nature.

3. Identification of risk and resilience factors within the family structure, and the nature of the relationships within the family.

The University of Al-Quds in East Jerusalem will be conducting an identical study in conjunction with this one, examining Palestinian families who have lost a child in the conflict with Israel. Collaboration between these studies will allow a cross-cultural comparison of family coping with traumatic loss, and of the identification of resilience and risk factors among the families.

Method of the study

b Participants. The assessment process will include some twenty-five Israeli families who have lost a son or daughter below the age of 18 as a result of a terrorist incident, at least six months previously. All family members living at home will participate in the study. The study will not include single-parent families, or family members who suffer from mental retardation, disturbances because of addiction, or psychiatric disturbance from the psychotic or autistic spectra (schizophrenia, manic-depressive illness, psychotic disturbances, PDD).

Procedure. The recruitment of families will be done by the Kobi Mandel Foundation, which is involved in helping families that have been victims of terror. The families will be approached by the psychological consultant of the Foundation, who is in constant contact with the families and is well known to them. The Foundation will not approach families who fit the criteria of ineligibility for the study, as described in the previous paragraph. The parents will fill out a form of informed consent on their own behalf, and on behalf of their children who are under the age of 18, after they have received an explanation about the procedure of the study, and have been given an opportunity to ask questions about it. Teenagers over 14 years old will sign a form of informed consent, with parental permission.

b Family members over the age of 18, living at home, will fill out a form of informed consent on their own behalf.

After completion of the forms of consent, the stage of answering the questionnaire can begin. To carry out this stage, each family will be assigned a professional by the Israel Center for the Treatment of Psychotrauma, who will be its liaison and responsible for the process of assessment. The completion of the questionnaires will be coordinated with the family members, and canied out in the presence of the liaison, who will assist in explaining the questionnaire, and provide support in the event of emotional difficulties arising.

Every member of the family will fill out the questionnaire separately; the liaison will focus on helping children who have difficulty doing so. The parents will fill out questionnaires for small children (under 10 years old). In order to preserve the privacy of the participants, each family member will receive a personal code to be written on the questionnaire. The liaison alone will have the key to identify each participant, which is important for the identification of needs within the family, and the ability to dilect them for appropriate treatment.

Possible risks. The main risk for the participants relates to the possible uncomfortable feeling the questionnaire might raise by evoking memories of the deceased, and to personal distress. For this reason, the questionna&s will be given to the participants by a trained professional who will be able to provide support, identify distress and suggest seeking professional treatment if necessary.

Qualifications of the Principal Investigators. The work will be camed out under the supervision of Dr. Danny Brom, the founder and current director of the Israel Center for the Treatment of Psychotrauma. He was previously among the founders of the Dutch Institute for Psychotrauma, and its first director. He served as scientific director of the Latner Institute for the Study of Social Psychiatry and Psychotherapy, and has published many books and articles on the subject of trauma, loss and coping. In addition, several senior researchers and clinicians in the fields of grief and of the family have agreed to be accompany the study as consultants. Among them are Dr. Cynthia Carel of the Family Healthcare Unit of Schneider Children's Medical Center, Petach Tikva; Dr. Claude Shem Tov of Mount Sinai Hospital, New York; and Dr. Ruth Malkinson of Tel Aviv University. @ID

Description of the research instruments

Demographic and organizational details. The participants will relate to demographic details like age, sex, family status, place in the family, occupation and socio-economic status, as well as information about the death (circumstances and time of death, description of the loss). In addition, the questionnaire will examine various details like present occupation and income, medical problems and their treatment, connection with social services, and educational needs. These questions will examine the family's level of organization for the purpose of assessing its social and material needs.

McMaster Family Assessment Device (FAD): This questionnaire contains 60 self-reported items that assess six aspects of family functioning:

1. Problem solving: The ability to deal with threats to family integrity and functioning; 2. Communication: The way information is exchanged within the family; 9 3. Roles: The existence of behavior patterns that are intended to deal with different

functions in the home and the family; 4. Affective responsiveness: The ability to experience a range of emotions; 5. Affective involvement: The degree of interest of one person in the activities and

concerns of others in the family; 6. Behavior control: Relating to standards of behavior in the family in the context of

patterns of control.

In addition, the questionnaire contains a component (12 items) of general functioning (Epstein, Baldwin and Bishop, 1983). A high internal reliability (over 0.70) was found for six out of seven dimensions of the questionnaire. The reliability of the family roles dimension was found to be marginal in a clinical sample (alpha=0.69), and lower in a non-clinical sample (alpha=0.57). The internal construct of the FAD was validated by factor analysis. indicating six separate factors. This was similarly found in different non-clinical, clinical and medical samples (Kabacoff, Miller, Bishop, Epstein and Keitner, 1990).

Couple adjustment: Dyadic Adjustment Scale (DAS) (Spanier, 1976).

The quality of mutual adjustment in the marital system will be measured by the DAS questionnaire, which contains 32 items in four subscales: Dyadic Consensus, Dyadic Satisfaction, Dyadic Cohesiveness and Affectional Expression. Different studies found high internal reliability (alpha=0.9), and high retest reliability after eleven weeks (alpha=0.96). Subscales of couple cohesiveness and expression of affect~on exhibited slightly lower reliability. This scale has a high convergent validity with the Locke-Wallace Marital Adjustment Test (Locke-Wallace, 1959).

Stress measures The study will measure a number of stress variables. We will use different indicators and instruments according to their appropriateness for the age range of the subjects. Here is the list of measuring instruments, according to age:

tr Grief Response: Inventory of Complicated Grief - ICG (Prigerson and Jacobs, 2001). The questionnaire examines adjustment to grief. Its 33 items measure non-adaptive symptoms of response to loss. The items make up two primary distress scales -traumatic distress and separation distress - which represent a uni-dimensional construct. The participants are asked to grade the degree to which they experience each of the symptoms presented, on a Likert scale of 1 (never) to 5 (always). Some studies found high internal internal reliability of the questionnaire (Croncach's alpha20.83) (Goodenough et al, 2004), and discriminant validity regarding anxiety and depression disturbances (Ogrodniczuk et al, 2003), adjustment disturbances and post-traumatic disturbances (Pri~erson and Jacobs, 2001). The structure of the questionnaireand the distinction between anx;ety and depression disorders were found valid across different population groups (Prigerson & Maciejewski, 2005).

Exposure to trauma and post-traumatic distress. The PDS questionnaire (Foa, Feske & Murdock, 1993) will examine the history of traumatic events, subjective trauma response, post-traumatic symptoms and functional impairment. The questionnaire includes yeslno questions for the parent to answer regarding possible traumas in his or her past (e.g. road

Cr accident, natural disaster, sexual attack). Four yeslno questions (like 'Were you afraid' or 'Did you feel helpless' during the traumatic event?) examine the subjective response to the event (criterion A2). The section that examines post-traumatic symptoms includes 17 items that relate to the appearance of different symptoms, according to DSM, within the last month: re-experiencing the event (criterion B), avoidance (C) and hyperarousal @). The scale of responses runsfrom 0 (not relevant or happened only oncejto 3 (almost all the time). A grade of 2 or more is regarded as verifying the existence of a symptom.

Beyond this, the questionnaire contains nine yeslno questions that relate to impaired functioning in different areas of life. like work. relations with farnilv members. leisure time activity, anb so on. Foa, Feske & ~ " r d o c k (19'93) report high inteGa1 reliabliljty (Cronbach alpha=0.85) and high validity (r=0.94) with theSCID results (Structured Clinical Interview for DSM-In). ~dentification of post-traumatic disturbance depends on the report of at least one symptom of criteria A1 and A2 (subjective and objective exposure to the event), at least one of group B (re-experiencing the event), three from C (avoidance) and two from D (hyperarousal), and consequent damage to the subject's functioning in one area at least. Furthermore, participants who suffer from post-traumatic symptoms that match the criteria of objective and subjective exposure, impaired functioning, two out of three avoidance clusters,

re-experiencing the event and hyperarousal, will be considered to be suffering from partial post-traumatic distress.

Depression: Beck Depression Inventory (BDI-11). This widely accepted questionnaire measures the severity of symptoms of depression. It was updated in 1996 in order to meet the criteria of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition). The participants are asked to relate to 21 items that describe different depressive symptoms on a scale of 0-3. A general score on the questionnaire can therefore lie between 0 and 63 (a higher score indicates greater severity of depressive symptoms). A score of 20-28 is defined as moderate depression; a score of 29 and above is defined as serious depression (Beck, Steer & Brown, 1996). In this study we propose using a score of 20 as the cut-off point for depressive symptoms. The questionnaire will be given to both the adult and the adolescent sample.

Adolescents

Grief response: UCLA Trauma Psychiatry Service Grief Inventory (Layne et al, 1998). On this questionnaire, the participants are required to answer ten items that relate to loss response, from 0 (not at all) to 4 (very much) on a Likert scale. The questionnaire is appropriate for ages 8-18, It begins as a screening measure, showing high reliability and validity. It has served as an assessment instrument in studies that examined the efficacy of treatment of adolescents exposed to loss in war (Layne et al, 2001) and in violence within the community (Saltzman et al, 2001).

Post-traumatic symptoms. UCLA PTSD Reaction Index Adolescent Version (RI-R) (Rodriguez, Steinbeg, & Pynoos, 1999). The RI-R is a new version of the earlier UCLA Reaction Index (Frederick, Pynoos, & Nader,1992), which was based on the DSM-ID. The RI-R includes 22 items for self-report. It measures the frequency of post-traumatic symptoms in the previous four weeks. Subject are asked to note the frequency of symptoms on a scale from 0 (never) to 4 (most of the time). The measure of the severity of post-traumatic symptoms will be computed by summarizing 20 items on the questionnaire, as per Rodriguez et a1 (1999). This scale has been extensively used in the assessment of PTSD in adolescents and children (for example: Pynoos et al., 1987; Schwarzwald, Maitisyhu, Waysman, Solomon, & Klingman, 1993). The internal reliability in the Israeli version of the questionnaire was found satisfactory (Cronbach's Alpha-0.72) (Pat Horenzyck, 2002). This questionnaire will be given to children as well.

Functional impairment. This will be measured by means of Items on the Diagnostic Predictive Scale (DPS), which relates to significant impairment in different areas of functioning (APA, 2000), for example: functioning in school, social relations, family relations, activity outside school and dangerous behavior. The participants will be asked to grade, on a scale of 0 (not at all) to 5 (very much) the degree to which they have experienced impairment in functioning in these areas. The severity of functioning impairment will be computed as the sum of all the items. In order to meet the criterion of functioning impairment in post-traumatic disturbance, at least one of the items should be endorsed as "much" or "very much"." The internal reliability of the scale, among 5,000 Israeli adolescents, was found to be satisfactory (Cronbach's Alpha=0.756) (Pat Horenzyck, 2002).

Exposure to traumatic events. This self-repon questionnaire is a translation of the questionnaire by Ford et al. (1997), and works on the same basis. The subjects will be asked to answer, yes or no, whether they were ever exposed to one or more of 17 different traumatic events (for example: a road accident, an attack by an animal, exposure to violence, exposure to a terrorist incident).

Strengths and difficulties. The Strength and Difficulties Questionnaire (SDQ), self-reported or filled out by parents, contains 25 items which assess different aspects of adjustment among children and adolescents focusing on behavioral symptoms. The questionnaire is intended to be completed by parents (or teachers) for children aged 3-16. Adolescents aged 11-16 can fill out the questionnaire by themselves (Goodman, 1997). The participants are asked to relate to 25 positive and negative statements, and respond as to what degree each statement fits their children, on a Liken scale of 1 (not true) to 3 (certainlytrue). The questionnaire is made up of five main factors: emotional symptoms, behavioral problems, attentiveness and hyperactivity, relations with the peer group, and pro-social behavior. Internal reliability (Cronbach's Alpha=O.73) and retest reliability (Cronbach's Alpha=0.62) were found to be satisfactory, Cv and the instrument was validated for its ability to predict adjustment and psychopathology (Goodman, 2001).

Children (Grades 3-6)

Depression. Children Depression Inventory (CDI) (Kovacz, 1992) is a self-report questionnaire that assesses cognitive, affective, somatic and behavioral aspects of depression in children and adolescents from age 6 to 17. The original version of the questionnaire has 27 items, each containing three sentences. The child needs to choose the sentence that best describes his feelings over the previous two weeks. The scoring of the questionnaire presents a general score and five sub-scores: negative mood, interpersonal problems, ineffectiveness, anhedonia and self-image. The questionnaire has high internal reliability(alpha=0.85). Kovacs (1992) reported retest reliability and convergent validity. Likewise, the questionnaire is valid as an instrument to identify depression symptoms in a non-clinical population. A 10- item abbreviated version of the questionnaire has bcen developed to provide rapid assessment

W of symptoms of depression in children and adolescents. This version gives a similar result to that of the original version, but without the division into factors. This study will use the abbreviated version.

Anxiety. The Screen for Child Anxiety Related Emotional Disorders (SCARED), (Birmaher et al, 1997) is a self-report questionnaire that assesses anxiety symptoms in children. A general anxiety measure (eight items) and a separation anxiety measure (seven items) will be computed from the questionnaire. The subjects will be asked to grade, on a scale from 0 (generally not true) to 2 (generally true), the degree to which the items describes their situation. The general score. on the two scales will be computed as the sum of the items.

Small children

The report on the distress of small children in the family will be divided into two. For children aged 2-11, the parents will answer SDQs. For children aged 2-5, the parents will answer the Post-traumatic Stress Questionnaire. Each parent will answer a separate questionnaire.

Post-traumatic stress. The questionnaire is based on a semi-structured interview with the parents with respect to post-traumatic symptoms in their little children (ages 2-5) (Scheeringa & Zeanah, 1994). The parents will be asked to mark, on a scale of 0 (never) to 3 (yes), whether each one of the symptoms were evident in their children within the previous month. Symptoms include re-experiencing, hyperarousal, avoidance, impaired functioning, and special age-related symptoms of regression in certan areas, caused by exposure to trauma (like drinking from a bottle, new fears and bed-wetting).

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Prigerson HG, Maciejewski PK, Reynolds CF 3rd. et a1 (1995): Inventory of Complicated Grief: A scale to measure maladaptive symptoms of loss. Psvchiatrv Research, 59: 65-79.

Prigerson HG (2004): Complicated Grief: when the path of adjustment leads to a dead-end. Bereavement Care 23: 38-40.

Prigerson HG, Bierhals AJ, Kasl SV, et a1 (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Joumal of Psvchiatry, 154: 616-23.

Pynoss, R.S, Fredrick, C., Nadar, K., Arroyo, W., Steinberg, A,, Eth, S., et al. (1987). Life threat and posttraumatic stress in school-aged children, Archives of General Psychiarty, 44. 1057-63.

Rodriguez, N., Steinberg, A. and Pynoos, R.S. (1999): UCLA PTSD Index forDSM4 Ici)

(revision I ) instrument information: Child verslon, parent version, adolescent version.

Saltzman, W.R., Pynoos, R.S., Layne, C.M., Steinberg, A. & Aisenberg, E. (2001): Trauma/ grief focused intervention for adolescents exposed to community violence: Results of a school based screening and group treatment protocol. Group dynamics: Theon, research & m, 5,291-303

Schwartzwald, J.M., Wesenberg, INITIALS MISSING et al. (1993), Stress reaction of school-age children to the bombardment by SCUD missiles, Journal ofAbnormal Psychology, 102 (3), 404-410. Spanier. G.B. (1976): Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family. 38:15-30.

Solomon L. (2004): Update on bereavement research: Evidenced based guidelines for the diagnosis and treatment of complicated gnef. Journal of palliative medicine, in press??

Zhang B, Maciejewski PK, Vanderwerker LC, et al. A preliminary empirical examination of the state theory of grief resolution. JAMA (re-submitted).

Horowitz, M.J., Siegel, B., Holen. A., Bonanno, G.A., Milbrath, C.. & Stinson, C.H. (1997). Diagnostic criteria for complicated grief disorder. American Joumal of Psychiatry, 154.904- 910.

Silverman GK, Johnson JG, Pngerson HG (2001): Preliminary explorations of the effects of prior trauma and loss on risk of psychiatric disorders in recently widowed people. Israel Joumal of Psvchiatrv and Related Sciences, 38: 202-215.

Vanderwerker LC, Jacobs SC, Parkes CM, et a1 (2006): An Exploration of Association between Separation Anxiety in Childhood and Complicated Grief in Late-Life. Journal of Nervous and Mental Disease, 194:121-123.

b Vanderwerker LC, Prigerson HG (2004): Social support, technological connectedness and periodical readings as protective factors in bereavement. Joumal of Loss and Trauma, 9: 45- 57.

Walsh, F. & McGoldrick, M. (1990): Loss and the Family: A System Perspective. In ?I/, Walsh, F. & McGoldrick, M (eds). Ch 1

Wolfelt, A.D. (1996): Healinq the bereaved child: Grief pardening. growth through giief and other touchstones for caregivers, Foa Collins, CO: Companion Press.

Worden, J.W. (1996): Children and grief: When a parent dies. New York: Guilford.

McMaster Family Assessment Device- FAD (Epstein, Bishop and Levine, 1978): The FAD is a 60 item self- report instrument developed to assess 6 dimensions of the family functioning A. Problem solving- refers to the family's ability to resolve issues of threat to family integrity and functioning. B. Communication- the exchange of information among family members. C. Roles- family's establishment of patterns of behavior for handling a set of family functions. D. Affective responsiveness- ability to experience various emotions E. Affective involvement- extent of interest in each other's activities and concerns within the family. F. Behavior control- way of expressing and maintaining different patterns of control. Additional General functioning scale (12 items) is included (Epstein, Baldwin and Bishop. 1983). A high internal reliability of more then 0.70 was found for 6 of the 7 scales. The roles scale was a sole exception, having marginal reliability for psychiatric and medical samples (alpha=0.69) and lower reliability in a non-clinical sample (alpha=0.57). The internal construct of the FAD was validated by factor analysis indicating six separate scales. This was similarly found in non-clinical, clinical and medical samples. (Kabacoff, Miller, Bishop, Epstein and Keitner, 1990). 9

Demograohics and Bereavement H ~ s ~ o N . In addition to standard demographic information such as ~ender, age, family status, SES, and occupation, we will obtain detailed information about the - - circumstances surrounding the child's death (type of death, description of the loss, number of siblings, age of siblings, immediate impact of the death, and perceived continuing impacts).

B e r e a v e m Adaptation to bereavement will be measured using the Inventory of Complicated Grief (ICG) (Prigerson and Jacobs, 2001).This is a 33-item self report measure of maladaptive symptoms of reaction to loss. Responses are given on a Likert scale. This measure was normed with a population of conjugally bereaved adults. Reliability and validity tests point toward a distinct measure of distress related to loss as compared with traditional measures of depression. Intemal consistency was high producing a Cronbach's alpha of .94, and test-retest reliability was .8 over six months. Subjects who scored over 25 (top 20%) showed significantly greater impairment on measures of mental health, physical health, physical pain, and social functioning as measured with subscales of the Medical Outcomes Short Form (MOS) than subjects scoring below 25 on the MOS. The ICG showed a moderately high convergence with the Beck 3 Depression Inventory (BDI; .67) and a high convergence with another measure of grief experience, the Texas Revised Inventory of Grief (TRIG; .87). Subjects in this validation study were also asked to compare the ICG with the TRIG and 85% of respondents said that they preferred the ICG in terms of comprehensibility and ease of response. Given the extremely vulnerable nature of the population, this was an important factor in choosing this measure as well.

PTSD. PTSD will be measured with both a clinician administered measure (CAPS)" and a self- report measure (PDS)."' The CAPS is a 30-item interview that provides a diagnosis of PTSD based on all 17 symptoms of the DSM-IV defined disorder including frequency and intensity of symptoms. It also provides a measure of the impact of the symptoms on the patient's social and occupational functioning, the overall severity of the symptom complex, the patient's global improvement since baseline, and the validity of ratings obtained. The CAPS provides both dichotomous and continuous scores. Psychometric data points to strong reliability and validity for the CAPS. Test-retest correlations were between .90 and .98. A Cronbach's alpha of .94 showed very strong internal consistency. Convergent validity as measured against other PTSD measures was strong (Mississippi Scale r=.91, Keane PTSD scale of the MMPI-2 r=.77, SCID

1=.89). Divergent validity was established through low correlations of measures of anti-social personality disorder.

Developed by Edna Foa, the PDS is made up of 3 sections. The initial section provides a checklist of traumatic experiences and asks respondents to check off which ones, if any, they have experienced and then asks them to select the event that has been most disturbing to them in the last month, to describe it and to use this event when answering subsequent questions. The next section asks them to rate the frequency that they have experienced each of the DSM-IV symptoms of FTSD in the past month. The final section measures impairment in 7 spheres of work and personal life as well as general life satisfaction and general impairment. Internal consistency was measured by determining coefficient alphas for the total score and for each of the DSM-IV symptom clusters: hyperarousal, re-experiencing and avoidance. These alpha scores were .92. .78, 34 , and .84 respectively. Test-retest reliability for diagnosis produced a kappa of .74 with 87% diagnostic agreement between the two time points measured. Test-retest reliability for symptom severity produced negligible effect sizes indicating a lack of clinically significant

b change over the course of this study. Test-retest reliability was also determined for the total PDS scores (33) and the subscale scores (hyperarousal=.85, re-experiencing=.77, avoidance=.81). Convergent validity of the FTSD diagnosis was measured in comparison to the SCID and this produced a kappa of .65 with 82% agreement between the measures.

Depression. Depression will be measured with the SCID-I~' (described above) and the Beck Depression Inventory (BDI- II). " The BDI (and subsequently, the BDI-11) is the most widely used instrument for measuring the severity of depression and a 'gold standard' among self-report measures of depression. The BDI was updated in 1996 (BDI-II) to correspond to the revised diagnostic criteria for depressive disorders as listed in the Diagnostic and Statistical Manual of Mental Disorders 4"' Edition (DSM-IV). It is a 21-item scale, with possible scores ranging from - - 0 to 63 (higher values correspond to higher depressive sympt&natoiogy). Beck et al. (1996) suggest scores for moderate depression of 20 to 28 and for severe depression of 29 to 63. We - -

propose to use 20 as our cut-off.

'W Marital Impairment. The quality of ad'ustment in the rnantal relationship will be measured using 49 . . the Dyadic Adjustment Scale @AS). T h ~ s 32 Item measure is widely used in clinical and

research settings and consists of four subscales: Dyadic Consensus, Dyadic Satisfaction, Dyadic Cohesion and Affectional Expression. Various studies have found strong internal consistency for the total measure, producing Cronbach's alphas of .90 and above. Test-retest reliability for the total measure has been found to be .96 after 11 weeks. The Affectional Expression subscale and the Dyadic Cohesion subscales produce somewhat lower reliabilities. The DAS has high convergent validity with the Locke-Wallace Marital Adjustment Scale (Jkcke-Wallace, 1959).

JDC-Middle East Fmgram Center for Development in Israel Center for the (JDc-Bsrae' Mwm-JDC- Pnhafy Health Care (CDPHC) Treatment of Psycho-tmuma Brookdale Institute, AJJDC), A1 Quds Univemi?y of H e m g Hospital

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(0173 D ~ ~ Y S i ~ u n ) v n n o

- N% niynwn n u n IN 07p)i a'mnw nwn '>N PI314

niynwn iuin IN ni>p'i >w nwinn )'N o

niynwn iuin IN nilp'i >W nwinn uyn w' o 3 nn'iwn iiwinn w) o

n i ~ ~ nwinn w) o

niinn nwinn W, o

.'>N i s m - > W n/iYip nN nyniw )IN p s i 5

(lnnnn wtin3 nnEc aysn nins) N> DYD q~ U Y D ~ o

( Y ~ X J ~ OYDD nins , ) i i n ~ n w7in3ini' I N nnN O Y ~ ) nipini o'n7~> o

(01x1 DYSD ning ,in17 i ~ y i 2 w l oys) omyg', o

loi"l33 ni3np o'nv:, o

(01x1 o'nym man) v n n o


5w nrrnn tNn inp ,win nwmn QN IN ,nwlnn mon5 , n x n I P N ~ nwma ,IN P B I ~

owrn ninpbw nwlnn ),N o

nini, bw nwmn uyn w, o

nn'iwn nwlnn W, o

ni3,1 nwlnn W, o

nrnp 5w mlnn nwlnn w, o

.nmn ~ W N J i7'nNw p 7 1 ~ ~b ntw nw,nn ,IN PB18

~b N ~ I I ,n ,INW 73 by nnwN nwinn 1 , ~ o

nnwN nwlnn uyn w, o

nn ,~on nwlnn w, o

ni3,1 nwlnn w, o

n9'~nl nptn nwlnn W, o

5w nnnln5 ~ w p l n i v n ,IN Pa19

nn'in nwinn 1 ' ~ o

n n n n 5w nwlnn uya w, o

nn ' in 5w nn,rwn awrnn w, o

ni3'1 nwrnn w, o

ns'xni nptn nwlnn w, o

.1np D - ~ N 1 - r m N ~ W D'V-IN D ) W I N ~ n ~ ~ p n )IN pa20

())inNn w-rli-12 nnN oY9n nln9) ~5 O Y ~ IN U Y D ~ o

( Y I ~ W I 0~91) nlns ,l)inNn w7ln2inl, IN nnN oys) nlpini o,n,y5 o

(oi,3 D Y ~ D nlns ,inn, IN Y ~ ~ W I D Y ~ ) o,nvs5 o

(01, >32 OYB) n n n p o,nw> o

( 0 1 5 D),> o>aYm v v n ) 7,nn o


- N>> mun IN nlynwn >3 )six ~ P N T~nynW nwn )IN PB21

vny> niynwn inin >w awlnn )'N o

vny> niynwn loin >w awlnn uvn w, o

nn,ion nwmn o

ni3v nwinn o

nlynwn ),N -r,ny>w nprni niinn nwinn o

nmn w t ~ n T117712 awn ,IN PB22

( i i i n ~ n w-finl nnN ~ y s n nms) N> oys IN uyn3 o

( ~ 1 2 ~ 2 oysn nins ,)iinNn w-fin2 in), i~ nnN oys) nipmi o,n,Y> o

(oia oysn nins ,in?, IN ~ 1 2 ~ 1 2 D Y ~ ) o'nYs> o

(017 332 oys) nillip o,n,y> o

(oin omys isun) 7,nn o

NK o,psnni o , ~ ? n nn nn ),,n-r>n>aion ,I,N PB23

()llnNa wmn2 nnti oysn nins) N> oys q~ UYDJ o

(Y13W3 oysn nins ,)ilnNn w-rln3in1, IN nnN ovs) nipini o,n,y> o

(~1 '2 DY9n nina , ~ n i , IN Y I I W ~ oys) o,nys> o

(01' 532 O Y ~ ) nillip o,n,Y> o

(or3 omys isnn) v a n o

DY nn ,Inn p>nw nwn XN PB24

(1iin~;l wtinz nnN oysn nins) N> 09s q~ uyn3 o

( ~ 1 3 ~ 3 oysn nins ,)nnnn wTin3 ini, IN nnN O Y ~ ) nipini o,n,y> o

(oin ~ y s n nins ,in>, IN y i ~ w l oysl o,nYs> o

( ~ 1 ' >33 oys) nillip o'n,Y> o

(oln 0)nys ison) t,nn o

'>w o>lyn n w i nN nsw aipw niinnw nwn ,IN PB25

.35w o>iyn n , , ~ i ~ , i s w )'N o .,>w 05iyn n w i l uyin ,117w w? o

.,>w o>iyn n , , ~ i l inw>3 7 1 1 ' ~ W) o .,>W 0 > 1 Y i l n'7N13 lJ,I ,117Y.J W, 0

. w Y n N l > l 3 1 w w 0


>W n/inin tnn ,>w )inu>3n nwinn nN 'mln PB26

linv2n nwinnx ~ isw ),N o

linu2 loin >w nwinn vyo o

Iinvx loin >w no,ioo nwinn o

linvx ioin>w n i ~ v nwinn o

Iinvx loin >w nwroi nptn nwinn o

>W n/inin tun '>w nu'>wn nwinn nnrn-rmi PB27

nu,>wn nwinn2,11,w 1,n o

nv,>w loin >W nwinn vyo o

nv0w loin >w nnvon nwinn w, o

nv,>w loin >w n i s ~ nwinn o

nv3w loin >w niion nwinn o

IN n-ri2y3 tipgn3 ,,>w 7nilnn tipgnx n,niyown ny,ag w, ,>w >xnnn nnrin m,nnn ,IN PB28

.'>w -Iipgnn >w o,inN ominnx -ripwnn~>ag )'N o

7ipgnl n>p nym o

i n n i i n n a w o

lipgn2 minn nym o

-11pgnx n,)ir,p nym o

n i>p~ n > m ~ in n')rgip ,upw nion ,"D,xI~ nwmn ,IN niinn tno PB29

vpw loin >w nwinn2 ,il,w pn o

vpw ioini ni~rgip >w nwinn VYD o

vpw ioini nilrgig >w nn,ioa nwinn w, o

ni3,l nwinn o

vpw ioln >w minn nwmn o

o,w-rin - ?>yy> n),,rw niwinnn bnn l - r l i ~n in^> ~w- r in no3 PI331

(ow y = O ) n'w-r)n - !i>~ niwlnn mln nn \at nn2 lwo2 PB32

N:, 13 !2iw 7 n i ~ vivn> bnn tni lnin ~-r,iun N> i>>n o,nlvsn,an on2 omt in oNn PB33

? Y ~ N W niinn ttin i>>n o~nivgo,on 73nn nn inn> n>is nu onn pa34


HSI 19 .(DIIN> JIJD*] IN DllN ,?wn?J m'x~ llnw D-IN IN nnown 3 n p 17, ?Y n v n ns'pn P C ~

x5 13 .(DIIN> JI'D,I IN DIIN ,>wn>) 71 D ~ N "I, >Y nWn ns'pn P C ~

x5 1s .nn>n> 7rtn 1~ 37p pC7

x5 1s ,),nn ' 7 ~ ~ 3 y).n ,>wn>) Tnr' IN D>IW 5-2 7nn ,212~ n,nw 1nwm DY 18 5'1 ,195 '~'n yln Intnl PC8 ,,&


omyo 2-4 i~ Y ~ S U ~ oys IN ,1131 N>>>J~ y i i )nn >w nilinn IN n i l ) ryn nilulna PC21 vYn3 un /Y~>WI O Y ~ / nin9 O Y ~ p l mj7w ln"" lnrnn in? n n ~ l n n ~ nuiw )>xn i>)nnnw )vnINiun

o w s 2-4 in yisul oye IN ,1131 N>>>J~ VYn3 wn I Y ~ W I OY9 / nin, oyo 71 inpw )vn\Niun Y ~ V N ~ >Y DXJ~XJ 1N 0 7 ~ 1 nini>n PC22

'nrn" lnriln \ni nnx n n ~ o'nvs2-4 1N Y l l w l oyg 1 J nwlnn IN nimnn ,ynmn >w winn nvin PC23

VYn3 ,xn / Y I ~ W ~ O Y ~ / n,ns oys p l nipw la'"' 1nrnn in! no32 n n ~ ,099 71Y 1111p T l lW

o7nvn 2-4 IN Y ~ ~ V J oys i~ ,1121 N> Y > J ~ VYn3 'rn 1~11~s OYD / nins OYD p i mpw nail31 nnwn , x r ~ ,WYJ ,n>nx nwinn PC24

- lnln'> ininn ini nnx n n ~

omys 2-4 i~ y s w ~ OYD ?N ,1131 N> >>~l 7> i i n r n w niui>i)?m nix im >w niwninn

VYn' lyn / ~ i l w l oys nlng OY9 p i mpw ,nixnn nyrn ,>wn>) wniNivn Y1l)Nn nrc PC25 lain" lninn lni nnx n n ~ ( w i n ~ 9 1 1

. ,. ,. . Y,NYS ‘-+ ~n YIJWJ u ~ o )N !1)J) N>>?Jl nwinn IN nimnn ,ynmn >w winn nvin PC23

VYn3 ,xn / Y I ~ W ~ O Y ~ / n,ns oys p l nipw la'"' 1nrnn in! no32 n n ~ ,099 71Y 1111p T l lW

o7nvn 2-4 IN Y ~ ~ V J oys i~ ,1121 N> Y > J ~ VYn3 'rn /~ l lws inin >J OYD / nins OYD p i mpw nail31 nnwn , x r ~ ,WYJ ,n>nx nwinn PC24 ...,-.. .-. -..-- --.,

o'n~s 2-4 IN yllv> OYD JN ,1131 N>>>J~ IN ,Y\~)NTI >Y 1x75 IN ,3iwn> N> )~)D~I PC26 Vynl lyn / y i l w l O Y ~ / nins oyo i.n mpv lnrn" ln~nn 1nr fin31 n n ~ Y~-I)N> nlilwpn nlwlnn in>

o'n~9 2-4 IN YIYUJ O Y ~ 1 N 1 nin1pn IN OWIN , ni)i>)ysn Y~n>n> l i ~ov PC27 VYn3 ,xn I y i l w > oys nlns OYD p i mpw

\"'"" ininn lni an31 nnN Y1i)Nn nrc 7> o)i)>tnw OVJYD 2-4 )N ~ 1 1 ~ 1 OYD >N ,1131 N> %>I ~ i i ' ~ n n xiwn p>nx i ~ t ) n > n513) 'N PC28

VYn' u n IY~IW~ oyo / nrno oys in nipw lnrn" 1n1nn lnr an31 n n ~ )unINiuil

o'nys 2-4 IN yiZ1w3 OYD ?N ,1131 N>>>J~ nnins nisnnwn i~ J")YI mi TIT?) PC29 VYn3 >yn / ~ n v ~ , 099 / nins oys in mpw ln"" ininn 1n1 nnx n n ~ nimwn ni~i>)ys3

vyn3 O X Y 9 2-4 1N Y l l W l DYD iK ,)131 N> >>31

. . 'xn I Y I ~ W ~ DY9 I ning OY9 p i nipw 7213'303 D'WIND pin') IN pin'i >W nwinn PC30

o'n~s 2-4 IN yllv> OYD JN ,1131 N>>>J~ IN ,Y\~)NTI >Y 1x75 IN ,3iwn> N> )~)D~I PC26 Vynl lyn / y i l w l O Y ~ / nins oyo i.n mpv lnrn" ln~nn 1nr fin31 n n ~ Y~-I)N> nlilwpn nlwlnn in>

o'n~9 2-4 IN YIWJ O Y ~ 1 N 1 nin~pn IN O'WIN , ni)i>)ysn Y~n)n> l i ~ov PC27 VYn3 ,xn I y i l w > oys nlns OYD p i mpw

\"'"" ininn lni an31 nnN Y1i)Nn nrc 7> o)i)>tnw , , OVJYD 2-4 1N Y l l W 1 OYD 1N ,1131 N> >>31 vwNan i i w n a>nx i ~ t ) n > n513) 'N

-. , . --- lnrnY3 \ ~ ~ a n lnr an31 n n ~ )unINiuil , , o'nys 2-4 IN yiZ1w3 OYD ?N ,1131 N>>>J~ anin9 nrsnnwn i~ J")YI n 3 i n ~ n ) PC29

- . . --- ln"" ininn i n ~ nnx n n ~ nimwn ni~i>)ys3

vyn3 O X Y 9 2-4 1N Y l l W l DYD iK ,)131 N> >>31

. . 'xn I Y I ~ W ~ DY9 I ning OY9 p i nipw 7213'303 DVJIND pin') IN pin'i >W nwinn PC30 IaraI 2, lnrnn DI an31 2

o w s 2-4 IN y n w 1 oys )N ,11~1 N> >>J> >11on N> ,>wn>) nwn nlnp >w nwinn PC3, VYn3 lxn / y i ~ ~ 1 O Y ~ / nins OYD p i mpw lnrn" lnrnn lni nnx n n ~ ( n ~ n ~ win> IN nix>

o'ny!, 2 4 i~ y i w 1 oys IN ,li31 N>>>J~ N> 7'ny> 7nnpn IN 7%minw nwnn

Vyn3 r m / y a w 1 DYD I nrns oys p~ inpw O)NIW>) ,m))ip T> nmn N>W >wn>) inwln) PC32 lniil " lnmn 1n1 nnx n n ~ ( D D ~ N o m IN

o w s 2-4 JN YIWI O Y ~ IN ,1131 N>>>x 09s / nins ova 71 mpw TIIW IN n>niinx a w ~ p PC33 ni nn31 3

O)nY9 2-4 1N Y l l W l OYt, 1N ,llX K>>>>l vYn3 wn / y i x ~ l oys / nins OYD p l i n v w V Y ~ nl'insnn IN ,upw i w ~ n nwinn PC44

1nla23 nlnn ini nnx 3 ow!, 2-4 IN y a w 1 O Y ~ >N ,1i~1 N> >>>I nxwnnn win nn'ix ,>way) r i ~ ~ i x onwp

VYn3 ,xn / y i l w 1 OY9/nlns o y ~ p i mpw ,nwii>v3 n>>>y 'inN l ipy> ) w ~ p IN ,nn)wx PC45 lnrn" lninn in1 nn31 n n ~ (nrcip nn i i ~ t > 'wlp

omyo 2-4 i~ y i x ~ 1 oye IN ,~IJI N> >>x NYDI 7n n i ~ i > p1ix ,>wn>) in) niJ'1-r

VYn3 ,xn I Y I ~ W ~ OY9 I n i n ~ OYO p i mpw n>i> 31 n'mnn ninij )N nw~nn ,p i l n~n PC46 lnril" lnrnn in1 nnx n n ~ ('131

o w s 2-4 IN Y ~ X J ~ oys i~ ,~IYI N> >>>I >xn / y i x n inin 53 OYD / nlns ow p l nlpw (7'iinNn l>in inw)nw~ ,>wn>) in) nm1y PC47

inmn lnr nnx n n ~


(nnN nnwn vpn) !>'Y> niN,nw niu3innn n > 2 ~ lnt nn2 7wn2 PC48

wirnn nlno (N

o,wiin nwi>w> wiin 132 (1

owirn nwr>wn in), (1

N!J 13 o n J l o Pc57

N!J 1' -pnl ominnn >JZ ,>>J iipon nni PC58

VYD 333 .nhaWnn on3 o*ona aarw b*ntnn5 u*on**nn;, o*vawnn 3asrn Nan )tf~wn :? p b : v * ~ B ? I OY Tnn3on nvn5 uzinna ,n3rwn> nvnwan 4 ~ Q N w ~

n/onoa N> N> o>mn n m ~ ~ o n nnownn ,>I ~ N W ,Y-I n i l 2rn W' nn3wn2 inw,n> ~ W N J v>nm n/o~>on n/ v>nnl .nab a,v-n, PD3


inwa T W N ~ p i naiwn

.7n n i w n o,>'a~ NU>> i ~ w p ~ ~ 2 2

il/O,JDD N> N> D'3Dtl il/O73DD

b u9nm n/o,~on n/ v>nm ."li'p'~> 7il'n11 ,w> nniv ni,s,r u> 1 , ~ PD27

nlovon N> N> 0'3DtI n / o~~un v>nnl nlonon n/ v>nn~ .vw> '11nN ilnlnN nN 0 7 ~ i n N> i>nlN ~ ~ 2 8

n/onun N> N> o m n n/omn v>nnl n ~ o j ~ u n 31 v>nnl .0,3iinn 71-1 ~ > i nii,w, DWJIN OY o , i~ ln iln>N ~ ~ 2 9

n/onun N> N> 0 '3~n n/o'3un vL)nnl i l m l ~ ~ n ill v>nm .i>wn nl'inN1 nr>va w, ilnwa - r n ~ >3> PD30

.nnswnl O ' Y ~ n i w n n l in w, PD31

nlor~on N> N> o n ~ n nmuDn v>nn~ nloooa n/ v>nm nnswa p >Y '11, nain ,XI> O,ain 115 W, PD32

il/0)3DDN> N> 0'3Un il10~30D u>nm n/o?~on n/ u>nnl . i in i~ )WYD inwn ~ W N > p i vwn "nl - r n ~ 071>iva \IN ~ ~ 3 3

- -

n/0'3DnN> N> 0'3DD il/D'JDD v>nnl n/o,~on n/ v>nm .o,,w,N ),,IY m n n nns> lot uYn w' PD34


nlo73on N> N> 0'3un n/0130n u>nm n l o m n 31 u>nm .nnn ni-rilv nti nwv' ,a 0'17 ~ I ~ I N PD40

n / o ~ ~ u n N> N> o v ~ n n1013on u>nm n/oy~on n/ v>nnl .i15w ilnswnl il,yx rrrrnn nrvbnil n h p P D ~ I

n lo l~on N> N> o130n il/nQon ib ~ r i ' 1 ~ ~ 3 p i ' I W ~ inti P'IY n5>n 1 1 5 ~ ilnswnn v>nm n/o ,~on n/ u>nm .nln lilwn PD42

i l /0,3~n N> N> 0,30)3 il10,3CJ0 u>nnl n /o ,~on n/ v a n 1 .'lwn o y inti 0'13 l l n l ~ PD43

; I /O>JD~N> N:, 0,3011 n / n ~ ~ u n ~ n ? n n i n ~ )N (03pin) 0,55> oiw o,n,,pn N> I I ~ I N PD44 u>nn> n /n ,~on 31 u > n n ~ .ID,v)~IvD)


l r x n)yrxv))~ua) m)¶a nrv NIX .ynlr av ownnnn f>w arm nar nnx ?a prxlr enrrlrn nt )rlrxw :a glrn ( .nul¶r xlr nwwn ) )>~wa 1~ .flrw *WW;I asnlr a'xnnil ~ i a v i l nx a5xw h a aw5m 1nu . ? W D N ~ ,

.75w n m la v ~ a 75w nnnn nx nu3an nx ia 1~1x2 p ~ i u Nan p5nn

o>n'~> o,n,y> n~ n3)iYn ) l N W n~-r5 7%~ 211n 125 mni) )IN ~ , n ) y > ornv>

niliip niziip D'nY9' nipini nrpmi ni-r-rinnnl mtyni ,niryn ,n>wynn nsnnn PEI 7 1 ~ n TIN^ .)n>n12 5w ) - r ~ i ~ n OY

o>nly> ornly> oln'y> o>nyg> D'na' n ipn i

T W N ~ o)i2-r niwb )5w Aim p n n w p n )IN niliip nillip nipini .niwy:, nn >-r>n inv '5 w, PE2 71Nn 71tin

o,nv> ornv> ni~mnnn nil3 71-1 >>w 211 125 n ~ i n 'IN omv> o?n?y> n n n p o,n~s> nipini n i ~ i i p nrpini )5 w) i w ~ 3 IN )n)N 1 - 1 ~ 2 ~ 5 inwnw )5w P E ~ iitin litin .~n2r125w 1721~n OY -1-1innn5 >wip - - - - - -

o>nv> >>~7'Ns\ln'~926VJ 211il p 5 nlnlN )IN

L. O"'" o,nys> omy> nillip ni>np nipmi nipini ni-I-Iinnil2 in3)nn nN 7 ' 1 ~ ~ )INWI T I W ) ~ ~ D P E ~ 71Nn 71Nn .>nx>12 >w 1 - 1 1 1 ~ ~ ) OY

.7na/-pa 5w l i n x n 5w3 nnn n w r i n nN i w ~ a nww l ~ i t nxw nna poiu Nan pk:,

orn?y> o,nly> o'n'y> o>nly> 1 ~ ~ 3 i l ) n 9 ~ ~ 1 n13n ,953 ))29n )5w 2113 7 i ~ n n i ~ i i p nillip o'nYs' nipini i r ~ n nipini .mxn12 5w l - r n ~ n OY n-mann 'IN PE5

o>n?y> o>nry> OlnlY> OTI~YY )IN lWN3)7)35 NlnW ilNln ~ J w 21til)2 T ~ N D niliip nlliip D'nYs' n~p in i i i ~ n nipini . )nv12 >w 1 7 2 1 ~ ~ 1 DY n711nnn PE6

n-I-Iinnn ~5 )INW )niN O)WND )5w liln 12 o,nly> o'nry> o,nv>

7iNn n n n p n i m o O"ys' i n 7iNn nipini 5~ 1121N1 ilplVY )>N l W N 3 p)9DLl 210 PE7 .)n2/>12

o)rv-tm 0)3rn niNi5 )5 1 1 1 ~ )5w )i?n 12 omy> o>n,y> owy> o,nv>

i r ~ n n a i i p n i m p O'nYs' nlprni i i ~ n nrpini 5t'J ll2lN2 ilj7lVY )IN l W N 3 lnl) 3 U 11N2 pE8 . > n v n

b 13-15 ni>n-I?il )> lni>i )5 2wpn )5w ~ i ~ n 12

ornv> omy> o'nry:, o,n>y> irNn n i ~ l r ~ p m1np O'nys' nipini inn nipini n-I-Iinnn 'IN T W N ~ '5 ~ ' 1 9 ~ nnmw no 5~ p ~ g

. > n l n n 5w 1-11i~n OY

o>nly> o,nv> o'nv> o,n,y> )5w nnnn n~ ni1'~i3 np15 1 1 ' ~ )5w ~ i l n 12 7 i ~ n nillip ni3)ip o'nY" nipini iiNn nrpini mm12 >W 1-121~2 n p i o ~ )IN ~ W N J PEIO

inn 12 'nm12 5w )-1n~1 n p i u ~ 'IN TWNJ o>n,y> o,n?y> o,nys> omy> O ~ Y >

iinn nn i ip niliip niprni 7rm nrjini )in loin2 nrc? nwiv 7~ n m n )5 )nil ' 5 ~ PEI 1 . n ' r ~ ~ u i n ioini

Aim 12 'nv125w )?lircl npioy VN ~ W N J o>nv> o>n'y> o,nv>

iiNn ni>np n n n p D'n'Y' 553 7712 TlWlY )lNW 0'121 lDYY >Y nplb >kJW pE12 o'nYs' nlprni iinn nipini

.,5 71195 )-I3

V N W 73 u n n nN 1'1~15 )5 i 1 i ~ ' 5 ~ )11n)2 o,nry> o>nrv> o*n'y>

- r i ~ n n n n p n n n p o'n'~> 'IN T W N ~ n i ) ~ 3 OY lni) 2iu -I-Iinnn> n5i~' PE13

O'nY" nipini iinn nrpmi .~n2rol >W 1-111~2 nnoY

D'~'Y> D ) ~ > Y > oln,~:, o,n,y> i i ~ n n n n ~ n i l n o D'ny" nioini iinn nioim .)5 711Y ' 5 ~ 111~112 )-I'D n p o ~ )>N ~ W N J p ~ 1 4

o>n'y> D ~ Y > ~ ' n ' ~ b Q,,,,:, 5w 1-13~2 npioy )INW )n11 nnnl )IN ~ W N J 7 i ~ n nillip n n n p O'nYs' nrpini i ~ n n nipini . i~nvnb null )5w ~l1n 12 ,)n2n12 PE15


nnn w l r i n xln i w ~ 3 i w m n ~ 5 w r l n 13 na iin 3 0 1 ~ ~ 5 n n

'"'Y' o>n>y:, nlnv> nti -piyn N ) ~ W n ~ r 5 '5 in?) '5w Ntn 11 olnry:,

r n ~ r i ~ omvg5 nil i ip n ~ p i n i nigini 1 w l . c ~ '5w mtyn rti n w n ,n'wynn n rnnn PE16

T ~ N D ' 1 1 ~ 0 . v~n ,uu>n >w 1~21tin oy ~ m n n Nln

o'nv:, o>nw:, O""' i5,2w20,727 nlwy:, ']no wpm b w xtn 13 nrliip

niliip '""' nrpini

O'ny" nipin, .nlw~:, nn w n in), 15 W' iwN3 PE17

11NO 11Nn

o'nry:, oln)~:, lbw nlmlnnn ~ 7 7 , b n ~ l n 7 5 ~ 21111 12 o,nry:, olnly:, niziip ovau35 nipini n n n p niprni

'Wlp 15 W' 7WN3 1N ln'N 7703 Nb lilWDW PE18 11Nn 11NO . I I ' J I , ~ / ~ I ~ I ~ 5w 1-13r~n OY i-rlnnn?

- o,~,Y:, w'nn N I ~ 7 ' ~ nln'ns26 7 n 1 ~ 6 w G n 13

orn'y' Q , ~ > ~ > o,ns5 n n n p

O""' nipini nipini

n a i i p DY nrrvnnn3 ' n m n nti -piv, ~ m w l PEI 9 7 1 ~ ~ 7iNn .~1~n'm1,13 5w ir21tin

-

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(01'7 o)nys ison) -r,nn o

D~WIN 5y 7inu5 75 nwp n/nn - WtNn PBIO

DW)N >Y 7 1 ~ 0 5 ,Wlp ],N 0

,WlpuYnW, 0

o)ion ,wip 07,p o

13)l Wlp o,,p 0

>inn wip o))p o


w,r,n ,INW IN DWIN ,D>> ~ D S N nvn> n b i s n n~ 7n71,~ I > , N ~ wn ,IN nn w t ~ n ~ ~ 1 1

.unn 75, n m N w D'WIND pniin

D,inN> iiwp i~ mip wuin> 'wip ),N o

D,7nND pin'1 >w nwinn vvn w, o

u,inN> 7iwp IN 7iip w,)in> u,iun ~ 1 p W, o

73,l'wlp w, 0

i inn ,wip w, o

IIYN w '5, i,3taw 7x7 >JD Y I D , ~ > 7 i ~ n yannn a~ P ~ i 3

()iinnn w-rrnJ nnN DYDD ning) N> DYS VN VYDJ o

(Y17W7 D Y ~ D ning ,)iinnn w-rinx in], IN nnn DYS) niprm D,n,v> o

(oin DYgn nrng ,in], rn v i ~ x DYS) D,DYD> o

(01, >J> DYD) nixnp o,n,y> o

(~172 O ~ Y S ~ S U D ) i,nn o

N>> niynwn 'mn IN ~ , p ' i m n n w wn ,IN PBi 4

nrvnwn 7uin IN nilp'i >w nwinn ),N o

niYnwn iurn 1~ ni>p'i >w nwinn vya w, o 4

nnvun nwinn w, o

n i s ) nwinn w, o

minn nwinn w, o


.75in 7niy nN TINIT 'IN PB16

(]nnNn w-rinx n n ~ 0 ~ 9 n nins) ~5 O Y ~ q~ vvn> o

(YIIWI oYsn nins ,]iinNn wmn1 in)' IN nnN ovs) nipini o7n7v5 o

( 0 1 7 1 oygn nin9 ,in17 IN Y ~ I W I OM) o7nvs5 o

(017 531 ovg) n n n p o7n7v5 o

( 0 1 7 1 mnY9 ison) -rmn o

5w niinn rNn inp winw w7nn ,IN IN ,nwinn ion5 7nxn 1 5 7 ~ ~ wnin ,IN PB17

o7win ninp 5w nwrnn 1 7 ~ o

ninp 5w nwinn vvn w 7 o

nn7ion nwinn w7 o

n i s ] nwinn w, o

ninp 5w minn nwinn w7 o

.nmn ~ W N > PnNw p - r i ~ N!J n ~ w w,>in ?IN PB18

~5 ~ i n i 7n ~ I N W 73 5v nnwN nwinn ),N o

nnwN nwinn vvn w7 o

nn7iun nwinn w 7 o

n i s ~ nwinn w 7 o

ng,yni ngrn nwrnn w 7 o

5w nlinrn5 iwp1 i7in ,IN PB19

n w i n nwinn 1 7 ~ o

nii7in 5w nwinn vyn w, o

nii7in 5w nn7ion nwinn w7 o

n i s ~ nwinn w 7 o

nstini nprn nwinn w, o

. ~ n p D - ~ N 1 - r ~ ~ N ~ W 0 1 i n ~ D ~ W I N I Nlpn ?IN PB20

(InnNn w-rinl nnN ov9n ning) ~5 D Y ~ q~ vyn> o

(YIIWI oy9n nins ,liinl.tn w-rin~ in17 IN nnN D Y ~ ) nipini o7n7v5 o

(0171 omn ning ,in\' IN v a w ~ ov9) o7nys5 o

( 0 1 7 531 D Y ~ ) n i m p o7nv5 o

( D I ~ 0 1 7 1 D ~ D Y ~ I ison) -rmn o


N>> m v n IN niynwn >J )sly IYN 7vvnw wn 'IN ~ ~ 2 1

niynwn loin > w nwinn 1 ' ~ o

vny> niynwn loin > w nwinn oYn w, o

nn,ion nwinn o

nisi nwinn o

nivnwn )'N -r,ny>w npmi rninn nwinn o

N>> o,psvni O,N>D ,,n nrc l"n-r> >lion PB23

( l i i n ~ n w7inl nnN ovsn nins) N> O Y ~ q~ vyn3 o

( Y l 2 W 2 OYsn nins ,111nNn w-rin~ ini, IN nnN oYs) nipini o,n>y> o

(01'2 oY3n nins ,in), IN v i2wl oys) o,nys> o

(01, >>I ovs) ni2iip o'n,y> o

OY nn wzm p>nw wn ,IN ~ 6 . ~ 4

( l i i n ~ a w-rinl nnN ovsn nins) N> O Y ~ q~ U Y ~ J o

(Yl2w2 ovsn nin3 ,liinNn w-nnlini' IN nnN ovs) nipini o,n,Y> o

(01,l oysn nins ,ini, IN v l l w l oys) o,nys> o

(oi,>m ovs) ni21-13 o,nv> o 3


5w nlinin ~ N D '>w ]inu,~n nwinn nN 7n-13~ PBX

Iinvln nwinnl711,w ),N o

)invl loin >w nwinn uvn o

linul loin 5w n o m n nwinn o )inul loin 5w n i ~ ~ nwinn o

1inu2 ioin5w nmnr nprn nwinn o

>W minin IN13 7 5 ~ TIU~JWTI nwinn nN 7nrlw PB27

nu75wn nwinnl , i ~ , w )>N o nu3w loin 5w nwinn uYa o

TIU,!JW loin 5w nnvon nwinn w 7 o

nv75w loin >W ni371 nwinn o

nu75w loin >w niinn nwinn o CI

IN nf i l~27ipgnl ,'>w ,nixnil 7ipgnl n~nivowa n~,ag w, 3 w h ~ n a n~rin3w l ' n ~ n ,IN P B Z ~

.75w 7ipgnn >w minN ominn2 i n a N 0

7ipgnln5p T I Y ' ~ ~ o 7ipgnl (n~li172/n1lno) ny'ag W, o

7ipgnl niinn nym o

7 1 I Y 0

nbp2 5321 IN 71rgip ,upw ion ,"o7rip >Y" w7aio ?IN niinn rNn P B Z ~

upw loin >w nwinn2 , i~ ,w ],N o

upw ioini nilrgip 5w nwinn UYD o upw ioinr ni~rgip 5w na7ioo nwinn w7 o

n i m w i n n o upw loin 5w niinn nwrnn o

o,w?in ?57~5 n~,,rw niwinnn bnn )721~a inti:, o,w-rin nn2 PB31

( O Y ~ q ~ = o ) 07w7in - !15~ niwinn nnn n n ~ lot nn2 7wn2 P B ~ Z

~5 13 ? l l W TnlN 7 '1~i l> l>nn tN17nlN iT,lUil ~5 I!J!Jil Q~DiVgDmn Dnl 07>Dt 1 7 2 ONn PB33

! Y ~ > N W niinn IND b5n ~ ~ n i u ~ n ~ u n 7 5 n n nN i ~ n 5 5127 anti D N ~ PB34


>w ;laws )!Jib .anyma ynwk nnpra y,n!Jnr * a n r N s a n N a vrsw!J QVY rm 1~ rrn aas QYWIN :a p!Jn I .an5 7~ nyww rN .I> nsp ON:, ~ r s , ~ !J3 at5 l"r NIN . Q ~ , U ~ ~ N S V 0 9 ~ 1 1 9 ~

-

Nlr 13 ,ynn , 1 1 7 ~ 3 Y)n ,>WD>I in), IN D,)W 5 - 3 -,no i m n n,nw inwm OY is 59 vs> ,)G yy,n .(n!nl

N!J 13 8

. ( n 3 i i ~ n l IN nnn>n n,ilw ,iniu n m ,>wn>) ~ N ' > J P C ~

N!J 13 Y PC1 0

N!J 13 .om n j ~ o n n n>nn PCII

N!J 13 111V YlP9 PC12

N!J ) 3 l i i p DTN >W niia P C I ~

N!J ) 3 V l 9 . l n N ~ U D l N l U Yll'N P C 1 4


( I d . I I,,

0')3Y3 2-4 vYn3 tin /YIXI~

lorn >J lnrnn o>nm 2-4

UY)33 ,rn / y i ~ w ~ lorn" ,n,nn

-

nwinn IN nimnn , y i i , ~ n >W wlno n'iin PC23 .DY9 11Y nil? TItW

T1131731213WN , l Y Y ,wY3 ,n>nl nwinn PC24

OlDY9 2-4 1N Y l l W 1 OY3 IN ,1131 N> >>21 7> nmnw nIw>i't'9 nnim >w niwninn

VYn3 ,yn /YPWI O Y ~ Inin3 om p i mpw ,nixin nytn ,>wa>) ,UolNlUn Yii,xn nN PC25 lorn'' ~nrnn 1n1 n m l n n ~ (ynin j79i-i

o>n% 2-4 1~ ~ 1 1 ~ 1 OY3 1~ ,)>>I N> >>Jl IN ,Y~~,NTI >Y 1311 IN ,11wn> N> l i ' w ' ~ PC26 VYn3 7xn / ~ 1 1 ~ 1 om ninr, oy3 p i inpw In'n" )nrnn 1131 ilD31 n n ~ y l i ' ~ > nlilwpn nlwlnn w,iin>

o w 3 2-4 1~ ~ 1 1 ~ 1 om 1 ,111 N J ninipo IN D,WIN , ni,i>,v9o YID,~> i i ' w ' ~ PC27 VYn3 7yn I Y I ~ W ~ O Y ~ / nmg om p i nipw lorn'' lnrnn int no31 n n ~ Y11,Nn nN 75 D,l,JtDW

OV3Y3 2-4 1N y l l w l OY3 IN ,1131 N> >>31 ~ i i , ~ a o liwn p>nl i ~ t , n> n31s ,N PC28 VYn3 y n I Y I ~ W ~ D Y ~ / ning om p~ mpw lorn" lornn lor no31 nnn ,UDINiUTI

ornvg 2-4 IN y i l w x om i~ ,~ ix N> >>31 anin9 nignnwn IN p y l a31 n-r,i, PC29 VYn3 n / 1 om I ning ovg p i nipw

lorn" lnrnn lnr n n x n n ~ niliwn ni,i>,ym

vyn3 o,nYg 2 4 i~ Y I ~ W ~ ow 1~ ,1131 N> >>x

. - >rn ~ y i l w l oy31nin3 om p i mpw 7nmw3 OW IN^ j7in'I IN pin'i >W nwlnn PC30 lnrn ,J lornn 1n1 nnx n n ~

07n~g 2-4 IN YIIW~ D Y ~ IN ,1131 N> 2 ~ 2 1 h ~ o o N> ,>wa>) n'wm ninp >w nwinn PC31 VY" / y a w l om Inin3 oy3 p i mpw lnm" lnrnn 1nr no31 n n ~ am^ win> i~ nix:,

O>DY!, 2-4 1N Y l l W l OY3 IN ,IlX N> >>31 N> vny> 7niipn IN 7'ni'13inw nwnn

VYD3 u n / YITU~ O Y ~ /nIng ow p i mpw D'NIW~I ,m,,ip 7> man N>W >wn>) iowm, PC32 Inrn" ~ornn lnr nnx n n ~ ( D , ~ N o m IN

o,am 2 4 IN ~ 1 1 ~ 3 O Y ~ IN ,1131 N> >>x VYn3 wn / ~ 1 3 ~ 1 O Y ~ / ning oy3 p i mpw ~I,W IN nin-~inl D,w.J~;~ PC33 lorn" lnrnn in? no>> n n ~

O,DY9 2-4 1N Y13W3 093 IN ,)131 N> >>31 Vyn3 )yn / Y ~ ~ W J O Y ~ Inin3 O Y ~ p i mpw

lorn >3 WYJ n1vw-m IN ,upw i w ~ n nwinn PC44

lnrnn lor no31 n n ~

o7ny3 2-4 i~ Y ~ T U ~ O Y ~ i~ ,1131 N> 2 3 1 nwnoa uin nnw ,>wo>) ti3)ix o))wj;l

uYn3 > y n / y ~ ~ w l 0y31nlng y p i p ,iPt'il>Vl n>,>Y ?nN l l p Y > Wlp IN ,nn'wl PC45 lnrn" lnrnn ~ n r nnx n n ~ (nNi9 no i i ~ t > ,WID

ornv3 2-4 IN y r l w l oy3 i~ ,1121 N> >>>I NYD) ,n n i ~ i > p7i3 ,>wD>) in, ni3,i-r

uML3. n Y O Y ~ I ning Y 1 37575 11 n'mno nini] ,N nwinn ,-r?inNn PC46 lnrnn . . lnrnn lor n n x n n ~ ('131

o,ny!, 2-4 i~ y u w l oyg IN ,lix N> 5531 uYn3 an I Y ~ X J ~ oy31 nlng oy9 p i mpw (7? inN~ :,>in inw~nwJ ,>wn>) in' n l i i l y PC47 lnm" lnrnn lor nnx n n ~


m<~o. cuu<o /u uac'wu cuu<o OLad NIL UIILN~O mere UU~GUU UU<N~O NU UUUIL~I~IU uac~o /u u a c a <N <N uac'wu

6ad NCI UOUCCICO U~ULNIU cc<icc UCCL! NUL < m c ~ . E u y o /u uacto/u cuu<o UOCLO/U uac'o CN CN U ~ C C W U

Lad NIUIl <N elLKt0 UU <r(mlU CNaL dlLU UKC UcLlO' w u < o /u uac'o/u cuuco

UOCtOIU UOCcO CN CN UOCcO/L!

cuu<o /u uacto/u cuu<o gad C L U ~ UmcL NIUCL eCl<cO <GClU NU1 <mIc <dc<U UUcCU' u,c,w, ,, , uac~o,,

cuu<o /u uacco/u cuu<o Sad NO u~mui cull rrcr(cuf w u L ~ o cAato ciuL ULL UKILCCO. uaC,wu uaCcO <N <N uaC~O/u

<CLK! mi^! N C ~ crtm~. cuu<n /u uac'o/u cuu<a Pad C N ~ L NU/U ucdm uucmui <rtmku LCL UL! NU/U KL~LIL! uac~o /u UOC'O <N <N uac~o /u

Zad NIL GlULcO NU LlC UCKcLU U4UclUelU CCeU' cuu<o /u uacro/u cuu<o

43 uacro/u uac'o <N <N uacto/U

UcClU CcCcCl' cuu<o /u uacto/u cuu<o lad NCUCl Uudfi'O CUCCI~ Gr(c<lclU UmGUUclU CI<< Nc UOC'O/U U ~ C ' O <N <N unc~n/u

Gtc6C UGdU.eU: UNO L!Cr(cLU mL!u~~Unu N<LPI C U < ~ Udl10 ILUl gdmcto CNUL Nl clUL UUUULUcO L!CNcO

CJ UKc mcu N l cLUL NULc UNcLlr(

N) GUlU UUKc mCL! NULc UNcLlr(

6P3d CUL! \uL <NUL UNcLLA L!C\LNlUOc L!UUc<l UlGAlU N<li (L!dL UmlCL! NUU)

-

zcad em <CL u~dta <[re ~LUU CL KC rl um~uu cuu<c\ /u uac~wu cuu;c\ uac'o/u uaca N <N UOCIO/~

OEad <C< NU1 UNcUCL em UO<lU LNULtlU Um<L' cuu<c\ /u uac'wu cuu~n UOC'O/L! UOC'O <N <N UOC'O/L!

6ZOd NCUCL ULCLtO 60 NCmtO tAcLLU L<N ILL UULLCta' cuu<n /u UOC'~/~ cuu<n uac'o/u uoc'o <N <N uac'a/u

8Zad NCUCL <N ULNtO NU NUITUCL NU1 <mCc' cuu<c\ /u uac~o/u cuucn uac'o/u uaao <H <N uac<wu

SZad NCUCL ULLCltO ULt CriKUCL'

~cta CNO ucritu CGULU NL <N' cuu<c\ /u uac~o/u euu<c\ NULC muum~uu mcci ucau CGUIL critud NCUCL ~LLL ccc UOC'O/~ UOC~ <N <N U~C~/C

6 Lad u<C! UN~UCL G~LCI <N urtcta ~rmtu' cuu<c\ /u uac'wu CCU<CI uacto/u uocro <N <N UOCLWU

81ad Ncmta GmLn NLuLta LrLta rud~a <LUU ri<tua' cuu<c\ /u uac~o/u cuu~n "I UOCLO/LI UOC'O CN CN UOC'O/C

cuu<n /u uacto/u cuu<n Zlad CLLL C<< NCUCL GLri<cO CUUNO <UU<flLLEcCL <CCc CKcLU. uOC'o/u uOCcO <N <N uOC,O/u

u~rtmta' cuu<n /u uoc'o/u cuu<n lad NCU~L <N tc~<ca <L~L NUL KO umct KC u~~r~u m~rucc craaa/u uac'o <N <N UOC'O/U

il/ooon N> N> o ,~on n / o ~ ~ o n ~nwn ntn I>> NYI' ~ W N J ,IWI 7 n ~ 1 ' 7 1 ~ u,>>n llnlN PD37 v>nm nlonon n/ v>nm .,W,N

n/0'3on N> N:, 0,3on n/D~Jon v>nnl n/03>on n/ v>nm .nl>lyw nvwnn nlplron l i i nN u,ini3 )IN PD38

n/ol>oo N:, N> o ,~on n / o ~ ~ o n 0,lnN 0,117 nnly> ,IW ulpnl-rnw ( n l ~ i ) In PD39 v>nm n/o,~on n/ v>nn1 .i~>w nn3wnl

nwy inwmw


. ~5w aim na -=s ~ 5 w nnnn nx Y-sn anx is 1~1x2 poi^ xan p5nn

o ~ > Y > o*n>y> n~ 7 ' 3 ~ ~ ,INW ny75 ' 5 ~ 111n n2> )nil 'IN o'n'Y' o>nyg> omy>

nllnp n i ~ i i p nipini nipini nrninnn2 mwn1 ,nirYn ,n,wynil n m n n PEI

71Nn 7iNn . , n ~ 1 2 5 w 1 7 2 1 ~ ~ 1 DY -

o*nv> o,n ,~> o>nv> ~ W N J 0,127 niwY5 ' 5 ~ 1113 n2n wpm ,IN niliip

ni l l ip O""' nipini

o'nYg' n i p ~ n i .niwy5 nn ~n in>, '5 w, PE2 71ND 71Nn

O ~ Y > o,nv> 'IN 7'N nin,nm 3 w 1i1n n2> :,,DIN 'IN o'na' o>nyg>

oynw ni l l ip nipini

nl~i ,p nlpinm nlnlnnnl nn3,nn nrc 7 ' 1 ~ ~ , I N W ~ w'>in P E ~

7iNn 7iNn .,nm12 5w ) - I I ~ N ~ DY

.~nxlpa 5w 17aixz 5ws nnn wain anx ' 1 ~ x 2 :WID ~ n t naw zna poi^ xaa p5nz

D'n'y' o>nry> o,n,y> TllDnn ~5 ,JNW ,niN nn,WNn ,>w 11rn n2 = n1,iip O"'" nipim o'nYg' nipini > W 1721N2 plDY ')N 7 W N 3 pE!DD 21U PE7 71Nn 71Nn . , n v n

olnv> 0 7 2 ~ ~ n l ~ 7 5 '5 nitiy '>w 11rn n l O""' nipini plWY ,IN 7 W N 3 lnl, 2 l V l l N 2 O,r,n5n PE8

7lNn 7iNn .'nsn12 5w )-rmta

o'nly> O"'Y' o,nyg>

o'n'y' nnnn nrc nil,ri> nnpi5 nlw ,5w 1ltn ns n13"\n,=lmp nipin, O""' nipmi ~ n 2 r l 2 5w 1721~1 p 1 0 ~ 'IN 1 ~ ~ 3 , 5 ~ PElO

7 l N n 7 l N n . .. . ..

ornv> o,n,y> O'n'y' >\rn n2 , n l r n 5w 1721~2 j7iv~ 'IN ~ W N J O"'Y' o,nyg>

nl'np n i ~ n p nipin, nipini 7~11-12 n ~ r n w i ~ 7~ n3mn ,> m n i ~ ,5w PEI I

71Nn 71Nn . n ) ~ m x n iuini t i ~ i

o'n'y' 0,j-p~' o?nly> 11rn n l ~ I ~ I I 5w )-rsi~l piwy 'IN ~ W N J

nl"lp ni=np o'n'y' nipini 7172 n w i ~ ,)NW o,is7 nnry 5~ nnpi:, t ~ w PE12

71ND olny" nipin,

71Nn .,5 lltY5 ,73 5>3

o>nv:, omv> 73 ~ r n n n~ inn> ,> niriy ,>w ~ i r n n2 o'n'y' ,,nyg>

"'=llp n1>,1p nipini

nipini nvy2 OY in13 mu 77innn5 313, 'INW PEI 3 71ND 7lNn .,n3~11 >W 1721~2 j 7 1 0 ~ 'IN 7 ~ ~ 3

D ~ . Y > olnly:, o'n'" O,nyg>

nr'llp n i l n p O""' nipini nipim .,5 nitiy 3 w 11tn n s ,-r,n piwy ,)N ~ W N J PE14

71Nn 71ND


nnn nwialn N l n YwNa n-~wpnn 75a a m na 72 7 v a p0111 ~ 2 n 75177

o?n,y:, n N n m y n NVW ny7> ,> n1n13 ,>w ~ t n n3 o'n'Y' orn>y> ornv:, nillip

nixiip o'nvs' nrplni nrpini Y W N ~ ,>w mtyn IN nlrvn ,n,wynn n3,nnn PE16

7iNn TIND . ~ > n ~ n m >w I ~ I I N ~ DY n771nnn ~ ' n o>nv:, o'nly:, oms:, ~71x7 nwy> ,Inn nwpm 3 w u tn n2

o'n'y' o,,,y,, ni'llp nixiip

n i p n i nipini

.n~wy> nn w n in), n> w, iwn3 n>,xwx PE17 iirin 71Nn

oln,~:, o>nw:, n>w n12n)nnn 71-1 ,> n ~ i n 3 w ~ ~ t n n l O""' fJ>nyg>

olnw:, ni'iip nipini ,w~p n> w, 7WN3 I N nn,N 1701 N> Inwnw PE18

n i lnp 71Nn

nlvlni 71Hn .11nx/m3 >w 1711~n DY 771nnnb

n5w nnnn n N nNin 75w avrr na i w ~ a nwln mu rrn3 ~ O ' I Y ~ 2 7 ~ 5 n n a

- -

O'"'Y' o,n>y:, oynv:, O""' nipini

7 w ~ 3 n7'x> ~ I N W ,>w u t n nl> nNin V N PE21 nr1"i7 nili7p -,IN13

o'nYs' nipini ,,,, . I I ~ Y D ~ >w l-rnnn OY n-r-r,nnn N ~ T I . .. . ,.

o'n'" o,nry> onv> N> N ~ W '>w 21tn n l nn o,wtin VN

nl'np nili7p o'n'y' nipini o'nY" nrpinl 71Nn PIU,YTI >w nnnn DY P ~ D D 110 n771nnn PE22

iirin .1>nx1>13 >w 1711~1

o'n"' o,nryb o,n)y> 1 1 N l ~ n n n N n l~ i : , '>w ~ I t n nl> 1 1 1 ~ ,IN

nr1np o'n'y' nipini >w INTI o y n77Innn ~ , n ~ W N J in), 310 P E Z ~ 71Nn

o'nys' nipin, . I I ~ ~ I I I , I ~

-

O'n'y' o,n,y> o,n>y:, lnrl D l ~ n TI> 1nvI d w mtn nx> 3wpn ,>N

n l x l l ~ n i m p O""' nipini D'nY" nipim NV lWN3 nDN3 TI> Y'i9nw TID >Y >TI> PE24

7iNn . I I ~ ~ / I I I ~ >w l f x 1 ~ 3 npiuy

a'n'y' o,n,y> otnv:, 21x3 n3 >w nnnn nn n11,x-13 npl> N> ,>N hill nP17i7 ni l l ip O""' niprm a'nY"' nipini 71Nn >w 1711~n DY n771nnn ~ , n ~ W N J ,>w ~ ~ 2 5 71Nn . r3nx1111l

o'n'Y' o,n,y:, o,n,y> o'n'y' DY nn-r~nnnn >w3 nnnx ,>w 21tn n l i w ~ 3 n"np nili7p nrpini D'nys' nipin7 71Nn . i~non> ~ V I I 'IN ,11nxm>l >W 17x1~~1 PE26 1lNn

n771nnn ,>w Ann nx iwn3 m n n inv ~ J N fJ'n'y' o'n,yb o>n?~> D'n'y' ,IN n n ~ n ~ n > IN , I I ~ ~ I I ~ >w )TIINTI OY PE27 nr'np ni l i ip O'"'" nipini nrpini 71Nn )fx)nn my f71nnnb n ~ i ~ N ~ W lwln 71Nn

.nnwx o,n>yb o,n,y:, ~ W I Y ,>w ~ r t n nlw o,i37 ynry >Y npi> ,,N

D'n'Y' o>nya> n1'i19 n a n p O""' nrpini

n i i~ in i l,Nn nqrov N Y ~ i w ~ 3 TI:, i ~ t y > , f ~ 533 7171 P E Z ~ iirin 11nx111l >w 17x1~3

oln7y3 o>nry:, D'n'Y' o,nys' o'n'y' nipin, OY 771nnnb ,>w 21171 nl> 711~3 n01n ,IN

ni'llp n i ~ i i p nipini . ~ ~ I / I I I I >w 1711~~1 ~ € 2 9 iirin 7 i ~ n

-

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Training in Trauma Focused Cognitive Behavioral Therapy: Description and Objectives.

Prepared by: Gafnit Aghassy, M.A., January 2006

Background Research over the last decennia has demonstrated the potentially debilitating effects of exposure to traumatic events. Previous estimations held the effects of exposure to trauma to be relatively less severe in children versus adults. Recent findings, however, show the opposite to be true. Children appear to be more vulnerable to trauma. Exposure. to trauma and the development of post traumatic disturbances, especially PTSD, furthermore place children at greater risk for developing a wide range of psychiatric disturbances, including:

b risk seeking behavior, conduct disorders, anxiety disorders, depression, borderline and dissociative personality disorders. Research in Israel and Palestine show a proportion of between 15% and 30% of children aged 5 to 18 suffering from PTSD. Child therapists in both countries however, lack training in the necessary skills to carry out specialized trauma focused therapy.

The object of the present training is to teach mental health practitioners to treat children suffering from PTSD, and their families, according to evidence based, (treatment of choice) therapeutic methods. The models developed and researched by Cohen, Deblinger and Manarino, have been proven to provide good treatment results with traumatized children, which are clearly superior to psychodynamic models of treatment with such populations. These treatment modules use trauma focused cognitive behavioral therapy to treat both children and their parents. They comprise a 16 session treatment model for children with a parallel 16 sessions for the parents, some of the sessions being joint parent child sessions.

Objectives It is our objective to provide a training that will train mental health professionals who are

6~ currently treating children, with the theoretical knowledge and the practical skills necessary for identifying, diagnosing and treating children with ITSD.

By identifying and training relevant mental health professionals we hope to provide state of the art treatment to children on both sides. Furthermore we intend to begin to develop a children's trauma treatment network by providing a sequel to the present training, to train future trainers who will provide supervision and training to a widening circle of child therapists on both sides.

Components of the training In the course of the training therapists will use material from their own lives and from the cases of traumatized children they treated, to conceptualise the theoretical aspects of traumatic experiences and to practice therapeutic skills with each other. The training will include a thorough basis in theoretical knowledge about:

4 What constitutes a traumatic experience? 4 What are the healthy coping mechanisms people usually use to overcome traumatic

experiences? 4 What does exposure to trauma entail in terms of meaning attribution,

psychobiological processes, somatic processes, cognitive changes, and social process?

4 In what way the healthy coping process differs from post traumatic disorders?

In the course of the practical side of the training, the teaching will aim at developing therapists awareness of their reactions to traumas they have overcome in their own lives, in order to be better able to remain attuned to the trauma's recounted by their patients. Therapists will acquire on one hand various exposure tools (to help patients focus in on the

kt3 trauma and allow for processing) and various tools for relaxation and self regulation. Exposure will be taught by conducting demonstrations of therapeutic interventions and have participants practice these methods in pairs using their own traumatic memories as learning tools. Techniques include building exposure hierarchies, practicing imaginal exposure using alternately verbal, visual, imaginational, cognitive and somatic channels, and giving each other homework assignments for in vivo exposure. Relaxation techniques taught will include breathing to counteract hyperventilation, muscle relaxation, imagery, Somatic Experiencing and cognitive techniques.

The practical part of the course is given parallel to the theory, with the following objectives: 4 To help therapists recognize and identify common ways of reacting to traumatic life

events. 4 To teach them how to conduct interviews and to use questionnaires to accurately

assess post-traumatic disorders 4 Help them understand the function of different facets of stress reactions in the

healing process, the development of the disorder, the function of the different parts 3

of the treatment to their patients 4 To teach self regulation techniques 4 To master different tools to bring about therapeutic exposure to the memory in order

to advance the processing of traumatic memories

Hours: 20 four hour sessions will be employed for the training and a further 8 sessions will be dedicated to supervision.

JDC-Middle East Program Center for Development in Israel Center for the Primary Health Care

(ICC-Israel, Myers-JCC- (CDPHC) Treatment of Psycho-trauma Brookdale Institute, NJCC),

L C O P S I ~ L I Y AND H O P E J Ashalim Al Quds University of Herzog Hospital

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