Training Teachers to Build Resilience

in Children in the Aftermath of War: A

Cluster Randomized Trial
Naomi L.Baum, Barbara Lopes Cardozo,
Ruth Pat-Horenczyk, Yuval Ziv, Curtis
Blanton, Avid Reza, Alon Weltman &
Danny Brom
Child & Youth Care Forum
Journal of Research and Practice in
Children's Services
ISSN 1053-1890
Volume 42
Number 4
Child Youth Care Forum (2013)
42:339-350
DOI 10.1007/s10566-013-9202-5

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Child Youth Care Forum (2013) 42:339350
DOI 10.1007/s10566-013-9202-5

Training Teachers to Build Resilience in Children

in the Aftermath of War: A Cluster Randomized Trial
Naomi L. Baum Barbara Lopes Cardozo Ruth Pat-Horenczyk
Yuval Ziv Curtis Blanton Avid Reza Alon Weltman
Danny Brom

Published online: 11 May 2013

Springer Science+Business Media New York 2013

Abstract

Background

There is growing interest in school-based interventions for building resilience in children facing trauma and adversity. Recent studies focus on teacher training as
an effective way to enhance resilience in their students, and emphasize the need for
additional evidence-based practice.
Objective The aim of this study was to evaluate the effectiveness of a short-term
resilience-building teacher intervention on reducing post-traumatic distress in students in
the context of exposure to recurrent rocket attacks in Israel.
Methods A quasi-experimental, cluster randomized design employing intervention and
wait-list control groups was implemented with students from grades four-six (N = 563) in
four schools in Acre in the aftermath of the Second Lebanon War. We assessed the
students trauma exposure, posttraumatic symptoms and anxiety before and after the
intervention or the wait-list condition.
Results There was a significantly (p \ 0.001) greater decrease of posttraumatic symptoms and anxiety levels among the students whose teachers participated in the intervention
group as compared to students whose teachers were in the wait-list control group. A
multiple regression model showed that this greater decrease in posttraumatic symptoms
and anxiety levels was statistically significant after controlling for demographic variables,
trauma exposure and past trauma history.

Disclaimer: The conclusions of the study are those of the authors and may not necessarily reflect the
views of the US Centers for Disease Control and Prevention.
N. L. Baum (&)
R. Pat-Horenczyk
Y. Ziv
A. Weltman
D. Brom
Israel Center for Treatment of Psychotrauma-Herzog Hospital, Jerusalem, Israel
e-mail: nbaum@herzoghospital.org
B. L. Cardozo
C. Blanton
A. Reza
Center for Global Health, International Emergency and Refugee Health Branch, Center for Disease
Control and Prevention, Atlanta, Georgia, USA
R. Pat-Horenczyk
D. Brom
Hebrew University of Jerusalem, Jerusalem, Israel

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Conclusion

The results of this study show that the training of teachers alone in building
resilience can effectively lower post-traumatic distress and anxiety in their students. The
empowerment of teachers and by building upon their expertise and experience are crucial
for creating sustainability in school-based interventions.
Keywords

Resilience
School-based
Trauma
Interventions
Children
War

Introduction
Mental health surveys conducted in post-disaster and post-war settings have shown a high
prevalence of mental health problems associated with the effects of armed conflict (Lopes
Cardozo et al. 2004; Mollica et al. 2004; Pat-Horenczyk et al. 2011). Children are the most
vulnerable segment of the population in the wake of exposure to trauma, violence and
armed conflict and are at high risk for developing Post-Traumatic Stress Disorder (PTSD)
(Pat Horenczyk et al. 2009).
The mental health of children affected by war and violent conflict has become a core
public health issue. A range of mental health and psychosocial programs during and after
natural disaster, war and complex emergencies has been created and implemented. However, despite the progress that has been made toward reaching consensus regarding need
and standards of care, the scientific basis for many of these mental health and psychosocial
interventions is still weak (Lopes Cardozo 2008).
The next step forward in improving the mental health of war-affected populations, and
children in particular, is to increase the knowledge base regarding which interventions are
effective in increasing mental health and well-being while decreasing post-traumatic distress
and psychiatric disorders associated with trauma in armed conflicts. Schools provide a promising setting in which to implement interventions in the aftermath of war and natural disaster
because they provide efficient and easy access to children of school age in a setting that is
familiar and non-stigmatizing (Gelkopf and Berger 2009; Layne et al. 2008; Pat Horenczyk
et al. 2009; Tol et al. 2008; Wolmer et al. 2005). School-based interventions have been successfully used in a variety of post-traumatic contexts including natural disasters (Baum et al.
2009), inner-city violence (Wong et al. 2007), and war and terrorism (Berger et al. 2007, 2012).
Research on School-Based Interventions
School-based interventions focusing on direct treatment of children that have reported a
reduction in the childrens post-traumatic symptoms include a randomized wait-list control
study of cognitive-behavioral therapy (CBT) for individual children (Chemtob et al. 2002),
as well as CBT group interventions for children (Dean et al. 2008; Layne et al. 2008;
Morsette et al. 2009; Stein et al. 2003; Wong et al. 2007). These interventions have been
implemented by trained mental-health professionals.
A parallel approach to working in schools has focused on training teachers to assist
mental health professionals in creating a healthy posttraumatic environment for children.
Teachers described as efficient clinical mediators (Wolmer et al. 2005, p. 1162) are
trained to introduce structured units of study and activity into the classroom, where these
units are focused on targeting traumatic exposure and reducing post-traumatic symptoms
(Gelkopf and Berger 2009; Berger et al. 2007; Cox et al. 2007; Gelkopf and Berger 2009;
Gelkopf et al. 2008; Gillham et al. 2007; Gupta and Zimmer 2008; Tol et al. 2008; Wolmer

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et al. 2005; Wong et al. 2008). Significant reductions of measured post-traumatic stress
symptoms, somatic complaints, and anxiety levels in students have been reported in several
controlled studies (Gelkopf and Berger 2009; Berger et al. 2007; Gelkopf and Berger 2009;
Gelkopf et al. 2008). These studies provide support for training teachers as mediators in
post-disaster and post-war intervention programs within the school classroom.
The current study sought to evaluate the efficacy of the Building Resilience Intervention (BRI) (Baum 2004; Baum et al. 2009), an intervention that utilizes brief teacher
training (12 h) to provide teachers with resilience-building tools both for themselves and
for their students in classroom settings. As there is no consensus on a signal definition of
resilience, in this article resilience is defined as the ability to establish a pattern of stable
and healthy adjustment following an aversive event (Bonanno 2012). The intervention
consists of four 3-h workshop meetings with teachers held over the course of 2 months,
which are led by mental health professionals with expertise in trauma and resilience who
are trained in this manualized intervention model. Each workshop meeting focuses on one
objective and includes a unit of psycho-education as well as a workshop activity. Teachers
learn activities, skills and tools that they can utilize in their own lives or implement in their
classrooms. The intervention also gives teachers the opportunity to process any personal
traumatic material, including stress reactions, feelings of loss, helplessness and devastation
that they have experienced as the result of their exposure to trauma. The workshop model,
described in depth elsewhere (Baum et al. 2009), consists of four underlying objectives,
known as the four Ss: (1) Self awareness and regulation; (2) Support for feelings; (3)
Strengths and personal resources for coping; and (4) Significance, meaning, and hope.
These four objectives form the cornerstone of the teacher training and inform the hands-on
activities that the teachers subsequently implemented in their classrooms.
Teachers manuals (Baum et al. 2004) are distributed to all participants, containing information pages as well as guides for facilitating discussions in the classroom about emotionally
laden and often traumatic material. These manuals include evidence-informed activities,
ranging from meditation techniques to expressive art therapy, which were presented in an easily
accessible format for classroom implementation by the teacher. Teachers participating in the
workshop are also given guidelines for implementing the program in their classrooms and are
encouraged to choose activities from the manual and adapt them to meet the needs of their class.
The BRI differs substantially from previously studied interventions in that the amount of
classroom time needed to implement the model is minimal and controlled by the teacher.
There is no protocol for structured classroom implementation, and each teacher decides how
and when to utilize resilience-building activities in the classroom. While many of the studies
cited earlier train teachers to become classroom trainers, the primary focus of this intervention
is expanding the teachers personal sense of resilience. The hypothesis is that when the
training program focuses on teachers themselves and the ways they relate to trauma as
individuals, increasing their own resilience and coping skills, there will be a positive impact
on their students. Thus, though the BRI Program does not directly train students, this study
hypothesized that results of the intervention would be evident in the students of teachers who
participated in the BRI Program. Specifically, there was a predicted decrease in PTS and
separation anxiety symptoms among students whose teachers participated in the BRI program in comparison to students whose teachers were in the wait-list control group.
In this study, we evaluated the BRI Program in schools in Acre, a town in northern
Israel that was heavily bombarded and suffered loss of life during the Second Lebanese
War (July, 2006). The BRI intervention was initiated to help the school population cope
with the aftermath of the war. A randomized cluster design was chosen as it was the most
feasible method to measure the effect of the intervention between schools.

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Method
Participants
Four elementary schools in Acre, out of a total of five Jewish schools in that city, participated in this study. One school declined to participate. The four schools were matched
by neighborhood, size, age and religiosity, resulting in two matched pairs. In each of the
pairs, one school served as a wait-list control. All the teachers were invited to participate in
the intervention. The assessments before and after the BRI teacher-training intervention
were done with all students in grade four (n = 158 before and n = 141 after) and grade six
(n = 129 before and n = 135 after) in all four schools. Each grade was considered its own
cluster.
Several strategies were employed to maximize participation rates among students and
involve the parents in the process. The evaluation coordinator personally visited all the
schools in Acre and explained the purpose of the intervention and evaluation program. A
letter detailing the procedure was sent to parents, explaining the intervention process and
the use of anonymous questionnaires. Parents had the option of refusing to allow their child
to participate, but no such requests were received. There were 287 students for the first
measurement (138 students in seven classes for the intervention group, and 149 in eight
classes for the wait-list control group) and 276 students for the second measurement (116
in six classes for the intervention group, and 160 in nine classes for the wait-list control
group). This represents 97 % of students in attendance on the day of the evaluation. The
remaining eight students had incomplete questionnaires and were dropped from the study.
This sample represented 85 % of the entire student body. The numbers of students in the
measurement in both the intervention and wait-list control groups are shown in Fig. 1.
Study Design
In May, 2008, an evaluation of all the students in grades four to six in all four schools was
conducted before the BRI intervention was initiated with teachers (T1). The next evaluation of all the students (T2) took place in December 2008 after the completion of the
intervention in the two selected schools. The study protocol was approved by the Chief
Scientist of the Ministry of Education in Israel, which is equivalent to IRB approval.
The students filled out the screening questionnaire anonymously for ethical and legal
considerations, so it was not possible to create a nested cohort design (Murray and Hannan
1990). A randomized cluster design was therefore implemented. It was not possible to have
the schools themselves serve as clusters, as there were an insufficient number of schools in
the study; thus, each grade served as its own cluster. The students in each grade were then
measured through use of a nested cross-sectional design. The pre- and post-intervention
measurements were performed on different groups of students to ensure that pre/post
observations were independent. The first measurement was completed in the spring of
2008, and the second measurement in the late fall of the next school year. Thus, students in
the grade six at the time of the first measurement had graduated from the elementary school
before the second measurement took place, and the students in grade four at the time of the
second measurement were initially in grade three during the first measurement and thus did
not participate in the first measurement. Selecting students from the grades four and six,
and not grade five, ensured that the pre/post observations were independent.
Once two independent sets of observations were obtained, as previously stated, the data
was treated as a nested cross-sectional design, as explained by Murray and Hannan (1990):

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Fig. 1 CONSORT flow diagram

The essential features in the nested cross-sectional design are that different persons are
measured at each measurement occasion and that groups rather than individuals are
assigned to conditions (p. 458).
Instruments
Instruments developed to screen schoolchildren for post-traumatic and related distress were
utilized (Pat-Horenczyk et al. 2007a, b, 2011; Baum et al. in press; Astor et al. 2012). The
questionnaire included questions about demographics, exposure to war, and trauma history

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(see Table 4), the UCLA PTSD index for DSM IV reference (Steinberg et al. 2004),
functional impairment (Pat-Horenczyk et al. 2002), and the separation anxiety subscale of
the SCARED (Birmaher et al. 1997). For the UCLA PTSD index a total posttraumatic
severity score (PTS) was computed using the responses to 20 of the 22 items. The internal
consistency of the PTSD Child Reaction Index in the study was highly satisfactory
(Cronbach alpha .903). For the SCARED, separation anxiety was computed as a sum of
eight items of the separation anxiety subscale. The internal consistency of the subscale
in the study was highly satisfactory (Cronbach alpha .806).
Analyses
Analyses were performed using SPSS 14.0. The exposure measure was divided into two
categories: war exposure and trauma history. War exposure included four items, and
trauma history included ten items (see Table 1). The differences between the intervention
and the wait-list control group in PTS severity and the total score of anxiety were measured
by t tests.

Table 1 Demographic and clinical characteristics of intervention and wait-list control groups at baseline
Sample characteristics at baseline
Intervention
(n = 138)

Wait-list control
(n = 149)

Test

0.149

Chi Square

\0.001

0.333

Chi Square

0.179

Chi Square

0.181

Chi Square

0.156

Chi Square

0.001

0.009

0.001

Demographic
Male

Count (%)

73 (54.48 %)

69 (46.62 %)

Female

Count (%)

61 (45.52 %)

79 (53.38 %)

Missing

2.90 %

0.67 %

Mean (SD)

11.08 (1.07)

10.63 (1.08)

Missing

1.45 %

0.67 %

Count (%)

115 (84.56 %)

127 (85.23 %)

Missing

0.00 %

0.00 %

Age
War exposure
Stayed in a bomb shelter
Evacuated your house
Someone you know was wounded
Someone you know died

Count (%)

101 (74.26 %)

119 (79.87 %)

Missing

0.00 %

0.00 %

Count (%)

48 (35.56 %)

38 (25.85 %)

Missing

0.00 %

1.30 %

Count (%)

26 (19.12 %)

42 (28.77 %)

Missing

1.45 %

2.01 %

Trauma history*
No. of reported events

Mean (SD)

2.03 (1.66)

1.42 (1.44)

Missing

0.00 %

0.00 %

Pathology
PTS
Anxiety

Mean (SD)

19.86 (14.14)

14.15 (12.66)

Missing

1.45 %

3.36 %

Mean (SD)

5.85 (4.14)

4.30 (3.47)

Missing

13.80 %

6.71 %

* Trauma history determined by questionnaire in Table 4

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A multiple regression model was run to examine the effect of the intervention versus the
control on mental health outcomes, adjusting for risk factors and demographic variables.
The war-exposure variables were entered as categorical variables in the regression, and the
trauma history was computed as the sum of all reported events. The PTS and anxiety
outcomes were log-transformed prior to running the linear regression. The effect of
treatment was established by testing for two-way interactions (time 9 intervention). The
interaction variable coefficient reflected the difference between the changes in symptoms
in the intervention group as compared to the wait-list control group. A negative coefficient
indicates a greater reduction in symptoms for the intervention group as compare to the
wait-list control group during the same period of time. A p value of \0.05 was considered
to be statistically significant. To take into account the clustered sample (a total of 30
classes), robust standard errors and variance estimates were obtained by using the cluster command in the STATA software (Williams 2000). Here too, a p value of \0.05 was
considered to be statistically significant.

Results
The demographic and mental health characteristics of the intervention and the wait-list
control groups at baseline are shown in Table 1. PTS and anxiety were both significantly
higher at baseline for the intervention group than for the wait-list control group. The results
show that the levels of PTS and anxiety decreased significantly in the intervention group
from T1 to T2 (p \ 0.001, p \ 0.001 respectively), whereas no such differences were
found in the wait-list control group (Table 2).
The multiple regression model (Table 3) shows that the intervention resulted in a statistically significant decrease in levels of PTS (p = 0.006) and anxiety (p \ 0.001), after
the demographic variables, trauma exposure, and past trauma history were controlled for.
Being female or having a history of trauma experiences was associated with significantly
higher levels of PTS (p = 0.012 and p \ 0.001, respectively) and anxiety (p = 0.003 and
p \ 0.001, respectively). Younger age was also associated with higher levels of PTS and
anxiety (p \ 0.001, p \ 0.001, respectively).

Table 2 Comparison of mean changes between intervention and wait-list control groups for PTS and
anxiety at T1 and T2
Time

Mean

SD

Mean (SE)

Pre- Post D p value

CI

Pre

19.86

14.14

136

7.71 (1.70)

0.000

(4.36 to 11.05)

Post

12.15

12.50

115
0.69 (1.51)

0.651

(-2.29 to 3.67)

2.07 (0.54)

0.000

(1.02 to 3.13)

-0.65 (0.43)

0.137

(-1.50 to 0.21)

PTS severity
Intervention
Wait-list control

Pre

15.65

12.66

144

Post

14.96

13.53

157

Pre

5.85

4.14

119

Post

3.78

3.88

107

Anxiety
Intervention
Wait-list control

Pre

4.30

3.47

139

Post

4.95

3.88

153

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Table 3 Multiple linear regressions of PTS and anxiety, T1T2

Ln(PTS)
B

Ln(Anxiety)
Robust
SE

Sig.

Robust
SE

Sig.

0.000

Interventiontime interaction

-0.571

0.194

-2.94

0.006

-0.646

0.122

-5.32

Female

0.238

0.089

2.69

0.012

0.233

0.072

3.23

0.003

Age

-0.211

0.038

-5.58

0.000

-0.220

0.025

-8.67

0.000

Number of reported events

0.230

0.025

9.10

0.000

0.118

0.016

7.43

0.000

Stayed in a bomb shelter

0.256

0.156

1.64

0.111

0.190

0.158

1.20

0.240

Evacuated your house

0.042

0.107

0.39

0.697

0.028

0.064

0.44

0.666

Someone you know was

wounded

0.032

0.110

0.29

0.777

0.023

0.113

0.20

0.839

Someone you know died

0.144

0.123

1.17

0.250

0.060

0.117

0.51

0.612

Intervention

0.296

0.100

2.97

0.006

0.341

0.047

7.30

0.000

Time (Post)

-0.120

0.105

-1.14

0.265

0.106

0.072

1.48

0.149

(Constant)

3.912

0.486

8.05

0.000

3.233

0.363

8.90

0.000

Model

R-squared

F(10,29)

Sig.

R-squared

F(10,29)

Sig.

0.212

16.35

524a

0.000

0.177

35.32

490b

0.000

270 T1, 254 T2

248 T1, 242 T2

Discussion
This evaluation study is the first of its kind to support the premise that through simply
training teachers, their students will benefit through a significant reduction in their levels of
posttraumatic distress and anxiety. Working with teachers to expand their capacities and
skills in meeting the mental-health challenges of a post-traumatic environment is both costand time-effective and has an impact on students well-being. Empowering teachers and
capitalizing on their natural leadership roles in the BRI intervention appears to be effective.
In addition, while the BRI has been implemented elsewhere in both peri- and posttraumatic environments (Baum 2004; Baum et al. 2009), in this study the BRI was used
well over a year after the end of the Second Lebanon War and was still shown to be both
relevant and effective. Thus, these results show that the time frame in which post-disaster
interventions have been traditionally implemented can be extended.
Strengths of the current intervention include both feasibility and the empowerment of
local systems that remain in place long after the intervention has been completed and the
outside experts have departed. By building on the expertise, experience, relationships, and
teaching styles of local teachers, this program leverages on the strengths of local resources.
Other programs that have evaluated the impact of teacher training on students have
required teachers to employ a standardized six- to twelve- session protocol in the classroom and to expand their role from educators to mental health technicians (Gelkopf and
Berger 2009; Berger et al. 2007; Cox et al. 2007; Gelkopf and Berger 2009; Gelkopf et al.
2008; Gillham et al. 2007; Gupta and Zimmer 2008; Tol et al. 2008; Wolmer et al. 2005;
Wong et al. 2008). In these studies, the expansion of the teachers role has required large

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commitments of both time and effort on the part of the teachers as well as large blocs of
classroom time dedicated to implementation. While the BRI provides teachers with new
skills, it clearly acknowledges the teachers primary roles as educators and offers both
information and classroom tools that easily mesh with the teaching role, requiring smaller
time commitments and activities that are well within the purview of the educators role.
Evaluations of other school-based mental health interventions, such as the one implemented by Tol et al. (2008) with children in Indonesia who were affected by political
violence, brought in outside trainers to work directly with children in the school. In that
study, the students post-traumatic stress symptoms did decrease as a result of the schoolbased group intervention, as in the current study. However, their anxiety symptoms did not
decrease, and no follow-up data were reported. The strength of the current BRI intervention is that the teachers who have been trained in the BRI are those who work directly
with students in the classroom and remain in the childrens environment, continuing to
have a positive impact on the children long after the intervention has been completed.
The present study underscores the importance of the teachers role and their ability to
impact the students mental health in their daily contact with them. In future research,
isolating the essential features of the BRI that impact children will help to refine the BRI
and our understanding of the salutary effects of adults on childrens mental health. Identifying these features may include measuring teachers stress levels and their ability to selfsoothe and self-regulate, as well as their ability to communicate about emotionally laden
topics with their students.
While the initial results strongly support the hypothesis that teachers can impact their
students mental health, this study has some limitations. One of the main limitations is the
studys quasi-experimental nature. The significant differences at baseline of our intervention and wait-list control groups in trauma exposure, PTS and anxiety are often an
inevitable feature of naturally occurring groups. While these significant differences at
baseline were controlled for in the regression analysis, some unknown mediating variable
that may have contributed to this baseline difference may also have contributed to the
intervention effect. Further studies can increase the number of schools involved in the
study, as well as incorporate a one-year follow-up to test for the long-term effectiveness of
intervention.
A further limitation was the sample, which was drawn from schools in the Jewish sector
only, limiting the ability to generalize results to students in other school populations.
Moreover, the unit of selection was the school, so a more appropriate unit of analysis
would have been the school rather than individual students. This would have required a
much larger number of schools.
Despite these limitations, the generalizability of the study is enhanced by the fact that it
was conducted in a natural environment. Thus, what may be lost in scientific precision is
gained in the direct implementation of the intervention in the field. The further applicability of this program can be strengthened by conducting future evaluation studies with
other groups in different cultural contexts. Continued evaluation of the BRI protocol with
different cultural and ethnic groups is recommended.
An additional limitation is the lack of objective data about teacher implementation in the
classroom. While we did gather qualitative interviews of teachers post-intervention activities that strongly indicated both enthusiasm and actual implementation of exercises and tools
learned in the BRI, there is no objective measure of what was actually implemented in the
classroom. Further studies should consider measuring teacher implementation.
In summary, the BRI is a promising, short-term, post-trauma/disaster intervention
focusing on expanding teachers capacities and empowering them in their role as

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educators. Based on the findings thus far, it appears that training teachers can effectively
reduce the effects of traumatic exposure on children, thus reducing their post-traumatic
distress and anxiety. Mitigating the effects of trauma in children worldwide is a humanitarian enterprise of the first degree, and introducing a program that is effective as well as
easy to implement makes this enterprise a reachable goal.
Acknowledgments This study was funded in part by the Center for Disease Control and Prevention
(Atlanta, Georgia) and implemented in collaboration with the Israel Trauma CoalitionUnited Jewish
Communities. Acknowledgements to Iris Alaluf, Director of the Resilience Center of the Municipality of
Nahariya, who served as on-site coordinator for data collection and implementation of the intervention, and
to Lisa Chalik and Rebecca Ginat, research assistants.

Appendix
See Table 4.

Table 4 Trauma history questionnaire and war exposure items (Pat-Horenczyk 2006)
No

Yes

Trauma history was comprised of the following ten items

1. A severe disease of a relative

2. A sudden or unexpected death of a relative

3. Your parents divorced or separated

4. You were a victim of physical abuse/assault (non-sexual)

5. You were a victim of sexual harassment/assault/violence

6. Were you ever in a serious or life-threatening situationaccident/natural disaster (e.g. a fire)?

7. Did you ever witness a serious or life threatening accident?

8. Did you ever witness a serious injury or death of another person in an accident, natural
disaster or other situation that was not a terrorist incident?

9. Suffered from a severe disease that threatened your life

10. Moved out of your house, whether by choice or not

War exposure items included

1. Have you stayed in a bomb shelter or a safe space due to the war or missile attacks?

2. Did you evacuate your house for a period of time due to the war?

3. Was someone you know wounded during the war?

4. Did someone you know die during the war?

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