Improving Educational Outcomes for Students Exposed to Violence: the CBITS Program
Marleen Wong, Ph.D., Director Crisis Counseling and Intervention Services Los Angeles Unified School District LAUSD/RAND/UCLA Trauma Services Adaptation Center for Schools and Communities National Child Traumatic Stress Network/SAMHSA
How does violence exposure impact learning?
q Decreased IQ and reading ability (Delaney-Black et al., 2003) q Lower grade-point average (Hurt et al., 2001) q More days of school absence (Hurt et al., 2001)
q Decreased rates of high school graduation (Grogger, 1997)
q Increased expulsions and suspensions (LAUSD Survey)
THE ACHIEVEMENT GAP?
The negative effects of trauma exposure may explain one aspect of the bleak reality that African American and Latino students continue to trail far behind their Caucasian peers in schools, such as higher drop out rates from high school after generations of education “reform”.
National Survey of Adolescents Prevalence of Violence History (N=1,245) Kilpatrick et. al., 1995
27% No Violence
2% Direct Assault Only
48% Witness Only 23% Assault + Witness
LAUSD 6th Grade Students (n=28,882) Prevalence of Past Year Violence for 2004
6%No Violence
40%Gun or knif e violence
54%Non-weapon relat ed violence
How does distress from violence affect students in the classroom?
• Decline in classroom performance from
– Inability to concentrate – Flashbacks, preoccupation with trauma – Avoidance of school and other places
• Development of other behavioral and emotional
problems – Substance abuse – Aggression – Depression
Which students are at greatest risk for violence exposure?
• Ethnic minorities (90% in LAUSD) • Lower socio-economic status (73% in LAUSD on
free or reduced lunch program)
• Older children • Early conduct problems
• Living in urban areas or in areas of high poverty
and crime
• Males
Why a Program for Traumatized Students?
One night several years ago, I saw men shooting at each other, people running to hide. I was scared and I thought I was going to die. After this happened, I started to have nightmares. I felt scared all the time. I couldn’t concentrate in class like before. I had thoughts that something bad could happen to me. I started to get in a lot of fights at school and with my brothers.
Martin, 6th grader
Why a Program for Traumatized Students?
One night several years ago, I saw men shooting at each other, people running to hide. I was scared and I thought I was going to die. After this happened, I started to have nightmares. I felt scared all the time. I couldn’t concentrate in class like before. I had thoughts that something bad could happen to me. I started to get in a lot of fights at school and with my brothers.
Martin, 6th
grader
What can be done for students exposed to violence?
• Early detection of violence exposure and
associated distress
• Teaching students skills to cope better with
distress and to learn social problem solving skills
• Informing teachers and parents how they can
support these students in the classroom and at home
Results of a school-wide screening of LAUSD 6th graders
Type of exposure reported
Knife or gun involved Victimization Witnessed violence
0% 20% 40% 60% 80% 100%
Screening also identified many children with clinical symptoms
Type of exposure reported
Knife or gun involved Victimization Witnessed violence
0% 20% 40% 60% 80% 100%
Symptoms PTSD symptoms in clinical
range Depressive symptoms in clinical range 0% 20% 40% 60% 80% 100%
Cognitive Behavior Therapy for Trauma in Schools:
The CBITS Program
• 10 child group therapy sessions for trauma
symptoms
• 1-3 individual child sessions for exposure to trauma
memory and treatment planning
• Parent sessions on education about trauma,
parenting support
• A teacher in-service includes education about
detecting and supporting traumatized students in the classroom
Key Program Components
• Educating students about trauma and common
symptoms
• Relaxation training and fear thermometer • Cognitive therapy
• Learning to face the trauma
• Building skills to get along with others
CBITS tailored for delivery in schools
• CBITS can be provided by school-based clinicians
– Short training (2 days maximum) – Ongoing supervision can be provided – Easy to follow treatment manual with handouts for students
• CBITS is feasible within schools
– Sessions occur during one class period – Can be flexible with school schedule – Minimal burden on teachers
• Easy identification of students for the program
– Short screening questionnaire filled out by students
CBITS developed for multicultural communities
• CBITS has been delivered to immigrant and nonimmigrant communities in LAUSD
• CBITS has been delivered in multiple languages • CBITS program is flexible to meet the needs of
students and families from diverse backgrounds
Program evaluation overview
61 students receive program immediately
769 students screened for eligibility
159 students eligible for program
126 students randomly assigned
65 students to receive program later
Treatment improves trauma symptoms
Immediate CBITS group Delayed group 30 25 Received CBITS Observation
Average PTSD symptoms score
20 15 10 5 0 Before program 3-month assessment 6-month assessment
Stein et al., JAMA 2003
Improvement in symptoms lasts
Immediate CBITS group Delayed group 30 25 Received CBITS Observation
Average PTSD symptoms score
20 15 10 5 0 Before program 3-month assessment 6-month assessment
Stein et al., JAMA 2003
Parents report children doing better
Immediate CBITS group Delayed group Received CBITS Observation
25
20
Average psychosocial 15 impairment score 10
5 0 Before program 3-month assessment 6-month assessment
Stein et al., JAMA 2003
Improvement in functioning lasts
Immediate CBITS group Delayed group Received CBITS Observation
25
20
Average psychosocial 15 impairment score 10
5 0 Before program 3-month assessment 6-month assessment
Stein et al., JAMA 2003
Grades and classroom behavior improved
• As trauma symptoms decreased, grades
improved
• Teachers reported fewer classroom learning
problems after program
• U.S. Department of Education has identified
CBITS as a program that meets the standards of NCLB
GRADE POINT AVERAGES
3
Group Grade Point Average
2.5 2 1.5 1 0.5 0
Dana MS Jefferson HS
1.57
2.18 1.68
1.731.8 1.89
Fall GPA Spring GPA
Narbonne HS
GROUP ATTENDANCE
100 100 90 80 70 60 50 40 30 20 10 0
Number of Days
50
Fall Absences Spring Absences
13
5
8 3 Jefferson HS Narbonne HS
Dana MS
Recommendations: The President’s New Freedom Commission on Mental Health • Bring Science to School Services
– Train school psychologists, social workers and counselors in effects of trauma and trauma interventions – Include teacher pre-service education on trauma and learning
• Build the knowledge base for the treatment of trauma
– Insist on outcome measures after crisis interventions
• Expand and enhance school-based mental health programs
– Organize existing school and community resources into integrated school mental health services
Further reading
Jaycox, L. (2004). Cognitive-Behavioral Intervention for Trauma in Schools. Longmont, CO: Sopris West Educational Services. Jaycox, L.H., Stein, B., Kataoka, S., Wong, M., Fink, A., Escudera, P. & Zaragoza, C. (2002). Violence exposure, PTSD, and depressive symptoms among recent immigrant school children. Journal of the American Academy of Child and Adolescent Psychiatry, 41(9): 11041110. Kataoka, S., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., Zaragoza, C. & Fink, A. (2003). Effectiveness of a school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3):311-318. Stein, B.D., Jaycox, L.H., Kataoka, S., Rhodes, H. & Vestal, K. (2003) Prevalence of child and adolescent exposure to community violence. Clinical Child and Family Psychology Review, 6(4):247-264.
Further reading
Stein, B.D., Jaycox, L.H., Kataoka, S.H., Wong, M., Tu, W., Elliott, M.N. & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290(5): 603-11. Stein, B., Kataoka, S., Jaycox, L., Wong, M., Fink, A., Escudero, P. & Zaragoza, C. (2002). Theoretical basis and program design of a school based mental health intervention for traumatized immigrant children: A collaborative research partnership. Journal of Behavioral Health Services and Research, 29(3), 318-326. Stein, B. D., Kataoka, S., Jaycox, L.H., Steiger, E.M., Wong, M., Fink, A., Escudero, P., Zaragoza, C. (2003). The Mental Health for Immigrants Project: Program design and participatory research in the real world. In: M.D. Weist, S. Evans, N. Lever (Eds) Handbook of School Mental Health: Advancing Practice and Research. (pp. 179-190). New York: Kluwer Academic/ Plenum Publishers.