# Presentation: 045183

## 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?

******  ****Decreased IQ and reading ability (Delaney-Black et al., 2003)  **
******  ****Lower grade-point average (Hurt et al., 2001) **
******	****More days of school absence (Hurt et al., 2001) **
******  ****Decreased rates of high school graduation  (Grogger, 1997)**
******  ****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”.  **

## Slide 4

**Notes:**
20% - 50% of children in the U.S. exposed to community violence

## Slide 5

**Notes:**
“Violence is one of the most significant public health issues facing America”
Disproportionately impacts urban, poor, and minority youth 
Screening for Violence in the General School Population
Modified Life Events Scale
Past year and lifetime
Victim and witness 

Types of violence included: 
Being slapped, hit, or punched
Being beaten up
Violence involving a knife or gun

Emotional problems such as PTSD, depression, and other anxiety disorders more common with violence exposure
School problems, lower GPA, and increased absenteeism more common with violence exposure

## Slide 6

## Slide 7

## 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**

**0%**

**20%**

**40%**

**60%**

**80%**

**100%**

**Witnessed violence**

**Victimization**

**Knife or gun involved**

**Notes:**
All 769 children

## Screening also identified many children with clinical symptoms

**Symptoms**

***Screening also identified many children ******with clinical symptoms***

## 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**

**Notes:**
How was the program tailored?
The training for the school SW was relatively brief- they had 2 intensive days of training, and all the sessions, everything that was covered, was also provided in a manual. We also had a phone meeting once a week, to talk about any issues that came up during the sessions.

The program was also designed to fit into the school environment. For example, the sessions were set up so that it could be done bell to bell, all within one class period. It was flexible, so that students could skip a week and double up the next week if there was a field trip or standardized test. Finally, the structure of the sessions were quite similar to classroom lessons- the social workers taught the students the skills for that week, they’d practice them with the social worker and other students in the group, and then they were often given homework to practice them at home.

Finally, the social workers worked closely with the school liason to trouble shoot any issues that came up

## CBITS developed for multicultural communities

**CBITS has been delivered to immigrant and non-immigrant 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

**769 students ****screened for ****eligibility**

**126 students ****randomly ****assigned**

**61 students receive ****program ****immediately**

**65 students to ****receive program ****later**

**159 students ****eligible for ****program**

**Notes:**
I’d like to tell you now more about how students were selected for the program, and how the program was evaluated.

As you can see in this slide, sixth grade students at 2 schools were screened to determine if they were eligible for the program.

Since there weren’t enough trained social workers to run groups for all the children who qualified at once, about half the children were placed on a wait-list to get the program later in the school year. 

## Treatment improves trauma symptoms

**Average****PTSD****symptoms****score**

**Immediate CBITS group**
**Delayed group**

**Received CBITS**
**Observation **

**Stein et al., JAMA 2003**

**30**

**25**

**20**

**15**

**10**

**5**

**0**

**Before program**

**3-month****assessment**

**6-month****assessment**

## Improvement in symptoms lasts

***Improvement in symptoms lasts***

**Average****PTSD****symptoms****score**

**Immediate CBITS group**
**Delayed group**

**Received CBITS **
**Observation**

**30**

**25**

**20**

**15**

**10**

**5**

**0**

**Before program**

**3-month****assessment**

**6-month****assessment**

**Stein et al., JAMA 2003**

## Parents report children doing better

**Average****psychosocial****impairment****score**

**Immediate CBITS group**
**Delayed group**

**Received CBITS **
**Observation**

**25**

**20**

**15**

**10**

**5**

**0**

**Before program**

**3-month****assessment**

**6-month****assessment**

**Stein et al., JAMA 2003**

**Notes:**
From baseline to followup

## Improvement in functioning lasts

***Improvement in functioning lasts***

**Average****psychosocial****impairment****score**

**Immediate CBITS group**
**Delayed group**

**Received CBITS **
**Observation**

**25**

**20**

**15**

**10**

**5**

**0**

**Before program**

**3-month****assessment**

**6-month****assessment**

**Stein et al., JAMA 2003**

**Notes:**
From baseline to followup

## 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**

**Notes:**

As a clinician and researcher, I’ve very excited about these results showing that such a program can really help kids

But was it a program that could be rolled out- was it a program that people wanted in their schools

## Slide 25

## 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): 1104-1110.**
**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.**