Exposure to Violence References

January 1, 2008

A Public Health Approach to Intervening With Youth in Schools

Tragedies such as the school shootings at Virginia Tech and Columbine or the devastation following Hurricane Katrina refocus our attention on the tremendous impact that trauma can have on our nation's youth. In fact, it is estimated that 20% to 50% of children and adolescents in the United States are exposed to violence, whether it is in their homes, at school, or in their communities. However, despite this "public health emergency" as declared by the former Surgeon General C. Everett Koop more than a decade ago, few children and adolescents are receiving the trauma interventions that they need.1

Youth violence exposure

Exposure to violence is a relatively common experience among children and adolescents.2 Even though overall national levels of victimization have been declining, between 1976 and 2000, the rate of violent victimization among adolescents aged 12 to 19 was higher than in all other age groups.3 One estimate is that by age 16, about 25% of adolescents will have experienced at least one traumatic and potentially life-threatening event.4 It is estimated that nearly 1.8 million US teenagers were victims of violent crimes, including rape/sexual assault, physical assault, and robbery.4 Youths at increased risk for violence exposure tend to be males, of older age, living in urban areas, of ethnic minority background, and from families with lower socioeconomic status.2 In one study of poor, urban, immigrant youths in Los Angeles, Jaycox and colleagues5 found that 49% of those aged 8 to 15 years reported being victims of violence and 80% had witnessed violence in the past year, with 40% reporting life-threatening violence involving a knife or a gun.

Trauma-related mental health problems

The psychiatric effects of trauma on children have only recently been widely recognized, and disorders such as posttraumatic stress disorder (PTSD) have been shown to be related to such diverse traumas as community violence,5-7 child physical and sexual abuse,8,9 natural and man-made disasters,10-12 and war.13 Some of the early landmark cases describing childhood PTSD include astudy by Terr14,15 of children from Chowchilla, Calif, traumatized by kidnapping and underground burial in their school bus, and a study by Pynoos and coworkers,16 who described children with PTSD who witnessed a sniper attack on their schoolyard.

Although many children are quite resilient following exposure to violence, studies of high-risk populations have shown that symptoms of PTSD will develop in approximately 1 of every 3 youths exposed to community violence.17 PTSD in children and adolescents, although described in the same 3-symptom clusters as in adults (reexperiencing, avoidance, and hyperarousal), may manifest as repetitive play; re-enacting the trauma; regression of previously acquired skills, such as using the toilet; irritability; and anger.

The main risk factors for PTSD in youth are related to the severity of the trauma, a parent's reaction to the event, and the proximity of the youth to the trauma. In addition to PTSD, trauma can lead to negative psychological and social outcomes, such as depression, anxiety disorders, substance abuse, and aggressive and delinquent behaviors.18-22 Besides emotional and behavioral problems related to trauma, youths exposed to violence are more likely to have poorer school performance, decreased IQ and reading ability, lower grade-point average, and more school absence.20,23-25

Treatment approaches

Although there is a growing body of evidence for best practices to treat trauma-related mental health problems in youth, few of these interventions are reaching the children and adolescents who need them most. There has been increasing recognition that these treatments need to be delivered in naturalistic settings, such as schools, in order to break down some of the access barriers to mental health care. These treatments need to be developed not only with sensitivity to the cultural context of the community but also with particular attention to the organizational culture of the setting.

Given the high rates of violence exposure in youth and the multidimensional effects that trauma can have on children and adolescents, including PTSD and major depressive disorder, as well as academic failure and functional impairment in multiple domains, there is a great need to disseminate effective programs in community settings, such as schools. One promising method of developing such treatments is community-partnered research, in which the best science of effective treatments is combined with acceptable and feasible practice in the community.26

School-based treatment of traumatized youth

Given the widespread exposure that children and adolescents have to violence nationally and the deleterious impact of this trauma on their mental health and functioning, early interventions for traumatized youth are imperative. Studies for treating PTSD in youth have supported the use of cognitive-behavioral therapy (CBT) for sexually abused children and children exposed to single-incident trauma.27,28 The treatment of grief in traumatized youth, which can be comorbid with PTSD, has also been described. In addition, psychoeducation has been found to be important in reducing emotional distress in traumatized youth.29

Based on research, the Cognitive Behavioral Intervention for Trauma in Schools (CBITS)30 was developed in response to the need for a more public health approach to providing evidence-based treatment for the many children and adolescents who are exposed to multiple types of violence but who rarely are identified and treated. From its inception, CBITS has been the product of a community-partnered research approach that has brought together community experts from local public schools from the Los Angeles Unified School District and clinician-researchers from the University of California, Los Angeles, and the RAND Corporation to collaborate in the development of the intervention as well as its implementation and dissemination.

What has made this partnership and program development unique is the attention to culturally relevant aspects of treating ethnically diverse children with PTSD31 and the expertise of the community partners in shaping a program that attends to the important aspects of school culture.32 Dr Marleen Wong, an administrator in the Los Angeles Unified School District and a main collaborator on CBITS, states :

Too often, academic researchers have approached schools with promises of assistance. Once the formal study is completed, they have left without much lasting benefit to the school program or the educational mission. Educators and other school personnel want researchers who understand the hierarchical relationships in a district and how business is conducted in schools.33

The issue of widespread chronic violence exposure and its impact on students in the classroom was first identified by the school partners as a significant unmet need of this district, and this community-research partnership was formed with the purpose of developing an effective school-based trauma program. CBT was identified as appropriate for this setting not only because it had been found to be effective for other groups of traumatized youth but also because it was a straightforward, skills-building treatment with homework assignments that could easily be understood by educators and other school staff. Some of the effects of this community partnership on program development has included sessions fitting within one class period and treatment delivered in a group format both to compensate for the scarce mental health resources in schools and to build peer support. In this way, the burden on teachers is minimized, and the parent component is optional to minimize the number of students excluded from treatment.

The CBITS program has been evaluated in a randomized controlled trial in the public schools and delivered by typical school-based clinicians. The community partners improved the evaluation process by making it more relevant to everyday service delivery in the schools. Community partners were also actively involved in determining which evaluation measures to use and in interpreting the final results of the study.

CBITS is a 10-session CBT intervention that incorporates standard CBT skills in a group format (typically 6 to 8 students per group) to address PTSD, anxiety, and depressive symptoms related to violence exposure. During each session, a set of techniques is introduced through age- appropriate examples and games as well as some didactics to solidify skills such as relaxation, cognitive restructuring, exposure therapy, and social problem solving (Table). Various modalities to process the trauma are also used in the program, including drawing and writing. The homework assignments for each lesson are developed collaboratively between child and clinician and reviewed at the beginning of the next session.

CBITS was initially piloted in a multicultural student population. It was offered in several languages, including Spanish, Korean, Armenian, Russian, and English and delivered by bilingual, bicultural school-based clinicians. In a quasi-experimental study of 198 students in third through eighth grade, youths who received CBITS had significant improvement of PTSD and depressive symptoms compared with those who were on a waiting list.31 These results were replicated in a randomized controlled trial by Stein and colleagues.34 They concluded that CBITS is effective in treating trauma-related mental health problems in youth. In addition, there is preliminary evidence that as PTSD symptoms declined in this population the students' grade point averages improved.35

With the success of this evaluation and the support for this program by local school partners, CBITS has begun to be broadly disseminated across the country and internationally. Supported in part by a grant from the Substance Abuse and Mental Health Services Administration's National Child Traumatic Stress Network, the CBITS community research partners have been able to train local clinicians in such diverse settings as the Rocky Boy's Reservation in Montana, the Madison School District in Wisconsin, and multiple sites in the gulf region following Hurricane Katrina. Dissemination is also under way in Australia, Japan, and Israel.

To support dissemination of this program, the CBITS partners have developed implementation resources, including a practical tool kit of hands-on support materials as a compendium to the CBITS manual; a brief video for schools about trauma and the impact on academic performance using the words of students, principals, and other school staff; a train-the-trainer model to support sustainability within local districts and schools; and ongoing training support that follows the Learning Collaborative model to support local learning and problem solving around implementation of CBITS in schools. (See www.tsaforschools.org for more information.)

Dr Kataoka is assistant professor at the University of California Division of Child and Adolescent Psychiatry Health Services Re-search Center in Los Angeles. She reports no conflicts of interest concerning the subject matter of this article.

1. Koop CE, Lundberg GB. Violence in America: a public health emergency: time to bite the bullet back. JAMA. 1992;267:3075-3076.

2. Stein BD, Jaycox LH, Kataoka S, et al. Prevalence of child and adolescent exposure to community violence. Clin Child Fam Psychol Rev. 2003;6:247-264.

3. Klaus P, Rennison CM. Age Patterns in Violent Victimization, 1976-2000. Washington, DC: Bureau of Justice Statistics; 2002.

4. Costello EJ, Erkanli A, Fairbank JA, Angold A. The prevalence of potentially traumatic events in childhood and adolescence. J Trauma Stress. 2002;15:99-112.

5. Jaycox LH, Stein BD, Kataoka SH, et al. Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. J Am Acad Child Adolesc Psychiatry. 2002;41:1104-1110.

6. Berton MW, Stabb SD. Exposure to violence and post-traumatic stress disorder in urban adolescents. Adolescence. 1996;31:489-498.

7. Boney-McCoy S, Finkelhor D. Is youth victimization related to trauma symptoms and depression after controlling for prior symptoms and family relationships? A longitudinal, prospective study. J Consult Clin Psychol. 1996;64:1406-1416.

8. Mannarino AP, Cohen JA, Smith JA, Moore-Motily S. Six and twelve month follow-up of sexually abused girls. J Interpers Violence. 1991;6:484-511.

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11. Goenjian AK, Pynoos RS, Steinberg AM, et al. Psychiatric comorbidity in children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry. 1995;34:1174-1184.

12. March JS, Amaya-Jackson L, Terry R, Costanzo P. Posttraumatic symptomatology in children and adolescents after an industrial fire. J Am Acad Child Adolesc Psychiatry. 1997;36:1080-1088.

13. Macksoud MS, Aber JL. The war experiences and psychosocial development of children in Lebanon. Child Dev. 1996;67:70-88.

14. Terr LC. Children of Chowchilla: a study of psychic trauma. Psychoanal Study Child. 1979;34:547-623.

15. Terr LC. Chowchilla revisited: the effects of psychic trauma four years after a school-bus kidnapping. Am J Psychiatry. 1983;140:1543-1550.

16. Pynoos RS, Frederick C, Nader K, et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry. 1987;44:1057-1063.

17. Berman SL, Kurtines WM, Silverman WK, Serafini LT. The impact of exposure to crime and violence on urban youth. Am J Orthopsychiatry. 1996;66:329-336.

18. Brent DA, Perper JA, Moritz G, et al. Psychiatric risk factors for adolescent suicide: a case-control study. J Am Acad Child Adolesc Psychiatry. 1993;32: 521-529.

19. Clarke GN, Hawkins W, Murphy M, et al. Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of a group cognitive intervention. J Am Acad Child Adolesc Psychiatry. 1995;34:312-321.

20. Saigh PA, Mroueh M, Bremner JD. Scholastic impairments among traumatized adolescents. Behav Res Ther. 1997;35:429-436.

21. Singer MI, Anglin TM, Song L, Lunghofer L. Adolescents' exposure to violence and associated symptoms of psychological trauma. JAMA. 1995;273:477-482.

22. Weine SM, Becker DF, McGlashan TH, et al. Psychiatric consequences of "ethnic cleansing": clinical assessments and trauma testimonies of newly resettled Bosnian refugees. Am J Psychiatry. 1995;152:536-542.

23. Hurt H, Malmud E, Brodsky NL, Giannetta J. Exposure to violence: psychological and academic correlates in child witnesses. Arch Pediatr Adolesc Med. 2001;155:1351-1356.

24. Schwab-Stone ME, Ayers TS, Kasprow W, et al. No safe haven: a study of violence exposure in an urban community. J Am Acad Child Adolesc Psychiatry. 1995;34:1343-1352.

25. Delaney-Black V, Covington C, Ondersma SJ, et al. Violence exposure, trauma, and IQ and/or reading deficits among urban children. Arch Pediatr Adolesc Med. 2002;156:280-285.

26. Jones L, Wells KB. Strategies for academic and clinician engagement in community-participatory partnered research. JAMA. 2007;297:407-410.

27. Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multi-site, randomized controlled trial for children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry. 2004;43:393-402.

28. March JS, Amaya-Jackson L, Murray MC, Schulte A. Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor. J Am Acad Child Adolesc Psychiatry. 1998;37:585-593.

29. Chemtob CM, Nakashima JP, Hamada RS. Psychosocial intervention for post-disaster trauma symptoms in elementary school children: a controlled community field study. Arch Pediatr Adolesc Med. 2002; 156:211-216.

30. Jaycox LH. Cognitive Behavioral Intervention for Trauma in Schools. Longmont, Colo: Sopris West Educational Services; 2004. Available at: http://store. cambiumlearning.com/InitialSearchResults.aspx? searchtype=Basic&sorttype=Basic&Query=jaycox& criteria=0100&site=sw. Accessed August 31, 2007.

31. Kataoka SH, Stein BD, Jaycox LH, et al. A school-based mental health program for traumatized Latino immigrant children. J Am Acad Child Adolesc Psychiatry. 2003;42:311-318.

32. Stein BD, Kataoka S, Jaycox LH, et al. Theoretical basis and program design of a school-based mental health intervention for traumatized immigrant children: a collaborative research partnership. J Behav Health Serv Res. 2002;29:318-326.

33. Wong M. Commentary: building partnerships between schools and academic partners to achieve a health-related research agenda. Ethnic Dis. 2006; 16(1, suppl 1): S1-S149.

34. Stein BD, Jaycox LH, Kataoka SH, et al. A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. JAMA. 2003; 290:603-611.

35. Stein BD, Jaycox LH, Kataoka SH, et al. Community violence exposure and posttraumatic stress symptoms: effect on school outcomes. In press.