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”.
 National Survey of Adolescents
Prevalence of Violence History
(N=1,245) Kilpatrick et. al., 1995

2%
27% Direct Assault Only
No Violence

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 knife violence 54%Non-weapon related 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
Knife or gun involved
exposure
reported Victimization

Witnessed violence

0% 20% 40% 60% 80% 100%

 Screening also identified many children
with clinical symptoms
Type of
Knife or gun involved
exposure
reported Victimization

Witnessed violence

0% 20% 40% 60% 80% 100%

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
 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
61 students receive 
program 
immediately

769 students  159 students  126 students 

screened for  eligible for  randomly 
eligibility program assigned

65 students to 
receive program 
later
 Treatment improves trauma symptoms
Immediate CBITS group Received CBITS
Delayed group Observation 

30

25
Average
PTSD 20
symptoms 15
score
10

0
Before program 3­month 6­month
assessment assessment

Stein et al., JAMA 2003

 Improvement in symptoms lasts
Immediate CBITS group Received CBITS 
Delayed group Observation

30

25
Average
PTSD 20
symptoms 15
score
10

0
Before program 3­month 6­month
assessment assessment

Stein et al., JAMA 2003

 Parents report children doing better
Immediate CBITS group Received CBITS 
Delayed group Observation

25

20
Average
psychosocial 15
impairment
score
10

0
Before program 3­month 6­month
assessment assessment

Stein et al., JAMA 2003

 Improvement in functioning lasts
Immediate CBITS group Received CBITS 
Delayed group Observation

25

20
Average
psychosocial 15
impairment
score
10

0
Before program 3­month 6­month
assessment 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

Group Grade Point Average

2.5 2.18
1.89
2 1.68 1.731.8
1.57
Fall GPA
1.5
Spring GPA
1

0.5

0
Dana MS Jefferson Narbonne
HS HS

GROUP ATTENDANCE
100
100
90
80
70
Number of Days

60 50 Fall Absences
50
40 Spring Absences
30 13
20 5 8 3
10
0
Dana MS Jefferson Narbonne
HS HS
 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.