School-Based Program Can Decrease Emotional Symptoms Among Students Exposed to Violence

A simple school-based program can help students suffering from emotional and behavioral problems that are caused by exposure to multiple acts of violence, according to a RAND study released today.

The sixth grade Los Angeles Unified School District students who participated in the program had fewer symptoms of violence-related distress and depression, compared with the fellow sixth graders who had also been exposed to multiple acts of violence. Students' improvement remained six months after receiving the therapy.

The study is featured in the August 6 edition of the Journal of the American Medical Association, a special edition devoted to studies about violence and human rights.

Participating students' experience with violence ranged from witnessing serious physical fights to being attacked with a knife or gun. In the previous year, the 126 participants reported being victims of 2.8 violent events and witnessing 5.9 such events on average.

The Cognitive Behavioral Intervention for Trauma in Schools program was developed at RAND in close collaboration with school-based mental-health clinicians from the Los Angeles Unified School District.

“It's very important that it was regular school clinicians who successfully implemented this new program,” said RAND researcher and child psychiatrist Dr. Bradley D. Stein, lead author of the study. “In many cases, effective mental health programs for children just gather dust because they demand time, training or funds that clinicians working in schools and other community organizations simply do not have.”

“The program was extraordinarily successful and useful,” said Roy Romer, superintendent of the Los Angeles Unified School District. “We will continue to use it in the district. Children and their parents identified personal challenges related to violence that seriously impaired their social and emotional adjustment, and then they changed their behavior to ameliorate or totally eliminate those challenges.”

The study is the first to use the research technique of random assignment in evaluating a program for students who have experienced multiple kinds of violence. Stein noted that clinicians from other school districts from across the country have expressed interest in using the program.

The core of the program is a series of group sessions where students are taught coping skills to help reduce their feelings of anxiety and sadness. In the study, the sessions were led by specially trained school social workers: professionals already employed by the school district.

Students were taught how to deal with negative thoughts, how to solve real-life problems, how to approach anxiety-provoking situations, and how to cope with a violent event through talking, drawing pictures, and writing. The program was designed to build peer support within the group, and encouraged children to talk more with their parents about their problems related to violence exposure.

In addition to the group sessions, the program also included at least one individual session for each child, four group meetings for parents, and an educational presentation for teachers. Students in the study attended one of two Los Angeles public middle schools in largely Latino neighborhoods.

The students in the program were randomly assigned to two groups. One group took part in weekly intervention sessions; the other was put on a waiting list for future groups. Researchers then compared changes among students in the two groups.

After three months, 86 percent of the students who received the intervention had fewer symptoms of violence-related distress than would have been expected without the intervention, and 67 percent had fewer symptoms of depression. More than three-quarters of parents reported that their child was functioning better than would have been expected without the intervention.

After the second group of students participated in the same 10-session program, they showed improvements in symptoms similar to those found in the first group. Moreover, after six months, students in the first group maintained their decreased symptoms of violence-related distress and depression, and parents continued to report improved psychosocial functioning.

One unexpected finding of the study was that classroom teachers observed no significant improvements among students who received the intervention. Discrepancies between teachers' observations and those of other respondents will be addressed in future studies.

As part of the National Child Traumatic Stress Network, the study collaborators are working with clinicians in other school districts to replicate the program. The research team is also considering future research on the long-term effectiveness of the program, such as whether periodic “booster sessions” would be beneficial, whether similar programs would be effective in other settings (such as non-urban schools, pediatric clinics, adolescent medicine clinics and community mental health centers), and whether non-clinical school staff can effectively deliver a modified version of the program.

In addition to Stein, authors of the study were Lisa H. Jaycox, Ph.D., Marc N. Elliott, Ph.D., and Wenli Tu, M.S. from RAND, Marleen Wong, M.S.W. from the Los Angeles Unified School District, Sheryl H. Kataoka, M.D., M.S.H.S. from the Department of Psychiatry and Biobehavioral Sciences at UCLA, and Arlene Fink, Ph.D. from the Schools of Medicine and Public Health at UCLA.

RAND Health is the nation's largest independent health policy research organization, with a broad research portfolio that focuses on medical quality, health care costs and delivery of health care, among other topics.