As gang shootings and other types of community violence in Los Angeles mushroomed in the late 1980s, Marleen Wong, M.S.W., who was director of mental health services for the Los Angeles Unified School District (LAUSD), turned her thoughts to the students. How many had witnessed life-threatening violence, she wondered, and how did it impact them?
Years later, her quest for answers would lead to the implementation of a school-based screening and intervention program that is helping students cope with the trauma that results from witnessing the kind of violence most people see only in movies.
One of Wong’s tasks was to organize school-district crisis teams of school administrators and school mental health clinicians to help students cope with violence in or around the school.
"Each year in the late 1980s, we had 800 to 900 incidents of gang violence around the city," she told Psychiatric News. "Students would see their fathers and brothers shot and killed in front of them."
Realizing that many Vietnam veterans were at increased risk for posttraumatic stress disorder (PTSD) due to their exposure to life-threatening violence, she wondered whether some Los Angeles school students were at similar risk.
When Wong became director of crisis counseling for LAUSD, she began working with immigrant students through the Emergency Immigrant Education Program (EIEP). This program was created in 1999 to help children who had been in the United States fewer than three years adjust to school. Among the services that the children received were tutoring, language classes, and mental health counseling.
During the project, Wong noted that many of the immigrant children—most of whom were Latino—had witnessed life-threatening violence in their countries of origin and benefited from individual counseling. "Their fear and anxiety would subside after they had a chance to talk about their traumatic experiences," she said.
But she quickly realized that helping one child at a time wasn’t going to work, especially for a school district with 748,000 children.
Her desire to find a more practical way to help students who had witnessed life-threatening violence was soon fulfilled through a collaboration with researchers at the RAND corporation and the University of California at Los Angeles.
As part of the immigrant project, Wong began in 1999 to implement the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) program in 11 East Los Angeles schools.
CBITS is an early intervention developed by RAND researcher and psychologist Lisa Jaycox, Ph.D., for students who experience symptoms of PTSD, depression, and/or anxiety in relation to exposure to violence in the community.
Jaycox told Psychiatric News that she developed the group intervention with three goals in mind: to reduce symptoms associated with trauma in students, build resilience so students can cope with future trauma, and build parent and peer support.
"One of the things we teach students is that it’s OK to feel fear and anxiety," Jaycox said, and "that it’s not necessary to avoid thinking or talking about the trauma."
The10-session intervention is designed so that students learn about common reactions to trauma and the link between thoughts and feelings, receive relaxation training, learn how to problem-solve, and discuss their traumatic experiences in a safe environment.
School social workers typically lead the groups, which usually have five to eight students. Students and their parents are also allotted a certain number of individual sessions with the social worker.
Many of the participating children, said Jaycox, have witnessed the shooting or stabbing death of someone in their neighborhood.
It is not uncommon for children to blame themselves for such an event, according to Jaycox, or believe they could have stopped it from happening, she said that group facilitators help the children challenge such thoughts and work on overcoming avoidant behaviors they may develop in relation to the trauma—such as being too afraid to walk to school or avoiding the local playground.
Group leaders sometimes walk a fine line when trying to help students cope with all-consuming fears about the world around them, Jaycox said. "When something bad happens to us, we tend to believe the world is an extremely dangerous place."
Although CBITS is designed to challenge such fears, "the world is a dangerous place for many students who live in impoverished neighborhoods where there is a lot of violence," Jaycox explained, so group leaders teach students to distinguish between safe and dangerous situations and how to stay as safe as possible.
During the first year of the EIEP project, Wong said school counselors screened about 1,000 immigrant children in the third to eighth grades.
The children were asked if they had witnessed or been the victim of an attack with or without a weapon. The levels of exposure to violence differed from school to school, she recalled, but ranged from 75 percent to 90 percent in the 11 East L.A. schools.
Schools didn’t have the staff or resources to conduct the intervention with that many children, so those with three or more incidents of exposure to violence were given priority.
She noticed that the students who wound up in the group intervention would never have been identified if it weren’t for the screening. "They might not be doing as well as their teachers wanted them to, but they weren’t acting out."
Wong said she calls these children "hidden in plain sight."
In addition, many of the children who participated in the group intervention were experiencing clinically significant levels of PTSD and depression.
Such was the case with one student from Central America. During a New Year’s celebration, Wong said, the boy’s family members were outside socializing when a group of soldiers burst on the scene and shot and killed the boy’s uncle. A year after the child emigrated to the United States, Wong said, "he couldn’t think straight—he had nightmares and intrusive thoughts about the violent scene."
The boy’s mother did not understand why her son was performing poorly in school until the boy, in an individual session, began to describe the violence in detail and talk about how the memories haunted him, Wong said.
"She began to understand what her son was experiencing," she added, "and the empathy she was able to show him was additionally healing."
The CBITS intervention is now being implemented and studied in one school in South Central Los Angeles, Wong said, with funding from the Substance Abuse and Mental Health Services Administration.
More information about the CBITS program is posted on the Web at www.rand.org/publications/RB/RB4557. ▪