Download A School-Based Mental Health Program for Traumatized

A School-Based Mental Health Program for
Traumatized Latino Immigrant Children
SHERYL H. KATAOKA, M.D., BRADLEY D. STEIN, M.D., LISA H. JAYCOX, PH.D., MARLEEN WONG, M.S.W.,
PIA ESCUDERO, M.S.W., WENLI TU, M.S., CATALINA ZARAGOZA, M.S.W., AND ARLENE FINK, PH.D.
ABSTRACT
Objective: To pilot-test a school mental health program for Latino immigrant students who have been exposed to community violence. Method: In this quasi-experimental study conducted from January through June 2000, 198 students in
third through eighth grade with trauma-related depression and/or posttraumatic stress disorder symptoms were compared after receiving an intervention or being on a waitlist. The intervention consisted of a manual-based, eight-session,
group cognitive-behavioral therapy (CBT) delivered in Spanish by bilingual, bicultural school social workers. Parents and
teachers were eligible to receive psychoeducation and support services. Results: Students in the intervention group (n =
152) had significantly greater improvement in posttraumatic stress disorder and depressive symptoms compared with
those on the waitlist (n = 47) at 3-month follow-up, adjusting for relevant covariates. Conclusions: A collaborative research
team of school clinicians, educators, and researchers developed this trauma-focused CBT program for Latino immigrant
students and their families. This pilot test demonstrated that this program for traumatized youths, designed for delivery
on school campuses by school clinicians, can be implemented and evaluated in the school setting and is associated with
a modest decline in trauma-related mental health problems. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(3):311–318.
Key Words: posttraumatic stress disorder, treatment, cognitive-behavioral therapy, Latinos, trauma, violence.
As national attention begins to focus on racial disparities
in health care (U.S. Department of Health and Human
Services, 2000), the Surgeon General has raised concerns
about access to mental health services for ethnic minority children (U.S. Public Health Service, 2000). One
growing population in the United States at particular risk
for not receiving specialty mental health care is Latino
children (Kataoka et al., 2002). Latinos have been found
Accepted October 29, 2002.
Drs. Kataoka and Fink are with the University of California, Los Angeles;
Dr. Stein is with the University of California, Los Angeles, and RAND; Dr.
Jaycox and Ms. Tu are with RAND; Ms. Wong, Ms. Escudero, and Ms. Zaragoza
are with the Los Angeles Unified School District.
This work was supported by the Los Angeles Unified School District, the
Emergency Immigrant Education Program, the UCLA Center for Health Services
Research, the NIMH Faculty Scholars Program, the Robert Wood Johnson Clinical
Scholars Program, and NIMH grant MH54623. The authors thank Ken Wells,
Naihua Duan, and Jeanne Miranda for their consultation.
Correspondence to Dr. Kataoka, UCLA Health Services Research Center, 10920
Wilshire Blvd., Suite 300, Los Angeles, CA 90024-6505; e-mail: [email protected].
For information about the CBITS treatment manual, contact Dr. Jaycox at
[email protected].
0890-8567/03/4203–03112003 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097/01.CHI.0000037038.04952.8E
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 3 , M A RC H 2 0 0 3
to be less likely than others to receive health care services
because of such factors as disproportionate numbers without health insurance, parental preferences and helpseeking patterns, and an unrecognized need for services
(Flores and Vega, 1998; Guarnaccia, 1997; McMiller and
Weisz, 1996; Organista, 2000). Although this underserved group has been found to consistently underutilize
mental health care (Bui and Takeuchi, 1992; McCabe
et al., 1999; Vega et al., 1999), there has been little effort
in developing and evaluating accessible and evidencebased interventions specifically for Latino children.
Delivering mental health services through the school
system can address key financial and structural barriers
that often prevent Latinos from receiving needed services
(Garrison et al., 1999). Schools have long been identified as an ideal entry point for improving access to mental health services for children (Allensworth et al., 1997).
However, few programs have been rigorously evaluated
in the real-world setting of schools (Hoagwood and Erwin,
1997), and even fewer are designed specifically for ethnic minority children.
One significant mental health concern of schools and
communities has been the effects of violence on children.
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KATAOKA ET AL.
Although the prevalence of trauma-related mental health
problems in Latino children remains unclear, youths who
have been exposed to violence have been found to be
more likely to develop psychological problems and have
poor functioning at home and school (Cohen, 1998;
Pynoos et al., 1995; Richters and Martinez, 1993). Recent
studies have shown that about one third of children
exposed to community violence develop posttraumatic
stress disorder (PTSD) (Berman et al., 1996; Fitzpatrick
and Boldizar, 1993). Youths exposed to trauma also can
develop depression, other anxiety disorders, substance
abuse, and problems with school performance (Brent
et al., 1995; Clarke et al., 1995; Saigh et al., 1997; Singer
et al., 1995; Weine et al., 1995).
In an earlier study, we found that 49% of predominantly poor immigrant students in our school sample
reported violent victimization in the previous year and
32% had clinical levels of PTSD symptoms, with symptoms being predicted by level of violence exposure
(Jaycox et al., 2002). Given this high level of exposure to
violence and subsequent trauma-related mental health
problems, the Los Angeles Unified School District (LAUSD)
developed the Mental Health for Immigrants Program
(MHIP), a trauma-focused and culturally sensitive program for the District’s large immigrant student body. In
developing this program, a collaborative partnership was
formed between clinicians from the School Mental Health
Unit, educational specialists from the Emergency Immigrant
Education Program (EIEP), and research clinicians at
local academic institutions (Stein et al., 2002). We chose
an intervention that uses cognitive-behavioral therapy
(CBT), as recommended for the treatment of youth PTSD
(Cohen, 1998) and depression (Brent et al., 1997; Kaslow
and Thompson, 1998; Lewinsohn et al., 1990). Such therapies have been shown to be effective for children with a
history of sexual abuse (Deblinger and Heflin, 1996; King
et al., 2000) and single-incident trauma (March et al.,
1998). In addition to child-focused trauma treatment,
psychoeducation for parents about their child’s PTSD
symptoms has also been recommended (Rigamer, 1986)
and thus incorporated into the MHIP intervention.
This article will describe the development and preliminary results of this program. Although the MHIP
was offered to a multiethnic group, this report will focus
on the Latino children, who comprised the majority of
the participants.
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METHOD
Mental Health for Immigrants Program
The MHIP was developed in the context of an ecological framework
(Belsky, 1980; Cicchetti and Lynch, 1993; Trickett and Birman, 1989),
specific to both cultural and school ecologies. As part of the wide variety of supportive services offered to newly immigrant children in LAUSD
through the EIEP (orientation classes, medical and dental screening,
language classes, and tutoring), the MHIP addressed some of the mental health needs of the traumatized immigrant students.
The MHIP child intervention was an eight-session CBT group based
on the Cognitive-Behavioral Intervention for Trauma in Schools (L.H.
Jaycox, Ph.D., unpublished, 2000), which was designed for use in an
inner-city school mental health clinic with a multicultural student population (Table 1). The CBITS incorporates standard CBT skills in a
group format (five to eight students per group) to address PTSD, anxiety, and depression symptoms related to community violence exposure. Generally, in each session a new set of techniques was introduced
by a mixture of didactic presentation, use of age-appropriate cartoons
and games to solidify concepts, and individual work on worksheets in
session and between sessions. This program emphasized generalization
of techniques, and “homework assignments” were collaboratively developed between child and clinician in each session and reviewed at the
beginning of the next session. Although clinicians followed a treatment
manual for consistency of administration, they had some flexibility to
meet the specific needs of children in the group. Techniques in the
CBITS are similar to those used in other CBT groups for individuals
with PTSD (March et al., 1998). The CBITS was pilot-tested for feasibility and acceptability, but this particular manual and format was
untested prior to this study.
TABLE 1
Cognitive-Behavioral Intervention for Trauma in Schools
Session
1
2
3
4
Individual
session
5
6
7
8
Session Content
Introduction of group members, confidentiality,
and group procedures
Explanation of treatment using stories
Discussion of reasons for participation (types of
trauma)
Education about common reactions to trauma
Relaxation training to combat anxiety
Thoughts and Feelings (introduction to cognitive
therapy)
Fear Thermometer
Linkage between thoughts and feelings
Introduction of idea of combating erroneous
negative thoughts
Avoidance and coping (introduction to in vivo
exposure)
Construction of fear hierarchy
Imaginal exposure to traumatic event
Social problem-solving (Stop, Think, What’s Your
Goal?
Exposure to trauma memory through drawing/
writing
Exposure to trauma memory through drawing/
writing
Relapse prevention and graduation ceremony
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SCHOOL-BASED TRAUMA PROGRAM FOR LATINOS
As has been noted in other adult and child studies (Cohen, 1998;
Foa and Rothbaum, 1998), psychoeducation was an integral part of
the MHIP. The CBT intervention included relaxation training, cognitive therapy, exposure, and social problem-solving. Based on work
by March and colleagues (1998), imaginal exposure occurred first in
a private individual session with the clinician and then through drawings and descriptions of the event in the group. When appropriate,
this was followed by in vivo exposure. All exposures were paced according to the needs of the individual child, to avoid making children feel
overwhelmed or overly upset when they worked on this exercise.
For parents, the MHIP included four 2-hour optional multifamily group sessions designed to complement the child treatment. Parents
and clinicians discussed the effects of trauma on children and the
types of techniques that the children would be learning, which is similar to psychoeducation described by others (Cohen, 1998). Based on
our clinical experience with Latino immigrant families and descriptions by others (Azocar et al., 1996), the parent sessions included support around common experiences of loss and separation that many
had experienced during the immigration process. Finally, these sessions also included parenting techniques, a commonly requested topic.
Clinicians offered all teachers at the participating schools an inservice training on the effects of trauma on children and what symptoms can be related to emotional problems warranting further evaluation.
In addition, the clinicians developed relationships with key administrators and liaison staff at the schools. Clinicians minimized missed
class time by offering a brief intervention lasting 8 weeks on average,
with each session duration the equivalent of one school period. Sessions
were given at flexible times during the school day, depending on the
school’s preference. The program was also designed to be consistent
with the school culture, which incorporated CBT lessons and homework assignments, helping to demystify this mental health program
for school staff. Neither the parent nor teacher MHIP components
have been evaluated for effectiveness.
The MHIP clinicians were master’s-level school psychiatric social
workers and employees of the school district. They received 16 hours
of initial training on the MHIP intervention and 2 hours per week
of ongoing supervision by a psychologist (L.H.J.). In addition, they
received 1 hour per week of general school social work supervision
by their on-site clinical supervisor (C.Z.). They used a detailed treatment manual and could refer to a videotape of the initial training.
Participants and Procedures
Eleven public elementary and middle schools with high immigrant
enrollment and involvement in the EIEP were invited to participate
in the MHIP. Nine schools agreed to participate. Administrators at
the two nonparticipating schools expressed concern that students
would be missing class to attend the group.
Eligibility criteria for the MHIP screening included being in the third
to eighth grade, attending one of the nine participating schools, being
foreign-born and having immigrated to the United States within the
past 3 years (an eligibility criterion for the EIEP), and speaking Spanish.
MHIP staff presented information about the screening process to all
eligible students during meetings for new immigrant students. They
were told that a questionnaire would be given to them to determine
whether they would qualify to be in a program for immigrant students
with stress related to violence. Students were informed that the survey
was completely voluntary and would be kept confidential. A letter with
similar information was sent to their parents with instructions on how
to decline participation. Approximately 970 students were eligible for
the screening, and although we did not systematically track refusals or
the reasons for refusal (since this was a naturalistic study and screening
was conducted by school staff as part of their program), they represented fewer than 10% of those eligible for screening.
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A total of 879 students completed a self-report questionnaire regarding exposure to violence and symptoms. The questionnaire was administered in groups of 20 to 30 students. Students sat sufficiently far
apart from one another to allow privacy within the constraints of the
group setting.
Of those students screened, 276 (31%) reported exposure to violence and clinically significant symptoms of PTSD and/or depression
and were recruited for participation in the MHIP; 229 (83%) gave
informed written parental consent and child assent. We found no significant differences between those who consented to participate and
those who did not in terms of sociodemographic characteristics (age,
gender, grade, school location, country of origin), level of violence
exposure, or symptoms (depression or PTSD symptom levels). We
asked that the parent or guardian “most knowledgeable about the
child” complete a self-report questionnaire.
Seventy-two percent of those eligible to participate in the program
(n = 198) were available to complete the follow-up evaluation at 3
months. Those who completed the program did not differ from those
who did not complete the program in baseline levels of depression or
PTSD symptoms, level of violence exposure, gender, or ethnicity.
However, noncompleters were older than those who completed the
program (mean age of completers = 11.3 years, SD = 1.7; noncompleters = 12.5 years, SD = 1.4; t = 3.8, p < .001).
Early in the school year, eligible students were randomly assigned
to either the intervention or a waitlist comparison group. For those
assigned to waitlist, clinicians gave parents specific Spanish-language
referrals to community mental health agencies in their neighborhoods
and gave them the option of being placed on the waitlist for the MHIP.
Of the 198 who completed the program, 67 youths received the
intervention immediately and 46 students were randomized to the
waitlist group during the randomization period. When possible, children were randomized at the individual level. At year-round schools,
children are assigned at random by the school district to one of three
tracks. At these schools, program participants were randomized by
track to either immediate treatment or waitlist. Late in the school
year, to ensure that all eligible students would have the opportunity
to receive the MHIP treatment before the end of the school year, 85
eligible students were assigned to the intervention condition. The randomized and nonrandomized children did not differ at baseline on
violence exposure, symptom levels, or sociodemographic characteristics except for a significant difference in parental education (parental
education in the randomized group was 3.7 years compared with 6.1
years in the nonrandomized group, t = 4.9, p < .001). The main analysis reported in this article includes all 152 intervention and 46 waitlist children.
All parents of children in the intervention group were offered the
parent groups; 37% of parents attended at least one group. At the end
of the intervention period, all teachers at each school were offered the
educational teacher session. This voluntary activity was not part of
the randomized design.
Measures
We measured exposure to community violence with a modified
version of the Life Events Scale (Singer et al., 1995, 1999), a 34-item
measure that asks the frequency of several types of violence (threats,
slapping/hitting/punching, beatings, knife attacks, and shootings) in
multiple locations over the past year and lifetime. These items include
violence that was directed toward the respondent or directly witnessed.
Exposure to media or other indirect violence was specifically excluded.
For example, students were asked about violence directed toward them
in such questions as, “How often over the past year have you been
beaten up at school?” Students were also asked whether they had been
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beaten up in their neighborhood or anywhere else. One of the items
that elicited witnessed violence was the following: “How often over
the past year have you seen someone else getting beaten up at school?”
A 4-point Likert scale ranging from 0 to 3 points (“never” to “almost
every day”) was used; a total violence score was calculated by summing
the lifetime and current violence exposure scores for a total possible
score of 102. The Life Events Scale has been shown to have acceptable
reliability in elementary school, middle school, and high school in multicultural inner-city populations (Singer et al., 1995, 1999). Program
eligibility criteria for violence exposure was met if the summed score
was greater than 6 (consistent with exposure to greater than three or
more violent events) or if the child reported being a victim of or witness to any violence involving a knife or gun. We also defined weaponrelated violence as any violence involving a knife or a gun; non–
weapon-related violence as any violence involving threats, slapping,
hitting, punching, or beating; and threats as any violence involving
threats directed toward or witnessed by the subject.
Symptoms of PTSD in the past month were measured with the
Child PTSD Symptom Scale (CPSS), the child version of the
Posttraumatic Diagnostic Scale for Adults (Foa et al., 2001). This
measure has been used in school-age children as young as 8 and has
shown good convergent and discriminant validity and high reliability (Foa et al., 2001). In this sample, scale internal consistency was
high (Cronbach α = .89). A cutoff score of 11 was used to determine
eligibility for participation in the intervention, consistent with moderate clinical levels of PTSD symptoms.
The Children’s Depression Inventory (CDI) (Kovacs, 1992) was
used to measure depressive symptoms in the past 2 weeks. The CDI
is a widely used measure with good test-retest reliability and validity
in clinical and community-based samples. The school mental health
staff chose to not include the suicidal ideation item. A cutoff score of
18 was used to determine eligibility for participation in the intervention, which corresponds to clinically significant depressive symptoms.
The cutoff score was not adjusted to account for the dropped suicide
item. In this sample, scale reliability was high (Cronbach α = .82).
The parent-report questionnaire consisted of sociodemographic
questions such as age, ethnicity, number of years of education, marital status, and employment status.
All measures were translated from English to Spanish by the school
district’s Translation Unit, and translations were reviewed by multiple
bilingual/bicultural clinicians to verify accuracy and appropriateness
of the translation. Measures were pretested in a similar population of
Latino immigrant children, and cognitive interviews were conducted
to test the respondents’ comprehension and interpretation of the questions. Minor modifications were made to the measures in response to
this feedback. Despite careful work to ensure that the measures were
comprehensible to Spanish-speaking children, we note that these scales
have not been validated in Latino immigrant child populations.
Analysis
The data were analyzed for all 198 subjects for whom there was
baseline and 3-month follow-up information available. Child age,
baseline PTSD and depression scores, baseline total violence score,
and parent education were analyzed as continuous variables. The following were analyzed as categorical variables: group indicator (treatment versus waitlist), child gender, school (total of nine schools), child
country of origin (Mexico, El Salvador, Guatemala, and other Latin
American countries), parent marital status (married versus other), and
parent employment status (employed versus nonemployed). All these
314
variables were considered as clinically relevant covariates in prediction of follow-up PTSD and depression scores.
We performed comparisons of continuous data between baseline
and follow-up scores and between the treatment and waitlist groups
using a two-tailed Student t test. We compared categorical data by
using the χ2 statistic. A p value of .05 or less indicated statistical significance. Bivariate and multivariate relationships of outcome variables (follow-up CPSS score for PTSD and CDI score for depression)
were examined with linear regression. We chose covariates for each
multivariate regression model based on their clinical significance and
relationship to the outcome variable in bivariate regression analysis
(at p < .2). To obtain robust estimates of the standard errors, we
adjusted for clustering to account for the different assignment strategies and analyzed them by strata. By doing so, we were able to take
into account potential school effects as well as any systematic differences in school demographics.
We examined the impact of the intervention for the entire group
(those with symptoms of all severity), and again in the subset of children with symptoms in the clinical range on the symptom measures,
to ensure that inclusion of the less symptomatic children did not wash
out real intervention effects. Statistical analyses were conducted with
STATA, version 7.0 (Stata Corp, 2001).
RESULTS
Sample Characteristics
Table 2 describes the sample characteristics for students by treatment assignment. Participants had a mean
age of 11 years, with two thirds of the students in middle school (n = 156, 68%). Half of the students were
female (n = 114, 50%), and more than half were born in
Mexico (n = 131, 57%). The mean parental education
level was less than 5 years, and the majority of parents
were married (162, 71%). There were no significant differences in demographic characteristics between those
who received the immediate intervention compared with
waitlist, with the exception of parental education (lower
in the waitlist group, t = 3.04, p < .01).
Almost all children in the program had clinical levels
of PTSD symptoms (n = 207, 90%); one third of youths
had comorbid PTSD and depressive symptoms in the
clinical range (n = 73, 32%), and 10% (n = 22) of students had clinical levels of depression only. Exposure to
weapon-related violence involving a knife or gun was
common, with two thirds of children reporting exposure
to this type of life-threatening violence (n = 157, 69%).
The mean score on the Life Events Scale was 18, which
represents a high frequency of multiple violent events;
for example, a score of 18 could represent six types of violent experiences occurring almost every day. Immediate
intervention and waitlist groups did not differ by violence exposure or clinical characteristics.
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SCHOOL-BASED TRAUMA PROGRAM FOR LATINOS
TABLE 2
Demographic Characteristics of MHIP Participants by Intervention and Waitlist (n = 229), 1999–2000
Total (n = 229)
Mean (SD)
Child demographics
Age, years
Female
School type
Elementary
Middle school
Country of origin
Mexico
El Salvador
Guatemala
Other
Parent demographics
Parental education, years
Married
Employed
Child symptoms a
PTSD b
Depression c
Violence exposure
Total violence score d
Weapon-related violence e
Non–weapon-related violence f
Threats g
Intervention (n = 182)
n (%)
Mean (SD)
11.4 (1.7)
Waitlist (n = 47)
n (%)
Mean (SD)
11.5 (1.8)
n (%)
11.2 (1.5)
114 (50)
92 (51)
22 (47)
73 (32)
156 (68)
55 (30)
127 (70)
18 (38)
29 (62)
131
42
26
30
108
34
19
21
23 (49)
8 (17)
7 (15)
9 (19)
(57)
(18)
(11)
(13)
5.0 (3.8)
(59)
(19)
(10)
(12)
5.4 (3.8)
3.4 (3.3)*
162 (71)
146 (64)
134 (74)
112 (62)
28 (60)
34 (72)
207 (90)
95 (41)
164 (90)
76 (42)
43 (91)
19 (40)
18 (10)
18 (10)
157 (69)
227 (99)
210 (92)
18 (12)
125 (69)
180 (99)
169 (93)
32 (68)
47 (100)
41 (87)
a
Symptom eligibility was clinical symptoms of posttraumatic stress disorder (PTSD) and/or depression.
Child PTSD Symptom Scale score > 11.
c
Children’s Depression Inventory score ≥ 18.
d
Total violence score: mean score on modified Life Events Scale (score ≥ 6 for eligibility in program).
e
Weapon-related violence: number of children who witnessed or were threatened or attacked themselves with a knife or gun.
f
Non–weapon-related violence: number of children who witnessed or were threatened or attacked themselves by being
slapped, hit, punched, or beaten.
g
Threat: number of children who witnessed or were victims of a threat.
* p < .01.
b
Intervention Outcomes
Table 3 shows the mean baseline and follow-up scores
for depression and PTSD symptoms in the intervention
and waitlist groups. Depressive symptoms in the intervention group decreased from a mean CDI score of 16
to 14 (t = 5.1, p < .001) but remained 16 in the waitlist
group (t = 0.1, p > .05). The CPSS mean scores for PTSD
symptoms decreased from 19 to 13 in the intervention
group (t = 7.5, p < .001) and 18 to 16 in the waitlist (t =
1.3, p > .05).
In bivariate regression analyses, adjusting for baseline
scores, intervention participants had significantly lower
follow-up CDI scores than those in the waitlist (β = –2.7,
SE = 1.1, p < .05). In a similar analysis for PTSD symptoms, we found a nonsignificant trend for CPSS mean
scores improving more in the intervention than waitlist
group (β = 2.86, SE = 1.5, p = .06).
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Because the sample included children with a broad
range of symptom severity, we examined the subset of
children with scores in the clinical range on symptom
TABLE 3
Within-Group Comparisons Between Baseline
and Follow-up (n = 198), 1999–2000
Baseline
Follow-up a
Mean SD Mean SD
Intervention (n = 152)
CDI b
CPSS c
Waitlist (n = 46)
CDI b
CPSS c
t Test p Value
16.3
18.8
6.9
7.7
13.5
13.0
7.5
7.6
5.1
7.5
<.001
<.001
16.3
18.1
7.7
8.0
16.2 9.9
15.7 13.2
0.1
1.3
NS d
NS d
a
Approximately 3 months after baseline.
CDI = Children’s Depression Inventory (Kovacs, 1992).
c
CPSS = Child PTSD Symptom Scale (Foa et al., 2001).
d
NS = not significant.
b
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KATAOKA ET AL.
TABLE 5
Multivariate Linear Regression for
Predicting Follow-up CPSS Score
TABLE 4
Multivariate Linear Regression for
Predicting Follow-up CDI Score
Variable
Intervention group
Baseline CDI
Age
Female
El Salvador
Guatemala
Other
Parent education
Parent married
Coefficient ± SE
t
p Value
–3.06 ± 1.1
0.61 ± 0.06
0.00 ± 0.32
1.98 ± 0.75
–1.77 ± 1.39
–0.81 ± 1.0
–3.9 ± 1.24
–0.21 ± 0.11
2.09 ± 0.68
–2.77
10.25
0.01
2.65
–1.27
–0.81
–3.15
–2.00
3.08
<.01
<.001
NS
.01
NS
NS
<.01
NS
<.01
Variable
Intervention group
Baseline CPSS score
Age
Female
El Salvador
Guatemala
Other
Total violence score
Parent employed
Coefficient ± SE
t
p Value
–3.87 ± 1.6
0.14 ± 0.07
0.52 ± 0.39
3.90 ± 1.13
–3.33 ± 1.64
0.83 ± 1.6
–7.07 ± 1.47
0.12 ± 0.06
–2.08 ± 1.22
–2.39
1.93
1.35
3.47
–2.02
0.52
–4.81
2.07
–1.71
<.05
NS
NS
.001
<.05
NS
<.001
<.05
NS
Note: CDI = Children’s Depression Inventory; NS = not significant.
Note: CPSS = Child PTSD Symptom Scale; NS = not significant.
measures to examine the intervention effect more carefully. In subsample analyses, we evaluated only those children who had baseline symptoms in the clinical range for
depression and PTSD. Of the 83 students who had clinical levels of depressive symptoms (CDI ≥ 18) at baseline, mean CDI scores in the intervention group decreased
from 23 to 18 compared with 24 to 23 in the waitlist
group (β = –4.9, SE = 2.1, p < .05). One hundred eighty
children had clinically significant PTSD symptoms at
baseline (CPSS > 11), with mean scores declining from
20 to 13 in the treatment group and 19 to 16 in the waitlist (β = –3.2, SE = 1.5, p < .05).
Of the 47 children on the waitlist, 5 (11%) received
traditional mental health services and another 14 (30%)
reported seeking help from a spiritual leader, healer, or
friend or family.
baseline total violence score, country of origin, and parent employment status (F9,68 = 9.36, p < .001, R2 = 0.22).
In addition, boys, those from El Salvador compared with
Mexico, those from “other” Latin American countries
compared with Mexico, and those with lower baseline
violence exposure had lower follow-up CPSS scores when
controlling for other covariates.
Multivariate Analyses
We conducted multivariate regression analyses, with
relevant covariates for each of the two main outcome variables, CDI and CPSS follow-up scores. Table 4 shows
that the intervention group had lower follow-up CDI
scores compared with the waitlist group (β = –3.1, SE =
1.1, p < .01), controlling for baseline CDI score, age, gender, country of origin, parent education level, and parent marital status (F9,66 = 26.2, p < .001, R2 = 0.43). In
addition to the main effect, boys, those from “other” Latin
American countries compared with Mexico, and those
with nonmarried parents had lower follow-up CDI scores
than their peers, controlling for other covariates.
In evaluating follow-up PTSD symptoms (Table 5),
we found that the intervention group had a lower CPSS
score than did the waitlist group (β = –3.9, SE = 1.6, p
< .05), controlling for baseline CPSS score, age, gender,
316
DISCUSSION
These results provide evidence that this school-based,
trauma-focused, CBT intervention for Latino immigrant
students is associated with modest reduction in symptoms of PTSD and depression. Further investigation is
needed to determine whether symptoms continue to
diminish to nonclinical ranges over time. Nonetheless,
these results are encouraging and suggest that CBT can
be effectively delivered by school clinicians to treat children exposed to a wide range of community violence.
The translation of guideline-based trauma care to community settings such as schools has significant implications for decreasing the high level of unmet need for
mental health care that exists, especially for underserved
populations such as Latino immigrant children.
Because this program was developed in the context of
existing school services that support immigrants, students
and parents identified the MHIP as an extension of this
support structure. Anecdotal comments from participants
suggest that stigma usually associated with mental health
services was minimized in this program. However, qualitative studies that investigate immigrant Latino student
and family perceptions and attitudes toward school-based
mental health services are needed to further improve programs such as this one. For example, we found differ-
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 3 , M A RC H 2 0 0 3
SCHOOL-BASED TRAUMA PROGRAM FOR LATINOS
ences across Latino subgroups in follow-up symptom
scores controlling for treatment condition and other
covariates, which suggests that treatment may need to be
tailored for specific ethnic groups, as has been recommended by others (Lopez and Guarnaccia, 2000; U.S.
Department of Health and Human Services, 2001).
In addition to certain ethnic groups having higher symptom levels, we also found that girls appear to have greater
PTSD and depression symptoms than boys at follow-up,
irrespective of treatment condition and after adjusting for
covariates. In an earlier study examining symptomatology
of this sample at baseline, we found that PTSD symptoms
were not predicted by gender when we controlled for depressive symptoms, but gender did predict depressive symptoms (Jaycox et al., 2002). However, even when we control
for depressive symptoms in the present study, girls continue to have greater PTSD symptoms at follow-up than
boys (β = 3.4, SE = 1.1, p < .001; not shown). Others have
hypothesized that female coping strategies in response to
stressful events may influence treatment for depression in
women (Gillespie and Eisler, 1992). Whether gender-specific strategies should be incorporated into interventions
for youths exposed to community violence needs further
exploration.
Limitations
Several limitations of this study are worth noting.
Symptom changes were modest and on average remained
in the clinical range at short-term follow-up. Further research
is needed to determine whether modifications to the intervention such as a longer treatment period or booster sessions improve outcomes. Given that this is a vulnerable
population that rarely receives services, there were design
compromises made during this program to ensure that all
children who wanted to receive the intervention could do
so in a timely manner. Therefore, we randomized only a
portion of the participants. The differential attrition across
treatment groups makes comparison between groups more
tenuous, although we found no important differences in
dropouts compared with completers of the study. By using
a waitlist comparison group, the program was compared
with usual care (of which most subjects did not follow up
with the mental health referrals); future studies could compare this program with an alternative active treatment. In
addition, we found that students who dropped out were
older than those who remained in the program. However,
some of the older students had also been offered the MHIP
after school (to accommodate the request of administraJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 3 , M A RC H 2 0 0 3
tors), and clinicians reported that this time period conflicted with after-school activities of students. Therefore,
more research on this topic is needed, given that it is unclear
from our data whether the dropout rate of older students
is due to the format of the program or to the age of students. Of note, clinicians reported that older students
appeared to understand the CBT concepts better and participated more in group than did the younger students.
Finally, although the CBT groups for students were considered to be the primary treatment component to the
MHIP, we are unable to determine how each of the multiple components of this program (student and parent
groups, teacher education) contributed to its success.
Clinical Implications
It has been documented that the majority of mental
health care for children is delivered in schools (Burns
et al., 1995), yet little is known about how to deliver effective care in this setting. One recommendation from the
Surgeon General’s Conference on Children’s Mental
Health is to improve the quality of mental health services
in various sectors of care such as schools (U.S. Public
Health Service, 2000). The MHIP provides one example of how treatment for trauma-related emotional problems can be developed, implemented, and evaluated in
the context of schools. Further research is needed to determine how schools can replicate and sustain such programs as the MHIP in ways that not only meet the clinical
needs of students but also use the resources available at
schools and in neighboring communities. Collaborations
between nontraditional mental health delivery settings
such as schools and mental health services researchers can
result in programs that are evidence-based, effective, and
utilized by ethnic minority children and their families.
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