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 HIV and Trauma Research

Trauma-Informed Framework for HIV Prevention in Schools

PI – Sharon H. Stephan, Ph.D.

Background

Sexually Transmitted Diseases (STDs) are among the most widespread, least detected, and costly infectious diseases throughout the world.  Despite the burdens, complications, and preventable nature of STDs, they remain a significant public health problem in the United States.  A significant risk factor for HIV transmission is childhood trauma exposure[1].  The prevalence of exposure to traumatic events and their cumulative effects create severe barriers to student’s development[2]. When not addressed, these stressors are likely to result in negative consequences associated with trauma exposure including PTSD[3], depressive symptoms[4], increased behavioral problems (particularly delinquent and aggressive behavior)[5], and impairment in school functioning[6].  Further, children and adolescents who are exposed to trauma are at an increased risk for alcohol and drug use and abuse[7]. Childhood trauma increases the likelihood of engagement in risky sexual and substance use behaviors associated with HIV transmission, including unprotected sexual activity and intravenous drug use[8]. The prevalence of physical and sexual abuse is extremely high among HIV infected individuals, supporting the association between childhood trauma and risk for HIV infection[9]. Inner-city and minority youth are disproportionately impacted by traumatic experiences due to exposure rates and the lack of access to psychological care[10]^,[11].  Baltimore City youth are at particular risk of being impacted by traumatic events due to the city’s high rates of violent crime, substance abuse, poverty and parental loss. 

In order to effectively address traumatized children in schools, and to reduce risky behaviors associated with HIV transmission, it is critical that schools shift from the traditional discipline and disability paradigm of addressing children’s emotional and behavioral issues towards a model of identification of and effective mental health intervention with trauma-exposed children. There is a growing literature documenting the effectiveness of cognitive-behavioral interventions with traumatized youth in reducing trauma-related psychological distress and acting out[12].  Given the data that children with mental health problems, including trauma, are likely to have little to no contact with the mental health system[13], it is imperative that schools work toward appropriately integrating evidence-based trauma interventions into their programming.  In doing so, schools will diminish the barriers to learning imposed on children by trauma exposure, and will reduce the likelihood of students’ engagement in risky behaviors subsequent to traumatization.

With funding from the Department of Health and Mental Hygiene, AIDS Administration, investigators at the CSMHA investigated the feasibility and comparative effectiveness of two school-based interventions targeted towards decreasing risky behavior associated with HIV transmission among adolescents exposed to trauma.  Specifically, we examined the impact of an evidence-based HIV education and prevention curriculum for adolescents (“Standard HIV Education”; Making Proud Choices!) in one middle and one high school in Baltimore City versus the impact of the same program augmented by trauma training and intervention (“Trauma-informed HIV Education”; Cognitive Behavioral Intervention for Trauma in Schools) in two demographically similar schools.  Training for the Trauma-informed HIV Education involved school administrator, staff, and teacher education about the impact of trauma on youth, and appropriate responses to traumatized youth; Intervention involved implementation of an evidence-based, cognitive-behavioral group treatment program for trauma-exposed youth designed for use in schools.  Given the high rates of trauma exposure among youth in Baltimore City, along with the documented association between childhood trauma exposure and risky behaviors associated with HIV transmission, it was expected that schools that implemented a trauma-informed approach along with HIV education and prevention would be more effective at reducing risky behaviors than schools that implemented the HIV education and prevention alone.

Implemented in 4 schools in Baltimore City:

Calverton Middle School (2 groups)

West Baltimore Middle School (2 groups)

Southwestern High School (2 groups)

Walbrook Uniform Services Academy High School (2 groups)

Some findings:

• Overall, student attendance remained consistent and high for sessions that were implemented.
  
• Students reported an overall satisfaction with both interventions. 
  
• Students also reported that the information presented in the groups is applicable to their lives outside of the classroom.
  
• Evidenced-based HIV education and trauma interventions are feasible protocols in public urban middle and high schools. 
  
• Results supported the use of CBITS with students experiencing chronic trauma and/or complex PTSD reactions.
  
• Many inner-city youth are exposed to numerous incidents of violence; the data suggests that this intervention is appropriate to address all symptoms of PTSD for these students, even when they do not initially meet full criteria for a diagnosis of PTSD.
  
• Student self-report data regarding their completion of homework related to exposure may better explain why decreases in avoidance were not observed.
  
• Still assessing 6-month follow-up data on engagement in risky behaviors. Low base-rates of risky behaviors might make changes in risky behaviors hard to detect.

Selected Presentations:

1. Stephan, S., Nichols, T., Simpson, Y., Duffy, A., Weist, M., Shea, M. (2005, November). Feasibility of implementing a school-based trauma protocol. Poster presented at the 2005 Annual Meeting of the International Society for Traumatic Stress Studies, Toronto, Canada.
2. Monaghan, M., Stephan, S., Weist, M. & Shea, M.  (2005, October).  Relationship between type of trauma and student response to school-based cognitive behavioral trauma intervention.   Poster presented at the Tenth Annual Conference on Advancing School-based Mental Health, Cleveland, Ohio.
3. Ware, R., Monaghan, M., Stephan, S., Simpson, Y., Weist, M., & Shea, M.  (2005, October).  Feasibility and student satisfaction of evidence-based HIV prevention and trauma intervention protocols in urban schools.  Poster presented at the Tenth Annual Conference on Advancing School-based Mental Health, Cleveland, Ohio.
4. Owens, C., Simpson, Y., Stephan, S., Monaghan, M., Shea, M., Hull, R. (2005, August). Using evidence-based practices to prevent HIV in traumatized youth. Workshop presented at the Fifth Annual School Health Interdisciplinary Conference, Ellicott City, Maryland.
5. Simpson, Y., Stephan, S., Nichols, T., Shea, M., Tomoyasu, N., & Weist, M. (2005, June). Trauma-informed framework for HIV prevention in urban schools. Poster presented at the 2005 National HIV Prevention Conference, Atlanta, Georgia.
6. Weist, M, Stephan, S., Griffin-Deeds, B., Young, k., Giller, E., Owens, C., Simpson, Y. (2004, August). A trauma-informed framework for HIV prevention. Workshop presented at the Fourth Annual School health Interdisciplinary Program, Ellicott City, Maryland.
7. Simpson, Y., Owens, C., & Nichols, T. (2004, August). Implementation of the trauma-informed HIV prevention program in Baltimore City schools: Experiences from the field. Workshop presented at the Fourth Annual School health Interdisciplinary Program, Ellicott City, Maryland.
8. Simpson, Y., Nichols, T., Stephan, S., & Weist, M. (2004, August). Fidelity of implementation of a trauma-informed HIV prenveiton protocol in schools. Poster presented at the Fourth Annual School health Interdisciplinary Program, Ellicott City, Maryland.