CHICAGO—A standardized cognitive-behavioral group intervention can significantly decrease symptoms of stress and depression in students who have been exposed to violence, according to a study in the August 6 issue of The Journal of the American Medical Association (JAMA), a theme issue on violence and human rights.

In the last decade, there has been heightened awareness of the extent to which children personally witness or experience violence, according to background information in the article. Public health officials have responded by identifying violence as one of the most significant U.S. public health issues. Large numbers of U.S. children experience such violence, and an even greater number may experience symptoms of distress after personally witnessing violence directed at others. Exposure to violence is associated with depression and behavioral problems.

No randomized controlled studies have been conducted to date on the effectiveness of psychological interventions for children with symptoms of posttraumatic stress disorder (PTSD) that has resulted from personally witnessing or being personally exposed to violence.

Bradley D. Stein, M.D., Ph.D., of RAND, Santa Monica, Calif., and colleagues conducted a randomized controlled trial during the 2001-2002 academic year to test the effectiveness of a cognitive-behavioral therapy (CBT) group intervention to reduce symptoms of PTSD and depression and to improve psychosocial functioning and classroom behavior in students exposed to violence. The study included sixth-grade students at two large middle schools in Los Angeles who reported exposure to violence (defined as experiencing or witnessing violence involving a knife or gun or having a survey score consistent with exposure to three or more violent events) and had clinical levels of symptoms of PTSD.

The students were randomly assigned to a 10-session standardized cognitive-behavioral therapy (the Cognitive-Behavioral Intervention for Trauma in Schools) early intervention group (n=61) or to a wait-list delayed intervention comparison group (n=65) conducted by trained school mental health clinicians. Students were assessed before the intervention and 3 months after the intervention on measures assessing child-reported symptoms of PTSD and depression, parent-reported psychosocial dysfunction, and teacher-reported classroom problems (acting out, shyness/anxiety, learning problems).

"Students who received this brief standardized intervention, delivered by school mental health clinicians on school campuses, had significantly fewer self-reported symptoms of PTSD and depression, and fewer reports of psychosocial dysfunction by parents at the three month assessment, than did students who were randomly assigned to a delayed intervention comparison group," the authors write. "The delayed intervention group experienced a smaller decrease in symptoms of PTSD and depression while on a waiting list to receive the intervention; when they received the intervention, they too showed a significant reduction in symptoms of PTSD and depression."

At 6 months, after both groups had received the intervention, students in both groups had similar levels of symptoms of PTSD, depression, and psychosocial dysfunction.

CHICAGO—A survey of Israeli residents documenting the psychological impact of ongoing terrorist attacks and the mechanisms for coping with terrorism is reported in an article in the August 6 issue of The Journal of the American Medical Association (JAMA), a theme issue on violence and human rights.

According to background information in the article, since September 2000, Israeli society has been confronted by continual terrorism, including knife or gun attacks, drive-by shootings, intrusions into homes, and suicide bombings. By April 30, 2002, when the study was conducted, 472 persons (318 civilians) had been killed in terrorist attacks and 3,846 persons (2,708 civilians) had been injured. With the exception of several telephone and web-based surveys conducted after the September 11, 2001, attacks in the United States, few studies have examined the impact of modern forms of terrorism on people in developed countries.

Avraham Bleich, M.D., of Lev-Hasharon Mental Health Center, affiliated with Tel-Aviv University Sackler School of Medicine in Israel, and colleagues determined the level of exposure to terrorist attacks and the prevalence of traumatic stress-related (TSR) symptoms, symptoms of posttraumatic stress disorder (PTSD), and the sense of safety after 19 months of terrorism in Israel.

The researchers conducted a telephone survey in April and May of 2002 of a nationally representative sample of 742 Israeli residents older than 18 years. The survey measured self-reported exposure to terrorism, TSR symptoms, coping mechanisms, sense of safety and thoughts about the future.

Of 512 survey respondents, 84 (16.4 percent) had been directly exposed to a terrorist attack and 191 (37.3 percent) had a family member or friend who had been exposed. Of 510 participants who responded to questions about TSR symptoms, 391 (76.7 percent) had at least one TSR symptom. Criteria for having symptoms of PTSD were met by 48 respondents (9.4 percent) and criteria for acute stress disorder by one participant. The researchers also found that 299 (58.6 percent) reported feeling depressed.

The researchers state that their findings "suggest that the terrorism has had a substantial impact." Most of the respondents expressed a low sense of personal safety (60 percent) and for their friends and relatives (68 percent). However, the majority of the respondents reported feeling optimistic about their personal future (82 percent) and the future of Israel (66 percent) and expressed self-efficacy with regard to their ability to function in a terrorist attack (75 percent). Few reported a need for professional help (15 percent). The most prevalent coping mechanisms among the study participants were active information search about loved ones (83 percent) and social support (76-81 percent). A substantially smaller proportion of the participants reported using self-distraction (38 percent) or information avoidance (32 percent) and a smaller percentage reported using tranquilizers (7 percent) or alcohol or cigarettes (5.3 percent) as a specific means of coping.

CHICAGO—More than one-half of adult Latinos in Los Angeles who immigrated from Central America, South America, and Mexico, report previous exposure to political violence in their home country, and have associated impairments in mental health and health-related quality of life, according to a study in the August 6 issue of The Journal of the American Medical Association (JAMA), a theme issue on violence and human rights.

According to background information in the article, political violence is increasingly recognized as a threat to public health and includes many types of violence such as war, torture, forced disappearances, and extrajudicial killings. Although political violence continues in parts of Central America, South America, and Mexico, little is known about its relationship to the health of Latino immigrants living in the United States.

The Latino population is the fastest growing U.S. minority group, comprising 12.5 percent of the U.S. population. Over 4.2 million Latino persons live in Los Angeles County alone, representing 44.6 percent of its population.

David P. Eisenman, M.D., M.S.H.S., of the UCLA School of Medicine, Los Angeles, and colleagues conducted a study to determine the exposure to political violence among U.S. Latino immigrant adult primary care patients from Central America, South America, and Mexico. The researchers assessed: (1) the prevalence and types of political violence Latino immigrants reported experiencing before immigration, (2) whether prior exposure to political violence was associated with current mental health status and health-related quality of life, and (3) the rates of disclosure of political violence to primary care clinicians.

The study included a survey of 638 Latino immigrant adults in three community-based primary care clinics in Los Angeles, conducted from July 2001 to February 2002.

The researchers found that 54 percent of participants reported political violence experiences in their home countries, including 8 percent who reported torture. Of those exposed to political violence, 36 percent reported symptoms of depression and 18 percent reported symptoms of posttraumatic stress disorder (PTSD) vs. 20 percent and 8 percent, respectively, among those not exposed to political violence. "Controlling for age, sex, country, years lived in the United States, acculturation, income, health insurance status, and recruitment site in a subsample of 512 participants (56 percent), those who reported political violence exposure were [3.4 times] more likely to meet symptom criteria for PTSD and to have symptoms of depression [2.8 times more likely] and symptoms of panic disorder [4.8 times more likely] than participants not reporting political violence."

The authors add that those exposed to political violence reported more chronic pain and limitations due to physical problems, as well as worse physical functioning and lower perceptions of general health than those who were not exposed to political violence. Only 3 percent of the 267 patients who had experienced political violence reported ever telling a clinician about it after immigrating; none reported their current physician asking about political violence.

CHICAGO—Almost half of the people injured in Afghanistan by landmines or unexploded ordnance (including grenades, bombs, mortar shells, and cluster munitions) were under the age of 16 years, according to a report in the August 6 issue of The Journal of the American Medical Association (JAMA), a theme issue on violence and human rights.

"Approximately 60 million to 70 million landmines are placed in about 70 countries, and an estimated 24,000 individuals, mostly civilians, are killed or injured by landmines and unexploded ordnance worldwide every year," the authors provide as background information in the report.

Oleg O. Bilukha, M.D., Ph.D., and colleagues from the Centers for Disease Control and Prevention, Atlanta, evaluated the injury surveillance records of 1,636 individuals in Afghanistan who were injured by landmines and unexploded ordnance between March 2001 through June 2002. The data were obtained from the International Committee of the Red Cross.

The authors found an average of 102 new injuries were reported each month. "Forty-six percent of those injured were younger than 16 years. The highest number of injuries was seen among those aged 7 to 15 years. Reported injuries in all age groups were mostly among males (91.6 percent) and civilians (81.2 percent)," the authors report. "Children were more likely to be injured by unexploded ordnance; injuries among adults were caused predominantly by landmines."

The fatality rate was 9.4 percent. The authors state that this rate is probably underestimated because surveillance predominantly detects those who survive long enough to receive medical care.

CHICAGO—The war in Iraq and subsequent security problems, disruption of disease control programs, damage to public health facilities, and reduced access to safe water have created challenges for the control of disease and public health in the country, according to a report in the August 6 issue of The Journal of the American Medical Association (JAMA), a theme issue on violence and human rights.

Marta Valenciano, D.V.M., M.P.H., of the World Health Organization (WHO), and colleagues describe the communicable disease surveillance and control interventions implemented by the WHO in the Basrah governorate of southern Iraq (population of 1.9 million) during the first 2 months of humanitarian response following the war from April to May 2003. Data are reported through June 2003. The objectives of this intervention were to ensure early warning of infectious disease outbreaks, to provide control programs with impact indicators, and to compile data on health care activities for planning purposes and health status information.

"Several lessons on communicable disease surveillance and control have been learned, and in some cases, unfortunately relearned, from the emergency response in the Basrah governorate of Iraq," the authors write.

"First, humanitarian and public health specific needs should be properly identified before sending supplies and materials. Second, restoration of basic public health and water/sanitation services is critical in Iraq. Any further delay will increase the risk of large-scale outbreaks, particularly of diarrheal diseases. The outbreaks alert system and emergency disease surveillance system were successful in detecting a cholera outbreak in Iraq. However, reinstating communicable disease surveillance in collaboration with national staff is crucial to identify, monitor, prevent, and respond to outbreaks and to contribute to the evaluation of the public health consequences of such a crisis. It also is important to strengthen laboratory capacity to confirm outbreaks; without this, syndromic disease surveillance is the only interim solution."

They add that the absence of laboratory facilities and lack of supplies specifically impeded the response to the outbreak of cholera in Basrah. As of June 29, 2003, Iraqi hospital laboratories had confirmed 94 cases of cholera from 7 of the 8 districts of the Basrah governorate.

"With the current water situation, diarrheal diseases were first to be noticed because of their short incubation period. An increase in other waterborne diseases with longer incubation periods, such as hepatitis A and E, may be observed in the coming weeks. In fact, local health centers are beginning to report cases of jaundice and suspected cases of typhoid fever; however, a lack of appropriate laboratory equipment has prevented disease confirmation of these cases to date," they write. "To prevent the transmission of major communicable diseases, restoring basic public health and water/sanitation services is currently a top priority in Iraq."

SCHOOL-BASED THERAPY PROGRAM REDUCES SIGNS OF POST TRAUMATIC STRESS DISORDER IN CHILDREN EXPOSED TO VIOLENCE