Programs that Work
Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
Healthy and Safe Children
Children Succeeding in School
Students performing at grade level or meeting state curriculum standards
Children not experiencing anxiety or mood disorders, such as depression
Age of Child
Middle Childhood (9-12)
Type of Setting
Type of Service
Health Care Services
Type of Outcome Addressed
Cognitive Development / School Performance
Evidence Level (What does this mean?)
The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) program is a group intervention for children in grades six through nine. The program is aimed at relieving symptoms of post-traumatic stress disorder (PTSD), depression, and general anxiety among children exposed to trauma. Types of traumatic events that participants have experienced include witnessing or being a victim of violence, experiencing a natural or man-made disaster, being in an accident or house fire, or suffering physical abuse or injury. Symptoms of PTSD, depression, and anxiety among children can include disorganized or agitated behavior, recurrent distressing recollections of an event, nightmares, attempts to reenact an event, intense psychological or physiological distress from cues that symbolize an aspect of the event, diminished interest or participation in certain activities, feelings of detachment or estrangement, difficulty falling asleep or staying asleep, and outbursts of anger. Children in CBITS work on processing traumatic memories, expressing their grief, learning relaxation skills, challenging upsetting thoughts, and improving their social problem-solving. These techniques and skills are learned through the use of drawings and through talking in both individual and group settings.
The CBITS program has been used most commonly for children in grades six through nine. Preliminary versions of CBITS have been used for children as young as eight years old. More recently, CBITS has been used in high school, although these efforts have not been evaluated.
Kataoka et al. (2003) evaluated the CBITS program in a sample of 198 Spanish-speaking immigrant students in grades three through eight, with 152 students in the CBITS group and 46 students in the control group. Eleven public schools in Los Angeles, California, were invited to participate in the study, and nine schools agreed to participate. A total of 970 students met eligibility criteria to participate (i.e., were in grades three through eight, were foreign-born, had immigrated to the United States within the past three years, and spoke Spanish). Ninety-one percent of the sample (879 students) completed a questionnaire regarding exposure to violence and symptoms of trauma. Thirty-one percent of the screened students (276 children) reported clinical PTSD and/or depression symptoms and were recruited for the study, and 83 percent (229 students) of the students who reported these symptoms were given parental permission to participate. A total of 67 students were randomly assigned to the treatment group, and 46 students were assigned to a waitlist comparison group. Waitlist students were given referrals to community mental health agencies, although most subjects did not follow up on these referrals. Later in the school year, an additional 85 eligible students were non-randomly assigned to the intervention, for a total of 152 children participating in the CBITS intervention and 46 in the waitlist control group. The randomized and nonrandomized children did not differ on baseline violence exposure, symptom levels, or socioeconomic characteristics except for a significant difference in parental education (which was higher in the nonrandomized group). All students completed a three-month follow-up assessment for symptoms of childhood PTSD and depression.
A second study of the CBITS program was conducted by Stein et al. (2003), in a sample of English-speaking sixth-grade students from two middle schools in East Los Angeles. After parents and children agreed to participate in the study, a self-report questionnaire regarding exposure to violence and symptoms of PTSD was given to 769 students. Students eligible for participation in the study had the following characteristics: substantial exposure to violence, symptoms of PTSD in the clinical range, symptoms of PTSD related to exposure to violence that they were willing to discuss in a group, and were not too disruptive to participate in a group-therapy intervention session. One hundred fifty-nine students were offered the opportunity to participate, and 126 students were randomly assigned to either a ten-session CBITS group (61 students, with 56 eventually participating) or a waitlist control group (65 students). Students were assessed before the intervention and at three and six months post-completion on measures of PTSD, depression, parent-reported psychological dysfunction, and teacher-reported classroom problems. At follow-up, 54 CBITS and 63 control students were included in the three-month analysis (117 total, or 93 percent), and 53 CBITS and 60 controls were included in the six-month analysis (113 total, or 90 percent). At baseline, compared with students who completed all assessments, non-completers (13 students) had significantly higher PTSD and depression scores, acting-out behaviors witnessed in the classroom, and classroom learning problems.
Kataoka et al. (2011) further used their sample of sixth graders in East Los Angeles to look at the effects of CBITS on academic performance of students with mental health symptoms. Out of 159 students with PTSD symptoms according to the Child PTSD Symptom Scale (CPSS), 126 were randomly assigned to receive CBITS immediately or with a delay of 4-5 months after initial screening (61 immediate, 65 delayed). The randomized children did not differ on baseline violence exposure, symptom levels, or socioeconomic characteristics. After assigning students to either the immediate or delayed intervention group, their academic performance was recorded at baseline and closely monitored throughout the intervention period. The emphasis was on mean math and language/arts grades, as well as on the percentage of passing grades for each group. Grades were recorded during the spring quarter of the 2001-2002 academic year, as this was the only period when the immediate group had completed the intervention and the delayed group had not started. The study control group also received the program during the same academic year, and there was no longer-term tracking of changes in academic performance for a period exceeding the experiment time frame. Because of these issues, it was impossible to examine long-term differences in academic performance.
Key Evaluation Findings
Kataoka et al.'s (2003) study of 198 Spanish-speaking immigrant students found the following:
- Depressive symptoms in the CBITS group significantly decreased from pre- to post-test (by 17 percent) but did not change in the waitlist group.
- Similarly, PTSD symptoms in the CBITS group significantly decreased from pre- to post-test (by 29 percent), but the reduction in the waitlist group of 13 percent was not statistically significant.
- Of the 83 students with clinical depressive symptoms at baseline (i.e., serious levels of depression), mean depression scores for the CBITS group dropped significantly at post-test (by 22 percent), compared with a non-significant drop of 5 percent in the waitlist group.
- Similarly, of the 180 children with clinically significant PTSD symptoms at baseline (i.e., serious levels of PTSD), follow-up scores declined significantly in the treatment group (by 35 percent), compared with a non-significant decline of 16 percent in the waitlist group.
The study of 117 English-speaking sixth-graders (Stein et al., 2003) reported the following:
- At the three-month follow-up, CBITS students reported a significantly greater reduction of PTSD symptoms than did waitlist control students, with a 64 percent reduction from baseline compared with a 34 percent reduction from baseline.
- At the three-month follow-up, CBITS students also reported significantly lower scores on symptoms of depression than did control students, with a 47 percent reduction from baseline compared with a 24 percent reduction from baseline.
- Parents of CBITS students reported significantly less psychosocial dysfunction of their children at three months compared with parents of waitlist control students. CBITS parents reported a 35 percent reduction in psychosocial dysfunction in their children from baseline, compared with a 2 percent increase for control parents.
- At three months, no significant differences were found between the two groups for teacher-reported classroom problems of acting out, or problems with shyness, anxiousness, or learning.
- At six months, after both the initial group and the waitlist group had received the CBITS intervention, no significant differences were found between groups for symptoms of PTSD, depression, parent-reported psychosocial function, or teacher-reported classroom behaviors.
The study on the academic performance of 126 sixth graders (Kataoka et al., 2011) reported the following:
- Students in the immediate intervention group show higher mean grades in both math (2.0 vs. 1.6) and language/arts (2.2 vs. 1.9), after adjusting for prior test scores, than their counterparts in the delayed intervention group. However, only the difference in math mean scores was statistically significant.
- Students with early CBITS intervention were projected to pass both math (69.5%) and language/arts (79.7%) at significantly higher rates than students with delayed intervention (math: 54.7%; language/arts: 60.9%)
Public and private upper elementary, middle schools and high schools
Previously, schools have successfully implemented CBITS using existing mental health funding, insurance, County Department of Mental Health funding (including Medicaid), or monies from Safe and Drug Free Schools to support the program.
The CBITS program consists of ten one-hour group sessions with five to eight children, usually conducted once a week in a school or mental health or other office settings. The group sessions include exercises related to six cognitive-behavioral areas:
- education about common reactions to trauma
- relaxation training to combat anxiety
- cognitive therapy (developing an understanding of the link between thoughts and feelings; combating negative thoughts)
- gradual exposure to trauma reminders
- exposure to stress or trauma memory through use of the imagination, drawing, or writing
- social problem-solving.
Additional between-session activities that each student does as homework help strengthen his or her skills and allow group members to apply those skills to real-life problems. In addition to the group sessions, participants receive one to three individual sessions. Furthermore, the CBITS program includes two parent-education sessions and one teacher-education session to help adults to assist children in solidifying the skills learned during the program.
Reduction in symptoms of PTSD and depression is accomplished in CBITS via cognitive techniques (e.g., relaxation therapy and real-life exposure to traumatic cues) and trauma-focused memory work using the imagination, writing, and drawing. In each session, a new set of skills is taught to children through the use of age-appropriate examples and games. Participants then use those skills to address their problems through homework assignments collaboratively developed by the child and the CBITS social worker.
Typically, CBITS group leaders are trained clinicians, including social workers, marriage and family counselors, and psychologists, who attend a two-day training session and receive ongoing supervision from a local clinician with expertise in cognitive-behavioral therapy.
Issues to Consider
This program received a "proven" rating. The first two studies of the CBITS program (Kataoka et al., 2003; Stein et al., 2003) utilized rigorous evaluation methodology, studied groups with low rates of attrition, and found significant reductions in PTSD and depression symptoms for treatment children when compared with a control group. Additionally, the CBITS program demonstrated effectiveness at reducing parent-reported psychosocial dysfunction among participating children. However, teacher-reported classroom behavior problems did not decline as a result of the program.
The third study (Kataoka et al., 2011) examines the impact of CBITS on issues beyond PTSD and looks at the program's effect on academic performance. While results are very promising, there are several limitations to the study design that make the preliminary.
Although the evaluations of CBITS have been limited to Los Angeles, studies indicate that the program is effective with English-speaking students as well as Spanish-speaking immigrant children.
There have been various attempts to look at CBITS in different settings, notably post-Katrina New Orleans (Jaycox et al., 2010) and tribal reservations, yet none of these studies fully meet the criteria to be presented in this context (Morsette et al., 2009). While they provide several interesting insights into the external validity of CBITS components beyond the borders of Los Angeles, the results are exploratory and need to be tested further.
It should be noted that the program developers served as authors on all three evaluations of the CBITS program.
Los Angeles, California
New Orleans, Louisiana
San Francisco, California
Lisa H. Jaycox
1200 South Hayes Street
Arlington, VA 22202
Telephone (703) 413-1100 x5118
Fax (703) 414-4726
The CBITS treatment manual is available for purchase through Sopris West Educational Services at (800) 547-6747 or online at: https://cbitsprogram.org/survey/take/s=244&c=281&f=0#/g=1927&i=1&r=168416&h=298adc&t=227
Jaycox, Lisa H., Judith A. Cohen, Anthony P. Mannarino, Douglas W. Walker, Audra K. Langley, et al., "Children's Mental Health Care Following Hurricane Katrina: A Field Trial of Trauma Focused Psychotherapies,"
Journal of Traumatic Stress,
Vol. 23, No. 2, April 2010, pp. 223-231.
Kataoka, Sheryl H., Bradley D. Stein, Lisa H. Jaycox, Marleen Wong, Pia Escudero, Wenli Tu, Catalina Zaragoza, and Arlene Fink, "A School-Based Mental Health Program for Traumatized Latino Immigrant Children," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 42, No. 3, March 2003, pp. 311-318.
Kataoka, Sheryl, Lisa H. Jaycox, Marleen Wong, Erum Nadeem, Audra Langley, Lingqi Tang, and Bradley D. Stein, "Effects on School Outcomes in Low-Income Minority Youth: Preliminary Findings from a Community-Partnered Study of a School Trauma Intervention," Ethnicity & Disease, Vol. 21, No. 3, Supplement 1, 2011, pp. S1-71-7.
Morsette, Aaron, Swaney, Gyda, Stolle, Darrell, Schuldberg, David, van den Pol, Richard, and Young, Melissa. "Cognitive Behavioral Intervention for Trauma in Schools (CBITS): School-Based Treatment on a Rural American Indian Reservation," Journal of Behavior Therapy and Experimental Psychiatry, Vol. 40, No. 1, March 2009, pp. 169-178.
Stein, Bradley D., Lisa H. Jaycox, Sheryl H. Kataoka, Marleen Wong, Wenli Tu, Mare N. Elliott, and Arlene Fink, "A Mental Health Intervention for Schoolchildren Exposed to Violence: A Randomized Controlled Trial," Journal of the American Medical Association, Vol. 290, No. 5, August 6, 2003, pp. 603-611.