Programs that Work

Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

Program Info

Outcome Areas

Healthy and Safe Children

Indicators

Children not experiencing anxiety or mood disorders, such as depression

Topic Areas

     Age of Child
       Middle Childhood
       Adolescence
     Type of Setting
       Elementary School
       Middle School
     Type of Service
       Youth Development
     Type of Outcome Improved
       Behavior Problems
       Mental Health

Evidence Level (What does this mean?)

Proven

Program Overview

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.

Program Participants

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.

Evaluation Methods

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 nonrandomly 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, noncompleters (13 students) had significantly higher PTSD and depression scores, acting-out behaviors witnessed in the classroom, and classroom learning problems.

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.

Probable Implementers

Public and private elementary and middle schools

Funding

Previously, schools have successfully implemented CBITS using insurance, Medicaid funding, or monies from Safe and Drug Free Schools to support the program. In 2005, Los Angeles schools intend to use funding from Proposition 63, a new income tax earmarked for new, evidence based mental health programs.

Implementation Detail

Program Design
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)
Real-life exposure to traumatic cues (developing avoidance and coping strategies)
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.

Curriculum
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.

Staffing
Typically, CBITS counselors are trained psychiatric social workers who are required to 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. Both studies of the CBITS program 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.

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.

It should be noted that the program developers served as authors on both evaluations of the CBITS program.

Example Sites

Los Angeles, California

Contact Information

Lisa H. Jaycox
RAND Corporation
1200 South Hayes Street
Arlington, VA 22202
Telephone (703) 413-1100 x5118
Fax (703) 414-4726
jaycox@rand.org

Available Resources

The CBITS treatment manual is available for purchase through Sopris West Educational Services at (800) 547-6747 or online at:
http://positiveschoolclimate.sopriswest.com/product.asp?productid=120.

Bibliography

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, 2003, pp. 311-318.

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. 3, 2003, pp. 603-611.

Last Reviewed

June 2005

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