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Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

Scientific Rating:
3
Promising Research Evidence
See scale of 1-5
Child Welfare Relevance Level:
Medium

See descriptions of 3 levels

Brief Description

The information in this program outline is provided by the program representative and edited by the CEBC staff. The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) program has been rated by the CEBC in the areas of: Anxiety Treatment (Child & Adolescent) and Trauma Treatment (Child & Adolescent).

  • Types of Maltreatment: Does not target any specific kind of maltreatment
  • Target Population: 3rd through 8th grade students who screened positive for exposure to a traumatic event and symptoms of post-traumatic stress disorder related to that event, largely focusing on community violence exposure. It has been used in high school settings as well.

CBITS is a school-based, group and individual intervention designed to reduce symptoms of posttraumatic stress disorder (PTSD), depression, and behavioral problems among students exposed to traumatic life events, such as exposure to community and school violence, accidents, physical abuse, and domestic violence. It is designed for students, who have experienced a traumatic event and have current distress related to that event. The goals of the intervention are to reduce symptoms and behavior problems and improve functioning, improve peer and parent support, and enhance coping skills. The program includes 10 student group sessions, 1-3 student individual sessions, 2 parent sessions, and a teacher educational session. Developed for the school setting in close collaboration with school personnel, the program is well suited to the school environment.

The goals of CBITS are to:

  • Reduce symptoms related to trauma exposure.
  • Build skills and enhance resilience to stress.
  • Build peer and caregiver support.

    Essential Components

    CBITS relies on cognitive and behavioral theories of adjustment to traumatic events and uses the following techniques that can be considered essential components:

    • Psycho-education
    • Relaxation
    • Social problem solving
    • Cognitive restructuring
    • Imaginal exposure
    • Exposure to trauma reminders
    • Development of a trauma narrative

    Child Component

    Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was designed with a child component that addresses the following presenting problems and symptoms:

    • Symptoms of post-traumatic stress disorder include re-experiencing the traumatic event (nightmares, flashbacks, recurrent thoughts), avoidance of trauma reminders (places, things, or memories of the trauma), heightened arousal (irritability, sleep problems, hypervigilence), and numbing of emotions.

    Age range: 8 – 15

    Developmental Delays:

    This program was not developed for children with developmental delays, and has not been tested for children with developmental delays.

    Treatment Involves Family/Support Structures:

    This program involves the family or other support systems in the individual's treatment: The program includes extensive outreach to parents as well as 2 parent sessions to keep them informed about what is happening in the groups as well as to teach them some of the same skills as the child is learning.

    Parent / Caregiver Component

    Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was not designed with a parent/caregiver component.

    Group Format

    Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was designed to be conducted in a group setting, and has been tested for use in a group setting.

    Recommended group size:

    6-10

    Testing References:

    Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N. & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence:  A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-11.

    Kataoka, S., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., Zaragoza, C., & Fink, A. (2003). Effectiveness of a school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311-318.

    Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A.  K., Scott, M., & Schonlau, M. (2010). Children’s access to mental health care following Hurricane Katrina within a randomized field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23(2): 223-231.

    Delivery Setting

    This program is typically conducted in a(n):

    • School

    Homework

    Cognitive Behavioral Intervention for Trauma in Schools (CBITS) includes a homework component:

    The program uses activities to be practiced between sessions. Worksheets and handouts included with the manual.

    Languages

    Cognitive Behavioral Intervention for Trauma in Schools (CBITS) has materials available in a language other than English:

    Spanish

    For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

    Resources Needed to Run Program

    The typical resources for implementing the program are:

    • Whiteboard, blackboard, or flipchart with markers.
    • Private meeting room.
    • Some specific materials required for sessions as detailed in the manual.

    Minimum Provider Qualifications

    A Master’s or doctorate degree in a clinical field is required for this program.

    Education and Training Resources

    There is a manual that describes how to implement this program, and there is training available for this program.

    Training Contact:
    Training is obtained:

    Extensive training and implementation materials are available at no cost for registered users at www.cbitsprogram.org. Usually training is on-site. Some regional trainings are offered.

    Number of days/hours:

    2-day training, sometimes with ongoing consultation afterward.

    Relevant Published, Peer-Reviewed Research

    This program is rated a "3 - Promising Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one study utilizing some form of control (e.g., untreated group, placebo group, matched wait list study) establishing the practice's benefit over the placebo, or found it to be comparable to or better than an appropriate comparison practice. Please see the Scientific Rating Scale for more information.

    Child Welfare Outcome: Child/Family Well-Being

    Show relevant research...

    Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N. & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence:  A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-11.

    Type of Study: Randomized controlled trial
    Number of Participants: 126

    Population:

    • Age range — 10-12 years
    • Race/Ethnicity — Latino
    • Gender — 44% Male, 56% Female
    • Status — Sixth-grade students with exposure to violence and clinical levels of Posttraumatic Stress Disorder (PTSD) symptoms.

    Location / Institution: 2 large East Los Angeles middle schools

    Summary: (To include comparison groups, outcomes, measures, notable limitations)
    The study evaluated the effectiveness of a collaboratively designed school-based intervention for reducing children’s symptoms of PTSD and depression resulting from exposure to violence. Students were randomly assigned to a 10-session standardized early intervention group, the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS), or to a wait-list delayed intervention comparison group. Students and teachers completed questionnaires at baseline, 3 months, and 6 months. Measures used included the Child PTSD Symptom Scale (CPSS), Children’s Depression Inventory (CDI), Pediatric Symptom Checklist (PSC), and the Teacher-Child Rating Scale (TCRS). All children eventually participated in the intervention at some point during the academic year. Results at 3 months indicated that students assigned to the intervention had significantly lower scores of PTSD, depression, and psychosocial dysfunction than the children in the wait list group, but no significant differences were detected for teacher-reported classroom problems in acting out, shyness/anxiousness, or learning. Results at 6 months, when both groups had received the intervention, indicated no significant differences between groups. Study limitations included possible symptom detection and definition discrepancies among teachers, and lack of blinding to condition.

    Length of post-intervention follow-up: Approximately 14 weeks for the early intervention group. None for delayed intervention control group.

    Kataoka, S., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., Zaragoza, C., & Fink, A. (2003). Effectiveness of a school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311-318.

    Type of Study: Pretest-posttest control group design
    Number of Participants: 198

    Population:

    • Age range — Not Specified
    • Race/Ethnicity — Hispanic
    • Gender — 50% Male, 50% Female
    • Status — Participants were in third through eighth grade with trauma-related depression and/or posttraumatic stress disorder symptoms.

    Location / Institution: Nine public Los Angeles elementary and middle schools

    Summary: (To include comparison groups, outcomes, measures, notable limitations)
    The study objective was to pilot-test a school mental health program for Latino immigrant students exposed to community violence. The intervention consisted of a manual-based, eight-session, group cognitive-behavioral therapy (CBT) delivered in Spanish based on the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS). Parents and teachers were eligible to receive psychoeducation and support services. Measures used included a modified 34-item version of the Life Events Scale, Child PTSD Symptom Scale (CPSS), and the Children’s Depression Inventory (CDI). Results indicated that students in the intervention group had significantly greater improvement in posttraumatic stress disorder and depressive symptoms compared with those on the waitlist at 3-month follow-up. Limitations included modest symptom changes that remained in the clinical range at follow-up and that only a portion of the participants were randomized.

    Length of post-intervention follow-up: 3 months.

    Morsette, A., Swaney, G., Stolle, D., Schuldberg, D., van den Pol, R. & Young, M. (2009). Cognitive Behavioral Intervention for Trauma in Schools (CBITS):  School-based treatment on a rural American Indian reservation.  Journal of Behavior Therapy and Experimental Psychiatry, 40, 169-178.

    Type of Study: Series of within-subjects designs
    Number of Participants: 4

    Population:

    • Age range — 11 to 12 years
    • Race/Ethnicity — Native American
    • Gender — Not Specified
    • Status — Participants were Native American adolescents with Posttraumatic Stress Disorder (PTSD) and depressive symptoms.

    Location / Institution: Two schools on or near a Montana reservation

    Summary: (To include comparison groups, outcomes, measures, notable limitations)
    The study examined preliminary data from a school-based intervention, Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) to evaluate its effectiveness in a Native American community. Students completed the Life Events Scale (LES), Child PTSD Symptom Scale (CPSS), and Children’s Depression Inventory (CDI) at screening, pretest and posttest. Efforts to adapt CBITS in reservation schools included inviting Native elders and healers to participate in the intervention. Results indicated that three of the four students decreased substantially on PTSD or depressive symptoms. Limitations included lack of control/comparison group and small sample size.

    Length of post-intervention follow-up: None.

    Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A. K., Scott, M., & Schonlau, M. (2010). Children’s access to mental health care following Hurricane Katrina within a randomized field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23(2): 223-231.

    Type of Study: Randomized controlled trial
    Number of Participants: 118

    Population:

    • Age range — 9 to 15.5 years
    • Race/Ethnicity — African American (52%), Caucasian (42%), Hispanic (4%), and Other (2%).
    • Gender — 37% Male, 63% Female
    • Status — Participants were children in three schools with elevated Posttraumatic Stress Disorder (PTSD) symptoms assessed 15 months following Hurricane Katrina.

    Location / Institution: Three New Orleans schools and Mercy Family Center’s Metairie, Louisiana clinic

    Summary: (To include comparison groups, outcomes, measures, notable limitations)
    The study randomized students with PTSD symptoms post-Hurricane Katrina into one of two trauma-specific interventions: Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) and Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). Students completed the Disaster Experiences Questionnaire, UCLA PTSD Reaction Index, Child PTSD Symptom Scale (CPSS), Children’s Depression Inventory (CDI), Social Support Scale for Children (SSSC), Strengths and Difficulties Questionnaire (SDQ), and the PTSD section of the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL-PTSD). Children reported on hurricane exposure, lifetime trauma exposure, peer and parent support, PTSD, and depressive symptoms. Teachers reported on behavior. At baseline, 60.5% screened positive for PTSD symptoms and were offered a group intervention at school or individual treatment at a mental health clinic. Uptake of the mental health care was uneven across intervention groups, with 98% beginning the school intervention, compared to 37% beginning at the clinic. Results indicated that both treatments led to significant symptom reduction of PTSD symptoms, but many still had elevated PTSD symptoms at post-treatment. Limitations included a smaller than anticipated sample size, limiting analyses methods.

    Length of post-intervention follow-up: 4-5 months for CBITS groups, 1 month for TF-CBT groups.

    References

    Feldman, E. (2007). Implementation of the cognitive behavioral intervention for trauma in schools (CBITS) with Spanish-speaking, immigrant middle-school students: Is effective, culturally competent treatment possible within a public school setting? Dissertation Abstracts International Section A, 68, 1325.

    Schultz, D., Barnes-Proby, D., Chandra, A., Jaycox, L. H., Maher, E. & Pecora, P. (2010). Toolkit for Adapting Cognitive Behavioral Intervention for Trauma in Schools (CBITS) or Supporting Students Exposed to Trauma (SSET) for Implementation with Youth in Foster Care.  TR722.  Santa Monica, CA:  RAND Corporation. Available at http://www.rand.org/pubs/technical_reports/TR772/

    Stein, B. D., Elliott, M. N., Tu, W., Jaycox, L. H., Kataoka, S. H., Wong, M., & Fink, A. (2003). School-based intervention for children exposed to violence: Reply. Journal of the American Medical Association, 290(19), 2542.

    Contact Information

    Name: Lisa Jaycox, PhD
    Agency/Affiliation: RAND Corporation
    Website: www.cbitsprogram.org
    Email:
    Phone: (703) 413-1100 x5118

    Date Reviewed: April 2011