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The Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) program is a cognitive and behavioral therapy group intervention for reducing children’s symptoms of posttraumatic stress disorder (PTSD) and depression caused by exposure to violence that has been used successfully in innercity schools with multicultural populations. CBITS has three main goals: to reduce symptoms related to trauma, to build resilience, and to increase peer and parent support.
The theoretical underpinnings are based on cognitive behavioral theory regarding anxiety and trauma. In short, traumatic life events lead to impairment (including psychological reactions, behavioral problems, and functional impairment), and these lead in turn to long-term adjustment problems such as PTSD, depression, violent behavior, and substance abuse. These adverse outcomes, in turn, increase risk for exposure to more traumatic events and life stressors, compounding vulnerability in the future, creating a cycle.
CBITS was developed to reduce symptoms of distress and to build skills to improve children’s abilities to handle stress and trauma in the future. The program addresses the known risk factors for developing chronic disturbances following trauma summarized above, including poor coping skills, cognitive factors, and low levels of social support. Symptom reduction is accomplished by cognitive-behavioral theory practices—reducing maladaptive thinking that can drive depressive and anxious moods, reducing anxiety directly through relaxation training, reducing anxiety through behavior therapy (exposure to anxiety-provoking stimuli and habituation of anxiety), and processing the traumatic experience to reduce both anxiety and traumatic grief.
The CBITS program was designed for use in schools, for children aged 10–14 who have had substantial exposure to violence and who have symptoms of PTSD in the clinical range. The CBITS intervention incorporates Cognitive-Behavioral Therapy skills in a group format (5–8 students per group) to address symptoms of PTSD, anxiety, and depression related to exposure to violence. Symptom reduction is accomplished through cognitive techniques and trauma-focused work in imagination, writing, and narratives. In each session, a new set of skills to is taught to the child, using didactic presentation, age-appropriate examples, and games. The child then uses these skills to address his or her problems through homework assignments collaboratively developed between the child and the CBITS clinician. The program format is 10 child group sessions, 1–3 individual child sessions, two parent education sessions, and a teacher informational meeting.
A manual, available to the public, details step-by-step plans and provides scripts for implementing the program. Trainings are offered regularly at national professional meetings, at Los Angeles, Calif.–based trainings funded by the E. Mark Taper Foundation, and can also be arranged onsite. Consultation on implementation and evaluation, ongoing supervision of trainees, and monitoring adherence are also available.
Two evaluations of the program have been published. (Independent replications and evaluations are currently under way but not yet available.) In both studies, social workers were trained for 2 days on how to implement CBITS and were closely supervised throughout the implementation period to ensure quality and fidelity to the program.
The first study evaluated the program for recent immigrant Latino children in Los Angeles schools in a quasi-experimental design. Eleven public schools in Los Angeles were invited to participate in the study, and nine agreed to participate. A total of 970 students met eligibility criteria to participate (i.e., were in grades 3–8, were foreign born, had immigrated to the United States within the past 3 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 or depression symptoms (or both) and were recruited for the study. Of these, 83 percent (229 students) were given parental permission to participate. A total of 198 Spanish-speaking immigrant students in grades 3–8 were included.
Initially, 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, though 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, accounting for the 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 3-month follow-up assessment for symptoms of childhood PTSD and depression.
The second evaluation was a randomized controlled study conducted during the 2001–02 academic year to assess the effectiveness of CBITS. Students were randomly assigned to a 10-session standardized cognitive-behavioral therapy early intervention group (n=61) or to a waitlist delayed intervention comparison group (n=65) conducted by trained school mental health clinicians. The sample consisted of sixth grade students at two large middle schools in East Los Angeles. Students were considered eligible if they had substantial exposure to violence, clinical levels of symptoms of PTSD, symptoms of PTSD related to exposure to violence that they were willing to discuss in a group (as determined by their school-based mental health clinician), and did not appear too disruptive to participate in a group therapy intervention session (in the opinion of their school-based mental health clinician). Clinician adherence to the manual was monitored, and the program was found to be delivered with fidelity. Data from students was collected at baseline, at 3 months, and at 6 months. Multiple measures were used to assess symptoms of PTSD, symptoms of depression, child psychological dysfunction, and classroom behavior. An intent to treat analysis supported the conclusions of the main study.
It appears that a standardized 10-session cognitive-behavioral group intervention can significantly decrease symptoms of PTSD and depression in students exposed to violence and can be effectively delivered on school campuses by trained school-based mental health clinicians. Results of the first study included the following:
Results of the second study included the following:
Teachers did not report a significant difference in classroom behavior between students who received the CBITS intervention and the waitlist control students.
Jaycox, Lisa H. 2003. Cognitive-Behavioral Intervention for Trauma in Schools. Longmont, Colo.: Sopris West Educational Services.
Kataoka, Sheryl H., Bradley D. Stein, Lisa H. Jaycox, Marleen Wong, Pia Escudero, Wenli Tu, Catalina Zaragoza, and Arlene Fink. 2003. “A School-Based Mental Health Program for Traumatized Latino Immigrant Children.” Journal of the American Academy of Child and Adolescent Psychiatry 42(3):311–18.
Stein, Bradley D., Marc N. Elliott, Wenli Tu, Linda H. Jaycox, Sheryl H. Kataoka, Marleen Wong, and Arlene Fink. 2003. “School-Based Intervention for Children Exposed to Violence: Reply.” Journal of the American Medical Association 290(19):2542.
Stein, Bradley D., Lisa H. Jaycox, Sheryl H. Kataoka, Marleen Wong, Wenli Tu, Marc N. Elliot, and Arlene Fink. 2003. “A Mental Health Intervention for Schoolchildren Exposed to Violence.” Journal of the American Medical Association 290(5):603–11.
Lisa H. Jaycox, Ph.D.
RAND
1200 South Hayes Street
Arlington, VA 22202
Phone: (703) 413-1100
Fax: (703) 414-4725
E-mail: jaycox@rand.org
Web site: http://www.rand.org
Audra Langley, Ph.D.
300 Medical Plaza, Room 1265
University of California at Los Angeles
Los Angeles, CA 90095
Phone: (310) 825-4132
Fax: (310) 267-4925
E-mail: Alangley@mednet.ucla.edu
