Program Profile: Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

This is a cognitive-behavioral therapy group intervention designed to reduce children’s symptoms of posttraumatic stress disorder (PTSD) and depression caused by exposure to violence. The program is rated Effective. Intervention group participants showed statistically significant reductions in depressive and PTSD symptoms, compared with control group participants, at the 3-month follow up. However, there were no statistically significant impacts on classroom behavior problems.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

Program Goals

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was designed for use in schools for children ages 10–15 who have had substantial exposure to violence or other traumatic events and who have symptoms of posttraumatic stress disorder (PTSD) in the clinical range. The CBITS program has three main goals: 1) to reduce symptoms related to trauma, 2) to build resilience, and 3) to increase peer and parent support. The program was developed to reduce symptoms of distress and build skills to improve children’s abilities to handle stress and trauma in the future.

Program Theory

The theoretical underpinnings are based on cognitive–behavioral theory (CBT) regarding anxiety and trauma. In short, traumatic life events lead to impairment (including psychological reactions, behavioral problems, and functional impairment), which in turn leads to long-term adjustment problems such as PTSD, depression, violent behavior, and substance abuse. These adverse outcomes, consequently, increase risk for exposure to more traumatic events and life stressors, compounding vulnerability in the future and creating a cycle (Stein et al. 2003).

Program Components

The program addresses risk factors for developing chronic disturbances following trauma, including poor coping skills, cognitive factors, and low levels of social support. Symptom reduction is accomplished by CBT 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 intervention incorporates cognitive–behavioral therapy skills in a group format (five to eight 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 is taught to the child, using didactic presentation, age-appropriate examples, and games. The child then uses the skills to address his or her problems through homework assignments collaboratively developed by the child and CBITS clinician.

The CBITS program is formatted to take place in 10 child group sessions, each lasting one class period. The sessions adhere to the curriculum below:

• Session 1: Introduction of group members, confidentiality, and group procedures. Explanation of treatment using stories. Discussion of reasons for participation (kinds of stress or trauma).
• Session 2: Education about common reactions to stress or trauma. Relaxation training to combat anxiety.
• Session 3: Thoughts and feelings (introduction to cognitive therapy). Fear Thermometer. Linkage between thoughts and feelings. Combating negative thoughts.
• Session 4: Combating negative thoughts.
• Session 5: Avoidance and coping (introduction to real-life exposure). Construction of fear hierarchy. Alternative coping strategies.
• Session 6: Exposure to stress or trauma memory through imagination/drawing/writing.
• Session 7: Exposure to stress or trauma memory through imagination/drawing/writing.
• Session 8: Introduction to social problem solving.
• Session 9: Practice with social problem solving and hot seat.
• Session 10: Relapse prevention and graduation ceremony.

Between Session 2 and Session 6, there are also individual sessions that focus on imaginal exposure to a traumatic event. The imaginal exposure can then be brought out through drawing and writing exercises in group sessions.

Study

Stein and colleagues (2003) conducted a randomized controlled study during the 2001–02 academic year to assess the effectiveness of Cognitive Behavioral Intervention for Trauma in Schools (CBITS) at two large middle schools in a primarily Latino community in East Los Angeles, Calif. Sixth-grade students were considered eligible to participate in the study if they had substantial exposure to violence, clinical levels of posttraumatic stress disorder (PTSD) symptoms, PTSD symptoms related to exposure to violence that they were willing to discuss in a group (as determined by their school-based mental health clinician), and if they did not appear too disruptive to participate in a group therapy intervention session (in the opinion of their school-based mental health clinician).

Eligible students were randomly assigned to a 10-session standardized cognitive–behavioral therapy. Students were randomly assigned to either the early-intervention group (n = 61) or to a waitlist delayed-intervention control group (n = 65). School officials preferred to provide an intervention program to all students, so students assigned to the waitlist delayed-intervention control group received CBITS 3 months after the early intervention group participated in the program. Therefore, at the 3-month follow-up, the early-intervention group was compared to the waitlist delayed-intervention comparison group before they participated in the intervention. However, at the 6-month follow-up, all study participants had received the CBITS program. Data from students was collected at baseline and at 3 months. Data was also collected at 6 months after the waitlist delayed-intervention control group had received 3 months of intervention. The CrimeSolutions review of this study focused on the comparison between the early-intervention group and the wait-list delayed-intervention control group at the 3-month follow up.

The early intervention group had an average age of 11 years and was 33 percent female. The group also had a Child PTSD Symptom Scale (CPSS) average score of 24.5 (indicating moderate to severe PTSD symptom levels). The waitlist delayed-intervention control group had an average age of 10.9 years, was 38 percent female, and had an average CPSS score of 23.5. There were no significant differences between the two groups on baseline characteristics.

Multiple measures were used to assess symptoms of PTSD, symptoms of depression, child psychological dysfunction, and classroom behavior. PTSD symptoms were assessed using the CPSS, a 17-item child self-report measure where students rate how often they are bothered by each symptom in the past month on a scale from 0 (not at all) to 3 (almost always). Depression was measured using the Child Depression Inventory (CDI), a 26-item scale that assesses children’s cognitive, affective, and behavioral symptoms of depression. Child psychosocial dysfunction was measured using the 35-item Pediatric Symptom Checklist (PSC), in which a student's parents rate the frequency of the student’s emotional and behavioral problem on a scale from 0 (never) to 2 (often). Classroom behavior was measured by having the student’s teacher complete the 6-item Teacher–Child Rating Scale for shyness/anxiousness, learning problems, and an acting out behavior problem subscales. The teachers rate how much of a problem each behavior is on a scale from 1 (not a problem) to 5 (very serious problem).

Linear regression to estimate the mean difference in outcome scores between the two intervention groups at 3 months and 6 months was used to assess the effectiveness of CBITS. Effect sizes were calculated as the ratio of the estimated treatment effect (early intervention score minus delayed intervention score at follow-up, after controlling for baseline scores) to the pooled standard deviation at baseline. No subgroup analysis was conducted.

Study

Kataoka and colleagues (2003) evaluated CBITS using a quasi-experimental design with recent immigrant Latino children to test the effectiveness of the Mental Health for Immigrants Program (MHIP) child intervention, which is an eight-session cognitive–behavioral therapy group program based on CBITS. Nine public schools in Los Angeles, Calif., agreed to participate in the study. A total of 970 students were eligible for screening (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 screening 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 in the final sample because they were available for the 3-month follow up.

Initially, 67 students were randomly assigned to receive the MHIP intervention immediately, and 46 students were assigned to a waitlist control 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 assigned to the intervention (which introduced a nonrandomized group into the early intervention treatment group), resulting in a total of 152 children participating in the early MHIP intervention and the original 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). Data on the 152 students receiving CBITS and the 46 waitlist control group students was used in the analyses.

The early intervention group was 51 percent female with an average age of 11.5 years. The waitlist control group was 47 percent female with an average age of 11.2 years. All study participants were Latino, with country of origin varying from Mexico (57 percent), El Salvador (18 percent), Guatemala (11 percent), and other countries (13 percent). There were no statistically significant differences in demographic characteristics between the two groups, except for parental education; the parents of the students in the waitlist group had significantly fewer years of education.

During the 3-month follow-up period, exposure to community violence was measured with a modified version of the Life Events Scale, a 34-item scale that asks about the frequency of several types of violence directed at the study participant or directly witnessed by them (such as threats, slapping/hitting/punching, knife attacks, and shootings) in multiple locations over the past year and throughout the participant's lifetime. Symptoms of PTSD reported in the past month were measured with the CPSS. The CDI was used to measure depressive symptoms reported in the past two weeks. All measures were translated from English to Spanish by the school district’s translation unit.

Comparison of continued data between baseline and follow-up was completed using a two-tailed Student t-test. Categorical data was compared using the chi-square statistic. In addition, linear regression was used to examine bivariate and multivariate relationships of outcome variables. To obtain robust estimates of the standard errors, adjustments for clustering were also made to account for the different assignment strategies. This could take into account potential school effects as well as any systematic differences in school demographics. No subgroup analysis was conducted.

Start-up costs for Cognitive–Behavioral Intervention for Trauma (CBITS) include training as well as ongoing supervision or consultation by a CBITS expert. Training for 12–15 participants costs approximately $4,000, plus trainer travel expenses. Continuing education credits often can be arranged. Trainers typically conduct pretraining consultation on implementation issues and provide extensive implementation and implementation support materials via the CBITS website: http://cbitsprogram.org/<br><br> The cost of implementation can be calculated based on the salary of a full-time, school-based, mental health professional who is devoted to delivering CBITS. One professional can screen students in the general school population and select students with elevated symptoms, delivering up to 30 CBITS groups per academic year (6–8 students per group), for a total of about 210 students. Given an estimated annual cost of a full-time social worker at $90,000, this would result in a cost of $430 per participant.<br><br> The CBITS manual costs approximately $45 and is available from Sopris West/Cambium Publishing. The manual contains reproducible worksheets for use in the groups.

Required materials: The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) manual by Lisa H. Jaycox (2003) is available to the public (Cognitive–Behavioral Intervention for Trauma in Schools. Longmont, Colo.: Sopris West Educational Services). The manual contains reproducible worksheets for use in the groups, and details step-by-step plans and scripts for implementing the program.

You can download or purchase the CBITS manual. The CBITS manual for the entire course is available as a free download from the RAND website. 

Training requirements/provider certification: Trainings are offered regularly through the National Child Traumatic Stress Network and can also be arranged onsite. A free, online training course is available on the CBITS website, along with extensive implementation support. Consultation on implementation and evaluation, ongoing supervision of trainees, and monitoring adherence is also available. Psychiatric school clinicians or social workers should be at the master’s level and may require supervision in the beginning.

CBITS is being disseminated nationally for use with various ethnic and racial groups, and with high school students. Adaptations are available to accommodate Spanish speakers, low-literacy students, and those in the foster care system.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Cohen, Judith A., Lisa H. Jaycox, Douglas W. Walker, Anthony P. Mannarino, Audra K. Langley, and Jennifer L. DuClos. 2009. “Treating Traumatized Children After Hurricane Katrina: Project Fleur-de-Lis.” Clinical Child and Family Psychology Review 12(1):55–64.

Jaycox, Lisa H. 2003. Cognitive–Behavioral Intervention for Trauma in Schools. Longmont, Colo.: Sopris West Educational Services.

Jaycox, Lisa H., Judy A. Cohen, Anthony P. Mannarino, Douglas W. Walker, Audra K. Langley, Kate L. Gegenheimer, Molly Scott, and Matthias Schonlau. 2010. “Children’s Mental Health Care Following Hurricane Katrina: A Field Trial of Trauma-Focused Psychotherapies.” Journal of Traumatic Stress 23(2):223–31.

Morsette, Aaron, Gyda Swaney, Darrell Stolle, David Schuldberg, Richard van den Pol, Melissa Young. 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(1):169–78.

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.

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.

Following are CrimeSolutions-rated programs that are related to this practice:

Trauma-Focused Treatment for Juveniles and Young Adults With Trauma Symptoms and Externalizing Behaviors

This practice consists of trauma-focused interventions to treat trauma symptoms and externalizing behaviors in juveniles and young adults. The practice is rated Effective for reducing trauma symptoms and for externalizing behaviors in juveniles and young adults, compared with juveniles and young adults in the control group who did not receive treatment.

Evidence Ratings for Outcomes

	Mental Health & Behavioral Health - Trauma/PTSD
	Mental Health & Behavioral Health - Externalizing behavior

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?