Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

Study 1

Evaluation Methodology

Design: The first study was a randomized control trial examining the effectiveness of a cognitive behavioral therapy group intervention. The intervention was a 10-session Cognitive Behavioral Intervention for Trauma in Schools (CBITS). It was designed for use in an inner-city school mental health clinic with a multicultural population. The intervention incorporated cognitive-behavioral therapy skills in a group format. The 10 sessions were implemented on a continuous basis from late autumn through spring of the 2001-2002 academic year, in two middle schools in Eastern Los Angeles.

After parents agreed to have their children participate and children agreed to be screened, the mental health clinicians administered a self-report questionnaire regarding exposure to violence and symptoms of PTSD to 769 sixth-grade students. The students were screened for eligibility to the program; they were eligible to participate if (1) they had substantial exposure to violence; (2) they had symptoms of PTSD in the clinical range; (3) they had symptoms of PTSD related to exposure to violence; and, (4) they did not appear too disruptive to participate in group therapy intervention. One hundred and fifty-nine students met the criteria, of which 126 students chose to participate and complete baseline assessments. These students were randomly assigned into early intervention (n=61) or delayed intervention groups (n=65). Initial baseline scores were taken to account for individual differences. Program assessments were done for baseline (the initial screening), at 3 months, and at 6 months. The 3-month assessment served as a posttest for the early intervention group, who had just completed the program, while the delayed intervention group had yet to begin the intervention. The 6-month assessment served as a 3-month follow-up for the early intervention group and as a posttest for the delayed intervention group, who had just completed the program.

Sample: The sample contained one hundred and twenty six middle school students from two different East Los Angeles schools. This area of Los Angeles is primarily Latino and socioeconomically disadvantaged. Both males and females participated in the study, however, no exact calculations were presented as to how many males and females participated. Sample attrition was minimal; of the initial one hundred and twenty six student participants, one hundred and seventeen (93%) completed the 3-month follow-up assessments (54 IV, 63 control), and one hundred and thirteen (90%) completed the 6-month follow-up assessments. Overall, 90% of the participants (53 IV, 60 control) completed all assessments.

Measures: The CBITS intervention had been previously piloted for feasibility and acceptability. The school clinicians also followed a treatment manual to ensure that the application of the intervention was standardized across clinicians. The integrity of the intervention was tested through random assessment both to the extent of session completion and also the overall quality of therapy the intervention provided. On the seven items assessing quality, all sessions were rated moderate to high. Students' symptoms of PTSD were assessed using a seventeen-item Child PTSD Symptom Scale (CPSS) self-report measure (range, 0-51 points). This measure has been shown to have good convergent validity, discriminant validity, and high reliability. Students' depression levels were assessed using a twenty six-item Child Depression Inventory (CDI). This inventory assesses children's cognitive, affective, and behavioral symptoms of depression. The CDI was chosen for its good test-retest reliability and validity. Child psychosocial dysfunction was assessed using the thirty five-item Pediatric Symptom Checklist (PSC), in which the student's parent rated the frequency of emotional and behavioral problems (scale: 0=never and 2=often). Classroom behavior was assessed by the student's teacher using the six-item Teacher-Child rating scale (1= not a problem, 5= a very serious problem).

Analysis: Baseline measures were compared for the early intervention group and the delayed intervention group to assess individual differences. All clinical and demographic characteristics were compared in the baseline estimates. To assess the effectiveness of the intervention, a linear regression analysis was used to estimate the mean difference in outcome scores between the two groups at three and six months, adjusted for scores at baseline. Effect sizes were calculated to assess the magnitude of intervention effects. These were calculated as the odds ratio of the estimated treatment effect to the pooled standard deviation at baseline.

Outcomes

Intervention Integrity: Completion of required elements of the intervention program ranged from 67% to 100%, with a mean rate of 96%. Quality of sessions was assessed as moderate to high across all sessions.

Baseline Characteristics: In baseline characteristics, there were no significant differences between the students in the early intervention and delayed intervention groups. The 3-month assessment was completed by 117 students and 113 students completed the 6-month assessment. At baseline, compared with students who had completed all assessments, non-completers had significantly higher CPSS scores (mean difference, 5.4; 95% CI, 1.5-9.4), CDI scores (mean difference, 8.1; 95% CI, 3.0-13.2), acting out classroom behaviors (mean difference, 7.7; 95% CI, 3.4-11.9), and classroom learning problems (mean difference, 5.2; 95% CI, 0.4-10.0).

Posttest: At the 3-month assessment, students in the early intervention group had significantly lower self-reported symptoms of PTSD than students in the delayed intervention group. The mean difference between groups was -7.0 (95% CI, -10.8 to -3.2), with an effect size of 1.08. The results of the logistic regression analysis (adjusted for baseline scale scores) indicated that at the 3-month assessment, 86% of students in the early intervention group had significantly lower self-reported PTSD symptoms than students who did not undergo CBITS intervention. Students in the early intervention group had 67% lower self-reported symptoms of depression than students in the delayed CBITS intervention, with an adjusted mean difference of -3.4 (9.4 vs. 12.7) and an effect size of 0.45. At 6 months, when the delayed group received intervention, significant differences were no longer present between the delayed group and experimental group, in self-report PTSD scores or depression.

Parents of students in the early intervention group at 3-months reported significantly less psychosocial dysfunction (78%) than parents in the delayed intervention group. The adjusted mean difference was -6.4 (95% CI,-10.4 to 2.3), with an effect size of 0.77. Again, no significant differences existed after the parents in the delayed group received intervention; this finding was true for all measures. At the 6 month follow-up, after the delayed group had received CBITS intervention, the results indicated that students in the early intervention group had no significant differences on any tests from the delayed group. Teachers reported no differences between groups on classroom behaviors.

Long-term: This was the first study to date to use a randomized controlled trial to evaluate the effectiveness of an intervention for children with substantial levels of symptoms of PTSD. As this was a preliminary evaluation, the long-term effects will need to be revealed in time and with replication. However, the students that received this brief intervention had significantly fewer self-reported symptoms of PTSD and parent-reported psychosocial dysfunction than the delayed intervention group. While it is positive that the students in the delayed intervention had significant positive changes after receiving intervention and those in early intervention maintained improvement at the six month assessment, only short-term effectiveness of the intervention is known.

Study 2

Evaluation Methodology

Design: From an original potential pool of 609 fourth to eighth graders at three schools, after consents, 195 students were screened and 118 who met inclusion criteria were randomized into one of two programs, CBITS or Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006). Students were assessed at baseline, at 5 months, and at 10 months. The CBITS groups were implemented from March to May 2007 and TF-CBT was implemented from February to September 2007. Jaycox, et al. (2010) reports only on the 10 month assessment results.

TF-CBT, received by the comparison group, is a 12-session individual or conjoint intervention that includes child and parents and is typically delivered in clinics. For this evaluation, the 10 CBIT group sessions were provided along with 1-3 individual sessions designed specifically for use in schools. The earlier study by Stein et al., 2003, makes no mention of the individual sessions.

Sample: Three schools were selected to represent schools participating in a larger project, Project Fleur-de-Lis. An introductory letter was sent home with consent forms to the parents of 609 fourth to eighth graders at the three schools. 438 consent forms were returned (72%), and 202 (33%) granted permission to participate. Six students declined to participate and one moved, resulting in 195 (32%) participants in the screening. The consent rate was 41%, 27% and 46%, for the three schools. School 1 was predominately African American (74%), with 75% participating in the free/reduced lunch program (FRLP). School 2 was predominately Caucasian (90%) with 11% participating in the FRLP, and School 3 was predominately African American (97%) with 80% participating in the FRLP.

Of the 195 students who participated, 118 (61%) screened positive for PTSD symptoms. Students were randomized within strata to receive each intervention, resulting in 58 students being offered CBITS and 60 students offered TF-CBT (16, 57, and 45 participants in the three schools).

Participating students included slightly more girls (55.9%) than boys. Forty-eight percent of participants were non-Hispanic White, 46% were African American, 5% were Hispanic, and 2% were from other racial/ethnic groups. More girls (63%) than boys were determined to be at risk based on PTSD symptoms scores, with an average age of 11.5. More than half (52%) were African American, 42% were non-Hispanic White, 4% were Hispanic, and 2% were from other racial/ethnic groups.

Of children randomized to CBITS, 57 of 58 began treatment and 53 (91%) completed treatment. For children randomized to TF-CBT, 22 of the 60 (37%) attended the initial assessment, and of this number, seven (32%) did not meet PTSD criteria on the K-SADS and were not provided treatment. Another child had a pervasive developmental disorder that precluded inclusion in the study, and thus 14 students (23%) began TF-CBT and 9 completed treatment at the 10 month follow-up.

Measures: At baseline, students completed the self-report measure, Disaster Experiences Questionnaire (Scheeringa, 2005), and the UCLA PTSD Reaction Index for DSM-IV (Pynoos, et al., 1998).

At baseline and at follow-up, students completed the Child PTSD Symptom Scale (Foa, et al., 2001), the Children's Depression Inventory (Kovacs, 1981), and the Social Support Scale for Children (Harter, 1985; subscales for friends and family). Teachers reported on student behavior problems using the Strengths and Difficulties Questionnaire (Goodman, 1997; Goodman, et al., 1998).

As part of the normal TF-CBT protocol, children assigned to TF-CBT were scheduled for a clinic intake consisting of the PTSD section of a diagnostic interview (the Schedule for Affective Disorders and Schizophrenia for School Aged Children - Present and Lifetime Version; K-SADS-PL-PTSD; Kaufman, et al., 1996). Children whose responses did not indicate PTSD were not included in the TF-CBT treatment.

Analysis: Missing items were imputed 5 times separately for each treatment group and time point using ProcMI in SAS. Descriptive analyses were conducted at baseline, and compared groups receiving CBITS and TF-CBT. The plan to examine predictors of improvement within each group was not possible due to limited numbers of children who participated in TF-CBT. Thus, predictors of improvement are examined for the CBITS group only, via regressions controlling for baseline PTSD levels, adjusted for clustering within CBITS intervention groups. In the TF-CBT group, researchers examined predictors of uptake of TF-CBT via logistic regression predicting intake attendance.

Outcomes: Students in the study report a median of one type of hurricane exposure (range 0-7; most common experiences included having seen something very upsetting or being separated from parent or caregiver). Lifetime trauma was common with students reporting a median of 4 traumatic events (range 0-10, most commonly learning about the death or injury of a loved one, witnessing violence, car accidents, being victims of violence, medical procedures) at baseline. At the 10-month assessment, students reported on traumatic events since the last assessment, and students reported a median of 3 additional recent traumatic exposures.

Measures of PTSD, depression, and teacher reported behavior problems demonstrated that the two groups of children were comparable to each other.

At 10 month follow-up, PTSD scores improved for youth in both interventions, compared with baseline scores. Mean PTSD scores for the TF-CBT group had moved to the normal range whereas mean scores in the CBITS group were in the low clinical range. Thirty-seven of the 57 children (65%) in the CBITS group remained in the at-risk range on the Child PTSD Symptom Scale at 10 month follow-up, whereas 6 of the 14 children (43%) in TF-CBT remained at risk. A Fisher's Exact test revealed these two rates of clinical change were comparable across the two groups.

Changes in depressive symptoms also improved for both groups, but the improvement was only statistically significant for the CBITS group, with mean depression scores moved to the normal range for both groups.

Predictors of treatment outcome for the CBITS group were examined, predicting PTSD symptoms at 10 months while controlling for baseline PTSD. Baseline PTSD was a strong predictor of PTSD at 10 months. Support from family predicted lower PTSD scores, whereas higher baseline depressive symptoms and additional exposures to traumatic events as reported at follow-up predicted higher PTSD scores. Gender, school, teacher reported behavior problems at baseline, hurricane exposures, and social support from friends were unrelated to PTSD at follow-up.

Limitations

Though the subjects were randomly assigned to treatment group, there was no control group. The study was originally conceived as having a comparison group that received another CBT-based program. However, enrollment in that program was very low, and only 9 subjects completed the full program though post-testing, and thus comparisons between the treatment group and any other group (no treatment control or alternative treatment) were not possible.

Study 3

The program was modified to address the issue that CBITS relies on clinically training school mental health professionals which limits its reach, because many schools do not have access to such professionals. This project aimed to establish the feasibility of implementing the program with non-clinical school personnel, including both structural implementation issues and implementer fidelity (to the manual). A small pilot study was also conducted to observe change as a function of participation and to evaluate participant and parent satisfaction with the program.

Like CBITS, the SSET program consists of 10 lessons designed to reduce post-traumatic and depressive symptoms and improve functioning in middle school youth who have been exposed to traumatic events, but did not include individual child sessions nor parent or teacher sessions. The core cognitive behavioral elements of the 10 lessons are the same as those used in CBITS. The primary differences between the two programs are: (1) format (SSET converts the CBITS session format to a lesson plan format); (2) elimination of individual break-out sessions in SSET; (3) elimination of parent sessions in SSET; and (5) changes in the imaginal exposure to trauma that is conducted in CBITS to a more curricular format in SSET.

Evaluation Methodology

Overall Research Design and Subjects: The project was conducted in two middle schools in the Los Angeles Unified School District, chosen by convenience. One middle school serves 1,840 6th to 8th grade students, primarily Latino youth (91%), and the second middle school serves 2,403 6th to 8th grade students, primarily Latino youth (82%). Parental consent forms were returned for 52% of the 1,657 6th and 7th graders across the two middle schools over a two-year period, with 52% of those (453) granting permission for participation. 383 students also gave their own assent and were administered the screening protocol. Of those, 58% (n=222) met the criteria for exposure to severe violence and current PTSD symptoms. After being interviewed individually, 183 remained eligible and a second level of parental consent was requested. Of these, 98 (51%) were returned, with 84 (84% giving consent to participate). Of these, 78 students consented to participate in the intervention and were randomized within schools to the immediate program or to be on the waiting list control group. Two students withdrew shortly after randomization, before the start of groups, leaving 76 in the sample. Those in the immediate group began to receive services within a few weeks, both groups completed posttests after 3 months, and then the waiting list control group received services. All but 10 of the students (who had to receive services the following year) were assessed again after both groups had received the program (n=66).

Measures:
Feasibility and Acceptability: Lessons were audio-recorded, a measure of fidelity was developed, and three raters (two developers and an independent research rater) used it to rate three randomly selected lessons. An independent rater who was not involved with the pilot study used the measure to rate two components of each session: coverage (the degree to which the group leader covered a number of required elements unique to each lesson) and quality (assessed with 7 items, such as whether the group leader conveyed empathy). Student compliance was measured by attendance (kept by the four group leaders). Parent and child satisfaction with SSET was assessed after the intervention. Parental satisfaction was based on a series of 13 questions regarding items such as privacy given to the child and family), and child satisfaction was determined in a similar manner (a 15 item survey).

Child Screening and Outcome Measures: Study students' assessments were completed at school in small groups in English. Parent assessments were conducted by telephone, in English or Spanish. The Modified Life Experiences Survey was used to assess exposure to violence through direct experience and witnessing of events at home, at school, and in the neighborhood. The Child PTSD Symptom Scale was used to assess PTSD symptoms for both assessment and child outcomes. The Children's Depression Inventory was used to assess children's cognitive, affective, and behavioral depressive symptoms. Parents and Teachers completed the Strengths and Difficulties Questionnaire -- Parent Report and Teacher Report.

Analysis: Descriptive statistics were computed for parent and child satisfaction with CBITS, implementer fidelity to the model, and student attendance and compliance to examine the feasibility and acceptability of the new program model. Because there were not enough pilot study participants to have adequate power to detect statistically significant effects, the authors focused on trends and effect sizes rather than significance.

Outcomes

Implementation and Fidelity: 26 of the 159 tapes were selected to measure fidelity. Both coverage and quality were found to be high. The average coverage rating was 2.39 out of 3, with a slight decrease in average coverage rating from year 1 (2.43) to year 2 (2.35). The ratings ranged from a low of 1.80 to a high of 3, with the majority of sessions rating above 2.20. The average coverage ratings for each lesson varied. Group leader coverage ratings also showed variability, but all implementers were in the acceptable range of fidelity. The average quality rating was 2.37 out of 3, with the quality of each session improving from 2.31 in Year 1 to 1.23 in Year 2. Quality by group leader also varied, ranging from 2.31 to 2.59. Of the four group leaders, all but one teacher returned attendance data for their four groups. Using the attendance data for the remaining 12 groups yielded that students attended approximately 8 of the 10 lessons, but this was quite variable, ranging from 1 to 10. Of the 76 parents with participating children, 49 (64%) completed the parent satisfaction survey. Their individual satisfaction scores were averaged, yielding an overall satisfaction score of 4.50 out of 6, indicating parental satisfaction between "very good" and "excellent." No parents were dissatisfied. Child satisfaction was similarly high. Of the 76 participating students, 64 (84%) completed a satisfaction survey. More than 50% of the sample (35 students) had satisfaction scores between "mostly true" and "very true," and the overall average child satisfaction score was 2.52 out of 3, ranging from 1.41 to 3.0.

Child Outcomes: Between the baseline and first follow-up, during which the immediate SSET group participated in the lessons, decreases were observed in youth self-reports of PTSD and depression. However, changes in parent reported problem behavior were negligible. Changes in teacher reports showed a small effect size, with the immediate intervention group showing slight decreases in comparison with the delayed intervention group that showed slight increases in behavior problems. During the time between the first and second follow-up, it was observed that the immediate SSET group scores stayed approximately the same, and there was some decrease in the self-reported PTSD and depression, as well as parent reported behavior problems in delayed group. Little change was noted in teacher reports of behavior problems. Regression analyses found a significant intervention group effect for depression and a non-significant trend for PTSD scores (p=.058). Neither parent nor teacher reports showed a significant intervention effect. Impact among children in a high symptoms group were examined for each measure, and for this group, intervention effects were more pronounced for PTSD, depression, and behavior problems.