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Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

A multi-session group intervention that aims to reduce children's post-traumatic stress disorder (PTSD) symptoms, as well as anxiety and depression resulting from exposure to violence, through child, parent, and teacher educational sessions.

Program Outcomes

  • Depression
  • Post Traumatic Stress Disorder

Program Type

  • Counseling and Social Work
  • School - Individual Strategies
  • Skills Training

Program Setting

  • School

Continuum of Intervention

  • Indicated Prevention

Age

  • Early Adolescence (12-14) - Middle School
  • Late Childhood (5-11) - K/Elementary

Gender

  • Both

Race/Ethnicity

  • All

Endorsements

Blueprints: Promising
Crime Solutions: Effective
OJJDP Model Programs: Effective
SAMHSA : 3.0-3.4

Program Information Contact

Lisa H. Jaycox
Rand Corporation
1200 South Hayes Street
Arlington, VA 22202
jaycox@rand.org

Program Developer/Owner

Lisa H. Jaycox, Ph.D.
Rand Corporation


Brief Description of the Program

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is designed to reduce posttraumatic stress disorder (PTSD), depression, and anxiety among children with symptoms of PTSD. The 10-session school-based intervention teaches cognitive behavioral skills in a group format, led by mental health professionals, with 6-8 students per group, using a mixture of didactic presentation, examples, and games to solidify concepts. Some components of the program include: relaxation training, combating negative thoughts, reducing avoidance, developing a trauma narrative, and building social problem solving skills. The program also includes 1-3 individual child sessions, 2 optional parent sessions, and a teacher inservice session.

Outcomes

(Stein et al., 2003)

  • Decrease in self-reported PTSD and depression, relative to a waitlisted control group, at 3 month followup.
  • Intervention parents reported their children to be functioning significantly better than did the parents of children in the delayed intervention group.
  • Teachers reported no significant difference in classroom behavior between intervention and waitlisted control students at 3 months.
  • At 6 months, after the delayed intervention group had received the CBITS intervention, there were no longer significant self- or parent-reported differences between the two groups.

CBITS used in New Orleans after Hurricane Katrina (Jaycox et al., 2010)

  • At 10 month follow-up of a treatment/alternative treatment comparison, PTSD scores improved in both interventions including all students who began treatment, compared with baseline scores.
  • Changes in depressive symptoms improved for both groups, but the improvement was only statistically significant for the CBITS group, with mean depression scores moving to the normal range for both groups.

Brief Evaluation Methodology

The original CBITS program has been evaluated in one randomized control trial in The Los Angeles Unified School District (LAUSD), and a second randomized control trial in New Orleans. Modifications of the program have been piloted to allow for its implementation by non-clinically trained school personnel (renamed Support for Students Exposed to Trauma) in Los Angeles. The original version of the program used with immigrant populations was named Mental Health for Immigrants.

Study 1

Stein, B., Jaycox, L., Kataoka, S., Wong, M., Tu, W., Elliott, M., & Fink, A. (2003). A mental health intervention for school children exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-611.


Risk Factors

Individual: Stress*

Family: Family conflict/violence

Protective Factors

Individual: Coping Skills, Problem solving skills


* Risk/Protective Factor was significantly impacted by the program

Race/Ethnicity/Gender Details

All, but designed for multi-cultural schools.

$4,000 for two days of onsite training for up to 15 trainees.

Training Certification Process

An intensive two-day training and consultation is available through the Los Angeles Unified School District (LAUSD) Trauma Services Adaptation Center for Schools and Communities. Before taking the CBITS training course, please download or purchase the CBITS manual. The CBITS manual for the entire course is available as a FREE download, or you can purchase the paperback manual.

www.rand.org/pubs/commercial_books/CB209.html#download

Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.

Start-Up Costs

Initial Training and Technical Assistance

Training costs $4,000 plus travel for on-site training of up to 15 trainees. For programs of adequate size, train the trainer opportunities are available.

Before taking the CBITS training course, please download or purchase the CBITS manual. The CBITS manual for the entire course is available as a FREE download, or you can purchase the paperback manual.

www.rand.org/pubs/commercial_books/CB209.html#download

Curriculum and Materials

$23.20 plus tax and shipping for a reusable manual.

Licensing

None.

Other Start-Up Costs

None.

Intervention Implementation Costs

Ongoing Curriculum and Materials

None, unless manuals need replacement.

Staffing

Qualifications: Implementation by a master's degree mental health professional is recommended. Such a person can be employed by a school or mental health agency. The purveyor suggests a salary and fringe cost of $90,000 for group leaders.

Ratios: A Mental Health Professional delivering CBITS can serve up to 30 groups of 6-8 students annually, reaching a total of 210 students in a year.

Time to Deliver Intervention: For each participant, the complete program consists of 10 group sessions, 1 - 3 individual sessions, 2 parent psychoeducational sessions, and 1 teacher educational session.

Other Implementation Costs

For programs offered in schools, classroom or other available space is typically used at no additional cost. For programs in other venues, meeting space for 8-10 people is needed.

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

School systems can choose to have an annual refresher course at $2,000 per day plus trainer for on-site training.

Fidelity Monitoring and Evaluation

Can range from no cost (using a session checklist) to taping sessions for expert review at $100 per hour.

Ongoing License Fees

None.

Other Implementation Support and Fidelity Monitoring Costs

No information is available

Other Cost Considerations

A co-leader can be used if desired, at additional staffing cost.

Year One Cost Example

A school system wishing to implement CBITS in 10 schools can expect the following year one costs:

Training, including trainer travel $5,000.00
Manuals (10) $500.00
Salaries Fringe (10 mental health professionals) $900,000.00
Total One Year Cost $905,500.00

At a ratio of 30 groups serving 6 - 8 children per Mental Health Professional, the above costs would support CBITS for 2,100 children and youth at a per youth cost of $431 for year one.

Funding Overview

CBITS is a school-based intervention and many districts train existing social work and counseling staff in the delivery of CBITS. CBITS, as a mental health intervention targeted to youth with trauma exposure, can be billed to Medicaid for Medicaid-eligible participants. In addition, core child welfare and mental health funding streams are good options for supporting costs not Medicaid billable or populations not eligible for Medicaid.

Funding Strategies

Improving the Use of Existing Public Funds

Many school systems train school social workers or other staff to deliver CBITS and then have the potential to access Medicaid to support some costs for these staff. This assumes a high proportion of Medicaid-eligible youth among participants.

Allocating State or Local General Funds

School systems and child welfare agencies might consider supporting CBITS for youth not eligible for Medicaid.

Maximizing Federal Funds

Entitlements: Since CBITS is a targeted intervention aimed at youth exposed to trauma, Medicaid is an important source of funding. When the CBITS group leader is a Medicaid qualified mental health professional, Medicaid can be billed for eligible participants. Billing would be for group therapy unless the Medicaid agency elected to make CBITS a Medicaid service.

Formula Grants: The core child welfare, and behavioral health formula funds are potentially options for needed start-up funding, or to cover ongoing staffing, technical assistance and fidelity monitoring costs that are not billable under Medicaid. They can also be used to pay for children not eligible for Medicaid.

  • The Mental Health Services Block Grant (MHSBG) can fund a variety of mental health promotion and intervention activities and is a potential source of support for CBITS programs.
  • Title IV-B, Parts 1 & 2 provides fairly flexible funding to state child welfare agencies for child welfare services including prevention and family preservation activities.

Discretionary Grants: Grants that could potentially support CBITS can be found in the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control (CDC) within the Department of Health and Human Services.

Foundation Grants and Public-Private Partnerships

Foundation grants can be considered for the cost of initial training of group leaders.

Data Sources

All information comes from the responses to a questionnaire submitted by the purveyor, The National Child Traumatic Stress Network, to the Annie E. Casey Foundation.

Program Developer/Owner

Lisa H. Jaycox, Ph.D.Rand Corporation1200 South Hayes StreetArlington, VA 22202jaycox@rand.org

Program Outcomes

  • Depression
  • Post Traumatic Stress Disorder

Program Specifics

Program Type

  • Counseling and Social Work
  • School - Individual Strategies
  • Skills Training

Program Setting

  • School

Continuum of Intervention

  • Indicated Prevention

Program Goals

A multi-session group intervention that aims to reduce children's post-traumatic stress disorder (PTSD) symptoms, as well as anxiety and depression resulting from exposure to violence, through child, parent, and teacher educational sessions.

Population Demographics

The participants across multiple studies were in grades 4-8. The Blueprints-certified study was conducted only with 6th graders. The schools were located in socioeconomically disadvantaged areas, and the population was primarily Latino or African American. All participants had reported exposure to violence and had clinical level symptoms of PTSD.

Target Population

Age

  • Early Adolescence (12-14) - Middle School
  • Late Childhood (5-11) - K/Elementary

Gender

  • Both

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

All, but designed for multi-cultural schools.

Other Risk and Protective Factors

Risk: Community Factors (direct experience of violence), Family factors (witnessing violence at home).

Protective: Individual (learned skills in social problem solving and avoidance/coping).

Risk/Protective Factor Domain

  • Individual
  • Family
  • Neighborhood/Community

Risk/Protective Factors

Risk Factors

Individual: Stress*

Family: Family conflict/violence

Protective Factors

Individual: Coping Skills, Problem solving skills


*Risk/Protective Factor was significantly impacted by the program

Brief Description of the Program

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is designed to reduce posttraumatic stress disorder (PTSD), depression, and anxiety among children with symptoms of PTSD. The 10-session school-based intervention teaches cognitive behavioral skills in a group format, led by mental health professionals, with 6-8 students per group, using a mixture of didactic presentation, examples, and games to solidify concepts. Some components of the program include: relaxation training, combating negative thoughts, reducing avoidance, developing a trauma narrative, and building social problem solving skills. The program also includes 1-3 individual child sessions, 2 optional parent sessions, and a teacher inservice session.

Description of the Program

Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) identifies children who have been exposed to violence and show symptoms of posttraumatic stress disorder (PTSD). Once the children have been identified, they begin an intervention program based in cognitive behavioral therapy. CBITS is a 10-session intervention designed for use in an inner-city school mental health clinic with a multicultural population in a group format, augmented by 1-3 individual child sessions, 2 optional parent sessions, and a teacher inservice session.The groups meet once a week and have homework assignments in between groups.

CBITS emphasizes applying techniques learned in the program to the child's own problems. Some components of the program include: relaxation training, combating negative thoughts, reducing avoidance, developing a trauma narrative, and building social problem solving skills. The skills are introduced by a mixture of didactic presentation, age-appropriate examples, and games to solidify concepts.

There is a modified version of the program for use specifically with immigrants, and this very similar program was named Mental Health for Immigrants Program (MHIP), which is reviewed elsewhere under that name (Kataoka, Stein, Jaycox, Wong, Escudero, Tu, Zaragoza, & Fink, 2003).

The program was also modified by the original researchers to be administered by school personnel without clinical training, and was renamed Support for Students Exposed to Trauma (SSET; Jaycox, Langley, Stein, Wong, Sharma, Scott, & Schonlau, 2009), reviewed as Study 3.

Theoretical Rationale

Several studies have found that the majority of children exposed to violence display symptoms of posttraumatic stress disorder (PTSD), and a substantial minority develop clinically significant PTSD. The authors' concern was that exposure to violence alone had several negative effects (e.g., depression, behavioral problems, poor school performance, decreased IQ and reading ability, lower grade point averages, developmental problems), even if the children did not develop PTSD. In this investigation, a cognitive behavioral therapy group intervention was used to reduce symptoms of PTSD and depression and to improve psychosocial functioning and classroom behavior in students.

Theoretical Orientation

  • Skill Oriented
  • Cognitive Behavioral
  • Social Learning

Brief Evaluation Methodology

The original CBITS program has been evaluated in one randomized control trial in The Los Angeles Unified School District (LAUSD), and a second randomized control trial in New Orleans. Modifications of the program have been piloted to allow for its implementation by non-clinically trained school personnel (renamed Support for Students Exposed to Trauma) in Los Angeles. The original version of the program used with immigrant populations was named Mental Health for Immigrants.

Outcomes (Brief, over all studies)

Study 1 (Stein et al., 2003): Overall, results of self- and parent-reports in a randomized control trial with urban, primarily Latino, youth, demonstrated positive intervention effects. Eighty-six percent of the students in the early intervention group reported significantly lower self-reported PTSD symptoms and 67% reported lower symptoms of depression. The parents of the early intervention group reported 78% less child psychosocial dysfunction than parents of children in the delayed intervention group. However, teachers did not report significant differences in classroom behaviors between students who received CBITS and the waitlist control students. At the six-month follow-up, after the delayed intervention group had received the CBITS intervention, results indicated that students in the early intervention group had no significant differences on any tests from the delayed group.

Study 2: CBITS used in New Orleans after Hurricane Katrina (Jaycox et al., 2010): At 10 month follow-up, PTSD scores improved for youth in both interventions, compared with baseline scores. Mean PTSD scores for the Trauma Focused-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 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.

Study 3: Pilot Study of SSET (Jaycox et al, 2009), a program which modified CBITS to be implemented by non-clinically training school staff: A pilot study examining whether a version of CBITS that can be implemented with non-clinically trained school staff found high implementation fidelity and moderate to high satisfaction with the program. 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.

Outcomes

(Stein et al., 2003)

  • Decrease in self-reported PTSD and depression, relative to a waitlisted control group, at 3 month followup.
  • Intervention parents reported their children to be functioning significantly better than did the parents of children in the delayed intervention group.
  • Teachers reported no significant difference in classroom behavior between intervention and waitlisted control students at 3 months.
  • At 6 months, after the delayed intervention group had received the CBITS intervention, there were no longer significant self- or parent-reported differences between the two groups.

CBITS used in New Orleans after Hurricane Katrina (Jaycox et al., 2010)

  • At 10 month follow-up of a treatment/alternative treatment comparison, PTSD scores improved in both interventions including all students who began treatment, compared with baseline scores.
  • Changes in depressive symptoms improved for both groups, but the improvement was only statistically significant for the CBITS group, with mean depression scores moving to the normal range for both groups.

Generalizability

Study 1, which used random assignment to immediate and waitlisted treatment groups, and Study 3, a feasibility and pilot study, were implemented with urban, primarily Latino, youth.

Study 2, which randomly assigned youth to CBITS or an alternative therapy among youth in New Orleans after Hurricane Katrina, was conducted on primarily white and African-American youth. Completion of the alternative therapy was low, resulting in the inability to use tests of significance to compare outcomes.

Potential Limitations

Informants (teachers or parents) were not blinded to the treatment conditions. In Study 1, there were no differences between conditions reported by teachers at either 3 months or 6 months, which the researchers attribute to the use of multiple informants, teachers' attunement to behavior not symptoms, time lags for behavior to change, and/or that classroom behavior is affected by many factors other than mental health. Because the control group received the intervention after 3 months, there is no true control group at the 6-month follow-up.

In Study 2, 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 through post-testing, and thus comparisons between the treatment group and any other group (no treatment control or alternative treatment) were not possible.

In Study 3, appropriately labeled a pilot study, the sample size was too small to conduct tests of statistical significance.

Notes

In the study which qualified for Blueprints, the clinicians delivering the program received two days of training, plus weekly supervision. The program effectiveness without the weekly supervision is unknown.

Endorsements

Blueprints: Promising
Crime Solutions: Effective
OJJDP Model Programs: Effective
SAMHSA : 3.0-3.4

Program Information Contact

Lisa H. Jaycox
Rand Corporation
1200 South Hayes Street
Arlington, VA 22202
jaycox@rand.org

References

Study 1

Certified Stein, B., Jaycox, L., Kataoka, S., Wong, M., Tu, W., Elliott, M., & Fink, A. (2003). A mental health intervention for school children exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-611.

Study 2

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

Study 3

Jaycox, L. H., Langley, A. K., Stein, B. D., Wong, M., Sharma, P., Scott, M., & Schonlau, M. (2009). Support for students exposed to trauma: A pilot study. School Mental Health, 1(2), 49-60.

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.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

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Blueprints for Healthy Youth Development is
currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.