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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, Developer
Rand Corporation
1200 South Hayes Street
Arlington, VA 22202
jaycox@rand.org

CBITS Website: www.traumaawareschools.org
CBITS Email: info@traumaawareschools.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 with 6-8 students per group, is led by mental health professionals, and uses 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

Primary Evidence Base for Certification

Study 1

Stein et al. (2003) and Kataoka et al. (2011) found that the intervention group, compared to the control group, had significantly

  • Decreased self-reported PTSD symptoms at posttest.
  • Decreased depression at posttest.
  • Better parent-reported child functioning at posttest.
  • Higher math grades at the end of the school year.

Additional Studies

Study 2

Jaycox et al. (2010) found significant improvements from baseline to 10-month follow-up in

  • PTSD symptoms among youth in both interventions.
  • Depressive symptoms among youth in the CBITS group.

Study 3

Halldórsdóttir (2015) found at posttest that the intervention group, relative to the control group, showed significantly reduced

  • self-reported problematic behavior at school.

Study 4

Ochieng-Munda (2020) found that students in the treatment school, relative to students in the control school, reported significantly

  • fewer PTSD symptoms at posttest and three-month follow-up.

Study 5

Sumi et al. (2021) found that the intervention group relative to the control group reported significantly

  • reduced PTSD symptoms at posttest.

Brief Evaluation Methodology

Primary Evidence Base for Certification

Study 1

Stein et al. (2003) and Kataoka et al. (2011) conducted a randomized controlled trial in the Los Angeles Unified School District. A total of 126 sixth-grade students were randomly assigned within two schools to the intervention group or to a waitlist control group. Assessments at baseline and after program completion included measures of PTSD, depression, and grades.

Additional Studies

Study 2

Jaycox et al. (2010) conducted a randomized controlled trial in New Orleans. A total of 118 students were randomly assigned to a modified intervention group that received the program as implemented by non-clinically trained school personnel or to an active control group that received Trauma-Focused Cognitive-Behavioral Therapy. Assessments at baseline, five months, and 10 months measured PTSD symptoms and depression.

Study 3

Halldórsdóttir (2015) conducted a randomized controlled trial to examine 28 college students at one university in North Carolina. The students were randomly assigned to an intervention group or a no-treatment control group. Posttest measures at the end of the six-week program included GPA and student problematic behavior at school.

Study 4

Ochieng-Munda (2020) conducted a cluster randomized controlled trial with two schools and 212 students ages 10-14 in an area outside of Nairobi, Kenya, with informal settlements. One of the two schools was randomly chosen for the treatment, and the other for the control. Baseline, posttest, and three-month follow-up assessments measured PTSD symptoms.  

Study 5

Sumi et al. (2021) conducted a randomized controlled trial that examined 296 sixth-grade students in 12 northern California middle schools. Individuals within the schools were randomly assigned to the intervention group or treatment-as-usual control group. Assessments of mental health problems, behavior problems, and academics occurred at baseline, posttest, and one-year follow-up.

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

See also: Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Logic Model (PDF)

Race/Ethnicity/Gender Details

All, but designed for multi-cultural schools.

The 2-day clinical training for CBITS includes: 1) An overview of child trauma and PTSD and the mental health and academic consequences, 2) A review of the history and evidence base of CBITS, 3) Thorough session by session demonstrations and supervised practice of each core concept for child group and individual sessions, including how to make the material culturally and contextually relevant to the audience, 4) Review of parent and teacher sessions, and 5) Engagement activities around implementation issues and site planning. This package is the essential CBITS training recommended for mental health clinicians with some familiarity with child trauma, group therapy and cognitive behavioral therapy.

The intensive two-day training and consultation is available through the Center for Safe and Resilient Schools and Workplaces. 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.

https://www.rand.org/pubs/tools/TL272.html

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 $6,000 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. Manuals are available in English, Spanish, and Arabic.

https://www.rand.org/pubs/tools/TL272.html

Curriculum and Materials

Manual can be downloaded for free or purchased for approximately $30.00 plus shipping.

1-year subscription to implementation materials and online training at www.traumaawareschools.org is $35.00

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 15 groups of 6-8 students annually, reaching a total of 105 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 $3,000 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 $300 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 $7,000.00
Manuals (10) $300.00
Salaries Fringe (10 mental health professionals) $900,000.00
Total One Year Cost $907,300.00

At a ratio of 15 groups serving 6 - 8 children per Mental Health Professional, the above costs would support CBITS for 1,050 children and youth at a per youth cost of $864 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. 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 factors (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

See also: Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Logic Model (PDF)

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 with 6-8 students per group, is led by mental health professionals, and uses 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).

Theoretical Rationale

The program is grounded in theories of cognitive behavioral therapy (CBT) and includes CBT therapeutic components that focus on reducing students' maladaptive thoughts and destigmatizing the effects of trauma; consequently, students can express and cope with fear and grief reactions. Through social problem-solving techniques, role-playing and coaching activities, therapists help students to communicate their needs for support and find suitable ways to support their peers in the group. The program also provides tools to enhance students' affect regulation, such as relaxation techniques and exposure exercises to decrease anxiety and discomfort.

Theoretical Orientation

  • Skill Oriented
  • Cognitive Behavioral
  • Social Learning

Brief Evaluation Methodology

Primary Evidence Base for Certification

Study 1

Stein et al. (2003) and Kataoka et al. (2011) conducted a randomized controlled trial in the Los Angeles Unified School District. A total of 126 sixth-grade students were randomly assigned within two schools to the intervention group or to a waitlist control group. Assessments at baseline and after program completion included measures of PTSD, depression, and grades.

Additional Studies

Study 2

Jaycox et al. (2010) conducted a randomized controlled trial in New Orleans. A total of 118 students were randomly assigned to a modified intervention group that received the program as implemented by non-clinically trained school personnel or to an active control group that received Trauma-Focused Cognitive-Behavioral Therapy. Assessments at baseline, five months, and 10 months measured PTSD symptoms and depression.

Study 3

Halldórsdóttir (2015) conducted a randomized controlled trial to examine 28 college students at one university in North Carolina. The students were randomly assigned to an intervention group or a no-treatment control group. Posttest measures at the end of the six-week program included GPA and student problematic behavior at school.

Study 4

Ochieng-Munda (2020) conducted a cluster randomized controlled trial with two schools and 212 students ages 10-14 in an area outside of Nairobi, Kenya, with informal settlements. One of the two schools was randomly chosen for the treatment, and the other for the control. Baseline, posttest, and three-month follow-up assessments measured PTSD symptoms.  

Study 5

Sumi et al. (2021) conducted a randomized controlled trial that examined 296 sixth-grade students in 12 northern California middle schools. Individuals within the schools were randomly assigned to the intervention group or treatment-as-usual control group. Assessments of mental health problems, behavior problems, and academics occurred at baseline, posttest, and one-year follow-up.

Outcomes (Brief, over all studies)

Primary Evidence Base for Certification

Study 1

Stein et al. (2003) and Kataoka et al. (2011) found positive intervention effects at posttest on self-reported PTSD symptoms and depression, parent-reported psychosocial dysfunction, and math grades from school records. At the six-month follow-up, after the delayed intervention group had received the intervention, results indicated that students in the early intervention group did not differ from the delayed group on any of the outcomes.

Additional Studies

Study 2

Jaycox et al. (2010) found significant improvements from baseline to 10-month follow-up in PTSD symptoms among youth in both interventions. Depressive symptoms also improved for both groups, but the improvement was only statistically significant for the CBITS group.

Study 3

Halldórsdóttir (2015) found at posttest that the intervention group, relative to the control group, showed significantly reduced self-reported problematic behavior at school.

Study 4

Ochieng-Munda (2020) found that students in the treatment school, relative to students in the control school, reported significantly fewer PTSD symptoms at posttest and three-month follow-up.

Study 5

Sumi et al. (2021) found that, relative to the control group, the intervention group reported significantly reduced PTSD symptoms at posttest.

Outcomes

Primary Evidence Base for Certification

Study 1

Stein et al. (2003) and Kataoka et al. (2011) found that the intervention group, compared to the control group, had significantly

  • Decreased self-reported PTSD symptoms at posttest.
  • Decreased depression at posttest.
  • Better parent-reported child functioning at posttest.
  • Higher math grades at the end of the school year.

Additional Studies

Study 2

Jaycox et al. (2010) found significant improvements from baseline to 10-month follow-up in

  • PTSD symptoms among youth in both interventions.
  • Depressive symptoms among youth in the CBITS group.

Study 3

Halldórsdóttir (2015) found at posttest that the intervention group, relative to the control group, showed significantly reduced

  • self-reported problematic behavior at school.

Study 4

Ochieng-Munda (2020) found that students in the treatment school, relative to students in the control school, reported significantly

  • fewer PTSD symptoms at posttest and three-month follow-up.

Study 5

Sumi et al. (2021) found that the intervention group relative to the control group reported significantly

  • reduced PTSD symptoms at posttest.

Mediating Effects

Not examined.

Effect Size

Study 4 (Ochieng-Munda, 2020) reported large effect sizes for the intervention (d = .79-82).

Generalizability

All studies examined young people who had PTSD symptoms. Study 1 (Stein et al., 2003; Kataoka et al., 2011) examined urban, primarily Latino youth in only two middle schools in Los Angeles. Study 2 (Jaycox et al., 2010) examined youths in New Orleans after Hurricane Katrina who were primarily White and African American. Study 5 (Sumi et al., 2021) examined youths in 12 middle schools within one urban school district in northern California serving a diverse population.

Study 3 (Halldórsdóttir, 2015) differed from the others by examining a sample of college students at one North Carolina university. Study 4 (Ochieng-Munda, 2020) also differed from the others by examining students in Kenya.

Potential Limitations

Primary Evidence Base for Certification

Study 1 (Stein et al., 2003; Kataoka et al., 2011)

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 three months or six 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 three months, there is no true control group at the six-month follow-up.

Additional Studies

Study 2 (Jaycox et al., 2010)

Although 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 nine 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.

Study 3 (Halldórsdóttir, 2015)

  • No baseline controls
  • No tests for baseline equivalence and some apparent large differences
  • No attrition tests and attrition >5%
  • Only one significant effect in three tests
  • Small sample from one university

Study 4 (Ochieng-Munda, 2020)

  • Randomly assigned only two schools - design confound
  • No intent-to-treat analysis
  • No adjustments for clustering within schools, the unit of assignment
  • No control for baseline outcome
  • Incomplete tests for baseline equivalence
  • No tests for differential attrition
  • Specialized and small sample

Study 5 (Sumi et al., 2021)

  • Incomplete tests for differential attrition
  • Very few effects on behavioral outcomes

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, Developer
Rand Corporation
1200 South Hayes Street
Arlington, VA 22202
jaycox@rand.org

CBITS Website: www.traumaawareschools.org
CBITS Email: info@traumaawareschools.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.

Kataoka, S., Jaycox, L. H., Wong, M., Nadeem, E., Langley, A., Tang, L. & Stein, B. D. (2011). Effects on school outcomes in low-income minority youth. Ethnicity & Disease, 21(Supplement 1), 71-77.

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

Halldórsdóttir, K. M. (2015). Cognitive Behavioral Intervention for Trauma in Schools (CBITS): Improving academic performance among college students with PTSD symptoms. Reykjavik University.

Study 4

Ochieng-Munda, P. A. (2020). Cognitive Behavioral Intervention For Trauma In Schools (CBITS) in treating posttraumatic stress disorder among adolescents in selected public primary schools in informal settlements. PhD Dissertation. Daystar University, Kenya.

Study 5

Sumi, W. C., Woodbridge, M. W., Wei, X., Thornton, S. P., & Roundfield, K. D. (2021). Measuring the impact of Trauma-Focused, Cognitive Behavioral Group Therapy with middle school students. School Mental Health 13, 680-694. https://doi.org/10.1007/s12310-021-09452-8

Study 1

Kataoka et al. (2011) extended the outcomes used in Stein et al. (2003) to include measures of academic performance.

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.

Kataoka et al. (2011) examined 123 students (98%) with grades and standardized state test scores available for the spring semester of the year of program receipt. However, the authors noted that, because the waitlisted control group received the program before the end of the spring semester, "it is difficult to interpret the effect that CBITS has on grades immediately post-treatment."

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).

Kataoka et al. (2011) examined four outcome measures for the spring semester that related to academic performance: math grades, language arts grades, math passing grades, and language arts passing grades. Note that grades were not measured exactly after treatment, and many in the control group would have received the intervention by the time of final grades.

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.

Kataoka et al. (2011) used hierarchical linear models to account for clustering within each of the 5-8-person program treatment groups (with program non-participants treated as a separate group). The models treated the two schools as fixed effects and controlled for the standardized test score from the prior school year, as well as the baseline PTSD symptom score, total violence score, sex, school site, parent employment status, and time of screening.

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.

Kataoka et al. (2011) found one marginal and two significant intervention effects in four tests for academic outcomes: language arts passing grade (p = .033), math grade (p = .048), and math passing grade (p = .053).

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.

Study 3

The study evaluated the program with college students rather than middle school students. In order to suit college students, the sessions were reduced from ten to six, once a week for up to one hour. Also, the individual-based classes, two hours of education for parents, and the one-hour of education with a teacher were excluded from the program.

Evaluation Methodology

Design:

Recruitment: The sample consisted of 100 undergraduate students who were recruited from a mandatory psychology class at Methodist University in Fayetteville, North Carolina. Participation was voluntary but extra credit was offered. A total of 73 students filled out the screening questionnaires, resulting in a response rate of 73%. A total of 28 students (38%) met eligibility criteria and participated in the study. The eligibility criteria included having a traumatic event within five years and a high score on a trauma screening instrument.

Assignment: The study randomly assigned the 28 participants to an intervention group receiving CBITS and a control group not receiving therapy. The intervention group was split into three treatment groups.

Assessments/Attrition: A posttest came at the end of the six-week program. Of the 28 students, 21 had some missing data, and the results show that only 12-23 (43-83%) were used in the analyses.

Sample:

The sample included nine men (32%) and 19 women (68%).

Measures:

The three outcome measures came from independent sources. GPA measured assigned grades as obtained from school records. Student self-reported problematic behavior in school (e.g., completing assignments on time, attendance) came from surveys. Teacher reports on student problematic behavior came from surveys, but since teachers did not deliver the program or appear to be aware of condition assignment, the measure was likely independent. The student and teacher reports on problematic behavior in school came from the Weiss Functional Impairment Rating Scale and had good reliabilities (alphas = .74 and .78).

Analysis:

The analysis used independent sample t-tests to compare conditions on the outcome measures. Controls for the baseline outcomes were not used.

Missing Data Strategy: The analysis used only those participations with complete posttest data for each outcome.

Intent-to-Treat: The analysis used all participants with data for each of the outcomes.

Outcomes

Implementation Fidelity:

Not examined.

Baseline Equivalence:

No tests were conducted, but the study described several differences between condition. There were more freshmen in the control group than in the experimental group, the control group had more positive baseline teacher evaluations (0.77) than the experimental group (2.42), and the control group rated themselves higher on problematic school behavior (14.3) than the experimental group (8.3) at baseline.

Differential Attrition:

Not examined.

Posttest:

For GPA, the intervention groups had a significantly higher value at posttest than the control group (r = .56), but had there been a control for the baseline outcome, the effect would have been eliminated. Figure 1 shows that the intervention group increased less than the control group from baseline to posttest. For self-reported problematic behavior at school, the intervention group had a significantly better score at posttest than the control group (r = .39), and Figure 2 shows that the intervention group experienced a greater decline than the control group. For teacher reports, the conditions did not differ significantly at posttest.

Long-Term:

Not examined.

Study 4

Evaluation Methodology

Design:

Recruitment: The sample came from students attending two primary schools located in an area of Kenya outside of Nairobi with informal settlements (i.e., poor housing, lack of faculties, and insecure tenancy). It included adolescents ages 10-14 (grades five to seven of the Kenyan primary system of education) who experienced mild, moderate, or severe PTSD symptoms. Among the students meeting the eligibility criteria, every other one was selected to join the study. Of 698 students ages 10-14, 285 met the trauma screening criterion and 212 were selected to participate.

Assignment: The author referred to using a quasi-experiment design but randomly assigned one of the two schools to the intervention condition and one to the control condition. Each school had 106 participating students. The sample of one school in each condition creates a confound that prevents the study from isolating the impact of the program from the unique characteristics of the two schools.

Assessments/Attrition: The posttest assessment occurred 10 weeks after the program start and a follow-up occurred 12 weeks after the posttest. Of the 212 participants, 194 completed the follow-up (92%). The authors stated (p. 89) that participants "who abandoned more than two sessions would also be excluded from the study." It was not clear if the attrition figures counted these exclusions.

Sample:

Girls made up 54% of the sample, and their mean age was 12.2 years.

Measures:

The measures came from self-reports of PTSD symptoms (alpha = .67) administered by trained research assistants.

Analysis:

The analysis used t-tests for independent samples without controls for baseline outcomes or adjustment for clustering within schools (the unit of assignment).

Missing Data Strategy. The analysis used complete cases analysis, dropping those without posttest data and, it appears, those not attending at least eight of 10 sessions.

Intent-to-Treat: The analysis did not use an intent-to-treat sample, as students who attended fewer than eight of 10 sessions were excluded.

Outcomes

Implementation Fidelity:

Not examined.

Baseline Equivalence:

In Table 4.13 (p. 124), a t-test for equality of means found that baseline PTSD symptoms did not differ significantly across conditions.

Differential Attrition:

No tests were conducted, but the attrition rates were similar across conditions (90% in the intervention group and 93% in the control group).

Posttest:

In Table 4.13 (p. 124), t-tests for equality of means found that the intervention group had significantly lower PTSD symptoms at posttest (d = .79) and follow-up (d = .82).

Long-Term:

Not examined.

Study 5

School social workers (rather than therapists) implemented the program.

Evaluation Methodology

Design:

Recruitment: The sample came from 12 middle schools located within one large urban school district in northern California that served a diverse population. Eligible participants within the schools were in grade six, had experienced one or more traumatic events, and had elevated traumatic stress. Of the 4,076 students who returned screening consent forms from the fall of 2011 to the fall of 2015, 550 (13.5%) endorsed at least one event on a trauma exposure checklist and showed elevated levels on a trauma symptom checklist. Of these eligible students, 296 (54%) consented to participate in the study.

Assignment: The study randomly assigned the 296 students to the intervention group (n = 152) or to a services-as-usual control group (n = 144). Assignment of individuals was done within each school. After randomization, two intervention students and one control student declined to participate, and they were removed from the study sample. Most students in the control group received a range of non-program services (e.g., individual short-term goal-oriented supports, restorative justice groups, small group counseling, social skills groups, anger management groups).

Assessments/Attrition: Assessments occurred at baseline, posttest, and one-year follow-up. According to the CONSORT diagram (Figure 1), completion rates were 99% of the randomized sample at baseline, 98% at posttest, and 95% at follow-up. However, the authors noted that across the 16 outcome measures, the proportion of students with missing data ranged from 2-10% at baseline, 4-14% at posttest, and 7-25% at one-year follow-up.

Sample:

The sample included equal portions of males and females. Approximately 39% of the sample identified as Latinx, 24% as Asian, 12% as White, 7% as Black, and 18% declined to answer.

Measures:

The 16 outcome measures came from five instruments.

  • The student self-reported Trauma Symptom Checklist-Child Version consisted of 44 items and had internal consistencies ranging from 0.76 to 0.90 across the three waves of data collection.
  • The Achenbach System of Empirically Based Assessment-Teacher's Report Form consisted of three subscales that measured internalizing, externalizing, and total problems and, as reported by the scale developers, had alpha values at or above .90.
  • The Achenbach System of Empirically Based Assessment-Youth Self‐Report consisted of three subscales that measured internalizing, externalizing, and total problems and, as reported by the scale developers, had alpha values at or above .90.
  • The Woodcock-Johnson III Normative Update Brief Battery was administered by research assistants, consisted of four subscales assessing reading and math achievement, and had internal consistency coefficients of 0.95 to 0.97.
  • One measure of Academic Engaged Time came from classroom observations by research assistants unaware of condition.

Analysis:

The analysis used hierarchical linear models to account for students being nested in schools. The models controlled for baseline outcome measures, race/ethnicity, and gender.

Missing Data Method. The hierarchical linear models used full information maximum likelihood estimation to account for missing data.

Intent-to-Treat: The analysis used all available data with FIML.

Outcomes

Implementation Fidelity:

On a scale of 0 to 3, the average rating of session adherence was 2.85 and the average rating of session quality was 2.89. However, the authors noted that there were challenges to holding the parent education meetings.

Baseline Equivalence:

Using all participants with baseline data (99% of the randomized sample) and hierarchical linear models, tests for equivalence on 22 baseline measures (see Table 1) found two significant differences. Students in the intervention group self-reported significantly more symptoms of anger and depression than the control group.

Differential Attrition:

A Little test found that data were missing completely at random (MCAR). In addition, the authors reported that, across 16 outcomes at posttest, the treatment group attrition rate ranged from 4-15%, the control group attrition rate ranged from 4-12.5%, and the differential attrition rate ranged from 0-2.5%. Across 16 outcomes at follow-up, the treatment group attrition rate ranged from 5-23%, the control group attrition rate ranged from 9-26%, and the differential attrition rate ranged from 3-4%. The authors concluded that "According to the WWC standards (2017), the overall and differential attrition rate is low for this study" (p. 688).

Posttest:

In tests for the 16 outcomes at posttest (Tables 2 and 3), there was one significant effect. The intervention group reported significantly reduced PTSD symptoms (g = -.21). Moderation tests suggested that the program was significantly more effective for several outcomes (e.g., dissociation, anger) among students with externalizing behavior problems in the clinical range at baseline than for others.

Long-Term:

In tests for the 16 outcomes at one-year follow-up (Tables 2 and 3), there were no significant intervention effects. Moderation tests suggested that the program was significantly more effective for a few outcomes (e.g., externalizing, mathematics achievement) among students with internalizing behavior problems in the clinical range at baseline than for others.

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.