CBITS relies on cognitive and behavioral theories of adjustment to traumatic events and uses cognitive-behavioral techniques such as psychoeducation, relaxation, social problem solving, cognitive restructuring, imaginal exposure, exposure to trauma reminders, and development of a trauma narrative. The program includes 10 group sessions and 1-3 individual sessions for students, 2 parent psychoeducational sessions, and a teacher educational session. It is designed for delivery in the school setting by mental health professionals working in close collaboration with school personnel.
Quality of Research
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Stein, B. D., Elliott, M. N., Tu, W., Jaycox, L. H., Kataoka, S. H., Fink, A., et al. (2003). School-based intervention for children exposed to violence [Reply]. Journal of the American Medical Association, 290(19), 2542.
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., et al. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-611.  Study 2Kataoka, S. H., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., et al. (2003). A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311-318. Study 3Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A. K., Gegenheimer, K. L., et al. (2010). Children's mental health care following Hurricane Katrina: A field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23(2), 223-231.
Supplementary Materials Foa, E., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child PTSD Symptom Scale: A preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30(3), 376-384.
Jaycox, L. H., Stein, B., Kataoka, S., Wong, M., Fink, A., Escudera, P., et al. (2002). Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. Journal of the American Academy of Child and Adolescent Psychiatry, 41(9), 1104-1110.
Morsette, A., Schuldberg, D., van den Pol, R., Swaney, G., & Stolle, D. (2009). Culturally informed cognitive behavioral interventions for trauma symptoms: Group therapy in rural American Indian reservation schools. Manuscript submitted for publication.
Outcomes
| Outcome 1: PTSD symptoms |
|
Description of Measures
|
The Child PTSD Symptom Scale (CPSS), the children's version of the Posttraumatic Diagnostic Scale for Adults, was used to assess PTSD symptoms. The CPSS is a 17-item self-report measure that asks children to rate how often in the past month they were bothered by symptoms on a scale from 0 (not at all) to 3 (almost always), yielding a total score ranging from 0 to 51, with higher scores indicating more PTSD symptoms.
|
|
Key Findings
|
In one study, 6th-grade students who reported exposure to violence and had clinically significant PTSD symptoms (CPSS score > 14) were randomly assigned to a group receiving CBITS or to a wait-list control group. After adjustment for baseline scores, the intervention group had a significantly lower mean CPSS score at 3-month follow-up than the wait-list group (8.9 vs. 15.5; p < .001). The effect size for this finding was large (Cohen's d = 1.08). At 6-month follow-up, after the wait-list group completed the CBITS intervention, the difference between the intervention and wait-list groups' mean CPSS scores was no longer significant (8.2 vs. 7.2).
In another study, students in grades 3-8 with trauma-related depression and/or PTSD symptoms were compared after receiving CBITS or being placed in a wait-list control group. From baseline to 3-month follow-up, the intervention group's mean CPSS score decreased significantly from 19 to 13 (p < .001), while the wait-list group had a nonsignificant decrease from 18 to 16. In addition, in a subsample analysis of students with clinically significant PTSD symptoms at baseline (CPSS score > 11), the improvement in mean CPSS score was significantly greater for the intervention group (from 20 to 13) than for the wait-list group (from 19 to 16; p < .05).
In a third study, students in grades 4-8 who reported significant levels of mental health symptoms including PTSD were randomly assigned to receive CBITS or Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Mean CPSS scores improved significantly from baseline to 10-month follow-up in both groups, decreasing from 22.82 to 12.00 for the TF-CBT group (p < .01) and from 21.98 to 15.81 for the CBITS group (p < .001). While both treatments led to a significant reduction of PTSD symptoms, the difference between groups was not statistically significant.
|
|
Studies Measuring Outcome
|
Study 1, Study 2, Study 3
|
|
Study Designs
|
Experimental, Quasi-experimental
|
|
Quality of Research Rating
|
3.1
(0.0-4.0 scale)
|
| Outcome 2: Depression symptoms |
|
Description of Measures
|
Symptoms of depression were assessed using the Children's Depression Inventory (CDI). The CDI is a 27-item self-report instrument that assesses cognitive, affective, and behavioral symptoms of depression in children. Twenty-six of the 27 items were used; 1 item assessing suicidality was removed at the request of school personnel. For each item, the child was asked to describe his or her feelings during the past 2 weeks, with three possible response options associated with scores of 0 (an absence of symptoms), 1 (mild symptoms), and 2 (definite symptoms). Scores range from 0 to 52 points, with higher scores indicating more depressive symptoms.
|
|
Key Findings
|
In one study, 6th-grade students who reported exposure to violence and had clinically significant PTSD symptoms (CPSS score > 14) were randomly assigned to a group receiving CBITS or to a wait-list control group. After adjustment for baseline scores, the intervention group had a lower mean CDI score at 3-month follow-up than the wait-list group (9.4 vs. 12.7; p = .014). The effect size for this finding was small (Cohen's d = 0.45). At 6-month follow-up, after the wait-list group completed the CBITS intervention, the difference between the intervention and wait-list groups' mean CDI scores was no longer significant (9.0 vs. 10.0).
In another study, students in grades 3-8 with trauma-related depression and/or PTSD symptoms were compared after receiving CBITS or being placed in a wait-list control group. From baseline to 3-month follow-up, the intervention group's mean CDI score decreased significantly from 16 to 14 (p < .001), while the wait list group's mean CDI score remained unchanged at 16. In addition, in a subsample analysis of students with clinically significant depression symptoms at baseline (CDI score = 18), the improvement in mean CDI score at 3-month follow-up was significantly greater for the intervention group (from 23 to 18) than for the wait-list group (from 24 to 23; p < .05).
In a third study, students in grades 4-8 who reported significant levels of mental health symptoms including PTSD were randomly assigned to receive CBITS or TF-CBT. Mean CDI scores improved significantly for both groups from baseline to 10-month follow-up, decreasing from 15.43 to 11.14 for the TF-CBT group (p = 0.17) and from 13.40 to 9.72 for the CBITS group (p < .001).
|
|
Studies Measuring Outcome
|
Study 1, Study 2, Study 3
|
|
Study Designs
|
Experimental, Quasi-experimental
|
|
Quality of Research Rating
|
3.0
(0.0-4.0 scale)
|
| Outcome 3: Psychosocial dysfunction |
|
Description of Measures
|
Psychosocial dysfunction was assessed using the 35-item Pediatric Symptom Checklist (PSC). This instrument asks the child's parent to rate the frequency of the child's emotional and behavioral problems on a scale from 0 (never) to 2 (often), yielding a total score of 0 to 70 points, with higher scores indicating greater dysfunction.
|
|
Key Findings
|
Sixth-grade students who reported exposure to violence and had clinically significant PTSD symptoms (CPSS score > 14) were randomly assigned to a group receiving CBITS or to a wait-list control group. After adjustment for baseline scores, the intervention group had a significantly lower mean PSC score at 3-month follow-up compared with the wait-list group (12.5 vs. 16.5; p = .007). The effect size associated with this finding was medium (Cohen's d = 0.77). At 6-month follow-up, after the wait-list group completed the CBITS intervention, the difference between the intervention and wait-list groups' mean PSC scores was no longer significant (9.4 vs. 8.9).
|
|
Studies Measuring Outcome
|
Study 1
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.4
(0.0-4.0 scale)
|
Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
|
Study
|
Age
|
Gender
|
Race/Ethnicity
|
|
Study 1
|
6-12 (Childhood)
|
56% Female
44% Male
|
100% Race/ethnicity unspecified
|
|
Study 2
|
6-12 (Childhood)
|
50% Female
50% Male
|
100% Hispanic or Latino
|
|
Study 3
|
6-12 (Childhood)
|
56% Female
44% Male
|
48% White
46% Black or African American
5% Hispanic or Latino
1% Race/ethnicity unspecified
|
Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
|
Outcome
|
Reliability
of Measures
|
Validity
of Measures
|
Fidelity
|
Missing
Data/Attrition
|
Confounding
Variables
|
Data
Analysis
|
Overall
Rating
|
|
1: PTSD symptoms
|
4.0
|
4.0
|
2.0
|
3.0
|
2.0
|
3.5
|
3.1
|
|
2: Depression symptoms
|
4.0
|
3.5
|
2.0
|
3.0
|
2.0
|
3.5
|
3.0
|
|
3: Psychosocial dysfunction
|
3.5
|
4.0
|
3.0
|
3.5
|
2.5
|
4.0
|
3.4
|
Study Strengths Relevant and psychometrically sound measurement instruments were used in the studies. The measures have high levels of reliability and validity and have been widely used in other studies. Missing data were handled well and were factored into analyses (e.g., analyses used multiple imputation; intent-to-treat was used in two of the studies). A variety of analyses were used across the three studies, and the analyses generally were appropriate for the type of data collected.
Study Weaknesses Despite the availability of a treatment manual and clinician training, the methods used to assess intervention fidelity varied across the three studies and overall were not systematically strong. Several important confounding variables were not resolved in the studies, including baseline differences between completers and noncompleters, lack of blinding to treatment condition, a mixed approach to making condition assignments, and differential attrition across treatment groups.
|
|
Readiness for Dissemination
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Cognitive Behavioral Intervention for Trauma in Schools Dissemination Toolkit
Jaycox, L. (2004). Cognitive Behavioral Intervention for Trauma in Schools. Longmont, CO: Sopris West Educational Services.
Program Web site, http://www.tsaforschools.org/index.php?option=com_content&task=view&id=81&Itemid=69
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
|
Training and Support
Resources
|
Quality Assurance
Procedures
|
Overall
Rating
|
|
4.0
|
4.0
|
3.5
|
3.8
|
Dissemination Strengths Implementation materials are thorough and well developed. The manual and toolkit are easy to read, well organized, and clearly formatted. Detail is provided on screening students for appropriateness for inclusion in the program. Training packages are comprehensive and varied. The developers are clear about the skills and competences required by clinicians and supervisors who implement the program. Ongoing support is provided via remote telephone consultation and an online peer support network and resource library. Several options for fidelity monitoring are described, including the scoring of live or audiotaped sessions, therapist self-ratings, and supervision, and forms and rating instructions are included. Fidelity monitoring is stressed as an important component of the program.
Dissemination Weaknesses The quality assurance materials contain no cultural competency measurement component despite an emphasis on cultural adaptations of the program. Further, there is minimal explanation as to how supervisors should interpret the changes in participants' scores from pre- to posttest and how they should analyze this information.
|
|
Costs
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.
|
Item Description
|
Cost
|
Required by Developer
|
|
Manual
|
$40 each
|
Yes
|
|
Background reading information
|
Free
|
No
|
|
Adaptation materials
|
Free
|
No
|
|
Students and Trauma DVD
|
$15 each
|
No
|
|
2-day, on- or off-site training (includes pretraining consultation)
|
$4,000 for 12-15 participants, plus travel expenses
|
No
|
|
Clinical consultation
|
$200 per hour
|
No
|
|
Fidelity checklists with instructions
|
Free
|
No
|
|
Review of tape recordings for fidelity monitoring
|
$100 per hour
|
No
|
Additional Information The cost of implementation can be calculated based on the salary of a full-time, school-based mental health professional who is devoted to delivering CBITS. One professional can screen students in the general school population and select students with elevated symptoms, delivering up to 30 CBITS groups per academic year (6-8 students per group), for a total of about 210 students. Assuming an approximate staffing cost of $90,000 per year for a full-time social worker, the estimated cost per participant is $430.
|
Replications
Selected citations are presented below. An asterisk indicates that the document
was reviewed for Quality of Research.
Cohen, J. A., Jaycox, L. H., Mannarino, A. P., Walker, D. W., Langley, A. K., & DuClos, J. L. (2009). Treating traumatized children after Hurricane Katrina: Project Fleur-de-Lis. Clinical Child and Family Psychology Review, 12(1), 55-64.
Dean, K., Langley, A., Kataoka, S., Jaycox, L. H., Wong, M., & Stein, B. D. (2008). School-based disaster mental health services: Clinical, policy, and community challenges. Professional Psychology: Research and Practice, 39(1), 51-57.
Feldman, E. (2007). Implementation of the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) with Spanish-speaking, immigrant middle-school students: Is effective, culturally competent treatment possible within a public school setting? (Doctoral dissertation, University of Wisconsin-Madison, 2007). Dissertation Abstracts International, 68(A), 1325.
Jaycox, L. H., Langley, A. K., Stein, B. D., Wong, M., Sharma, P., Scott, M., et al. (2009). Support for students exposed to trauma: A pilot study. School Mental Health, 1(2), 49-60.
Kataoka, S. H., Fuentes, S., O'Donoghue, V. P., Castillo-Campos, P., Bonilla, A., Halsey, K., et al. (2006). A community participatory research partnership: The development of a faith-based intervention for children exposed to violence. Ethnicity & Disease, 16(1 Suppl. 1), S89-S97.
Kataoka, S., Nadeem, E., Langley, A. K., Jaycox, L., Stein, B. D., & Wong, M. (in press). Implementing school mental health programs in post-Katrina Louisiana: A focus group study. American Journal of Preventive Medicine.
Morsette, A., Swaney, G., Stolle, D., Schuldberg, D., van den Pol, R., & Young, M. (2009). Cognitive Behavioral Intervention for Trauma in Schools (CBITS): School-based treatment on a rural American Indian reservation. Journal of Behavior Therapy and Experimental Psychiatry, 40(1), 169-178.
|
|
|
