Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was designed for use in schools for children ages 10–15 who have had substantial exposure to violence or other traumatic events and who have symptoms of posttraumatic stress disorder (PTSD) in the clinical range. The CBITS program has three main goals: 1) to reduce symptoms related to trauma, 2) to build resilience, and 3) to increase peer and parent support. The program was developed to reduce symptoms of distress and build skills to improve children’s abilities to handle stress and trauma in the future.
The theoretical underpinnings are based on cognitive–behavioral theory (CBT) regarding anxiety and trauma. In short, traumatic life events lead to impairment (including psychological reactions, behavioral problems, and functional impairment), which in turn leads to long-term adjustment problems such as PTSD, depression, violent behavior, and substance abuse. These adverse outcomes, consequently, increase risk for exposure to more traumatic events and life stressors, compounding vulnerability in the future and creating a cycle.
The program addresses risk factors for developing chronic disturbances following trauma, including poor coping skills, cognitive factors, and low levels of social support. Symptom reduction is accomplished by CBT practices—reducing maladaptive thinking that can drive depressive and anxious moods, reducing anxiety directly through relaxation training, reducing anxiety through behavior therapy (exposure to anxiety-provoking stimuli and habituation of anxiety), and processing the traumatic experience to reduce both anxiety and traumatic grief.
The CBITS intervention incorporates cognitive–behavioral therapy skills in a group format (five to eight students per group) to address symptoms of PTSD, anxiety, and depression related to exposure to violence. Symptom reduction is accomplished through cognitive techniques and trauma-focused work in imagination, writing, and narratives. In each session, a new set of skills is taught to the child, using didactic presentation, age-appropriate examples, and games. The child then uses the skills to address his or her problems through homework assignments collaboratively developed by the child and CBITS clinician.
The CBITS program is formatted to take place in 10 child group sessions, each lasting one class period. The sessions adhere to the curriculum below:
· Session 1: Introduction of group members, confidentiality, and group procedures. Explanation of treatment using stories. Discussion of reasons for participation (kinds of stress or trauma).
· Session 2: Education about common reactions to stress or trauma. Relaxation training to combat anxiety.
· Session 3: Thoughts and feelings (introduction to cognitive therapy). Fear Thermometer. Linkage between thoughts and feelings. Combating negative thoughts.
· Session 4: Combating negative thoughts.
· Session 5: Avoidance and coping (introduction to real-life exposure). Construction of fear hierarchy. Alternative coping strategies.
· Session 6: Exposure to stress or trauma memory through imagination/drawing/writing.
· Session 7: Exposure to stress or trauma memory through imagination/drawing/writing.
· Session 8: Introduction to social problem solving.
· Session 9: Practice with social problem solving and hot seat.
· Session 10: Relapse prevention and graduation ceremony.
Between Session 2 and Session 6, there are also individual sessions that focus on imaginal exposure to a traumatic event. The imaginal exposure can then be brought out through drawing and writing exercises in group sessions.
The Mental Health for Immigrants Program (MHIP) is an eight-session CBT group based on CBITS. MHIP uses the same curriculum and session content as CBITS, but also includes four 2-hour optional multifamily group sessions designed to complement the child's treatment. The parent component was included because psychoeducation for parents about their child’s PTSD has been recommended. Parents and clinicians discuss the effects of trauma on children and the types of techniques that the children will be learning. The sessions also include parenting techniques.
10 to 14
Posttraumatic Stress Disorder (PTSD) Symptoms
Stein and colleagues (2003) found that at the 3-month assessment the group receiving Cognitive Behavioral Intervention for Trauma in Schools (CBITS) had significantly lower scores of self-reported PTSD symptoms than the comparison group (8.9 versus 15.5). The results indicated that 86 percent of students who received the CBITS intervention reported lower scores of PTSD symptoms at 3 months than the scores expected if they had not undergone the intervention. At 6 months, after the waitlist delayed-intervention comparison group completed the CBITS program, there was no significant difference between the groups.
At the 3-month follow-up, scores for self-reported depressive symptoms were lower for the CBTIS group than for the waitlist group. Again, the results showed 67 percent of the early intervention group reported lower scores of depressive symptoms than the scores expected if they had not undergone the intervention. At 6 months, after the waitlist comparison group completed the intervention, there was no longer any significant difference between the groups.
Parents of students in the CBITS group reported significantly less psychosocial dysfunction of their children at 3 months, compared with the reports from parents of students in the comparison group (12.5 versus 16.5, respectively). However, at 6 months, the parents of students in the early intervention and waitlist delayed-intervention groups had similar ratings of child psychosocial dysfunction.
No significant differences between the groups were found for teacher-reported classroom problems of acting out.
Kataoka and colleagues (2003) found that at 3 months the average score for depressive symptoms (Child Depression Inventory [CDI] scores) of the Mental Health for Immigrants Program (MHIP) intervention group had significantly decreased from 16.3 to 13.5. There was no significant change in depressive symptoms for the waitlist group.
Multivariate analysis showed that the MHIP intervention group had lower follow-up CDI scores, and therefore lower depressive symptoms, compared to the waitlist group, when controlling for baseline CDI score, age, gender, country of origin, parent education level, and parent marital status.
The Child PTSD Symptom Scale (CPSS) mean scores for PTSD symptoms also significantly decreased from 18.8 to 13 in the intervention group, but did not significantly decrease for the waitlist group.
Multivariate analysis found that the intervention group had a lower follow-up CPSS score, and therefore lower PTSD symptoms, than the waitlist group, when controlling for baseline CPSS score, age, gender, baseline total violence score, country of origin, and parental employment status.
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