Download Preventive Services Improvement Initiative

Cognitive Behavioral
Intervention for Trauma
In Schools (CBITS)
Part 1: Why a trauma program
in schools?
“Interpersonal violence
is a public health
emergency… and
one of the most significant
public health issues facing
America”
C. Everett Koop, JAMA,
1992
Some children are at greater
risk for violence exposure

Males

Older children

Early conduct problems

Living in urban areas

Lower socio-economic status
Schwab-Stone, 1995, 1999
Why a program for traumatized
students?
One night several years ago, I saw men
shooting at each other, people running to
hide. I was scared and I thought I was going
to die. After this happened, I started to have
nightmares. I felt scared all the time. I
couldn’t concentrate in class like before. I
had thoughts that something bad could
happen to me. I started to get in a lot of
fights at school and with my siblings.
Martin, 6th grader
Consequences of violence
exposure

Post traumatic stress disorder (PTSD)
● Re-experiencing
● Numbing/Avoidance
● Hyperarousal
● Prevalence in adolescents
● 4% of boys
● 6% of girls
● 75% of those with PTSD have additional
mental health problem
Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995
Consequences of violence
exposure
Post traumatic stress disorder (PTSD)
 Depression
 Substance abuse
 Behavioral problems
 Poor school performance

How does violence exposure
impact learning?

Decreased IQ and reading ability
(Delaney-Black et al., 2003)



Lower grade-point average (Hurt et al., 2001)
More days of school absence (Hurt et al., 2001)
Decreased rates of high school graduation
(Grogger, 1997)

Increased expulsions and suspensions
(LAUSD Survey)
How did this program come
about?

Concerned with the impact of violence
on students, Los Angeles Unified
School District officials wanted an
effective program for traumatized
students
● Based on the best available science
● Tailored for the school setting
● Designed for children and families of
diverse ethnic and social backgrounds
CBITS Program




10 child group therapy sessions for trauma
symptoms
1-3 individual child sessions for exposure to
trauma memory and treatment planning
Parent outreach, 2 sessions on education
about trauma, parenting support
1 teacher session including education about
detecting and supporting traumatized
students (1 session)
Goals of CBITS
 Symptom Reduction
● PTSD symptoms
● General anxiety
● Depressive symptoms
● Low self-esteem
● Behavioral problems
● Aggressive and impulsive
 Build Resilience
 Peer and Parent
Support
Part 2: Does it work?
High rates of violence exposure
in LAUSD 6th grade students
Knife or gun involved
Type of
exposure
reported
Victimization
Witnessed violence
0%
20%
40%
60%
80%
100%
Screening also identified many
children with clinical symptoms
Knife or gun involved
Type of
exposure
reported
Victimization
Witnessed violence
0%
20%
40%
60%
80%
100%
0%
20%
40%
60%
80% 100%
PTSD symptoms in clinical
range
Symptoms
Depressive symptoms in
clinical range
Results
PTSD and Depressive symptoms
decreased
 Grades and classroom behavior
improved

● As trauma symptoms decreased, grades
improved
● Teachers reported fewer classroom learning
problems after program

Parents reported overall improved
behavior and functioning
What did students say?
“The group helped me because I don’t have
nightmares about that anymore. I don’t think
about what happened anymore. Even though I
was nervous when I shared this in the group, I
felt much better after that. It helps kids
concentrate better in class and improve their
grades like I did and get along with their
teachers”
Martin
What did families say?
“My son is not afraid to come to school
anymore… he comes home and talks to me.
Before he would just cry and not say anything.
Now he’ll come home and tell us what’s
bothering him. I realize how important it is to
spend time with our kids and listen to them.”
Martin’s mother
What did teachers say?
“I was surprised that so many students
qualified for the program.”
“Initially, I was concerned because students
would be pulled out of class… they weren’t
going to do as well. But then you could see
them settling down… and doing better.”
“I’ve noticed that after the program, students
just seem more comfortable in class. And
because they are more comfortable, they
behave better and do better in class.”
Part 3: How do we Screen?
How do we screen students for
CBITS?
Step 1. Administer screening surveys
to class-sized groups

The screener includes:
●
Shortened Life Events Scale: 9 items asking
about violent events
● Foa’s Child PTSD Symptom Scale: 17 items

Screening should be conducted as close to
first CBITS session as possible (within 1-2
months)
How do we screen students
for CBITS?
Step 2. Score screener to identify
eligible students for CBITS
Life Events cut-off score: 3 or more
points OR any weapon-related event
 PTSD cut-off score: 14 or more points

How do we screen students for
CBITS?
Step 3. Interview eligible students
individually
Verify survey results and identify main
traumatic event
 Assess appropriateness for group

Part 4: CBITS Step by Step
Materials Needed

Required Supplies
-Group leader Manual
-Student activity worksheets

Optional supplies
-Chalkboard/large writing pad
-Crayons, Markers, Color pencils
CBT: Friend or Foe?
Assumptions about Cognitive Behavioral
Therapy
 Concerns about Manualized Interventions
 CBT in school setting:

●
●
●
●
●
Acceptable
Feasible
Amenable to group structure
Focus on building skill
Empowering
A Conceptual Model of the CBITS
Program
Targets of CBITS
Coping skills
Parent & peer support
Cognitions / Attributions
CBITS
Impairment
Traumatic Event(s)
PTSD symptoms
Depressive symptoms
Behavioral problems
Social dysfunction
School dysfunction
Long Term
Adjustment Problems
PTSD
Depression
Violent Behavior
Substance Use
Introduction to the Group
(Session 1)
Includes:
•
M&M game for warm-up
•
Introduction to the group rationale
•
Discussion of confidentiality
•
Beginning of any group management
techniques such as
•Reward chart for good behavior
•Group rules
• Goals Worksheet
Conceptual model for participants
(Session 1)
What we think
Stress or
Trauma
What we do
How we feel
Thoughts
Behaviors
Feelings
Tailoring CBT Treatment
Each Channel addressed with
specific interventions
Feelings/Physio. Arousal
----
Relaxation
----
Thoughts
Cognitive
Restructuring
Behaviors: Avoidance
Impulsive
----
Exposure
(social problem
solving)
Psychoeducation about trauma
and symptoms (Session 2)

Why?
● To reduce stigma about trauma symptoms
● To build peer and parent support
● To increase parent-child communication about
problems

How?
● Structured group discussion about symptoms
● Handouts sent home about symptoms
● Homework assignment to discuss with parents
Psychoeducation about trauma
and symptoms (Session 2)

Pitfalls
● Pathologizing
● Embarrassing students with extreme
symptoms
●
Need to keep tone educational and stress
commonalities across students
Relaxation training & fear
thermometer (Session 2)

Why?
● To enable child to reduce anxiety
● To enable child to observe his or her own anxiety
level
● To introduce a common language in describing
“fear” or “anxiety”

How?
● Exercise combining positive imagery, slow
breathing, and muscle relaxation
● Fear thermometer used throughout the groups
● Homework assignment to practice at home
The Fear Thermometer
Very anxious
10
9
8 – Walking home from school alone
7
6
5
4
3 – Going out on playground at recess
2
1
Not anxious at all
Relaxation training & fear
thermometer (Session 2)

Pitfalls
● Rarely students feel panicky
during exercise
● Giggling
Explain that you’ll move around the
room, check in with students, perhaps
touch them on the shoulder to check
in. Warn them that it sometimes
seems funny.
● Demonstration and Activity
●
Group Activity
1. What are your body clues when you are feeling
anxious?
2. Think of TWO different triggers that make you
feel anxious
• Fear Rating 3-4
• Fear Rating 7-8
3. What things do you do to help you
relax/cope…..?
Cognitive therapy
(Sessions 3 & 4)

Why?
● To increase children’s ability to observe their own thoughts
and interpretations, and to challenge ones that are getting in
their way
● Focus is on thoughts like,
● “The world is dangerous, I can’t trust anyone”
● “I can’t deal with things, what happened is my fault”

How?
● Didactic and exercises (the “Hot Seat”)
“Is there another way to look at this? Is there anything I
can do about this? How do I know this is true? –
catastrophic fears
● If this is true, what’s the worst/best/most likely thing to
happen? – common fears
● Lots of practice in session and on worksheets at home
●
Pre - Trauma Records:
Balanced, flexible premises about
“self” and “world”
Traumatic
Event
Post -Trauma
SCHEMAS
Events
Trauma
Records
Self
World
Schema
Schema
“It was not my
“I am mostly
“The world is
fault, I handled it
competent.”
mostly safe.”
Post - Trauma
Records
as well as could be
“Some but not all people
expected.”
can be trusted, PTSD
symptoms are normal and
temporary.”
RECOVERY
From: Foa, E. B. & Jaycox, L. H. (1999.) Cognitive-behavioral treatment of post-traumatic stress disorder. In Spiegel, D. (Ed.)
Efficacy and Cost-Effectiveness of Psychotherapy. Washington, DC: American Psychiatric Press.
Pre-Trauma
Schematic model underlying pathology
Records:
Extreme, rigid premises
about “self” and “world”
Traumatic
Event
Post -Trauma
SCHEMAS
Trauma
Records
“I failed, It is
my fault, I
deserve what
happened.”
Events
Self
World
Schema
Schema
“I am entirely
“The world is
Post-Trauma
incompetent.”
entirely
dangerous.”
Records
“People are
untrustworthy,
PTSD symptoms are
dangerous.”
PATHOLOGY
From: Foa, E. B. & Jaycox, L. H. (1999.) Cognitive-behavioral treatment of post-traumatic stress disorder. In Spiegel, D. (Ed.)
Efficacy and Cost-Effectiveness of Psychotherapy. Washington, DC: American Psychiatric Press.
Cognitive therapy
(Sessions 3 & 4)

Pitfalls
● Too much focus on surface thoughts, not the
ones that drive emotion
●
Need to look for thoughts that “match” emotion. Can
keep an eye out for the most common maladaptive
thoughts related to trauma
● Could make students feel badly about the way
they think
●

Continually normalize these kinds of thoughts, link them
to traumatic event
Demonstration
Cognitive restructuring
ADAPTIVE
COGNITIVE
COPING
THOUGHTS
Exposure: Processing the trauma
memory [Individual Session(s)]

Why?
● To decrease anxiety when thinking about the trauma
● To help child “process” or “digest” what happened to
them
● To build parent and peer support and reduce stigma

How?
● Individual sessions in which child recounts the trauma
● Encouragement to talk about the trauma at home while
the groups are running
Avoidance
10
9
8
7
6
FT
5
4
3
2
1
0
Time
Exposure-Avoidance vs.
Habituation
10
9
8
7
S
U
D
S
6
5
4
3
2
1
0
Time
Exposure-Habituation contd.
10
9
8
7
S
U
D
S
6
5
4
3
2
1
0
Time
How to help students process
the memory
1.
2.
2.
3.
4.
5.
Provide an example and rationale of why to
do this
Tell the student to tell the story of the trauma
in movie-like details and take notes
Break down story into parts and ask student
what he/she feels (NOW) at each part
Ask student to re-tell story, and get fear
ratings for the 2-3 most bothersome parts.
Repeat until distress is reduced if possible,
or schedule another meeting
Plan for disclosure and support in the group
meetings (Sessions 6 and 7)
Therapist Stance During
Exposure
●
●
●
●
Quiet
Supportive / empathic
Probing only as necessary to
engage the student
Not asking why’s or how’s or
trying to analyze what happened
Exposure: Processing the trauma
memory [Individual Session(s)]

Pitfalls
● Student gets very upset, feels
overwhelmed
●
Therapist needs to take care to temper the
experience (e.g., fast forward) for the
student and normalize upset
● Student feels nothing, shuts down
●
Therapist can ask for more detail, find
ways to engage student. But in early
intervention group approach, not
necessary to “dig up” the trauma if there is
little distress.
Approaching anxiety-provoking
situations(Session 5)

Why?
● To teach children that anxiety does not last
forever
● To get children able to do all the things they want
and need to do
● To build confidence

How?
● Identify things children are avoiding related to the
trauma, that are safe to do
● Make a plan for decreasing that avoidance
● Practice approaching those situations and
staying long enough for anxiety to decrease or
go away
Anxiety fear hierarchy
Fear Thermometer
Most Scared/Upset
Fear Hierarchy
Situation
Rating
10
9
Going to the park alone
10
8
Going to the park with friends
8
7
Going to the park with parents
6
6
Playing outside alone
6
5
Playing outside w/ brother
5
4
Seeing best friend
4
3
Going to different park
4
2
Driving past park
2
1
Least Scared/Upset
Approaching anxiety-provoking
situations (Session 5)

Pitfalls
● Does not apply to all students
● Focus on this with avoidant students. For non-avoidant
students, put other useful things on their hierarchy (e.g., talking
in front of class)
● Parents do not support homework
● Work with parents on their own anxiety and avoidance, find a
motivator for them to get things back to normal at home
● It is too dangerous to approach these activities
● Dangerous situations should not be attempted. Instead, find
ways to make them safe (vary time of day, alone or with others,
location)
● They get more anxious, not less
● Careful planning is crucial
Exposure: Processing the trauma
memory (Sessions 6 & 7)

Why?
● To decrease anxiety when thinking about the trauma
● To help child “process” or “digest” what happened to them
● To build parent and peer support and reduce stigma

How?
● Group sessions in which the child draws pictures or tells others
about the trauma
● Builds upon Individual Session Work
● Encouragement to talk about the trauma at home while the groups
are running
Imaginal, Pictorial, & Verbal exposures
Social problem-solving
(Sessions 8 & 9)

Why?
● To decrease impulsive reactions and decisions
● To improve real-life problems
● To build skills in handling future problems

How?
● Teach children the link between thoughts and
actions
● Teach children to “brainstorm” solutions to a
problem
● Teach children to weigh the “pluses and minuses”
or “pros and cons” for possible actions
● Practice in group with real problems and
worksheets at home
Social problem-solving
(Sessions 8 & 9)

Pitfalls
● Get stuck on a complicated problem.
● Work on just a part of the problem. Pick
examples carefully.
● Seems impossible to solve this one.
● Therapist can examine own negative
thoughts! Can always put informationgathering, seeking social support on the list of
solutions.
Graduation/Relapse Prevention
(Session 10)
Certificates
 Celebration of Progress
 Special activity/food/party
 Troubleshooting and
applying CBITS skills to
upcoming stressors

Other Treatment Issues
● Inclusion/Exclusion
Criteria
● Referrals
● Reinforcement/Rewards
● Homework
● Missed
Sessions
Parent and Teacher education
sessions

Parent Education Sessions
● 2 sessions related to CBITS
● Cover the 6 main techniques
● 2 sessions relevant to other parent
concerns

Teacher Education Sessions
● Overview of CBITS program
● Tips for working with traumatized youth
Part 5: Next Steps for CBITS
Implementation
Gaining support from the
school administration

First meeting with the Principal
● Discuss the impact of PTSD in terms relevant to
educators
●
●
●
●

Academic achievement
Grades and standardized tests
Emotionally Disabled (ED) Students and IDEA
Improving classroom behavior and performance
Coordinate with other relevant services on
campus
Gaining support from school
community

Liaison with teachers
● Find ideal time for group
● Present education about trauma to teachers and
respond to any concerns about program

Outreach to parents
● Depending on community and school issues,
consider working with parent leaders to engage
parents in process
● Develop parent component depending on needs
of parents
Forming CBITS groups



Screen about 60 students to form one group
of 6-8 participants
If there are multiple groups, consider age
and gender in forming groups
Start at the beginning of the quarter to make
sure that there is time to screen, score, meet
with eligible students individually, and
complete the program (17-20 weeks)