Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)
Type of Approach:
Provider Education Level:
Type of services:
Cognitive behavioral therapy for children
Type of service provider:
Trained school-based mental health clinicians
Length of program/number sessions:
10 group sessions plus at least one individual session for each student; up to four group parenting meetings and an educational presentation for teachers.
Type(s) of trauma addressed:
Childhood exposure to violence; CBITS has also been used to address other traumatic life events such as natural disasters.
The parent and teacher sessions focus primarily on education about trauma and CBITS.
Unique/Innovative Characteristics and Highlights
Developed through collaboration between clinician-researchers from the RAND Corporation, the University of California at Los Angeles, and the Los Angeles Unified School District.
This brief, school-based intervention was evaluated with inner-city, primarily Latino, and socioeconomically disadvantaged students. Since the initial evaluations, it has been disseminated widely to serve many other populations and address other types of traumatic events (e.g., natural disaster).
Adaptations have been made to serve low-literacy students, students in foster care, and students in faith-based settings.
Ethnic Racial Group:
Age range of children:
Initially evaluated with 3rd through 8th graders, CBITS has also been adapted for high school.
Parent/adult caregiver included in intervention:
Yes. Parents/caregivers optionally attend four group sessions and are engaged by the intervention leader to the greatest extent possible during the program.
Ethnic/racial and other groups served:
The program is being used broadly with many different groups, including Latino, African American, Native American, and Caucasian students in rural, suburban, and urban areas.
Specific cultural adaptations:
Initially designed for use in inner-city school mental health clinics serving multicultural, immigrant populations. Adapted for use on rural American Indian reservations.
English and Spanish
The program relies on cognitive-behavioral theory and resilience/positive psychological theory.
Randomized controlled trial was conducted with 6th grade students that were randomly assigned to an early intervention group (61 students) or a wait-list, delayed intervention comparison group that received the intervention three months after the early intervention group (65 students). At six-month follow-up, both groups had completed the intervention. The students were primarily Latino and socioeconomically disadvantaged.
The following findings were reported at three month follow-up for students in the early intervention group compared to students who not yet received CBITS (the delayed intervention group):
- 86% of the early intervention group reported less severe PTSD symptoms than what would have been expected without intervention
- 67% of the early intervention group reported less severe symptoms of depression than what would have been expected without intervention
- Students had less psychosocial dysfunction reported by parents
At six-month follow-up, there was no difference in PTSD symptoms, depression, or psychosocial dysfunction between the early intervention and the delayed intervention group (both groups had now received the intervention). This means that the positive effects were maintained in the early intervention group and that the delayed intervention group had achieved positive outcomes similar to the early intervention group.
Stein BD, Jaycox LH, Kataoka SH, et al. A mental health intervention for school children exposed to violence. JAMA. 2003;290(5):603-611.
Kataoka et al. (2011) further used their sample of sixth graders in East Los Angeles to look at the effects of CBITS on academic performance of students with mental health symptoms. Out of 159 students with PTSD symptoms according to the Child PTSD Symptom Scale (CPSS), 126 were randomly assigned to receive CBITS immediately or with a delay of 4-5 months after initial screening (61 immediate, 65 delayed). The randomized children did not differ on baseline violence exposure, symptom levels, or socioeconomic characteristics. After assigning students to either the immediate or delayed intervention group, their academic performance was recorded at baseline and closely monitored throughout the intervention period. The emphasis was on mean math and language/arts grades, as well as on the percentage of passing grades for each group. Grades were recorded during the spring quarter of the 2001-2002 academic year, as this was the only period when the immediate group had completed the intervention and the delayed group had not started. The study control group also received the program during the same academic year, and there was no longer-term tracking of changes in academic performance for a period exceeding the experiment time frame. Because of these issues, it was impossible to examine long-term differences in academic performance.
The study reported the following:
- Students in the immediate intervention group show higher mean grades in both math (2.0 vs. 1.6) and language/arts (2.2 vs. 1.9), after adjusting for prior test scores, than their counterparts in the delayed intervention group. However, only the difference in math mean scores was statistically significant.
- Students with early CBITS intervention were projected to pass both math (69.5%) and language/arts (79.7%) at significantly higher rates than students with delayed intervention (math: 54.7%; language/arts: 60.9%)
Kataoka, Sheryl, Lisa H. Jaycox, Marleen Wong, Erum Nadeem, Audra Langley, Lingqi Tang, and Bradley D. Stein, “Effects on School Outcomes in Low-Income Minority Youth: Preliminary Findings from a Community-Partnered Study of a School Trauma Intervention,” Ethnicity & Disease, Vol. 21, No. 3, Supplement 1, 2011, pp. S1-71-7.
A small pre- and post-test design study was conducted with American Indian children living on a rural reservation. Eligible children had symptoms of PTSD and depression. CBITS was adapted by consulting Indian Health professionals, elders, teachers and counselors, adding Native linguistic concepts, embedding local history and allegories into CBITS lessons, including traditional prayers, and other adaptations. Seven students of the 48 students that participated in the screening were eligible for the intervention, and 4 students completed the intervention. A comparison of pre- and post-intervention scores indicated that three of the four students had substantially decreased PTSD or depressive symptoms. When compared to other students screened at baseline that had equivalent levels of exposure to violence and symptoms of PTSD but did not receive CBITS, students who received CBITS showed greater improvement in depression and PTSD symptoms.
Morsette A, Swaney G, Stolle D, Schuldberg D, van den Pol R, & Young M. Cognitive Behavioral Intervention for Trauma in Schools (CBITS): School-based treatment on a rural American Indian reservation. Journal of Behavior Therapy and Experimental Psychiatry. 2009;40(1):169-178.
Other evaluation studies:
Jaycox LH, Cohen JA, Mannarino AP, Walker DW, Langley AK, Scott M, Schonlau M. Children’s access to mental health care following Hurricane Katrina within a randomized field trial of trauma-focused psychotherapies. Journal of Traumatic Stress. 2010;23(2): 223-231.
Feldman E. 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.
Kataoka SH, Stein BD, Jaycox LH et al. A school-based mental health program for traumatized immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry. 2003;42:311-318.
Stein BD, Kataoka S, Jaycox LH, Wong M et al. Theoretical basis and program of a school-based mental health intervention for traumatized immigrant children: A collaborative research model. Journal of Behavioral Health Services and Research. 2002;29(3):318-326.
Program replicated elsewhere:
Yes, see publications noted.
Rated/Reviewed by Evidence Based Registries:
NREPP: SAMSHA’s National Registry of Evidence-Based Programs and Practices
Promising Practices Network on Children, Families, and Communities
California Evidence-Based Clearinghouse for Child Welfare
Evidence-Based Practices for Children Exposed to Violence: A Selection from Federal Databases
National Child Traumatic Stress Network Empirically Supportive Treatments and Promising Practices