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Amanda Mohler Mashana L. Smith, Ph.D. Chicago Public Schools

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1 Cognitive Behavioral Intervention for Trauma in Schools (CBITS) within Chicago Public Schools
Amanda Mohler Mashana L. Smith, Ph.D. Chicago Public Schools Office of Diverse Learners and Student Supports Office of Social & Emotional Learning

2 AGENDA Chicago Public Schools at a Glance
Implementation and Use of MTSS Framework within CPS History of CBITS within CPS Training & Supported Implementation Referral, Screening and Assessment Process Implementation Fidelity Evaluation and Outcomes Challenges & Future Direction for Implementation

3 Chicago Public Schools at a Glance

4 Demographics

5 Demographics Chicago Public Schools (District 299) is the 3rd largest school district 85% of students live at or below the poverty line 91% of students are minority 70% graduation rate (within 4 years) 19% mobility rate 13.3% of students with disabilities English language learners 16%

6 Trauma Related Symptomatology among CPS Students
32.5% of CPS students felt sad or hopeless almost every day for 2 weeks or more in a row and stopped usual activities Provide access to much needed services for students whose health and wellbeing is compromised. They help address ad remove these health related barriers to learning. Here is what our youth face. Background Nearly 40% of CPS High School students did not see a doctor or healthcare provider for an annual check-up or physical High School Youth Risk Behavior Survey, 2013 More than 25% of students are impacted by chronic conditions such as asthma, diabetes, or food allergies CPS Chronic Condition Report, 2012 Nearly 50% of CPS student are overweight or obese CDPH Obesity Report, 2013 Cook County ranks 1st, 2nd, and 3rd respectively for rates of gonorrhea, chlamydia and syphilis among all counties and cities in the United States Chicago Department of Public Health Data, 2012 In 2013, 32.5% of CPS students felt sad or hopeless almost every day for 2 weeks or more in a row that they stopped doing some usual activities during the past 12 months 15.5% of CPS students seriously considered attempting suicide Youth Risk Behavior Survey, High School, 2013 15.5% of CPS students seriously considered attempting suicide

7 Implementation and Use of MTSS Framework within Chicago Public Schools

8 Multi-Tiered Systems of Support for
Social, Emotional, & Behavioral Needs POSITIVE LEARNING CLIMATE School climates with positive relationships, clear expectations, and collective responsibility establish appropriate behaviors as the norm. Respectful, learning-focused, participatory classroom environments with well-managed procedures and behaviors maximize learning time ALL STUDENTS (Examples: School-wide Expectations, Second Step, Talking Circles) SOCIAL AND EMOTIONAL LEARNING Explicit curricula, along with integrated instructional practices that promote social and emotional development, teach students how to form positive relationships, make responsible decisions, and set goals. These are critical skills for college and career success. SOME (Ex: Peer Council, Check In/Check Out) TARGETED SUPPORTS For at-risk students, classroom-based responses can help de-escalate behavior problems, clinical group interventions address anger, trauma, and violence; and restorative practices provide students with strategies to resolve conflicts FEW INDIVIDUALIZED INTERVENTIONS For students with the highest levels of need, highly-targeted and individualized behavior strategies provide more intensive intervention and monitoring. (Ex. Wraparound, Individualized Counseling)

9 Multi-Tiered Systems of Support for

10 History of CBITS within Chicago Public Schools

11 Identifying a Need for Evidence-Based Interventions within Chicago Public Schools
During a focus group attended by CPS social work and psychology coordinators (Winter, 2006), it was determined that: The majority of referrals for social work services were related to the experience of trauma or anger/aggression CPS didn’t have a firm understanding of the nature or effectiveness of services Despite numerous minutes of direct service minutes, students were not exiting related service delivery, indicating “improvement” In 2007, CPS collaborated with the University of Florida to review evidence-based interventions (EBIs) designed to address trauma in school-aged populations Cognitive Behavioral Intervention for Trauma in Schools (CBITS) LAUSD – Lisa Jaycox

12 Cognitive Behavioral Intervention for Trauma in Schools (Jaycox, 2004)
Includes 10, one hour cognitive behavioral therapy group sessions Recommended for students ages Skill Areas of the Intervention: Psychoeducation and Relaxation Realistic and Helpful Thinking Social Problem Solving Parent Education Teacher Education

13 Planning for the Adoption of CBITS: Identification/Selection of Schools Community Partners and Funding Mechanisms

14 Identification/ Selection of Schools
ISBE MH Leadership members or leadership teams had attended training related to early intervention Current infrastructure in place relative to preventative or early intervention SEL supports Indicators of need (disciplinary infractions, OSS, arrest rates, graduation rates) (e.g., Tier II teaming systems and structures with meeting, referral, and screening protocols) Initial implementation was supported by a Illinois Violence Prevention Authority (IVPA) grant for school based mental health services in the district. Illinois State Board of Education Mental Health I and II (ACES); Departmetn of Education Safe School Healthy Students (U.S. Departmetn of Education, Department of Justice and Element One—Safe School Environments and Violence Prevention Activities; Element Two—Alcohol, Tobacco, and Other Drug Prevention Activities; Element Three—Student Behavioral, Social, and Emotional Supports; Element Four—Mental Health Services; and Element Five—Early Childhood Social and Emotional Learning Programs. Coordination with other community-based organizations (CBOs) is required. Y.E.S. (Chicago Public Schools) The three local pilot communities will also be required to form Core Management Teams that will include

15 Identification/ Selection of Schools
ISBE MH/Englewood African American 97.82% Ranks 2nd for violent reports 32.3% of households below poverty level  34.7% of residents unemployed  30.3% of residents without high school diploma  SSHS/South Shore Ranks 12th for violent crime 31.5% households below poverty level 17.7% of residents unemployed 14.9% of residents without high school diploma

16 Training and Supported Implementation

17 Training for Chicago Public School Staff
In 2007, Chicago Public Schools partnered with UCLA Division of Child & Adolescent Psychiatry to train school based clinicians In 2008, clinical psychologists from Ann & Robert H. Lurie Children’s Hospital Community- Linked Mental Health Services Program partnered with CPS to train clinicians Training targeted the district’s school social workers, school psychologists, counselors, deans, and community mental health partners Two day training model offered: History of CBITS Cognitive-Behavioral Theory Education and Relaxation Imaginal Exposure Introduction to Cognitive Therapy Train the Trainer (TOT) in SY11 ( ) to include school-based clinicians Train the Trainer (TOT) Expansion during Spring, 2011 to include community mental health partners

18 CPS Training Data (SY08-SY14)
Training began in Fall, 2007 Over 1690 trainees ( ) 350/351 (99.7%) current School Social Workers trained in CBITS 226/228 (99.1%) current School Psychologists trained in CBITS 482/816 (59.1%) current School Counselors have been trained in CBITS 124 community mental health clinicians ( ) Bulk trained through a state/governor initiative

19 First Year of Implementation 2007-08
Clinicians (District & Community Mental Health Partner) Trainings Implementation

20 From Training to Implementation: Supported Implementation
EBT CBT Professional Learning Community Clinical Support Fidelity Monitoring Content Review Co Facilitation Inter-disciplinary Community mental health partners, district clinicians GOAL: Change practice for the delivery of school based Mental Health services for all students Clinical support – Best Practices Group Work Fidelity monitoring – Intervention Specific Content Review – Preparation for next sessions Meet monthly Provided by clinical psychologists from Lurie Children’s Hospital and CPS lead social workers and psychologists Intended to guide clinicians through implementation

21 MTSS Problem Solving Process: (Referral, Screening and Assessment Processes)

22 Behavioral Health Request for Assistance Form
Teachers observe behavior and attempt evidence-based behavioral strategies in the classroom If students do not respond, teachers complete a Request for Assistance (RFA) form The RFA is reviewed by a Behavioral Health Team (also known as CARE Teams) Additional screening is completed by a member of the BHT

23 Strengths and Difficulties Questionnaire (SDQ)
Originally developed by Robert Goodman (1997) Consists of 25 items in five different domains: Conduct Hyperactivity Externalizing Behavior Peer Problems Prosocial Behavior Similar versions for different informants 5 Domains of the SDQ Conduct Hyperactivity Externalizing behavior Peer problems Prosocial behavior It was originally developed by Robert Goodman (since 1997) from the Department of Child and Adolescent Psychiatry, King’s College, London. It consists of 25 items in five different domains: conduct problems, emotional symptoms, hyperactivity-inattention, peer problems and prosocial behaviour, and it contains both positive and negative behavioural traits. There are similar versions for different informants: parents, teachers and year-old children and adolescents themselves. There is also another version for the parents and the day care teachers of 3- to 4-year old children. The SDQ can be used by various mental health professionals and for different purposes, e.g. for screening, for epidemiological research, for clinical assessment and for evaluating intervention outcome. Since the questionnaire can be completed in about five minutes, a positive effect on its acceptance by the responding informants can be expected, thus leading to low rates of refusal and missing answers. In the child psychiatric epidemiology research, questionnaires are usually used in the first stage of surveys, and are followed by clinical interviews in the second stage. The better the first screening stage can be conducted, the easier and more accurate it becomes to apply the results and to choose the criteria for the clinical sample (Kresanov et al. 1998; Fombonne 1991). Screening in the first phase of a two-stage community survey should be achieved with sufficient efficiency. However, second-stage interviews are more difficult and more costly to carry out. Thus, sampling the screen-positive group should result in an elevated probability of selecting a case for further investigation, in order to make optimal use of interviewing resources. (Fombonne 1991). Thus, there is a need for further development of efficient and accurate assessing methods in child psychiatric research based on current theories of children’s emotional and behavioural problems. Besides the SDQ, there are only few questionnaires to assess a broad range of children’s mental health problems. TRRPB measures whether student behavior is proactive or reactive

24 Trauma Symptom Inventory
5 Domains of the SDQ Conduct Hyperactivity Externalizing behavior Peer problems Prosocial behavior TRRPB measures whether student behavior is proactive or reactive

25 Trauma Symptom Inventory
5 Domains of the SDQ Conduct Hyperactivity Externalizing behavior Peer problems Prosocial behavior TRRPB measures whether student behavior is proactive or reactive

26 Implementation Fidelity

27 Chicago Public Schools Implementation Model
Co-facilitation is considered best practice Co-facilitation is encouraged during Year I of implementation Co-facilitation not required during Year II and beyond New implementers are highly encouraged to attend supported implementation sessions

28 Co-Facilitation Guidelines
Lead Facilitator Co-Facilitator SBC Clinician (Masters level social worker, psychologist, or counselor supervised by a Licensed Mental Health Professional (LMHP) (LCPC, LCSW, PhD, PsyD) Type 73 school based professional (school psychologist, school social worker, school counselor) Graduate trainees/interns supervised by masters level social worker, psychologist, or counselor

29 Implementation Data Metric SY 2013 # of students referred 2815
# of students assigned to CBITS 253 # of students assigned to Anger Coping 1036

30 Fidelity of Implementation
Facilitators are asked to complete a fidelity monitoring form following each group meeting Intended to encourage accountability and uphold fidelity To be completed by both facilitators

31 Evaluation and Outcomes

32 Assessment Instruments
Pre and Post Assessment Strengths and Difficulties Questionnaire (SDQ) Trauma Symptom Inventory All data is entered into a district SharePoint

33 Scoring and Classification
Strengths and Difficulties Questionnaire Trauma Symptom Inventory Total Difficulties Score ranges between 0 and 40 16-40 Abnormal 12-15 Borderline Normal Scoring Exposure: One or more exposure Symptomatology: 14 or more

34 Pre-Post Analyses Assessment Time N Mean CI 95% Pre Post 220 40.155

35 Limitations of Evaluation
Single method of assessment Limited understanding of areas of impact No examination of domains with SDQ No examination of domains within the TRRPB In this article, the authors review the defining attributes of rating scales that distinguish them from other assessment tools, assumptions regarding the use of rating scales to measure children's social behaviors, and features of scale design that promote intervention validity. They argue that integration of a pragmatic theory for problem solution, assessment of socially valid content, and utilization of a reporting framework aligned to known and effective intervention options are essential to promoting intervention validity of rating scale measures. To illustrate, they describe the combined theoretical and empirical approach used to develop the Social Skills Rating System and its recent revision, the Social Skills Improvement System. Ongoing challenges in the integration and monitoring of social skills interventions are discussed, and possible strategies for linking assessment to intervention are described. Researchers often pay inadequate attention to whether the assessment measures they select reliably and validly assess the constructs they wish to measure. There is an unfortunate tendency to choose measures simply because they are in widespread use or because the names of the measures suggest that they represent the constructs of interest. Without valid and appropriate measurement, the results of a study are severely compromised if not meaningless, and time spent up front on selection of appropriate measures will pay off in the end. This is not a task to pass off to an inexperienced research assistant. preferable to use multiple methods of assessment including, for example, self-report, interviewer, and observational or behavioral measures.

36 CBITS: A School Psychologist’s Experience

37 Experience Two day training (December 2008); Dr. Audra Langley, ULCA Division of Child and Adolescent Psychiatry Initial implementation in March 2009 6th grade students attending a PK-8th school in Englewood Social-emotional Learning Grant School slated for closure hearing 10 year old classmate murdered in 2007 (previous school year) gang crossfire Teacher request for services

38 Community Partners Ann & Robert H. Lurie Children’s Hospital of Chicago SGA Youth and Family Services Children’s Research Triangle (Teacher Education Session)

39 Referral Process Teacher referral Counselor referral Group composition
May need to make referrals to outside counseling or alternate intervention Input from counselors may help to make referrals more accurate. Language with parents “stress vs. trauma- receptiveness to therapy

40 Trauma Symptom Inventory
Preferential to administer individually, read items orally Refer back to types of trauma student indicated and ask for more information Establish relationship and gain student assent Need to guide or reframe in cases of chronic or multiple traumas Guide student to select an event to work on in group

41 Types of Traumatic Events
Fire Parent incarceration Parent/ relative homicide Peer homicide Traumatic grief or multiple losses Witness to community violence

42 Incentive System Two levels Group Teamwork incentive
Individual point sheet

43 Behavior Management Establish group rules Introduce confidentiality
Co-facilitator roles Content Behavior management Allow group members to come up with rules to make them feel safe in group Have an idea of 3-4 basic rules you would like them to follow Reframe into positive language

44 Group Incentive Tracking

45 Group Incentive Tracking


47 Individual Incentive

48 Education and Relaxation
Common reactions to stress or trauma Write on slips of paper and have students pull and read them  Provide copies of handout and have students highlight them Allow students to share Normalize all feelings Encourage them to share with their families

49 Relaxation Training Read progressive relaxation script
Consider dimming lights and moving furniture Play calming music

50 Cognitive Therapy Teach students the link between thoughts and feelings Chicken Little example Hot Seat activity to challenge negative thinking and supply positive alternatives Chicken Little example (of thoughts that are negative or wrong) Consider bringing in a book or showing a short video

51 Fidelity Behavioral Technical Assistance Team meetings
Co-Facilitator reflection

52 Modifications Consider estimated cognitive and academic functioning
Read material orally Informally assess need for additional sessions Consider additional visuals Prefer middle school age Other ideas- competition/ games, multimedia

53 Challenges Logistics Space Time allocation Referral process
Screening appropriate referrals Paperwork

54 Successes Collaboration with other professionals
Internalizing and applying content and techniques Student and parent feedback

55 Impact “What I learned is that you can trust people you’re in the group with. The group helps you a lot. It gets the things that are in your mind out and to express what you’re feeling.” -Seventh grade female

56 Challenges & Future Direction for the Implementation and Evaluation of CBITS within Chicago Public Schools

57 Challenges to Training, Implementation and Evaluation
Training of district personnel to allow for internal training Allocations for Related Service Providers 60 minutes per school per week Use and Ease of Data Collection Platform Alignment of Assessment Tools with the Intervention Funding Mechanisms for Community Mental Health Partners May have the opportunity to strengthen capacity via newly hired Network SEL Specialists

58 Next Steps for Continuous Improvement
Train ALL counselors, psychologists, social workers, interns and community partners Improve supported implementation model Differentiate sessions for all levels of experience Increase accessibility and convenience for facilitators Increase number of groups implemented via increased allocations of clinical related service staff and community mental health partners and availability of Network SEL Specialists Improve generalization of curriculum to classroom Strategically align assessment instruments for identification Support community mental health partners in the identification of external funding mechanisms Planning to hold supported implementation on PD days Use web chats and go to meetings Increase number of groups implemented via increased allocations of clinical related service staff and community mental health partners in 14 schools

59 Questions?

60 Chicago Public Schools Office of Social & Emotional Learning osel@cps
Chicago Public Schools Office of Social & Emotional Learning

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