1. Introduction to Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Materials provided by CBITS developers National Child Traumatic Stress Network

2. Overview Why a trauma program in schools? Increasing School Buy-In How did this program come about? Does it work? Introduction to CBT CBITS Program: Step by Step Implementation Planning by Site

3. Part 1: Why a trauma program in schools?

4. 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

5. Why a program for traumatized students? While walking we saw people crying because they had no food and water. We saw bodies in the street. They had an old man dead in a chair. I was so scared I thought I was going to die. We were walking on the bridge, and the army men started to shoot in the air, and I just started to cry I was so scared. It started to rain and everyone started to cry, saying, “I hope another hurricane don’t pass by.” Keoka, 10 th grade

6. Why a program for traumatized students? More and more youth are experiencing traumatic events Community violence Natural and technological disasters Terrorism Family and interpersonal violence Most youth with mental health needs do not seek treatment Many internalizing disorders in children go undetected

7. “Interpersonal violence is a public health emergency… and one of the most significant public health issues facing America” C. Everett Koop, JAMA, 1992

9. LAUSD 6 th Grade Students Prevalence of Past Year Violence, 2004 (N=28,882) No Violence (6%) Non-weapon related violence (54%) Gun or knife violence (40%)

10. Consequences of trauma exposure  Posttraumatic 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 concerns Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995

11. Consequences of trauma exposure  Posttraumatic Stress Disorder (PTSD)  Depression  Substance abuse  Behavioral problems  Poor school performance

12. Top Ten Reactions to Trauma CPS Preliminary Results n=179 (illustrated by Mean)

13. Impact of trauma on 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)

14. Part 2: Increasing School Buy-In

15. Bringing Evidence-Based Treatment to Schools Kids are in schools (removes obstacles such as transportation, stigma, etc.) CBT in school setting: Acceptable Feasible Amenable to group structure Focus on building skills Empowering

16. Gaining support from school community Liaison with teachers and administration Find ideal time for group Present education about trauma and respond to any concerns about program Students and Trauma DVD Trauma Awareness Powerpoint Slides Trauma Factsheets for Educators 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

17. CBITS Program 10 group therapy sessions for trauma symptoms Students ages 8-15 (can be used through 12 th grade) 1-3 individual student sessions for exposure to trauma memory and treatment planning 2 parent outreach sessions on education about trauma, parenting support 1 teacher session including education about detecting and supporting traumatized students

18. 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

19. Part 4: Does it work?

20. Results from LAUSD 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

21. 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

22. What did students say? Things I learned from my CBITS group: Do things that scare you and you won’t be scared anymore How to deal with stress How to keep control of myself when it’s a stressful situation How to control anger, how to deal with fear, how to stay calm in bad situations

23. 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

24. What did families say? I liked the fact that [he] had the chance to see that he was not alone It is a great idea to have this group. It should be more constant and should be part of the education to all the kids. Thank you for your time and energy trying to help [my son] to live with life after the storm.

25. 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.”

26. Morning Conclusion: Quality Mental Health Treatment in Schools is Vital for our Youth! You are the local experts! CBITS in Chicago must be a marriage of core treatment components that work and your clinical and cultural expertise about your students AND Using a new skill or approach WILL feel strange at first AND CBITS is not a panacea BUT

27. Access: What you do is extremely important! New Orleans – School vs. nonschool based treatment CBITS (N=58) Group and individual sessions at the child’s school 53 participated in groups 2 dropped out, 2 pulled out by parents, 1 left school TF-CBT (N=60) Individual appointments at Community MH Clinic 7 completed treatment 6 ineligible 1 diagnosed with Asperger’s + PTSD Symptoms 16 did not come to appointment, 7 no interest, 16 never reached

28. CBT: Friend or foe?  Assumptions about Cognitive Behavioral Therapy and Exposure  Concerns about Manualized Interventions

29. How does CPS select students for the group ? Receive completed RFAs Consultation – Complete Strengths and Difficulties Questionnaire (SDQ) Administer Trauma Symptom Index during Individual meetings (screening)

30. Conceptual model for participants (Session 1) What we think How we feelWhat we do Stress or Trauma

31. ThoughtsBehaviors Feelings

32. 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

33. Relaxation training (Session 2) Why? To enable child to reduce anxiety First tool to help students “calm their bodies down” How? Exercise combining positive imagery, slow breathing, and muscle relaxation May incorporate wordless music, aromatherapy Feel free to use scripts that have worked in the past. What’s worked for you? Homework assignment to practice at home

34. Feeling Thermometer (Session 3)  Why?  To enable child to observe his or her own anxiety level  To introduce a common language in describing “fear” or “anxiety”  How?  Fear thermometer used throughout the groups

35. The Feeling Thermometer 10 8 – Walking home from school alone Very anxious Not anxious at all 3 – Going out on playground at recess 7 6 5 4 2 9 1

36. 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”

37. Cognitive therapy (Sessions 3 & 4)  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

39. Cognitive therapy (Sessions 3 & 4)  Keep an eye out for the most common maladaptive thoughts related to trauma  Continually normalize these kinds of thoughts, link them to traumatic event  Demonstration

40. Adaptive Cognitive Coping Thoughts

41. Cognitive restructuring

42. 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 their trauma story Encouragement to talk about the trauma at home while the groups are running

43. 0 1 2 3 4 5 6 7 8 9 10 Time FT Avoidance

44. 0 1 2 3 4 5 6 7 8 9 10 Time F T Exposure-Avoidance vs. Habituation

45. 0 1 2 3 4 5 6 7 8 9 10 Time F T Exposure-Habituation contd.

46. 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 in gradual steps  Kids often unable to break this down into steps alone.  This is a longer session; leader helps each child create steps.  Practice approaching those situations and staying long enough for anxiety to decrease or go away  Have you done this before? What about school avoidant kids?

47. Sample hierarchy: 10 year old boy who was with his friend at a park when they witnessed a shooting death. SituationRating Going to the park alone10 Going to the park with friends8 Going to the park with parents 6 Going to different park4 Driving past park2 * By the time students get to the 8-10’s, they are no longer 8-10’s because of the mastery they have gained Least Scared/Upset Most Scared/Upset 10 9 8 7 6 5 4 3 2 1 Fear HierarchyFear Thermometer

48. Sample hierarchy SituationRating Playing outside alone 6 Playing outside w/ brother weekday 5 Playing outside on weekend daytime 3 Least Scared/Upset Most Scared/Upset 10 9 8 7 6 5 4 3 2 1 Fear HierarchyFear Thermometer

49. 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

50. 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

51. Graduation/Relapse Prevention (Session 10) Certificates Celebration of Progress Special activity/food/party Troubleshooting and applying CBITS skills to upcoming stressors

52. 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

54. CBITS DVD

55. For More Information on CBITS Cognitive Behavioral Intervention for Trauma in Schools, Lisa Jaycox, Ph.D. Rand Corporation: 2004 Sharon Stephan, Ph.D. (sstephan@psych.umaryland.edu) Audra Langley, Ph.D (alangley@mednet.ucla.net) National Child Traumatic Stress Network (www.nctsn.org)