Jun 3, 2009
Ten years ago, RAND researchers joined colleagues at the Los Angeles Unified School District and the University of California Los Angeles to confront one of the saddest realities in the United States: the large numbers of children who go to school weighed down by experiencing or witnessing some form of violence, trauma, or maltreatment.
Out of this concern and collaboration grew the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS), a school-based early intervention program aimed at reducing children's symptoms related to existing traumatic experiences and enhancing their skills to handle future stresses.
CBITS is designed to be delivered by school mental health clinicians, but these professionals are a luxury for most schools. Responding to requests from school districts, the research team adapted the program so that teachers and school counselors with no mental health training can deliver it. This Research Highlight presents results from a small pilot test of the CBITS adaptation known as Support for Students Exposed to Trauma.
From community and family violence to natural disasters, around one in four youngsters is thought to be affected by trauma. A recent national survey of children and youth ages 2 to 17 provides a more detailed picture:
Exposure to trauma, whether caused by humans or nature, often manifests in children and adolescents as learning difficulties and/or behavioral problems. CBITS is founded on cognitive-behavioral therapy; of the common approaches used to treat childhood trauma, this therapy is the only one with strong evidence of effectiveness. For many students, especially those in poor and minority neighborhoods, school is one of the few sources for mental health care. CBITS targets the general school population, with flexibility built in to make the program relevant to racially, ethnically, and socioeconomically diverse groups. See the box for an update on CBITS.
With funding from the National Institutes of Health, the CBITS research team sought feedback from teachers, school counselors, clinicians, and national experts on how to make their program easier for schools to implement. The result is Support for Students Exposed to Trauma (SSET). SSET keeps the same cognitive-behavioral approach and ten group-session structure as CBITS, but the clinical aspects of the original program have been modified (see the table). Changes include the following:
|Targeted Population||Therapeutic Aims||Program Delivery||Intervention Approach|
|Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)|
|Students in grades 5–9 with exposure to trauma who have elevated symptoms of PTSD, depression, and anxiety||Reduce symptoms of PTSD, depression, and anxiety, resulting in better coping and cognitive skills||
School mental health counselors receive a two-day training session
During a class period, they deliver CBITS over ten weekly group sessions (6–8 children/group) and 1–3 individual student sessions
One teacher-education session, and 2–4 optional parent sessions
|Support for Students Exposed to Trauma (SSET)|
Teachers or counselors, after a two-day training session, deliver SSET over ten weekly group sessions during a class period
No individual sessions; no parent sessions
|Core elements are the same but delivered in lesson-plan format and without one-on-one sessions.|
Beginning in 2005, SSET was pilot-tested for two years in two Los Angeles middle schools, one in the San Fernando Valley and the other in South Central LA. Most of the students were Hispanic and came from lower socioeconomic backgrounds, and more than half were English learners.
Of the students screened for participation in SSET, 58 percent met the initial study criteria: They had experienced severe violence in the prior year and had moderately severe symptoms of post-traumatic stress disorder (PTSD). In the end, the pilot test sample consisted of 76 students with appropriate parental and student consent to participate in the study.
Three teachers and one school counselor without any specific mental health clinical background were trained over two days to deliver SSET. One teacher was an experienced social studies instructor; the second was an experienced algebra teacher; and the third was a new math teacher. The school counselor had training in school safety, peer relationships, and suicide prevention.
Each of the four instructors led four SSET groups; each group met once a week during the school day and received a total of ten lessons. Half of the students were given SSET immediately, while the start of the other half was delayed until the first intervention group had ended. Those students served as controls.
Students were surveyed to measure their trauma symptoms at baseline, at three months after the first group had completed SSET, and at six months after the control group had completed the program. Additional assessments focused on the instructors' ability to faithfully deliver quality SSET lessons. Both students' parents and teachers were surveyed about the students' behavior at home and at school, and students were surveyed about their own symptoms and behaviors. Parents and students were also surveyed about their satisfaction with the program.
Even in this small pilot test, the results indicate that SSET can be implemented successfully by teachers and school counselors without mental health training to address violence-related PTSD and depression, especially in low-income, urban students. The pilot test results indicate the following:
Given the promising pilot test results, a larger evaluation of SSET effectiveness is warranted. Until that time, the impact of this intervention is not fully known, but it does show promise. Schools interested in conducting SSET will be able to obtain detailed information from the manual, as well as information about training from the author, Lisa Jaycox, PhD (Lisa_Jaycox@rand.org).