Cognitive Behavioral Intervention for Trauma in Schools

1. Introduction

Version followed: Jaycox, Langley & Hoover (2018), CBITS, 2nd edition (RAND), with the session-by-session structure taken from the published CBITS Fidelity Measure, 2nd edition. The 2nd-edition manual itself is not drawn on here. Session contents come from the fidelity measure, clearinghouse profiles and trainer slide decks. Step-level procedures inside sessions are my paraphrase or [synthesis] and are marked as such. The 1st edition (Jaycox, 2004, Sopris West) has the same core concepts. RAND says most sessions in the 2nd edition kept the same agenda and activities. [source: RAND 2nd-edition announcement; Title IV-E Clearinghouse; CBITS Fidelity Measure 2nd ed.]

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is a manualised, school-based, cognitive-behavioural group programme for students with PTSD symptoms after trauma exposure. It was developed by RAND, UCLA and the Los Angeles Unified School District (LAUSD), originally for community-violence exposure. School-based clinicians deliver it. It has three aims: reduce trauma symptoms, build skills for managing stress and anxiety, and build peer and caregiver support. [source: CEBC; RAND announcement; Blueprints]

How change happens: CBITS teaches standard CBT techniques for adjusting to trauma: psychoeducation, relaxation, cognitive restructuring, real-life (in vivo) exposure to safe reminders, imaginal or narrative exposure to the trauma memory, and social problem solving. The students apply these to their own problems. Normalising reactions reduces stigma. Relaxation and cognitive skills give students coping tools. Graded exposure reduces avoidance and fear through habituation. Problem solving and peer and parent support carry the gains into daily life. [source: CEBC; Blueprints; Hoover slides; the habituation rationale for the individual sessions comes from the Hoover slides]

Related programmes, not covered here: SSET (Support for Students Exposed to Trauma), which teachers and school counsellors deliver, and Bounce Back, for children aged about 5 to 11. [source: Hoover slides]

2. Framework

Format [source: CEBC; Title IV-E Clearinghouse; Blueprints; EPISCenter fact sheet]

• Group sessions: 10, usually weekly, of about 45 minutes (one class period). The EPISCenter fact sheet says about one hour. Groups have 6 to 8 students of similar age; CEBC allows 6 to 10.
• Individual sessions: 1 to 3, each 30 to 45 minutes. They fall between group sessions 2 and 5, before the group exposure work. Every student has at least one. Up to two more are added depending on how the student reacted to the last session, symptoms since then, and progress in the group. [source: Title IV-E Clearinghouse; EPISCenter]
• Caregiver (parent) sessions: 2 psychoeducational sessions, plus outreach and letters. Blueprints calls them optional.
• Teacher session: 1 educational (in-service) session. The Title IV-E Clearinghouse calls it optional.
• Overall length: about 10 to 12 weeks. Groups run during class time or after school, by agreement with teachers and administrators.
• Who and where: CEBC gives ages about 8 to 15 (grades 3 to 8) and says older students can also take part. The Title IV-E Clearinghouse gives grades 4 to 12. The EPISCenter fact sheet says CBITS is not adapted for grades K to 2. Students must have been exposed to a traumatic event and have significant PTSD symptoms (some profiles add depressive symptoms). [uncertain: the age range differs between profiles]
• Clinician: a mental health professional with a master's or doctorate, trained in CBT, with trauma experience. Training is 2 days (about 12 hours) in person, a virtual course of four 3-hour modules, or a self-paced online course. Ongoing consultation is recommended. The certified trial used weekly supervision. [source: CEBC; Title IV-E Clearinghouse; Blueprints]

Phases and session map (group session contents follow the CBITS Fidelity Measure, 2nd ed.)

[uncertain] Sources differ on some placements. The Blueprints 2016 slides introduce the Feelings Thermometer in session 3, but the fidelity measure puts it in session 2. The Title IV-E profile groups session 5 with exposure. The Hoover slides describe session 1 as including "share part of their trauma story". The fidelity measure's version of this is a discussion of the kinds of stress or trauma that brought students to the group. This guide follows the fidelity measure.

3. Guiding principles

[source: Blueprints 2016 slides (Sumi & Woodbridge); CBITS Fidelity Measure Part 2; CEBC; EPISCenter; [synthesis] where marked]

• Teach skills and apply them to each student's own problems. Every skill ends with each student applying it to one of their own situations, not just the textbook example.
• Stay within the CBT framework. The fidelity measure rates this. Keep sessions on teaching skills; do not let them drift into unstructured support.
• Normalise and destigmatise. Present symptoms as common, understandable reactions to what happened, and link them explicitly to the event.
• Keep a hopeful, educational tone. Talk like a teacher, and expect that the skills will help.
• Keep it fun and predictable. Post the agenda every session. Use games, stories and age-relevant examples. Keep the core concepts but put them in your own creative language.
• Model good coping. Show the skills in how you handle stress in the room.
• Check understanding often. Ask students to summarise and check comprehension (a fidelity item). After each concept, have a student say it back in their own words.
• Respond with empathy. Consistently notice students' emotions and respond to them (a fidelity item).
• Manage the group actively. Control cross-talk and non-compliance so that sessions stay safe and on time (a fidelity item).
• Challenge unhelpful thoughts only. Accurate, protective thoughts are not disputed; they are met with problem solving. Do not replace negative thoughts with unrealistically positive ones.
• Homework links the sessions together. Every session from 2 to 9 opens with a homework review, and sessions 1 to 8 end with an assignment.
• Bring in parents and teachers. Handouts go home, parents learn the same skills, and teachers learn how to support students in class.
• The child chooses the target trauma. For a child with several traumas, the child decides, with the clinician's help, which event to work on.
• Adapt the examples to the culture. Replace manual examples with ones that fit the students, and deliver CBITS in the family's language where possible.
• Look after yourself as the clinician. Watch for secondary traumatic stress in yourself and seek consultation (Blueprints slides).
• Plan fit with the school first. Fit CBITS into the school calendar and agree staff roles before you start. [source: EPISCenter; NCSMH slides]

4. Intervention inventory

The order follows the programme. The session numbers match the CBITS Fidelity Measure, 2nd edition. Steps are written in my own words. Where the sources name an element but do not describe how to do it, the steps are [synthesis] built from standard CBT practice that fits the CBITS rationale. All example language is illustrative and is not taken from the manual.

4.1 Pre-implementation: school buy-in, screening and confirmatory interview

• Purpose: Find students with trauma exposure and significant PTSD symptoms who are suitable for a group. Do this before Group 1. [source: NCSMH slides; EPISCenter; Blueprints; Blueprints 2016 slides; Hoover slides]
• Steps:
  1. Meet the administrators and teachers. Explain the benefits of CBITS, plan the schedule (class time or after school) and agree staff roles. Name a clinical consultant for case questions.
  2. Decide how permission for screening will be obtained, where screening will take place and what parents will be told. Some trials used universal screening of a whole grade with active parental consent.
  3. Give a brief self-report screen covering trauma exposure and PTSD symptoms. Trials have used several combinations: a trauma events inventory with the PTS subscale of the TSCC; a violence-exposure checklist with the Child PTSD Symptom Scale; and, after disasters, the UCLA PTSD Reaction Index. Use licensed instruments as their publishers require. Do not adapt the items. Cut-offs varied by trial; one used a T-score of 58 or more on the TSCC-PTS. [uncertain: the 2nd-edition manual's recommended screen was not seen]
  4. Screen at least several weeks after a traumatic event, because many children recover on their own (Hoover slides).
  5. Hold a short one-to-one interview to confirm the screen result, check that symptoms relate to the trauma, and judge whether a group suits the student. One trial excluded students who were too disruptive for group therapy.
  6. Get parental consent and student assent for the group itself.
  7. Form groups of 6 to 8 students of similar age. Send parent and teacher letters. [synthesis: where possible, group by age and maturity rather than by trauma type, and avoid putting perpetrator and victim of the same incident in one group]
• Example language (illustrative): "You told me on the questionnaire about something scary that happened. Can you tell me a little about it, and how it's been affecting you lately?"
• Watch for: Acute suicide risk, active abuse, current danger at home, or psychosis. These need individual safety assessment and a referral before group work, or instead of it. [synthesis] Also watch for severe disruptive behaviour and for students who are distressed but whose symptoms are not trauma-related (refer them elsewhere).

4.2 Group introduction: members, confidentiality, group procedures (Group 1)

• Purpose: Build safety, cohesion and predictability. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Run a warm-up or ice-breaker game. The 2016 slides name an "M&M game" as the example.
  2. Explain confidentiality and its limits: harm to self or others, and abuse, which you must report. Agree that what others say stays in the group.
  3. Agree group rules together and write them up.
  4. Set up a reward chart for attendance, participation and homework.
  5. Post the session agenda. Do this in every session.
• Example language (illustrative): "What you share here stays here. The one exception is if I'm worried someone is being hurt or might get hurt. Then I'd need to get help, and I'd tell you first."
• Watch for: Students who joke about confidentiality, or who reveal another student's story. Restate the rules early.

4.3 Explaining the treatment using stories (Group 1)

• Purpose: Explain the rationale (stress reactions are common and these skills help) in concrete, age-appropriate terms. [source: Fidelity Measure]
• Steps: [synthesis: the manual's stories were not seen]
  1. Tell a short story about a fictional young person who has a frightening experience and then has trouble sleeping, nightmares, jumpiness and avoidance.
  2. Ask the group what that young person might be feeling and thinking.
  3. Map the CBITS skills onto the story: calming the body, changing thoughts, facing fears step by step, and solving problems.
  4. Present the 10 sessions as a training course.
• Example language (illustrative): "Like learning a sport, we'll practise skills each week. At first they feel awkward, but with practice they work when you need them."
• Watch for: Students recognising themselves in the story. That is a good sign of engagement.

4.4 Discussing reasons for participating (Group 1)

• Purpose: Name the kinds of stress or trauma group members have faced. This builds universality without detailed disclosure. [source: Fidelity Measure; the Hoover slides describe this as sharing part of the story]
• Steps:
  1. Invite each student to say in a sentence or two what kind of stressful event brought them here, for example violence they saw, an accident or a loss.
  2. Allow "I'd rather not say yet."
  3. Point out what the group has in common.
  4. Keep details for later sessions. [synthesis]
• Example language (illustrative): "Just the headline, not the whole story. For example, 'I saw a shooting near my house.'"
• Watch for: A student flooding into graphic detail. Gently stop them, validate what they said, and offer an individual follow-up.

4.5 Goal-setting homework (Group 1, reviewed in Group 2)

• Purpose: Set personal goals for what the student wants to change. These give motivation and a later yardstick. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Hand out the goals worksheet.
  2. Ask for 1 to 3 concrete goals, such as sleeping better, not getting into fights, or being able to walk past the corner store.
  3. Review the goals at the start of Group 2 and revisit them in Group 10. [synthesis]
• Example language (illustrative): "If this group really worked for you, what would be different by graduation?"
• Watch for: Goals that are vague or set by someone else ("my mom wants me to"). Help the student turn them into their own.

4.6 Psychoeducation: common reactions to stress or trauma (Group 2)

• Purpose: Normalise symptoms, reduce stigma, and link symptoms to the event. [source: Fidelity Measure; Blueprints 2016 slides; Title IV-E]
• Steps:
  1. Brainstorm with the group what people feel, think and do after something scary.
  2. Sort the answers into groups: re-experiencing (memories and nightmares), avoidance, feeling on edge or jumpy, and changes in mood. Add guilt, anger, sadness, and trouble concentrating at school. [synthesis: these clusters follow standard PTSD categories]
  3. Ask students to tick off privately the reactions they have.
  4. Give the parent handout. For homework, students review it with a parent.
• Example language (illustrative): "These are normal reactions to an abnormal event. Your brain is trying to protect you, but it's working overtime."
• Watch for: Relief and nodding, which show normalising is working. Watch for students who say they have "no reactions" while their screen was high; this may be avoidance.

4.7 Feelings Thermometer (Group 2, used throughout)

• Purpose: Give a shared rating of anxiety and fear for monitoring, exposure and checking relaxation. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Draw a thermometer scaled 1 to 10, where 1 is not anxious at all and 10 is very anxious. (Some versions use 0 to 10.)
  2. Practise with everyday situations and have each student rate them. The slides' examples were walking home alone and going out at recess.
  3. Use the ratings before and after relaxation, when building the hierarchy in 4.16, and during exposure.
• Example language (illustrative): "If 10 is the most scared you've ever been and 1 is totally calm, where are you right now?"
• Watch for: Every rating at 10 or at 1. Anchor the scale with examples from the student's own life.

4.8 Relaxation training (Group 2, practised throughout)

• Purpose: Calm the body to counter anxiety. This is used as a coping tool during exposure. [source: Fidelity Measure; Blueprints 2016 slides; Hoover slides]
• Steps: The sources name three methods: slow breathing, muscle relaxation and positive imagery. The steps are [synthesis]:
  1. Slow breathing: breathe in slowly through the nose, pause briefly, and breathe out more slowly. Hand on belly. Repeat for 1 to 2 minutes.
  2. Muscle relaxation: tense then release one muscle group at a time (hands, arms, shoulders, face, stomach, legs), about 5 seconds of tension and then let go. Notice the difference.
  3. Positive imagery: picture a safe, calm place in detail, using all the senses.
  4. Take a thermometer rating before and after.
  5. For homework, practise daily and teach it to a parent.
• Example language (illustrative): "Squeeze your fists tight, like you're squeezing a lemon... now let it drop. Notice how your hands feel now."
• Watch for: Giggling (normal at first), and students who become more anxious with eyes closed. Let them keep their eyes open and look at a point on the floor. Imagery of a "safe place" may be hard for a child who has no safe place; let them make one up. [synthesis] It is working if thermometer ratings drop and students report using it outside the group.

4.9 Thoughts and feelings: introducing cognitive therapy (Group 3)

• Purpose: Show that thoughts about an event shape feelings (and later, actions). [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Give one situation, such as someone bumping into you in the hallway.
  2. Ask for different possible thoughts ("they did it on purpose" / "it's crowded").
  3. Match each thought to a feeling and a thermometer rating.
  4. Ask students to catch one of their own thoughts linked to a strong feeling this week.
• Example language (illustrative): "Same bump, two different thoughts, two totally different feelings. So the thought matters."
• Watch for: Mixing up thoughts and feelings ("I thought I was mad"). Practise telling them apart.

4.10 Combating negative thoughts: Alternatives (Group 3)

• Purpose: Find other, more helpful explanations. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Take a negative thought from one student.
  2. Ask the group: is there another way to look at this, and is there another reason it could have happened?
  3. List the alternatives.
  4. Pick one that is believable. Rate how strongly the student believes it and how it feels.
• Example language (illustrative): "Your thought is 'Everyone's staring because they know what happened.' What else could explain people looking?"
• Watch for: Alternatives that are too positive to be believable. CBITS warns against swapping in unrealistically positive thoughts.

4.11 Combating negative thoughts: Implications (Group 3)

• Purpose: Reduce catastrophising by looking at what follows if the thought is true. [source: Fidelity Measure names the element; Blueprints 2016 slides list the questions about worst, best and most likely outcome]
• Steps: Ask, in order:
  1. If this were true, what is the worst that could happen?
  2. What is the best?
  3. What is most likely?
  4. Could you cope with the most likely outcome?
• Example language (illustrative): "Say she is mad at you. What's the worst, the best, and the most likely thing that happens next?"
• Watch for: Worst cases that are realistic threats, for example to safety. Switch to Plan of Attack in 4.13 or to problem solving.

4.12 Combating negative thoughts: Evidence, or "checking the facts" (Group 4)

• Purpose: Test a thought against the facts. [source: Fidelity Measure]
• Steps: [synthesis]
  1. Write the thought down.
  2. List the facts that support it and the facts that don't. Facts are things you could see or hear, not feelings.
  3. Write a balanced thought that fits all the facts.
  4. Re-rate the feeling.
• Example language (illustrative): "Let's be detectives. What's the proof this will happen again, and what's the proof it might not?"
• Watch for: Students using feelings as evidence ("I feel unsafe, so it's dangerous").

4.13 Combating negative thoughts: Plan of Attack (Group 4)

• Purpose: When a thought is accurate or partly accurate, plan what to do instead of disputing it. [source: Fidelity Measure names "Plan of Attack"; the Blueprints 2016 slides say accurate, protective thoughts are not challenged but met with problem solving. The exact content of this element in the manual was not seen.] [uncertain]
• Steps: [synthesis]
  1. Agree that the thought may be realistic.
  2. Ask what the student can do to stay safe or cope (who to tell, where to go, which skill to use).
  3. Write a short action plan.
• Example language (illustrative): "You're right that the park isn't safe at night. So what's your plan for getting home?"
• Watch for: Talking a child out of a valid safety concern. Never do this.

4.14 The Hot Seat (Groups 3, 4 and 9; worksheet homework)

• Purpose: Practise the combating-negative-thoughts skills under light, playful pressure until they become automatic. The 2016 slides expand HOT as "Helpful Other Thoughts"; the Hoover slides say "helpful other thinking". [source: Fidelity Measure; Blueprints 2016 slides; Hoover slides]
• Steps: [the format here is synthesis; the manual's procedure was not seen] [uncertain]
  1. One volunteer sits in the "hot seat". The leader or other students say negative thoughts about a realistic situation, kept mild.
  2. The student in the seat answers each one with a helpful other thought, using alternatives, implications or evidence.
  3. The group helps if the student gets stuck.
  4. Rotate so everyone has a turn.
  5. For homework, complete the Hot Seat worksheet on one of the student's own upsetting situations.
• Example language (illustrative): "Okay, hot seat! The thought is: 'It's my fault my brother got hurt.' What's a helpful other thought?"
• Watch for: Thoughts in the game that hit a real trauma too hard, or teasing. Keep the content mild and the tone warm. It is working when students come up with alternatives quickly and use HOT language spontaneously.

4.15 Avoidance and coping: introducing real-life exposure (Group 5)

• Purpose: Explain that avoiding safe reminders keeps fear going, and that gradually facing them makes fear fade. [source: Fidelity Measure; Blueprints 2016 slides; Hoover slides]
• Steps:
  1. Ask what students avoid since the event: places, people, sounds, talking about it.
  2. Draw the avoidance cycle: avoid, feel short-term relief, fear grows. [synthesis]
  3. Contrast this with staying in a safe situation until the anxiety comes down.
  4. Use an everyday example, such as getting used to cold water in a pool.
• Example language (illustrative): "When you jump in a cold pool, it feels freezing, but if you stay in, your body gets used to it. Fear works the same way if the place is actually safe."
• Watch for: Make sure students understand that only safe situations are targets. A dangerous place stays avoided, and the student plans for safety instead (4.13).

4.16 Steps for Facing Your Fears: hierarchy and real-life (in vivo) exposure (Group 5, homework through Group 9)

• Purpose: Reduce avoidance of safe trauma reminders through graded practice. [source: Fidelity Measure; Blueprints 2016 slides; Hoover slides]
• Steps:
  1. Choose the target: each student picks one safe but avoided situation that matters to them, such as a person, place or thing. Check that it is safe with the student, and with a parent or school staff if it is unclear. [synthesis]
  2. Build the steps: break it into about 5 to 10 graded steps. Rate each one on the Feelings Thermometer and order them from low to high.
  3. Practise: for homework, start with a low step. Stay in the situation long enough for the rating to come down noticeably. The sources say to stay until anxiety decreases. Repeat the step until it feels easy, then move up a step.
  4. Record: write down the thermometer rating before, at the peak and at the end.
  5. Review: at every later session, review progress, praise attempts and problem-solve setbacks.
• Example language (illustrative): "Step one might be looking at the corner from across the street with a friend. The top step might be walking past it on your own after school."
• Safety and consent: Get the student's agreement for each step. Do not set steps that are actually unsafe or involve contact with a perpetrator. Tell parents about the plan. [synthesis]
• Watch for: Escaping early (leaving when the rating peaks), using distraction to avoid the feeling, and steps that are too large. It is working when peak and end ratings fall across repetitions and the student climbs the ladder.

4.17 Alternative coping strategies: thought stopping, distraction, positive imagery (Group 5)

• Purpose: Give extra short-term tools for intrusive thoughts and distress outside exposure tasks. [source: Fidelity Measure; NCSMH slides; students pick 1 or 2 to practise each week]
• Steps: [synthesis]
  1. Thought stopping: when an unwanted thought intrudes at a bad time (for example in class), say "stop" silently, picture a stop sign, and switch to something else.
  2. Distraction: use a list of absorbing activities, such as counting backwards or describing the room in detail.
  3. Positive imagery: use the calm-place image from 4.8.
  4. Each student picks 1 or 2 strategies to practise this week.
• Example language (illustrative): "These are for times when you can't deal with the memory right now, like in the middle of a test. We'll still face the memory, but at a time we choose."
• Watch for: Using these strategies to avoid exposure work. Explain the difference: they are for getting through bad moments, not for skipping exposure. [synthesis]

4.18 Individual sessions: trauma narrative and imaginal exposure (1 to 3 sessions, between Groups 2 and 5)

• Purpose: Let the student tell the full trauma story in a safe one-to-one setting so they become more comfortable talking and thinking about it through habituation. This prepares them for the group exposure sessions. [source: Hoover slides; Title IV-E (timing, and criteria for extra sessions); EPISCenter (child chooses which trauma); CEBC (30 minutes)]
• Steps: [synthesis: the sources give purpose and timing but not the manual's procedure; these are standard imaginal-exposure steps adapted for school] [uncertain]
  1. Choose the trauma: if the child has several, they choose, with your help, the one that still bothers them most.
  2. Consent and rationale: remind the child why talking about it helps, and that they control the pace and can pause.
  3. Tell the story: ask for the story from just before, during and just after the event, with what they saw, heard, thought and felt. Use the past or present tense, whichever the child manages. Allow drawing or writing as well as talking.
  4. Ratings: take a Feelings Thermometer rating at the start, at the worst moment and at the end.
  5. Repeat: go through the story again, or the worst part ("hot spot"), if time allows, so the rating can come down.
  6. Close: use relaxation, praise the courage it took, and agree what the student will share in the group (they can share less than they told you).
  7. Decide on more sessions: add a 2nd or 3rd individual session if distress stayed high, symptoms worsened afterwards, or the student is struggling in the group (Title IV-E criteria).
  8. Back to class: make sure the student is settled before returning to class, as the session is during the school day.
• Example language (illustrative): "Tell me what happened, starting just before it began. Take your time. I'll ask you for a number on the thermometer now and then."
• Contraindications and safety: Hold off narrative exposure, and assess and stabilise first, if there is ongoing danger (current abuse or living with the perpetrator), acute suicidality, psychosis, or a substance-use crisis. Also hold off if the "trauma" is a current, continuing threat rather than a past event. [synthesis]
• Watch for: Dissociation (blank stare, lost time), shutting down, or new disclosures (mandated reporting). It is working when ratings within the session fall on retelling and avoidance between sessions eases.

4.19 Group exposure to the stress or trauma memory through imagination, drawing or writing (Groups 6 and 7)

• Purpose: Continue exposure to the trauma memory in the group, adding peer support and normalisation. [source: Fidelity Measure; Blueprints 2016 slides; Hoover slides; Title IV-E]
• Steps:
  1. Review homework and remind everyone of the rationale and the confidentiality rules.
  2. Each student works on their own trauma story by drawing a picture, writing a story or imagining it, building on what they did in the individual session. [source]
  3. Take Feelings Thermometer ratings before and after. [synthesis]
  4. Students volunteer to share their drawing or story with the group. The leader keeps the focus on the student's experience and reactions, and invites short supportive responses from the group. [synthesis]
  5. Students share as much as they agreed in the individual session.
  6. For homework, finish the drawing or story and think about it. Continue real-life exposure and the Hot Seat. Students are encouraged to talk about the trauma at home (2016 slides).
• Example language (illustrative): "Put on paper what happened in whatever way works: pictures, comic strip or words. When you're ready, tell us about it."
• Safety: Make sure no graphic material retraumatises other members. Coach students to share their own experience and feelings rather than graphic detail. Plan in advance what to do if a student becomes very distressed: a co-leader or a quiet space. [synthesis]
• Watch for: A student whose story triggers another student, and competitive or one-upping stories. It is working when students can talk about the event with falling ratings and listen to others without shutting down.

4.20 Closure after exposure: discussion, summary, next steps (Groups 6 and 7)

• Purpose: End exposure sessions in a contained way so students leave regulated. [source: Fidelity Measure]
• Steps: [synthesis]
  1. Talk about what the exercise was like.
  2. Summarise what students learned, for example "I could talk about it and I was okay".
  3. Do a short relaxation.
  4. Take a final thermometer check around the room.
  5. Preview next week and homework.
  6. Check individually with anyone above about 5 or 6 before they return to class.
• Example language (illustrative): "What did you notice about your thermometer between the start of today and now?"
• Watch for: Students who are still upset at the end. Do not send them straight back to class; do a short check-in first.

4.21 Introduction to problem solving: negative thoughts and actions (Group 8)

• Purpose: Show that thoughts drive actions as well as feelings, often towards fights, withdrawal or risky choices. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Present a social vignette. The 2016 slides use one about a student deciding whether to ask someone to a dance.
  2. Ask what the character might think, what he would then do, and what he could think instead, leading to a different action.
  3. Link this to students' own conflicts.
• Example language (illustrative): "If he thinks 'she'll laugh at me', what does he do? And if he thinks 'worst case she says no', what does he do then?"
• Watch for: Students jumping to an action without noticing the thought behind it.

4.22 Brainstorming solutions (Group 8)

• Purpose: Come up with many options before judging them, to break all-or-nothing reactions. [source: Fidelity Measure; Hoover slides (problem-solving steps)]
• Steps:
  1. Define the problem in one sentence.
  2. List every possible solution, however silly. No criticising at this stage.
  3. Aim for at least 5 options. [synthesis]
• Example language (illustrative): "Every idea goes on the board, even the ridiculous ones. We judge them later."
• Watch for: Students criticising ideas early, or only ever offering aggressive options.

4.23 Decision-making: pros and cons (Group 8)

• Purpose: Weigh the options and choose the best one, then evaluate how it went. [source: Fidelity Measure; Hoover slides (choose and evaluate)]
• Steps:
  1. For each option, list short- and long-term pros and cons, for the student and for others.
  2. Choose the best option.
  3. Plan when and how to try it.
  4. Afterwards, evaluate it. If it didn't work, go back to the list.
  5. For homework, do problem-solving practice on a real problem and continue real-life exposure.
• Example language (illustrative): "Fighting him feels good for a minute. What happens tomorrow, and next week?"
• Watch for: Ignoring real safety constraints. Combine with Plan of Attack (4.13).

4.24 Problem-solving practice, Hot Seat practice and review of key concepts (Group 9)

• Purpose: Consolidate problem solving on real problems and refresh all the skills. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps:
  1. Review problem-solving and real-life exposure homework.
  2. In the group, work through one or two real problems that students bring, using all the steps.
  3. Run a Hot Seat round (4.14).
  4. Do a quick review of every concept, such as a quiz game or each student teaching one skill. [synthesis for the format]
• Example language (illustrative): "Who's got a real problem from this week we can use?"
• Watch for: Gaps in understanding to target before graduation.

4.25 Relapse prevention discussion (Group 10)

• Purpose: Prepare students for future stressors and setbacks, and say how they will use the skills. [source: Fidelity Measure; Blueprints 2016 slides]
• Steps: [synthesis]
  1. Revisit the Group 1 goals and rate progress.
  2. Identify upcoming triggers, such as anniversaries, a new school or the neighbourhood.
  3. Explain that a return of symptoms is a lapse, not a failure.
  4. Each student names the 2 or 3 skills they will use and one adult they can go to.
  5. Troubleshoot problems that could get in the way.
• Example language (illustrative): "If the bad dreams come back around the anniversary, what's your plan?"
• Watch for: Students with persistent or high symptoms. Re-screen and refer for further treatment, such as individual TF-CBT. [synthesis]

4.26 Graduation ceremony (Group 10)

• Purpose: Mark achievement, reinforce skills and end the group well. [source: Fidelity Measure; Blueprints 2016 slides; Title IV-E]
• Steps: Hand out certificates, run a celebration or special activity (for example snacks), and give each member positive feedback. [synthesis: the format of the feedback]
• Example language (illustrative): "Each of you faced something hard here. That certificate is for courage, not just attendance."
• Watch for: Students who find endings hard because of loss histories. Name the ending ahead of time. [synthesis]

4.27 Homework assignment and review routine (all sessions)

• Purpose: Carry skills into daily life. Homework review opens Groups 2 to 9, and Groups 1 to 8 end with an assignment. [source: Fidelity Measure; CEBC (worksheets and handouts)]
• The sequence: goals worksheet; parent handout plus relaxation practice; Hot Seat worksheet (twice); real-life exposure plus coping practice; finishing the drawing or story, thinking about it, real-life exposure and Hot Seat (twice); problem-solving practice plus real-life exposure.
• Steps:
  1. Open with a review: each student reports, and you praise any attempt.
  2. Problem-solve what got in the way.
  3. Link homework to the reward chart.
  4. Explain the next assignment clearly. Start it in the session if possible. [synthesis]
• Example language (illustrative): "Let's start like always. Who tried their Hot Seat sheet? Even half counts."
• Watch for: See non-adherence in section 5.

4.28 Parent (caregiver) education sessions (2 sessions)

• Purpose: Explain how children respond to stress and trauma, review the programme's goals and guiding principles, and teach parents ways to help children relax and reduce fear or anxiety. Parents learn some of the same skills their child is learning, so they can support them at home and in the classroom. [source: Title IV-E; CEBC; NCSMH slides]
• Steps: [the session-by-session split is synthesis; the manual's parent agenda was not seen] [uncertain]
  1. Outreach first: send letters, phone, meet at times parents can manage, and use the family's language. CEBC describes "extensive outreach".
  2. Parent session 1 (around Groups 2 and 3): introduce the programme and confidentiality, cover common reactions to trauma, teach relaxation so parents can coach it, and explain the handout homework.
  3. Parent session 2 (around Groups 5 to 7): explain thoughts and feelings, real-life exposure, and why talking about the trauma helps. Explain how to respond when the child talks about it: listen, stay calm, don't force it. Ask parents to support exposure steps that are safe and to praise practice.
  4. Give parents a way to raise their own trauma or stress reactions, and refer them if needed.
  5. Adapt the content for the family's context. For immigrant families, for example, some parent sessions addressed separation and loss from migration (EPISCenter).
• Example language (illustrative): "Your child may start talking more about what happened. That's part of healing. The most helpful thing is to listen without panicking."
• Watch for: Parents who are traumatised themselves, parents who discourage talking about it, and parents who cannot attend (send handouts or phone instead). [synthesis]

4.29 Teacher education session (1 session, optional in some profiles)

• Purpose: Increase teachers' understanding of and support for CBITS. Educate them about trauma so they can support students in the classroom. [source: Title IV-E; NCSMH slides; Blueprints (in-service)]
• Steps: [synthesis, partly informed by the classroom supports in the Hoover slides]
  1. Give an overview of CBITS and the schedule. Explain why students leave class and how to handle missed work.
  2. Explain how trauma shows up in class: poor concentration, jumpiness, irritability, withdrawal, falling grades.
  3. Give practical supports: allow a student who is overwhelmed to leave class, check that homework is written down, offer a safe place to talk, and know the referral route.
  4. Protect confidentiality: teachers know who is in the programme, not students' stories.
  5. Point teachers to their own support and self-care.
• Example language (illustrative): "A student who seems defiant may actually be on high alert. A quiet check-in often works better than a public correction."
• Watch for: Teachers resisting students missing class. Offer to rotate the class period each week. [synthesis]

4.30 Process skills rated for fidelity (every session)

• Purpose: The fidelity measure scores how the session is run as well as what is covered. [source: Fidelity Measure Part 2]
• The items: summaries and comprehension checks, empathy, staying within the CBT framework, group management (cross-talk and non-compliance), and the group's overall motivation, comprehension and participation. Content elements are scored 0 to 3, where 3 is thorough, interactive and integrated.
• Steps: Use the fidelity measure to rate yourself after each session, or have a supervisor rate a recording. Aim for each element to be covered interactively rather than just mentioned. [synthesis]
• Watch for: Covering material as a lecture, which scores low. Do one interactive exercise for each element.

5. Handling problems

The sources give little guidance on handling problems. Except where a source is cited, all of this section is [synthesis] based on general CBT, trauma-focused CBT, group-work and school practice.

• Stuck student (no change in symptoms or avoidance):
  • Check whether exposure is actually happening: escaping too soon, or safety behaviours.
  • Shrink the hierarchy steps.
  • Add an individual session. The Title IV-E profile lets you add up to two based on progress.
  • Check whether the target trauma is the right one, since the child chooses (EPISCenter).
  • If symptoms persist at Group 10, re-screen and refer for individual trauma-focused treatment.
• Avoidance or refusal of the trauma work:
  • Go back over the rationale using the cold-pool example.
  • Offer a different medium (drawing instead of talking, writing instead of sharing aloud).
  • Let the student share less in the group than they did individually.
  • Never force a disclosure. Keep the student in the group for the skills.
• Overwhelm or dissociation during exposure:
  • Pause and ground the student: name five things you can see, feel your feet on the floor, slow breathing.
  • Take a thermometer rating, and continue at a lower step once the rating drops.
  • Have a co-leader or a quiet space available.
  • Never send a student back to class dysregulated. Tell the parent the same day if distress was significant.
  • Short-term increases in distress are an expected risk of exposure.
• Disclosure of abuse or current danger:
  • Follow mandated-reporting law and the school's child-protection procedure.
  • Tell the student what you must do and why.
  • Pause narrative exposure until the student is safe.
• Suicidal thoughts or self-harm:
  • Follow the school's protocol.
  • Do a structured risk assessment, and safety planning with the parent.
  • Do lethal-means counselling with the caregiver: safe storage or removal.
  • Make an urgent referral. Exposure waits until the student is stable.
• Disruptive behaviour or cross-talk:
  • Use the rules and reward chart set in Group 1.
  • Seat students strategically, give a disruptive student a job such as timekeeper or board writer, and praise on-task members.
  • Talk with the student individually.
  • If disruption continues, offer CBITS individually instead. CEBC lists individual delivery as an option.
  • One trial excluded students who were too disruptive (Blueprints).
• Homework non-adherence:
  • Make tasks smaller, start them in session, and link them to rewards.
  • Ask the parent to prompt, and problem-solve the barrier together.
  • Never shame a student. Review whatever partial attempt they made.
• Absences and missed sessions:
  • Hold a brief individual catch-up on the missed skill before the next group.
  • A student who misses both exposure sessions needs an individual exposure session.
• Rupture with the leader (for example feeling pushed, or broken trust after a report):
  • Name it, own your part, and validate the student's reaction.
  • Explain your reasoning, and give the student control over pacing.
• Group contagion (one story triggering others, or competitive storytelling):
  • Set sharing rules before the exposure sessions: feelings and meaning, limited graphic detail.
  • Debrief everyone, and follow up individually.
• Ongoing danger (community violence, unsafe home):
  • Do not challenge accurate threat appraisals. Use Plan of Attack and problem solving (Blueprints 2016 slides).
  • Set exposure targets only in safe situations.
• Parent disengagement:
  • Use letters, phone sessions and flexible times. CEBC describes extensive outreach.
  • Provide sessions in the family's language. Make cultural adaptations such as addressing migration loss, or prayer as a coping strategy (EPISCenter).
  • Engaging parents is a known barrier (NCSMH slides).
• School barriers (administrator or teacher resistance, competing clinician duties; named in the NCSMH slides):
  • Rotate the class period, share outcome data, and protect the group time in your schedule.
• Grief-dominant presentation (the death of someone close):
  • CBITS addresses fear more than grief. Add grief-focused support or refer. [uncertain whether the 2nd-edition manual covers grief]
• Clinician secondary traumatic stress:
  • Seek consultation if you have intrusive thoughts or dreams about students' traumas, sleep problems, irritability or numbness (Blueprints 2016 slides).

Sources

Sources:

• CEBC: Cognitive Behavioral Intervention for Trauma in Schools
• CBITS Fidelity Measure, 2nd Edition (accessible PDF, Colorado State University PRC copy)
• RAND: CBITS Has Been Updated (2nd edition announcement)
• Title IV-E Prevention Services Clearinghouse: CBITS
• Blueprints for Healthy Youth Development: CBITS
• Sumi & Woodbridge, CBITS presentation, Blueprints Conference 2016
• EPISCenter: CBITS fact sheet
• NCSMH archive: CBITS implementation (LAUSD) presentation
• Hoover, S.: trauma-informed schools presentation (Learning to End Abuse conference)

Further reading (not drawn on): RAND TL272 manual page. The procedures here are therefore not checked against the manual text.

Books:

• Jaycox, L. H. (2004). Cognitive Behavioral Intervention for Trauma in Schools. Longmont, CO: Sopris West. (1st edition)
• Jaycox, L. H., Langley, A. K., & Hoover, S. A. (2018). Cognitive Behavioral Intervention for Trauma in Schools (CBITS), 2nd ed. Santa Monica, CA: RAND Corporation (TL272). (Version followed.)