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The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
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Core Components
CBITS is a school based treatment programme for students who have experienced major traumatic life events, and as a result suffer emotional or behavioural problems e.g. PTSD, depression and anxiety. This manualised intervention is designed for children aged 10-15 years, who have moderate level symptoms, with the goal of developing skills to manage stress and anxiety; decreasing trauma related symptoms; and increasing peer and parent/ caregiver support. CBITS teaches skills/ techniques in relaxation, social problem solving, exposure, and cognitive restructuring, with focus on the interrelated cycle between thoughts, feelings and behaviours. This promotes positive thinking, reduces trauma related anxiety, promotes the safe approach to trauma reminders, and increases problem solving skills in these children.
Prior to CBITS programme delivery, screening of students for trauma exposure and current symptoms is necessary. Screening is carried out by CBITS practitioner or administrative personnel, and screening approach can be universal (a whole classroom or a whole grade) or selective (among those who are already on a counselling caseload). CBITS is delivered in 10 group sessions; 1-3 individual sessions; 2 parent/ caregiver sessions; and an optional teacher session. The 10 group sessions cover an introductory session; education and relaxation; cognitive therapy; combating unhelpful negative thoughts; real-life exposure; exposure to stress or trauma memory; problem solving; and relapse prevention. Group sessions are delivered to groups of 6-8 students, in 45 minute weekly sessions, over 10-12 weeks. The 30-45 minute individual sessions are focused on processing the trauma memory, and are usually delivered between group sessions 2 and 5. Parent/ caregiver and teacher sessions cover several aspects including common reactions to trauma; helping children relax; measuring children’s feelings; helping children with their thoughts and fears; and teaching traumatised children.
CBITS is typically delivered by one mental health practitioner, or is co-facilitated depending on organisations’ preference. Methods used in programme delivery include interactive discussions, assigned activities, games/ exercises, informational handouts, and homework assignment. CBITS is not intended for students with severe problem behaviours, students requiring immediate intensive treatment, or those with limited cognitive abilities (below primary 5 reading ability). Parental consent prior to programme delivery is required. Consent forms for screening and group participation are available on the programme website.
Fidelity
Programme fidelity is ensured by;
• Use of CBITS adherence / fidelity measuring tool, and CBITS self-evaluation tool
• Review and rating of recorded sessions by CBITS programme faculty
Modifiable Components
CBITS has been adapted for delivery to children in primaries 1 and 2 in form of the Bounce Back programme. CBITS has also been adapted for delivery by school teachers and counsellors in form of the Support for Students Exposed to Trauma (SSET) programme. A toolkit to adapt CBITS for use in children in foster care is also available. CBITS has been delivered in USA, Australia, China, Japan, Pakistan, Ukraine, and Guyana, and the manual is available in English, Spanish and Arabic language.
Implementation Support
CBITS was developed by clinical researchers at the RAND Corporation, the University of California Los Angeles (UCLA) and the Los Angeles Unified School District (LAUSD).
Free materials to support CBITS preparation, training, implementation, and sustainability are available on the CBITS programme website. CBITS preparation resources available online include the readiness to adopt questionnaire; implementation guideline; and a sample CBITS schedule. To support practitioner training, CBITS programme manual; training guideline; and training courses are available online. The online toolkit also has forms needed to deliver and evaluate the programme. These include consent forms for screening and group participation; screening forms; evaluation forms; and fidelity measuring forms. Other documents including sample letters to parents and teachers; record logs; case summary forms; and certificate of competition are also available online. The virtual toolkit has CBITS programme implementation tips for maintaining confidentiality, engaging parents, running sessions, adapting CBITS for special populations and adhering to the core concepts of the programme.
Practitioners can also request regular remote clinical and implementation consultation (e.g. twice monthly or as needed) from CBITS programme faculty. The consultation covers session by session protocol, trouble shooting barriers and CBITS delivery in schools. Additional implementation support is available from the CBITS online community.
Licence Requirements
There is no licence required to deliver this programme
Start-up Costs
CBITS programme manual is available at no cost on the programme website, however a paperback copy can be purchased for $34. Online training on the CBITS programme website is also available at no cost, however the 2 day in-person training costs $5000 per 15 practitioners. This does not include travel costs.
Other implementation costs include $250/hour for reviewing and rating recorded sessions; $250/hour for clinical and implementation consultation; and $2500 (per 15 practitioners) for a one day “Training on CBITS” course, for practitioners who want to deliver CBITS trainings to other practitioners.
Building Staff Competency
Qualifications Required
CBITS is delivered by social workers, psychologists, counsellors and psychiatrists. These practitioners should have clinical mental health intervention experience. Practitioner familiarity with cognitive behavioural therapy, child trauma and group therapy is desirable. One practitioner typically delivers the intervention to groups of 6-8 students, however two practitioners (one clinician and one trainee) can co-lead sessions.
Training Requirements
Training prior to delivering CBITS is highly recommended. Practitioners have access to a two part CBITS training course available on the programme website. This online training is available at no cost, and can be completed in about 5 hours (in total for parts 1 & 2). Completion of part 1 is required before access to part 2 is granted. Practitioners also have free online access to advice from CBITS developers and practitioners; as well as access to downloadable materials including the CBITS programme manual. In-person training which takes place over 2days can also be arranged at the implementing site. Programme training covers overview of child trauma and PTSD; CBITS history and evidence base; session by session demonstrations and supervised practise of programmes’ core concept; parent and teacher session review; as well as implementation issues and site planning. After completing the initial 2 days training, practitioners interested in delivering CBITS training programme to other practitioners will be required to implement at least one CBITS group under supervision. This train the trainer process will also require practitioners to complete a 1 day “Training on CBITS” course. Following this, practitioners co-facilitate at least two CBITS trainings with a certified CBITS Trainer.
Supervision Requirements
Practitioner supervision during training and programme delivery is not required.
Theory of Change
CBITS is based on post trauma adaptations of cognitive behavioural theories. It suggests that thoughts, feelings and behaviours are interrelated, and influence recovery time from traumatic events. CBITS therefore focuses on the development of specific skills to address what the children think, how they feel, and what they do. This is evident in the CBITS programme content which include processing the trauma memory; combating unhelpful negative thoughts and alternative coping strategies.
Primary school: 6 to 12 years - Rating: 4
Research Design & Number of Studies
The best evidence for children aged 6-12 years old comes from one RCT (Stein et al, 2003) and one QED (Kataoka et al, 2003) both conducted by programme developers. The studies included children aged 8-14 years, however separate data for children aged 6-12 years were not reported. Compared to the control group, the following outcomes were observed;
Outcomes Achieved
Child Outcomes
• Significantly lower scores on symptoms of PTSD and depression (Kataoka et al, 2003; Stein et al, 2003)
• Significantly reduced parent reported psychosocial dysfunction (Stein et al, 2003)
Parent Outcomes
None reported
Key References
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290(5), 603-11
Kataoka, S., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., ...Fink, A. (2003). Effectiveness of a school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311-318
Adolescents: 13 to 18 years - Rating: 4
Research Design & Number of Studies
The best evidence for children aged 13-18 years old comes from one internally conducted quasi experimental study. The study included 198 Latino immigrant students (in USA) with trauma-related depression and/or posttraumatic stress disorder symptoms. Students were in grades 3 to 8, with mean age 11.4 years (approximate age range 8-14 years). Separate data for students aged 13-18 years was not reported.
Outcomes Achieved
Compared to the control group, the following outcomes were observed;
Child Outcomes
Significantly greater improvement in posttraumatic stress disorder and depressive symptoms at 3 months follow-up
Parent Outcomes
None reported
Key References
Kataoka, S., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., ...Fink, A. (2003). Effectiveness of a school-based mental health program for traumatized Latino
Need
Comparable Population
CBITS treatment programme is for students aged 10-15 who have emotional or behavioural problems as a result of traumatic life experiences. The programme is designed to decrease trauma related symptoms; help students develop skills to manage stress and anxiety; and increase peer and parent/ caregiver support.
Is this comparable to the population your organisation would like to serve? Has your organisation identified students with behavioural or emotional problems associated with traumatic life events that may benefit from this programme? Is there a need for this programme? Desired Outcome
Programme delivery in children aged 8-14 years is associated with significant reductions across several outcomes, including PTSD symptoms, depressive symptoms and psychosocial dysfunction.
Are the above outcomes priorities for your organisation? Are there other primary outcomes that your organisation would like to achieve that are outside the premise of CBITS? Does your organisation have other systems in place that effectively and efficiency address the above outcomes?
Need Score
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Fit
Values
CBITS is a manualised, school based treatment programme for children aged 10-15 years, who have experienced major traumatic life events that have resulted in the development of behavioural or emotional problems. The goal of this programme is decreasing trauma related symptoms; developing skills to manage stress and anxiety; and increasing peer and parent/ caregiver support. In addition to student sessions, CBITS also has parent/caregiver sessions and an optional teacher session. CBITS is not intended for students with severe problem behaviours, students requiring immediate intensive treatment, or those with limited cognitive abilities (below primary 5 reading ability).
Is this the population your organisation would like to target? Are the above goals similar to what your organisation would like to achieve? Is your organisation looking to treat student with severe symptoms (e.g. severe depression), students requiring immediate intensive treatment or those with limited cognitive abilities? Priorities
Is your organisation looking to deliver an intervention to students (aged 10-15 yrs) who have experienced major traumatic life events that have resulted in behavioural or emotional problems? Is your organisations’ priority to deliver a school based intervention, or would a home visiting programme, telehealth programme or clinic based programme fit better? Will this intervention be delivered to students who have emotional or behavioural problems associated with specific traumatic events (e.g. only sexual assault survivors)? Or would this programme be delivered to all students who need it? Existing Initiatives
Does your organisation have existing programmes that support people who have emotional or behavioural problems associated with traumatic life events? Are the existing initiatives directed towards people who have experienced specific traumatic life events (e.g. only people who have experienced severe violence)? Or are they delivered to all people who need it? Are the existing initiatives effective? Do they fit your current and anticipated future requirements? Can they be delivered to students aged 10-15 years? Are the existing initiatives school based interventions? Do they address similar goals as CBITS? Are there components within CBITS that are not met by existing programmes? Do your existing initiatives also have components that delivered to parents and teachers?
Fit Score
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Capacity
Workforce
CBITS is delivered by social workers, psychologists, counsellors and psychiatrists. These practitioners should have clinical mental health intervention experience. Practitioner familiarity with cognitive behavioural therapy, child trauma and group therapy is desirable. CBITS training for practitioners is freely available online. A 2 day in-person training can also be arranged at the implementing site. Practitioners can also receive a one day training to deliver CBITS training programme to other practitioners. One practitioner typically delivers the intervention to groups of 6-8 students, however two practitioners (one clinician and one trainee) can co-lead sessions.
Does your organisation have practitioners with the required qualifications and experience, who are interested in learning and delivering this programme? If not, does your organisation have the capacity to recruit the relevant practitioners for this programme? How many practitioners will be delivering the sessions? How many practitioners will your organisation train? Will your organisation also train practitioners to become CBITS trainers? Technology Support
CBITS training manual and training courses for practitioners are free and widely available online. Other materials to support CBITS preparation, training, implementation and sustainability are also free and widely available on the programme website. Practitioners can request regular remote clinical and implementation consultation.
Does your organisation have the technology (computers/ tablet/ smartphone and broadband) to enable practitioners access the online toolkit? Can the technology be purchased? Does your organisation have the technology to receive remote consultation from CBITS faculty (e.g. telephone, computer/ tablet, internet access)? Administrative Support
CBITS is a school based programme, and active parental consent prior to programme delivery is required. Screening for trauma exposure and current symptoms is also necessary. Screening can be carried out by CBITS practitioner or administrative personnel.
Will a universal or selective screening approach be used to identify students for inclusion in this programme? Can your organisation provide administrative support for the screening process, or will screening be conducted by CBITS practitioner? How will your organisation reach out to parents to collect informed consent? Does your organisation have an onsite space to run programme sessions? Financial Support
CBITS training manual and training courses for practitioners are freely and widely available online. Other materials to support CBITS preparation, training, implementation and sustainability are also available on the programme website at no cost. The CBITS training manual in paperback can be purchased for $34. A 2 day in-person training can also be arranged at the implementing site at $5000 per 15 practitioners. Other implementation costs include $250/hour for reviewing and rating recorded sessions; $250/hour for clinical and implementation consultation; and $2500 (per 15 practitioners) for a one day “Training on CBITS” course. This does not include travel costs.
Will your practitioners use the free online resources for their training or will they also purchase paperback CBITS manuals and attend in-person training? If in-person training is desired, how many practitioners will your organisation train? Can your organisation afford the in-person training costs for that number of practitioners? How many practitioners will your organisation train to become trainers? Can your organisation afford the other costs for consultation and session review?
Capacity Score
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