Complete a Trauma-Informed Education Presentation for Educators

79

As reviewed in Chapter 4, several models have been proposed to

enhance school climate and schoolwide supports for students exposed

to trauma through the creation of trauma-informed schools. Although

research on the effectiveness of these models is lacking, the largest area

of growth in evidence-based trauma-informed programming for schools

has been in the area of interventions for trauma-exposed students. These

intervention models have received great interest in part because of their

ability to circumvent many of the barriers that impede children from get-

ting mental health care in specialty settings. By delivering mental health

care in schools, usually with no cost to the family, many logistical barriers

(transportation, scheduling) are removed, and the stigma associated

with mental health treatment is decreased as well. To date, the interven-

tions developed specifically for use in schools are targeted intervention

programs, designed to help students with elevated symptoms following

Targeted and Intensive Interventions for Trauma

in Schools

7

http://dx.doi.org/10.1037/0000072-008 Creating Healing School Communities: School-Based Interventions for Students Exposed to Trauma, by C. D. Santiago, T. Raviv, and L. H. Jaycox Copyright © 2018 by the American Psychological Association. All rights reserved.

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CREATING HEALING SCHOOL COMMUNITIES

80

trauma. Students requiring more intensive services are still generally

referred out to specialty care, although some evidence-based treatments

have been successfully delivered on school campuses. In this chapter, we

review each of these in turn.

SCHOOL-BASED TARGETED INTERVENTIONS

Compatible with the Multi-Tiered System of Supports models presented

earlier, targeted interventions generally fit into the Tier 2 level. Several

interventions have been developed in this area, and some have been eval-

uated and have demonstrated positive outcomes for students. A compre-

hensive review of these programs can be found in other sources (Jaycox,

Morse, Tanielian, & Stein, 2006; Jaycox, Stein, & Amaya-Jackson, 2008;

Jaycox, Stein, Amaya-Jackson, & Morse, 2007; Rolfsnes & Idsoe, 2011).

In general, the majority of such interventions involve cognitive behavior

therapy (CBT; Rolfsnes & Idsoe, 2011). The core components of CBT

that addresses traumatic exposure can be summarized by the acronym

PRACTICE: Parenting skills, Psychoeducation, Relaxation skills, Affective

Modulation skills, Cognitive coping skills, Trauma narrative, In vivo mas-

tery of trauma reminders, Conjoint sessions for parents, and Enhancing

safety (see Exhibit 7.1; Cohen, Mannarino, & Deblinger, 2006). Although

Exhibit 7.1

Evidence-Based Intervention Techniques

77 Parenting skills

77 Psychoeducation

77 Relaxation skills

77 Affective modulation skills

77 Cognitive coping skills

77 Trauma narration

77 In vivo mastery of trauma reminders

77 Conjoint sessions for caregivers

77 Enhancing safety

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TARGETED AND INTENSIVE INTERVENTIONS FOR TRAUMA IN SCHOOLS

81

other techniques and theoretical orientations are also used in some pro-

grams (e.g., psychodynamic theories, crisis intervention models), they are

less common and tend to be less well-tested to date. One obvious reason

for the popularity of CBT in these interventions is its strong evidence base

among adults and in different modalities (see Foa, Keane, Friedman, &

Cohen, 2008). In addition, these techniques can easily be delivered in group

formats in the school setting. For instance, the psychoeducational compo-

nents of CBT can be delivered in a didactic manner, and the behavioral

assignment setting that is integral to CBT is similar to the concept of home-

work. Table 7.1 summarizes key interventions; we review each in turn in

this section. The Resources section of this book lists URLs you can access

for more information about these programs.

Table 7.1

Selected School-Based Interventions

Name Description Target Evidence Dissemination

Cognitive Behavioral Intervention for Trauma in Schools

CBT, 10 group sessions, 1–3 individual sessions, 1 teacher ses- sion, 2 parent sessions

5th grade and above

1 RCT, 1 quasi- experimental study, 1 field trial

Wide dissemina- tion through http://www. cbitsprogram. org and national training

Support for Students Exposed to Trauma

CBT, adaptation of CBITS for nonclinical school person- nel, 10 group sessions

5th grade and above

1 pilot study Wide dissemina- tion through http://www. ssetprogram. org and national training

Bounce Back CBT, adaptation of CBITS for early elementary, 10 group ses- sions, 2–3 indi- vidual sessions

Grades K–5 2 RCTs Wide dissemina- tion through http://www. bounceback program.org and national training

(continues)

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CREATING HEALING SCHOOL COMMUNITIES

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Trauma- Focused Coping in Schools

CBT, 14 group and 1 individual session

6–18 years 1 quasi- experimental study

Information and training available from developers

Trauma Grief Component Therapy for Adolescents

CBT + grief work, 10–24 50-minute individual or group sessions

12–20 years 1 quasi- experimental study, 3 open trials

Information and training available from developers

Classroom- Based Intervention

CBT, 15 classroom- based sessions

7–19 years 1 RCT Information and training available from developers

Overshadowing the Threat of Terrorism

CBT for ongoing terrorism context

Grades 2–6 1 RCT Information and training available from developers

Enhancing Resilience Among Students Experiencing Stress

CBT curriculum for teachers related to ongoing terror- ism context

Grades 3–8 1 RCT, 2 quasi- experimental studies

Information and training available from developers

Note. CBT = cognitive behavior therapy; CBITS = Cognitive Behavioral Intervention for Trauma in Schools; RCT = randomized controlled trial.

Table 7.1

Selected School-Based Interventions (Continued)

Name Description Target Evidence Dissemination

Cognitive Behavioral Intervention for Trauma in Schools (CBITS;

Jaycox, 2003) is probably the most widely used and accessible program,

it has demonstrated improvement in child posttraumatic stress disorder

(PTSD) and depressive symptoms in several studies, and it is associated

with improved academic outcomes. It involves 10 group sessions, one

to three individual sessions, two parent meetings, and one teacher pre-

sentation and is delivered by school mental health providers. CBITS is

recommended for students in fifth grade or higher. The program was eval-

uated first in a quasi-experimental study with students who were recent

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TARGETED AND INTENSIVE INTERVENTIONS FOR TRAUMA IN SCHOOLS

83

immigrants to Los Angeles and who received the program in Spanish

(Kataoka et al., 2003). Results demonstrated a significant decrease in PTSD

and depressive symptoms in the group of students who received CBITS as

compared with those on a waiting list. A second evaluation among students

in the general school population showed similar results in a randomized

controlled trial (Stein et al., 2003), with significantly lower scores on mea-

sures of depression, PTSD, psychosocial dysfunction among those ran-

domized to receive CBITS, but no difference observed for teacher-reported

behavior problems. A subsequent analysis of changes in grades within this

study showed that those who received CBITS earlier in the school year had

improved grades compared with those who received it later in the year

(Kataoka et al., 2011). A field trial in New Orleans following Hurricane

Katrina showed comparable results in terms of reductions in PTSD and

depression scores among those randomized to CBITS as well as those who

received trauma-focused CBT (Jaycox et al., 2010). The program is being

implemented broadly within the United States (e.g., New Orleans, Chicago,

Los Angeles, San Francisco, several cities in Connecticut).

Three adaptations of CBITS are also promising. Bounce Back is a pro-

gram that has been developed for younger elementary students. This inter-

vention addresses the same core components but in a more developmentally

appropriate manner, and it involves parents to a larger degree than CBITS.

It has demonstrated improved child PTSD and anxiety symptoms in one

randomized controlled trial (Langley, Gonzalez, Sugar, Solis, & Jaycox,

2015) and improved PTSD symptoms and coping skills in a replication trial

(Santiago et al., in press). A second adaptation for CBITS, called Support for

Students Exposed to Trauma, was developed for nonclinical school person-

nel such as teachers or school counselors (Jaycox, Langley, & Dean, 2009). In

one pilot study it demonstrated improved outcomes (reductions in PTSD

symptoms and depression) and thus is considered a promising approach,

even though it led to no changes in parent- or teacher-reported behavior

problems (Jaycox, Langley, Stein, et al., 2009). The addition of a family

component showed that parent functioning can be improved alongside the

child improvements (Santiago, Lennon, Fuller, Brewer, & Kataoka, 2014).

CBITS, Support for Students Exposed to Trauma, and Bounce Back

are disseminated through the websites listed in the Resources section of

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CREATING HEALING SCHOOL COMMUNITIES

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this book, which provide extensive implementation materials and an online

training course for each. Live trainings are usually arranged on-site for

groups of school mental health providers. Training manuals for Bounce

Back and Support for Students Exposed to Trauma are available for down-

load free of charge; the CBITS manual is available for purchase.

Two other school-based interventions have also been evaluated and

have demonstrated improved child outcomes: Trauma-Focused Coping in

Schools (formerly called Multi-Modality Trauma Treatment; Amaya-Jackson

et al., 2003; March et al., 1998), and the Trauma Grief Component Therapy

for Adolescents (formerly called the University of California, Los Angeles

Trauma/Grief Program; Goenjian et al., 2005; Saltzman, Steinberg, Layne,

Aisenberg, & Pynoos, 2001). Both draw on evidence-based practices for

trauma, largely cognitive behavior techniques, and have empirical support

for the reduction of trauma-related symptoms. Specifically, Trauma-Focused

Coping in Schools was evaluated with a staggered start date control design

and showed decreases in PTSD, depressive, and anxiety symptoms among

14 treated students (March et al., 1998). These effects were replicated in sub-

sequent studies (Amaya-Jackson et al., 2003). Trauma Grief Component

Therapy for Adolescents, targeting community violence in Southern Cali-

fornia, showed reductions in PTSD and grief symptoms and improvements

in GPA among 26 participants in an open trial, but it did not show changes

in depressive symptoms (Layne, Pynoos, & Cardenas, 2001; Saltzman,

Pynoos, Layne, Steinberg, & Aisenberg, 2001). A brief version of the pro-

gram demonstrated reductions in PTSD symptoms in two field trials fol-

lowing an earthquake in Armenia (Goenjian et al., 1997, 2005). In addition,

the program was implemented in postwar Bosnia (Layne, Pynoos, Saltzman,

et al., 2001), showing greater reductions in PTSD, depression, and maladap-

tive grief, within the full program as compared with an active comparison

condition, with both groups improving significantly (Layne et al., 2008).

Trauma-Focused Coping in Schools is implemented with groups of

students, whereas Trauma Grief Component Therapy for Adolescents is

run with individual students or in groups. Both of these interventions

require 1 to 2 days of in-person training by the program authors. Access to

implementation manuals and materials requires contacting the authors of

the intervention.

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TARGETED AND INTENSIVE INTERVENTIONS FOR TRAUMA IN SCHOOLS

85

There also have been some notable international efforts in regions

affected by disaster or ongoing terrorist threat, five of which have been

evaluated. The Classroom-Based Intervention program (Macy, Bary, &

Noam, 2003) is a 15-session, classroom-based intervention providing a

psychoeducational curriculum for children ages 7 to 19 that is used to

address critical needs of children and youth exposed to threat and terror

(Macy et al., 2003). A large randomized controlled trial of 664 children

and adolescents in Turkey following an earthquake and in the West Bank/

Gaza schools and camps for Palestinian refugees showed improvements

among children (ages 4–11) and female adolescents (ages 12–16). Improve-

ments were noted on multiple domains, including communication, social

support, negotiation skills, use of relaxation as a coping strategy and,

among younger children, decreasing emotional and behavior problems. No

improvements were noted among adolescent boys (ages 12–16), however

(Khamis, Macy, & Coignez, 2004).

An eight-session program for second through sixth graders called

Overshadowing the Threat of Terrorism has been used and evaluated in

Israel (Berger, Pat-Horenczyk, & Gelkopf, 2007), showing reduced PTSD,

somatic, and anxiety symptoms 2 months after the intervention among

children who took part. A related program, more curricular in nature, is

Enhancing Resilience Among Students Experiencing Stress (ERASE-S),

designed to mitigate the effects of ongoing terrorism. ERASE-S uses teachers

to deliver the material and has demonstrated improved outcomes in terms

of PTSD and anxiety, as well as reduced stereotypes and discriminatory

behaviors (Berger, Gelkopf, & Heineberg, 2012; Berger, Gelkopf, Heineberg,

& Zimbardo, 2016; Gelkopf & Berger, 2009). Although these programs use

many of the same cognitive behavior techniques as those developed within

the United States, none of them have been tested within the United States

to date, and their applicability to U.S. schoolchildren is unknown.

OTHER TREATMENTS USED IN SCHOOLS

The interventions described in the preceding section were all developed

specifically for use in schools. It is certainly possible to bring clinical ser-

vices onto school campuses and adapt them to fit the school context and

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CREATING HEALING SCHOOL COMMUNITIES

86

culture. These are typically considered Tier 3 services within the Multi-

Tiered System of Supports framework, and a full review of their effec-

tiveness can be found in Foa et al. (2008). Implementing these types of

interventions can be challenging as they require more intensive training

and supervision for school mental health providers, fitting the sessions

into the school day, and handling logistical issues such as space and privacy.

Despite these challenges, these interventions can be good options

for students with demonstrated clinical need. We review a few selected

interventions here (and summarize the salient points in Table 7.2). For

instance, an adaptation of Trauma-Focused Cognitive Behavior Therapy

(TF-CBT; Cohen et al., 2006) has begun to be implemented in school

settings. Although this treatment has a good deal of empirical support

from multiple studies, its effectiveness in schools has not been formally

evaluated. Other examples of efforts to bring clinical treatments into

schools include Community Outreach Program—Esperanza (De Arellano

et al., 2005), which integrates the core components of a TF-CBT pack-

age with Parent–Child Interaction Therapy and case management for

children ages 4 to 18. Life Skills, Life Stories (Cloitre, Koenen, Cohen, &

Han, 2002) is a clinical program for women that was adapted for female

high school students with histories of sexual victimization and child

abuse. A version for adolescents, called STAIR-A, was tested in schools in

a quasi-experimental study and found to reduce depressive symptoms

and improve some aspects of functioning (Gudiño, Leonard, & Cloitre,

2016). Trauma Adaptive Recovery Group Education and Therapy for

Adolescents (Ford, Mahoney, & Russo, 2001) focuses on body self-

regulation, memory, interpersonal problem solving, and stress man-

agement for youths ages 10 to 18 affected by physical or sexual abuse,

domestic or community violence, or traumatic loss. Structured Psy-

chotherapy for Adolescents Responding to Chronic Stress (DeRosa &

Pelcovitz, 2009) for teens (ages 12–19) exposed to chronic interpersonal

traumas combines CBT and dialectical behavior therapy approaches

(including mindfulness) to improve coping, affect regulation, relation-

ships, and functioning in the present. Although each of these treat-

ments has some evidence of their effectiveness, their use in schools has

not been formally tested.

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Table 7.2

Selected Clinical Treatments Used in School Settings

Name Description Target Application in schools

Trauma-Focused Cognitive Behavior Therapy (Jaycox et al., 2010)

Cognitive behavior therapy in parent–child dyads

Ages 3–18 Limited use in schools, not for- mally tested

Community Outreach Program— Esperanza (De Arellano et al., 2005)

Trauma-Focused Cogni- tive Behavior Therapy components plus Parent–Child Inter- action Therapy components and case management for parent–child dyads, delivered in homes and community settings

Ages 4–18 Designed for use in schools and other community settings

Life Skills, Life Stories (Gudiño, Leonard, & Cloitre, 2016)

Group sessions to build social emotional competencies

Girls, ages 12–21 with a history of abuse

Some use in schools, tested in one study with good effects

Trauma Adaptive Recovery Group Education and Therapy for Adolescents (Ford, Mahoney, & Russo, 2001)

Group or individual cog- nitive behavior therapy with focus on emotion regulation

Ages 10–18, complex trauma

Designed for use in juvenile justice set- tings (community or residential) or schools

Structured Psychotherapy for Adolescents Responding to Chronic Stress (DeRosa & Pelcovitz, 2009)

Group cognitive behavior therapy and dialectical behavior therapy elements

Ages 12–19, complex trauma

Designed for use in clinical settings, not formally tested in schools

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CONCLUSION

This chapter summarized the most widely known and evaluated school-

based programs for trauma. However, many more programs have been

developed locally to respond to disasters, school crises such as shootings,

and the everyday occurrence of family and community violence. These

local efforts often remain untested, and so their effectiveness is unknown.

The few programs examined in randomized controlled trials show mod-

erate to large improvements in child outcomes (Jaycox, Stein, & Amaya-

Jackson, 2008). School mental health providers together with their school

administration can select programs that will best fit their school environ-

ment and student body. Programs that have been designed for and tested

within schools, with good evidence, will likely be most successful.

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