A school- and group-based program designed to improve symptoms of posttraumatic stress, depression, and anxiety among children with posttraumatic stress symptoms.
Blueprints: Promising
Crime Solutions: Promising
OJJDP Model Programs: Promising
Audra K. Langley, Ph.D.
UCLA Semel Institute for Neuroscience and Human Behavior
760 Westwood Plaza, Room 67-447
Los Angeles, CA 90095
Email: alangley@mednet.ucla.edu
Phone: 310-794-2460
Bounce Back Website: www.traumaawareschools.org
Bounce Back Email: info@traumaawareschools.org
Audra K. Langley, Ph.D.
UCLA Semel Institute for Neuroscience and Human Behavior
Bounce Back is comprised of 10 one-hour group sessions, two to three individual sessions, and one to three parent education sessions that last over a 3-month period. Group sessions are typically held during school hours and cover a range of topics such as relaxation training, cognitive restructuring, social problem solving, positive activities, trauma-focused intervention strategies, and emotional regulation and coping skills. These topics and methods derive from established successful interventions for children with PTSD, including a gradual approach of anxiety-provoking situations and a modified trauma narratives approach.
Bounce Back is comprised of 10 one-hour group sessions, two to three individual sessions, and one to three parent education sessions that last over a 3-month period. Group sessions are typically held during school hours and cover a range of topics, such as relaxation training, cognitive restructuring, social problem solving, positive activities, trauma-focused intervention strategies, and emotional regulation and coping skills. These topics and methods derive from established successful interventions for children with PTSD, including a gradual approach of anxiety-provoking situations and a modified trauma narratives approach.
Some of these elements have been altered to function with participants aged 5-11, including identifying feelings and their links to thoughts and actions, using published storybooks to relate concepts and connect engagement activities, and creating personal storybooks as an age appropriate concrete trauma narrative. Student participation is encouraged with games and activities specific to age groups and with "courage cards" tailored to each student. Group sessions are very structured, and include: agenda setting; review of activity assignments; introduction of new topics through games, stories, and experiential activities; and assigning activities for the next group meeting. Group sessions are small, with only four to six students all in the same age range.
Primary Evidence Base for Certification
Study 1
Langley et al. (2015) found that, as compared to the control group, at the posttest treatment students significantly improved:
In terms of risk and protective factors, Langley et al. (2015) found that compared to the control group at the posttest, treatment students significantly improved on measures of:
Study 2
Santiago et al. (2018) reported that at the posttest, compared to the control group, students in the treatment group showed improvements in:
In terms of risk and protective factors, Santiago et al. (2018) reported that treatment students, as compared to control students, showed improvements in:
Primary Evidence Base for Certification
Of the two studies Blueprints has reviewed, both studies (Study 1 and Study 2) meet Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness) and were done by the developer.
Study 1
Langley et al. (2015) randomly assigned 74 students within four different schools to either immediate intervention or the waitlist control group. Parent and child reports of posttraumatic stress and depression, and child reports of anxiety symptoms, were assessed at baseline and three months after baseline (posttest).
Study 2
Santiago et al. (2018) conducted a cluster randomized controlled trial in which eight schools and 52 students were assigned to immediate intervention or a waitlist control group. Measures assessing PTSD symptoms, anxiety, depression, coping skills and classroom behavior were collected before the intervention (pretest) and three months after baseline (posttest).
Study 1
Langley, A. K., Gonzalez, A., Sugar, C. A., Solis, D., & Jaycox, L. (2015). Bounce Back: Effectiveness of an elementary school-based intervention for multicultural children exposed to traumatic events. Journal of Consulting and Clinical Psychology, 83(5), 853-865.
Study 2
Santiago, C. D., Raviv, T., Ros, A. M., Brewer, S. K., Distel, L. M., Torres, S. A., . . . Langley, A. K. (2018). Implementing the Bounce Back trauma intervention in urban elementary schools: A real-world replication trial. School Psychology Quarterly, 33(1), 1.
Individual: Stress*
Family: Family conflict/violence
Individual: Coping Skills*, Problem solving skills
*
Risk/Protective Factor was significantly impacted by the program
Subgroup differences in program effects by race, ethnicity, or gender (coded in binary terms as male/female) or program effects for a sample of a specific race, ethnic, or gender group.
Study 1 (Langley et al, 2015) did not test for subgroup effects defined by race, ethnicity, gender, sexual identity, economic disadvantage, geographic location, or birth origin.
Study 2 (Santiago et al., 2018) found subgroup effects by using a homogenous sample with 75% or more of Hispanic participants.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
One-Day Bounce Back Training
The 1-day clinical training provides thorough session by session demonstrations and supervised practice of each core concept for child group and individual sessions, including how to make the material culturally and contextually relevant to the audience. This package is the essential Bounce Back training recommended for mental health clinicians who have been trained in CBITS and/or TF-CBT and who have solid familiarity with child trauma, group therapy and cognitive behavioral therapy.
|
Component |
Includes |
Total Cost |
|
One-day Onsite Trainer |
1 trainer per 15 trainees |
$3000 per trainer |
|
Travel Expenses |
Flight, hotel, meals |
Will vary depending on location |
|
Materials |
Bounce Back Manual |
Website subscription $35 per year/Cost of printing |
1.5-Day Bounce Back Training
The Bounce Back 1 ½ day Training Package includes all the essential elements provided in the one-day training package. However, this package also includes an extra ½ day of instruction for those clinicians who have not been previously trained in CBITS. It includes 1) Thorough session by session demonstrations and supervised practice of each core concept for child group and individual sessions, including how to make the material culturally and contextually relevant to the audience. 2) An overview of child trauma and PTSD and the mental health and academic consequences,3) A review of the history and evidence base of CBITS and Bounce Back, 4) Review of parent sessions, and 5) Engagement activities around implementation issues and site planning.
|
Component |
Includes |
Total Cost |
|
1.5-day Onsite Trainer |
1 trainer per 15 trainees |
$4500 per trainer |
|
Travel Expenses |
Flight, hotel, meals |
Will vary depending on location |
|
Materials |
Bounce Back Manual |
Website subscription $35 per year/Cost of printing |
Web Support: A 1-year subscription to the website costs $35 per professional. The website includes:
Quality Assurance and Coaching- To ensure fidelity to the Bounce Back model and improve treatment success, trainees will tape record group sessions or lessons, which are then reviewed and rated by our faculty. Estimated Cost: $300/hour
Ongoing Supervision- Implementers and/or supervisors may participate in regular conference calls on a prescheduled (i.e., twice per month) or an as-needed basis with our faculty, for ongoing clinical and implementation consultation as they implement the program. Specifically, clinicians, educators or supervisors can discuss session by session protocol as well as an opportunity to troubleshoot barriers and facilitating factors in delivering these interventions in schools under the guidance of our faculty. Estimated Cost: $300/hour
Train the Trainer-- After completing an initial training and implementing at least one Bounce Back group with close supervision by an approved supervisor, trainees may take the next step in the train-the-trainer process by completing a 1-day "Training on Bounce Back" training to prepare them to begin delivering Bounce Back trainings with faculty en route to being approved to do so independently. Estimated cost: $3000 per day (one faculty trainer). This is typically followed by co-training at two to three trainings with a Certified Trainer, at the expense of the participant. Individuals are certified as trainers when they've received a score of 80% or higher on the trainer rating checklist.
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
Free online course, or $4500 + trainer travel expenses for 1.5-day onsite or virtual training for up to 15 trainees
NOTE: The studies certified by Blueprints incorporated in-person training.
Subscription to website ($35.00) provides free download + cost of printing and putting in binders for trainees (estimate $40 per trainee)
None
Initial administrative planning is necessary to obtain parent permission, screen students, communicate eligibility, and obtain parent permission for group participation. The cost varies based on the number of students screened. The primary cost is clinician time.
Front-end time for increasing school buy-in, and educating staff and parents is recommended. We estimate buy-in activities that include teacher in-services and staff meetings to take 5-10 hours of staff time.
Private space for groups of 6-8 children is required. This can usually be secured within the school building at no cost.
The curriculum requires the purchase of the following materials:
Bounce Back is designed for professionals with clinical training. These could be clinicians already embedded or hired by the school, or located at a mental health clinic that is providing services in schools. We estimate that a full-time clinician focused on Bounce Back could deliver 10 groups during a school year. However, if Bounce Back work is delivered as part of the clinician's regular workload, they may be able to only offer 1-2 groups per year.
Administrative support in the form of school staff or interns helping with the consent and screening process can be helpful, but is optional.
Co-leading groups for new implementers or larger groups can be helpful, but is optional.
Local travel may be required for school-based clinicians if traveling from a different location.
Free refreshers with online course and quick-tips at www.traumaawareschools.org, or $3000 + trainer travel for 1-day refresher for 15 trainees, or $300 per hour for consultation calls.
Technical assistance is embedded in training and ongoing implementation support through our website - there is not a fee associated with this.
The fidelity tool is available for free on the website, or certified trainers can be hired at $300 per hour to rate audio taped sessions.
None
No information is available
None
This Year One cost example is for a school district implementing Bounce Back in 15 elementary schools. One staff clinician at each school delivers the program as part of their regular workload; each clinician implements the program twice during the school year to groups of six students each. Thus, 12 students in each of the 15 schools receive the program (180 students).
The example provides training and technical assistance estimates that roughly equate to that which was provided to schools in the Blueprints-certified studies.
| 1.5-day Training | $4,500.00 |
| Trainer travel expenses | $1,000.00 |
| Curriculum printing ($40 x 15 clinicians) | $600.00 |
| Books ($29 x 15 clinicians) | $435.00 |
| Toolkit (toys, laminated cards, box, worksheets, take-home packages) for 15 clinicians | $3,000.00 |
| Consultation calls - 8 through school year | $2,400.00 |
| Total One Year Cost | $11,935.00 |
During Year One, 12 students in each of 15 schools would receive Bounce Back for a total of 180 students. The per student cost would be $66.30.
Many systems have built capacity in Bounce Back following a school crisis (e.g., shooting) or community disaster (e.g., hurricane) when there is an acute need for trauma-focused interventions and extra funding available.
Systems with purchased mental health clinicians onsite can implement Bounce Back as part of their Tier 2 early intervention services.
Some States, Counties and Cities may provide funding for Bounce Back.
U.S. Department of Education, Federal Emergency Management Agency (FEMA), and/or Health and Human Services (HHS) grants may be used to support delivery.
Some locations bill services to Medicaid, if they are set up to do so through community mental health agencies or school-based health centers.
Foundations may provide grants to cover the cost of initial training and/or support program implementation.
Audra K. Langley, Ph.D.ProfessorUCLA Semel Institute for Neuroscience and Human Behavior760 Westwood Plaza, Room 67-447Los Angeles, CA 90095310-794-2460alangley@mednet.ucla.edu
A school- and group-based program designed to improve symptoms of posttraumatic stress, depression, and anxiety among children with posttraumatic stress symptoms.
Children in grades K-5 with diverse backgrounds and exposure to traumatic events.
Subgroup differences in program effects by race, ethnicity, or gender (coded in binary terms as male/female) or program effects for a sample of a specific race, ethnic, or gender group.
Study 1 (Langley et al, 2015) did not test for subgroup effects defined by race, ethnicity, gender, sexual identity, economic disadvantage, geographic location, or birth origin.
Study 2 (Santiago et al., 2018) found subgroup effects by using a homogenous sample with 75% or more of Hispanic participants.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
Individual: Stress*
Family: Family conflict/violence
Individual: Coping Skills*, Problem solving skills
*Risk/Protective Factor was significantly impacted by the program
Bounce Back is comprised of 10 one-hour group sessions, two to three individual sessions, and one to three parent education sessions that last over a 3-month period. Group sessions are typically held during school hours and cover a range of topics such as relaxation training, cognitive restructuring, social problem solving, positive activities, trauma-focused intervention strategies, and emotional regulation and coping skills. These topics and methods derive from established successful interventions for children with PTSD, including a gradual approach of anxiety-provoking situations and a modified trauma narratives approach.
Bounce Back is comprised of 10 one-hour group sessions, two to three individual sessions, and one to three parent education sessions that last over a 3-month period. Group sessions are typically held during school hours and cover a range of topics, such as relaxation training, cognitive restructuring, social problem solving, positive activities, trauma-focused intervention strategies, and emotional regulation and coping skills. These topics and methods derive from established successful interventions for children with PTSD, including a gradual approach of anxiety-provoking situations and a modified trauma narratives approach.
Some of these elements have been altered to function with participants aged 5-11, including identifying feelings and their links to thoughts and actions, using published storybooks to relate concepts and connect engagement activities, and creating personal storybooks as an age appropriate concrete trauma narrative. Student participation is encouraged with games and activities specific to age groups and with "courage cards" tailored to each student. Group sessions are very structured, and include: agenda setting; review of activity assignments; introduction of new topics through games, stories, and experiential activities; and assigning activities for the next group meeting. Group sessions are small, with only four to six students all in the same age range.
Bounce Back incorporates cognitive behavioral therapy in ways similar to previous successful use with children and youth with PTSD in Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools (Blueprints-certified as Promising).
Primary Evidence Base for Certification
Of the two studies Blueprints has reviewed, both studies (Study 1 and Study 2) meet Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness) and were done by the developer.
Study 1
Langley et al. (2015) randomly assigned 74 students within four different schools to either immediate intervention or the waitlist control group. Parent and child reports of posttraumatic stress and depression, and child reports of anxiety symptoms, were assessed at baseline and three months after baseline (posttest).
Study 2
Santiago et al. (2018) conducted a cluster randomized controlled trial in which eight schools and 52 students were assigned to immediate intervention or a waitlist control group. Measures assessing PTSD symptoms, anxiety, depression, coping skills and classroom behavior were collected before the intervention (pretest) and three months after baseline (posttest).
Primary Evidence Base for Certification
Study1
Langley et al. (2015) reported that at the posttest, treatment students showed greater improvements in parent- and child-reported posttraumatic stress, child-reported anxiety and social adjustment, and parent-reported emotion regulation and emotional/behavioral problems, as compared to the control group.
Study 2
Santiago et al. (2018) reported that at the posttest, students in the treatment group showed greater reductions in child-reported posttraumatic stress and improvements in parent-reported child coping, compared with the control group.
Primary Evidence Base for Certification
Study 1
Langley et al. (2015) found that, as compared to the control group, at the posttest treatment students significantly improved:
In terms of risk and protective factors, Langley et al. (2015) found that compared to the control group at the posttest, treatment students significantly improved on measures of:
Study 2
Santiago et al. (2018) reported that at the posttest, compared to the control group, students in the treatment group showed improvements in:
In terms of risk and protective factors, Santiago et al. (2018) reported that treatment students, as compared to control students, showed improvements in:
Not examined.
In Study 1 (Langley et al., 2015), Cohen's f2 ranged from .01 to .26, indicating small to medium-large effects. In Study 2 (Santiago et al., 2018), effect sizes were also small (.11 and .13).
Two studies meet Blueprints standards for high quality methods with strong evidence of program impact (i.e., "certified" by Blueprints): Study 1 (Langley et al., 2015) and Study 2 (Santiago et al., 2018). The samples for these studies included children with experience of traumatic events and symptoms of posttraumatic stress.
This program is distinct from another intervention on the Blueprints registry named Bounce Back Newham, developed and originally disseminated in Newham, a borough of London, U.K.
Blueprints: Promising
Crime Solutions: Promising
OJJDP Model Programs: Promising
Audra K. Langley, Ph.D.
UCLA Semel Institute for Neuroscience and Human Behavior
760 Westwood Plaza, Room 67-447
Los Angeles, CA 90095
Email: alangley@mednet.ucla.edu
Phone: 310-794-2460
Bounce Back Website: www.traumaawareschools.org
Bounce Back Email: info@traumaawareschools.org
Certified Langley, A. K., Gonzalez, A., Sugar, C. A., Solis, D., & Jaycox, L. (2015). Bounce Back: Effectiveness of an elementary school-based intervention for multicultural children exposed to traumatic events. Journal of Consulting and Clinical Psychology, 83(5), 853-865.
Certified Santiago, C. D., Raviv, T., Ros, A. M., Brewer, S. K., Distel, L. M., Torres, S. A., . . . Langley, A. K. (2018). Implementing the Bounce Back trauma intervention in urban elementary schools: A real-world replication trial. School Psychology Quarterly, 33(1), 1.
Summary
Langley et al. (2015) randomly assigned 74 students within four different schools to either immediate intervention or the waitlist control group. Parent and child reports of posttraumatic stress and depression, and child reports of anxiety symptoms, were assessed at baseline and three months after baseline (posttest).
Langley et al. (2015) found that, as compared to the control group, at the posttest treatment students significantly improved:
In terms of risk and protective factors, Langley et al. (2015) found that compared to the control group at the posttest, treatment students significantly improved on measures of:
Evaluation Methodology
Design:
Recruitment: Participants were recruited from four Los Angeles elementary schools. Students with psychotic disturbances (e.g. acute suicidal behavior) or sexual abuse as an only or primary trauma were excluded from participation given that Bounce Back is provided in a mixed-gender format. Students were invited to be screened; of the 417 screened, 113 were eligible based on past trauma experience and current elevated posttraumatic stress symptoms, and 74 enrolled.
Assignment: The 74 participants were randomly assigned within the four schools to immediate intervention or a delayed (waitlist) group. The waitlist group received the intervention approximately three months following the initial intervention group.
Assessments/Attrition: Participants completed assessments at baseline, 3 months after baseline (posttest), and 6 months after baseline (follow-up). By the time of the 6-month assessment, the waitlist control group had already received the intervention, thus analyses focused on the 3-month period from baseline to posttest. Three students did not complete a posttest assessment (sample n = 71), resulting in an overall attrition rate of 4% at the posttest.
Sample:
The sample was 50% male, predominantly Hispanic (48%) and Caucasian (27%), and fairly low household income (42% below $40,000/year). All schools qualified as Title I, with at least 40% of the students qualifying for free or reduced-price lunch. The average grade level was 2.73 and average age was 7.65.
Measures:
Primary Outcome Measures: Participants' levels of posttraumatic stress symptoms and symptom frequency were measured using the UCLA Posttraumatic Stress Disorder Reaction Index, with both parent and child reports of frequency and severity of PTSD symptoms (α=.88 for parents and α=.83 for children). The Children's Depression Inventory was used to assess children's depressive symptoms (α=.84 for parents and α=.82 for children). The Screen for Child Anxiety Related Emotional Disorders assessed child-reported symptoms corresponding to various anxiety disorders (α=.92).
Secondary Outcome Measures: The Strengths and Difficulties Questionnaire for parents and teachers assessed students' problem areas (emotional, conduct, hyperactivity/inattention, and peer relationships) as well as prosocial behavior (α=.61 for parents and .74 for teachers). The Social Adjustment Scale-Self-Report for Youth evaluated the degree of cohesion and support within a student's interpersonal relationships (α=.80). The Coping Efficacy measure assessed children's satisfaction with handling past and current stressors and their anticipated effectiveness for handling future stressors (α=.77). The Emotion Regulation Checklist, a parent-report measure. was employed to assess how easily children are upset and how quickly or easily they can get past stressors (α=.82 for the negativity subscale and α=.69 for emotional regulation).
Analysis: Linear mixed-effects models were used, with group (immediate treatment and waitlist control) as a between-subjects factor and time (baseline, 3 months, 6 months) as a within-subjects factor, and a group by time interaction to examine differential treatment effects from baseline (pretest) to 3 months (posttest). Main effects of site and group by site interactions were included in the models to control for clustering within schools, and the main effect analyses examined differences between groups from baseline to 3 months. In addition, the Benjamini-Hochberg false discovery rate approach was used to correct for multiple comparisons.
Intent-to-Treat: Mixed-effects models automatically handle missing values via likelihood-based methods, producing unbiased parameter estimates provided observations are missing at random. Because of this and small attrition rates, the authors did not impute missing data. However, they reported that if more than 25% of the items in a given outcome measure were unanswered, the total score for the instrument was treated as missing. If less than 25% were unanswered, the authors computed an expected total based on the average of the completed items.
Outcomes
Implementation Fidelity: Fidelity ratings indicated excellent therapist adherence to the intervention manual (mean 2.91 on a scale of 0 to 3) and excellent overall quality of content implementation (mean 2.94 on a scale of 0 to 3).
Baseline Equivalence: There were no statistically significant differences between treatment and control on 19 socio-demographic variables and outcome measures, except for the highest level of parental education, with the parents in the immediate treatment group being slightly more educated than those of the control group.
Differential Attrition: Langley et al. (2015) did not examine baseline differences for the analytic sample. In terms of differences between those who completed the study and those who did not, "there was no evidence of a baseline difference between the subjects who did and did not complete the study except with regard to ethnicity: six of the 13 African American participants did not complete the study (five of these six because they relocated from the area and changed schools) compared with one of 36 Hispanic participants and none in the other ethnic groups" (p.859).
Posttest: At the posttest (i.e., 3 months after baseline), Langley et al. (2015) found that treatment students, in comparison to control students, showed lower levels of parent- and child-rated posttraumatic stress symptoms, child-rated anxiety, and parent-rated emotional/behavioral problems while also exhibiting improvement in parent-rated emotional regulation.
In terms of risk and protective factors, compared to the control group at the posttest, treatment students significantly improved on measures of self-reported social adjustment.
Long-Term: Not conducted.
Summary
Santiago et al. (2018) conducted a cluster randomized controlled trial in which eight schools and 52 students were assigned to immediate intervention or a waitlist control group. Measures assessing PTSD symptoms, anxiety, depression, coping skills and classroom behavior were collected before the intervention (pretest) and three months after baseline (posttest).
Santiago et al. (2018) reported that at the posttest, compared to the control group, students in the treatment group showed improvements in:
In terms of risk and protective factors, Santiago et al. (2018) reported that treatment students, as compared to control students, showed improvements in:
Evaluation Methodology
Design:
Recruitment: Teachers and school social workers identified children in the first through fourth grades who might benefit from the program through the school referral process. The inclusion criteria were (a) exposure to trauma (identified using the modified TESI-C-Brief; Ford et al., 2000) and (b) current moderate to severe symptoms of posttraumatic stress (score of 25 on the UCLA-RI; Steinberg et al., 2004). According to the consort diagram presented in Figure 1 (p. 5), a total of 105 students across 8 schools were screened, and 52 were randomly assigned to condition.
Assignment: Using block randomization, 52 children nested in 8 schools were randomly assigned to immediate treatment or to a waitlist control once students were screened (thus, schools were the unit of assignment). Because of these block randomization procedures, schools that participated multiple years were not necessarily in the same condition across all three years of the study (2013 - 2016). The number of schools assigned to each condition was not reported. Treatment and control included six groups each (25 students in treatment and 27 students in control).
Assessments/Attrition: Assessments were conducted at baseline, and again at three months (posttest) and six months after baseline. The waitlist control group began receiving the intervention after the three-month assessment. According to Figure 1 (p. 5), there was no attrition from assignment to the three-month follow-up.
Sample: The mean age of the sample was 7.76 years, 65% were male, and 82% were Latino. Almost half of the students (47%) had two immigrant parents, 16% had one immigrant parent, and 37% had no immigrant parents. More than half of the participants (59%) had a household income of less than $25,000, supporting an average of four individuals. More than half (55%) of parents had an education of less than high school. The mean age of parents/caregivers participating in this study was 35.75 years, 83% were female.
Measures:
Posttraumatic stress symptoms: Both parents and children reported on children's symptoms of PTSD using the University of California-Los Angeles PTSD Reaction Index (UCLA-RI; Steinberg, Brymer, Decker, & Pynoos, 2004), a 20-item questionnaire on posttraumatic stress symptom frequency during the past month. This instrument was administered verbally by research staff and school social workers to children and with paper and pencil for parents. Items on this scale are rated on a 5-point Likert-type scale from 0 (never) to 4 (most of the time) and Cronbach's alpha in this sample ranged from .86 to .92 for parent report and from .74 to .92 for child report across time points.
Depression: Children completed the self-report version of the Children's Depression Inventory (CDI; Kovacs, 1992). An item assessing suicidal ideation was excluded in this study, yielding a 26-item version. For each item, children selected the statement that best described them from among three options, with item scores ranging from 0 to 2. Parents also reported on their child's symptoms by completing a parent version of the CDI at each time point. Cronbach's alpha for parent report in this sample ranged from .88 to .90 and from .85 to .86 for the child report.
Anxiety: Children completed the Screen for Child Anxiety Related Emotional Disorders Child Report (SCARED-C; Birmaher et al., 1999), a 41-item measure that includes five factors: somatic/panic (13 items), generalized anxiety (9 items), separation anxiety (8 items), social phobia (7 items), and school phobia (4 items). Participants rated the items of each factor on a 3-point scale. In the current sample, Cronbach's alpha ranged from .86 to .92.
Coping: Parents reported on children's coping using the Responses to Stress Questionnaire (RSQ; Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000), a 57-item measure that assesses responses to stress. The primary control coping factor was used in this study and includes nine items assessing problem solving, emotional expression, and emotion regulation rated on a 5-point scale of 0 (not at all) to 4 (a lot). In the current study, Cronbach's alpha ranged from .70 to .77.
Classroom behavior/school functioning: Teachers reported on children's school functioning using the Strengths and Difficulties Questionnaire (SDQ) Teacher Report (Goodman, 1997). The SDQ is a 25-item questionnaire with five subscales assessing school functioning: emotional symptoms, conduct problems, hyperactivity/inattention problems, peer problems, and prosocial behavior. A total difficulties score is calculated by summing the first four subscales, with a higher score indicating more problems. The Cronbach's alpha for the current sample ranged from .80 to .86.
Analysis: Repeated-measures analyses of variance (ANOVAs) were conducted using IBM SPSS Statistics. For the main effect analysis, a time (within-subject factor) by group (between-subject factor) interaction was examined (baseline to 3 months). Only one of the eight pretests were included in the model: since parent-reported posttraumatic stress symptoms was significantly higher for the treatment group at baseline, this pretest was adjusted for in the analysis. The main effect analysis also included hierarchical linear modeling (HLM) to account for the nested nature of the data (child nested within group/school). Though not presented in the current study, the authors reported that HLM results were replicated and are available upon request.
Intent-to-Treat: The authors reported on page 5 that "missing data ranged from 2% to 12% for child report and 10-23% for parent report across measures/time. However, data were imputed; thus, all cases were analyzed." The authors also reported that "Little's (1988) missing completely at random test was conducted, and data were determined to be missing at random. Subsequently, missing data were imputed using maximum likelihood multiple imputation procedures (using SPSS 24.0 Expectation Maximization program)" (p. 5).
Outcomes
Implementation Fidelity: Clinicians reported good fidelity of their delivery of Bounce Back (mean 2.53 on a scale of 0 - 3). In terms of dosage, 90-98% of children attended scheduled sessions or received a make-up over the 10 group sessions. Most of the children (84%) had caregivers who attended at least one parent session. Parent involvement ranged from zero to four sessions completed.
Baseline Equivalence: There were no significant differences between treatment and control groups across six demographic characteristics (gender, race/ethnicity, income, grade, age/years, and primary caregiver education). However, there were differences in one of 8 pretest measures (in favor of the control group). That is, parent report of posttraumatic stress symptoms was significantly higher for the treatment group at baseline, and (as mentioned in the analysis section) was adjusted for in the analysis. Teacher report of classroom behavior problems was higher for the treatment group (p=.05) but was not adjusted in the analysis.
Differential Attrition: No attrition.
Posttest: At the posttest (i.e., 3 months after baseline), Santiago et al. (2018) found an effect on two of seven outcomes. Results showed that students in the treatment group demonstrated greater reductions in child-reported PTSD (effect size = .11) and improvements in parent-reported child coping (effect size = .13), compared with the control group. There were no significant group differences in parent-reported PTSD, parent- and child-reported depression, child-reported anxiety, and teacher-reported classroom behavior.
Long-Term: Not conducted.