Program

Oct 17, 2016

OVERVIEW

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a cognitive-behavior therapy targeted at individuals who are experiencing symptoms of post-traumatic stress disorder (PTSD), with the aim of reducing PTSD symptoms and increasing mental health functioning. TF-CBT involves individualized therapy sessions in which children are given emotional skills training and later, with the help of trained therapists, children begin to confront the experience which initialized the PTSD symptoms. Randomized controlled trials of TF-CBT have found it to be effective in reducing the symptoms of PTSD in various populations of children and adolescents; the program was originally developed to treat children exposed to sexual abuse but has since been expanded to treat children who have experienced multiple types of traumatizing events such as domestic violence, traumatic grief, natural disasters, and terror attacks.

DESCRIPTION OF PROGRAM

Target population: Children and adolescents who have been diagnosed with post-traumatic stress disorder (PTSD)

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is used for children and adolescents who have developed clinical levels of PTSD. In young children, this disorder is often the result of sexual or physical abuse. Over the course of 12 to 15 sessions, the program seeks to teach children skills to cope with the difficulties that this disorder creates. At the same time, therapy sessions are used to help children confront and deal with painful or scary past experiences. TF-CBT has many variations for different target groups, and has been successfully adapted to be conducted by lay-leaders as a group intervention.

EVALUATION(S) OF PROGRAM

Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 393-403.

Evaluated population: 229 children ages 8-14 (M = 10.76 years) who had met at least 5 of the 6 DSM-IV criteria for PTSD. The sample was 60% white, 28% African-American, 4% Hispanic, 7% bi-racial, and 1% other ethnicity.

Approach: Participants were given an initial screening by evaluators and then randomly assigned to either a TF-CBT group or a comparison group which used a Child-Centered Therapy (CCT) program. CCT programs are focused on the development of a trusting relationship between the child and therapist. During therapy sessions, children choose what topics to discuss and largely lead the direction of the sessions. The TF-CBT treatment program focused on expressing feelings, training in coping skills, understanding relationships between thoughts and behaviors, and gradual exposure to the traumatic event. Both treatments were given once a week and involved two consecutive 45 minute sessions, one for the child and one for the child’s parent, for a total of 90 minutes of treatment sessions each week. Additionally, TF-CBT treatment included 3 joint parent-child sessions which lasted 30 minutes instead of consecutive 45 minute sessions. The total session breakdown for these 3 weeks was: 30 minutes for joint session, 30 minutes for child’s individual session, and 30 minutes for child’s parent’s individual session. Parents and children attended treatment sessions once per week for a total of 12 weeks.

Results: Participants in both conditions improved scores on all measures for post-traumatic stress disorder symptoms over the course of the study; however, TF-CBT therapy participants had significantly lower scores on survey measures of post-traumatic stress disorder (Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Child Behavior Checklist (CBCL), Children’s Depressive Inventory (CDI), Children’s Attributions and Perceptions Scale (CAPS), Shame Questionnaire, Beck Depression Inventory (BDI), and Perceived Emotional Response Questionnaire (PERQ)) when compared with children and adolescents in CCT treatment groups indicating that they were displaying fewer symptoms of post-traumatic stress disorder. TF-CBT participants likewise were less likely to be diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defined post-traumatic stress disorder (21%, 19 out of 89) at the end of the study when compared with participants in CCT groups (46%, 42 out of 91).

Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29, 135-145.

Evaluated Population: 82 children and adolescents ages 8-15 who were referred to a traumatic stress program. 60% of participants were Caucasian, 37% African-American, 2% bi-racial, and 1% Hispanic. To be included in the study these children and adolescents had to have had contact sexual abuse within the past 6 months, significant symptoms of PTSD (i.e. clinical levels), and an available non-offending caretaker.

Approach: After an initial interview which assessed eligibility for the study, participants were randomly assigned to TF-CBT or Non-Directive Supportive Therapy (NST). NST therapists fostered the development of therapeutic, trusting relationships and encouraged children and parents to choose which topics the therapy sessions would focus on. TF-CBT treatments focused on the topics of feeling identification, stress inoculation techniques, direct discussion and gradual exposure of traumatic events, education about healthy sexuality, and safety skill building. The therapy sessions for both treatments were individual and lasted a total of 90 minutes with 45 minutes devoted to individual child therapy and 45 minutes devoted to individual therapy for the child’s parent. Parents and children attended treatment sessions once per week for a total of 12 weeks.

Results: Participants in the TF-CBT group had greater improvement in scores over time on the CDI, State-Trait Anxiety Inventory for Children (STAIC), and Trauma Symptom Checklist for Children (TSCC) (Anxiety, Depression, and Sexual Problems subscales) scales compared with participants in the control group. This improvement in scores indicates that TF-CBT participants exhibited fewer and/or less pervasive symptoms of post-traumatic stress disorder. At a 6-month follow-up interval, participants in the TF-CBT group had greater improvement in scores on the STAIC-State, STAIC-Trait, and TSCC (Anxiety, Depression, Sexual Problems, and Dissociation subscales) scales compared with participants in the control group. At a 12-month follow-up interval, participants in the TF-CBT group had greater improvement in scores on the TSCC (PTSD and Dissociation subscales) scale. All of these results indicate that participants in the TF-CBT group were displaying fewer and/or less pervasive symptoms of post-traumatic stress disorder compared with participants in control groups.

Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavior therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52, 853-860.

Evaluated Population: The trial was conducted on 64 children in New Orleans, ages three to six, who were experiencing symptoms of PTSD. The children were recruited from a Level 1 Trauma Center, three battered women programs, and through newspaper advertisements. On average, the children were 5.3 years old. Sixty-six percent were male, 60 percent African American, 35 percent white, and 28 percent lived with their biological fathers. On average, female caregivers had 13.5 years of education.

Approach: Children were randomly assigned to either receive twelve weeks of TF-CBT (n=40) or to receive the same treatment after twelve weeks of waiting (n=24). The treatment was modified slightly to be developmentally appropriate for young children. Children were measured for symptoms of PTSD, Major Depressive Disorder (MDD), Separation Anxiety Disorder (SAD), Oppositional Defiant Disorder (ODD), and Attention-Deficit/Hyperactivity Disorder (ADHD) based on caregiver responses. Outcomes were measured pre-test, at twelve weeks, and at a six-month follow-up. More than half of the sample did not complete treatment (n=39), partially due to Hurricane Katrina causing a six-month hiatus in the study.

Results: At 12 weeks, participants in the TF-CBT group had greater improvement in PTSD symptoms than those who were waitlisted, and the effect remained high at the six-month follow-up. There were no significant differences in improvement for any of the other measured disorders.

O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H, & Black, A. (2013). A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 359-369.

Evaluated Population: The study treated 52 Congolese girls, ages 12 to 17 years, who had been affected by war and had personal experience of rape or sexual abuse. Most had been rescued from brothels, and were attending a six-month vocational training program. The average age of the girls was 16 years, with an average of 12 traumatic life events out of a possible 23.

Approach: The adolescent girls were randomly assigned to either receive a 15-session group treatment of TF-CBT over five weeks (n=24) or to receive the same treatment after five weeks of waiting (n=28). The treatment was modified to be culturally appropriate, and was conducted by lay social workers that were known to the girls. Pre- and post-test, and again at 3 months, subjects were measured for symptoms of PTSD, as well as depression or anxiety, socially unacceptable behavior, somatic complaints, and prosocial behavior, based on an African-developed questionnaire.

Results: TF-CBT had significant positive impacts on PTSD symptoms, depression and anxiety, conduct problems, and prosocial behavior. These improvements were maintained at the 3-month follow-up. There was no significant impact on somatic complaints.

Jensen, T. K., Holt, T., Ormhaug, S. M., Egeland, K., Granly, L., Hoaas, L. C., … Wentzel-Larsen, T. (2014). A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology43(3), 356–369.

Evaluated Population: This study treated children and youth who had experienced at least one traumatizing event and suffered from significant posttraumatic stress reactions. The sample was composed of 156 participants between the ages of 10 and 18 who had been referred to one of eight community mental health outpatient clinics in Norway by their primary physician or Child Welfare Services. The sample was 79.5% female, and the median age was 15.1. On average, participants had experienced 3.6 different types of traumas out of a possible 13.

Approach: The participants were randomly assigned to either receive 15 sessions of TF-CBT (n = 79) or therapy as usual (n = 77). In the therapy as usual (TAU) condition, therapists were instructed to provide the treatment they believed would be effective for the particular case. All TAU participants received individual therapy and in 55.3 percent (n = 42) of TAU cases, parents were also involved in the therapy process. TF-CBT therapists were trained and instructed to provide therapy that prioritized trauma intervention principles such as learning cognitive coping skills, in vivo mastery of trauma reminders, teaching relaxation and affective modulation skills, and working through the trauma narrative. All TF-CBT treatments included parent interventions intended to improve parenting skills. All participants completed computer-assisted assessments at pretest, mid-treatment (after the sixth therapy session), and post-treatment after all 15 sessions. The assessment measured posttraumatic stress symptoms, depressive symptoms, other anxiety problems, and externalizing problems. By post-test 122 participants remained, but the attrition rate was not significantly different between the control and TF-CBT groups.

Results: At post-test, participants receiving TF-CBT reported significantly lower levels of posttraumatic stress symptoms (d = 0.5), depressive symptoms (d = 0.5), and general mental health symptoms (d = 0.5) compared with participants in the TAU condition, but there was no significant impact on anxiety reduction. TF-CBT participants showed significant improvements in functional impairment (d = 0.6), and significantly fewer participants in the TF-CBT group were diagnosed with PTSD compared with participants in the TAU condition.

SOURCES FOR MORE INFORMATION

Contact information

Judith A. Cohen, M.D.

Center for Traumatic Stress in Children and Adolescents

Allegheny General Hospital

Pittsburgh, PA 15212

412-330-4321 (phone)

412-330-4377 (fax)

tfcbt@musc.edu

http://www.musc.edu/tfcbt

References

Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 393-403.

Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29, 135-145.

Jensen, T. K., Holt, T., Ormhaug, S. M., Egeland, K., Granly, L., Hoaas, L. C., … Wentzel-Larsen, T. (2014). A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology43(3), 356–369.

Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavior therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52, 853-860.

O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H, & Black, A. (2013). A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 359-369.

KEYWORDS: Children(3-11), Adolescents (12-17), Youth(16+), Males and Females, Female Only, High-Risk, Clinic-based, Urban, Manual, Counseling/Therapy, Parent or Family Component, Skills Training, Anxiety Disorders/Symptoms, Conduct/Disruptive Disorders, Depression/Mood Disorders, Other Mental Health

Program information last updated 10/17/2016.

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