Trauma-Focused Cognitive Behavioral Therapy (OJJDP Model Program Guide)

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Office of Juvenile Justice and Delinquency Prevention (OJJDP) Serving Children, Families and Communities

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Trauma-Focused Cognitive Behavioral Therapy

Intervention:

Trauma-Focused Cognitive Behavioral Therapy (TF–CBT) is designed to help 3- to 18-year-olds and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse. TF–CBT aims to treat serious emotional problems such as posttraumatic stress, fear, anxiety, and depression by teaching children and parents new skills to process thoughts and feelings resulting from traumatic events.

TF–CBT was created for young people who have developed significant emotional or behavioral difficulties following exposure to a traumatic event (e.g., loss of a loved one, physical abuse, sexual abuse, domestic or community violence, motor vehicle accidents, fires, tornadoes, hurricanes, industrial accidents, terrorist attacks). The program targets boys and girls from different socioeconomic backgrounds, from diverse ethnic groups, and in a variety of settings.

TF–CBT combines cognitive behavior and family theory and adapts them to the treatment of traumatic events. It is based on the theory that children (and others) have difficulty processing the complex and strong emotions and feelings that result from exposure to single or multiple traumatic events. By providing the child and the care-giving parents with the support, skills, and techniques to process traumatic events and their psychological consequences, TF–CBT aims to minimize the resulting emotional disorders.

TF–CBT is a treatment intervention that integrates cognitive and behavioral interventions with traditional child-abuse therapies. Its focus is to help children talk directly about their traumatic experiences in a supportive environment. The program operates through the use of a parental treatment component and several child–parent sessions. The parent component teaches parents parenting skills to provide optimal support for their children. The parent–child session encourages the child to discuss the traumatic events directly with the parent and both the parent and child to communicate questions, concerns, and feelings more openly. Typically, TF–CBT is implemented as a relatively brief intervention, usually lasting from 12 to 18 weekly sessions. These aim to provide the parents and children with the skills to better manage and resolve distressing thoughts, emotions, and reactions related to traumatic life events; improve the safety, comfort, trust, and growth in the child; and develop parenting skills and family communication.

Evaluation Methodology:

Study 1
Deblinger, Lippman, and Steer (1996) conducted a randomized trial to evaluate the impact of TF-CBT on 100 sexually abused children. These children had experienced sexual abuse that had been substantiated by an investigation conducted by the Division of Youth and Family Services or the Prosecutor’s Office. Child participants exhibited a minimum of three posttraumatic stress disorder (PTSD) symptoms. Their ages ranged from 7 to 13 years, with a mean age of 9.9 years. Eighty-three percent were female; 70 percent were white, and 21 percent were African American. The biological father or stepfather was described as the perpetrator in 31 percent of cases.

Over the course of roughly 4 years, subjects completed an initial assessment and were then randomly assigned to one of four treatment conditions: community control condition, child-only intervention, parent-only intervention, or parent and child intervention. The community control condition consisted of providing parents with information about symptoms and encouraging them to seek therapy for their children. The child-only intervention included several cognitive behavioral therapy methods such as gradual exposure, education, coping, and body safety skills. The parent-only intervention consisted of teaching mothers skills for responding therapeutically to their children. Subjects assigned to the three intervention groups participated in 12 weekly treatment sessions provided by a trained therapist who followed a detailed treatment manual. Treatment sessions for child-only and parent-only interventions lasted 45 minutes each; treatment sessions for the parent and child intervention lasted 80 to 90 minutes.

Measures used in the study included a structured background interview to collect demographic and abuse-related data and information about parent and child coping responses and support resources. PTSD was assessed using the epidemiological version of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. Anxiety was assessed using the 20-item State Trait Anxiety Inventory for Children; depression was assessed using the Child Depression Index; and child behavior problems were assessed using the Child Behavior Checklist. Parents’ interaction with children was evaluated using the Parenting Practice Questionnaire.

Results were reported for children 3 months after the intervention. Follow-up results at 6 months, 1 year, and 2 years posttest were reported by Deblinger, Steer, and Lippman (1999), who addressed missing 2-year follow-up data using a multivariate analysis of covariance with imputed end-point data in which the last obtained scores on outcome measures were carried forward for remaining follow-up analyses. Data from only those participants who had completed all six evaluations was used in the follow-up analyses.

Study 2
Cohen and Mannarino (1996) used a randomized experimental design with 67 sexually abused preschool children ages 3–6 and their parents. Participants were randomly assigned to either the treatment group, which provided cognitive behavioral therapy adapted for sexually abused preschool children or the control group, which provided nondirective supportive therapy. Subjects were referred from rape crisis centers, child protective services, pediatricians, psychologists, mental health agencies, police departments, and judicial systems. Of the 86 subjects recruited, 67 completed the study. The mean age of treatment completers was 4.7 years; 75 percent lived with both biological parents; 58 percent were female; 54 percent were white, and 42 percent were African American.

Treatment consisted of 12 individual sessions for both child and parent monitored for integrity through intensive training and supervision, use of treatment manuals, and audio-taped sessions. Outcomes were evaluated at posttreatment, which varied from 12 to 16 weeks after baseline.

Instruments used in this study included the Child Behavior Checklist form for 4- to 11-year-olds; the Parenting Practices Questionnaire; the 42-item Child Sexual Behavior Inventory, completed by parents regarding normative and inappropriate sexual behavior; the Weekly Behavior Report, a 21-item instrument for documenting problematic behaviors in preschool children completed by parents; and the Preschool Symptom Self-Report, a pictorial instrument used to obtain multiple sources of information.

Study 3
Cohen and colleagues (2004) evaluated TF–CBT using a sample of 229 consecutively referred children who had experienced contact sexual abuse confirmed by Child Protective Services, law enforcement, or an independent forensic professional. Children were recruited from two outpatient treatment sites—both academically affiliated, with one in a large metropolitan area and one in a suburban area. Children had to meet at least five criteria for sexual abuse–related PTSD, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Further, a parent or caretaker had to be willing to participate in the parent component of the treatment. The final sample included the 203 (89 percent) children who attended at least three therapy sessions. Of these children, 180 (89 percent) met full criteria for PTSD.

Since the sample included 14 sibling pairs, there were 189 caretakers in the study. An equal number of sibling pairs were assigned to treatment and control conditions. All children in the study exhibited multiple symptoms of PTSD. They all had at least one responsible, nonabusive parent or guardian willing to participate in the parental component of the study. About half of the children and their parents were randomized to treatment (receiving 12 weeks of TF–CBT treatment) and the other half to a comparison (receiving comparable levels of conventional child-centered therapy) group.

The sample was 79 percent female. Children in the sample ranged from 8 years to 14 years and 11 months, (mean=10.76 years). Sixty-percent were white, and 28 percent were African American. Participating parents included 78 percent biological mothers, 4 percent biological fathers, and the remainder adoptive mothers, foster mothers, grandmothers, and other female relatives.

Instruments used in this study included the PTSD, psychosis, and substance use disorders scales of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children—Present and Lifetime Version; the Child Depression Inventory; the State Trait Anxiety Inventory for Children; the Children’s Attributions Perception Scale; the Child Behavior Checklist; the Child Sexual Behavior Inventory; the Beck Depression Inventory; the Parent Emotional Reaction Questionnaire; the Parent Support Questionnaire; and the Parenting Practices Questionnaire modified for this population.

Evaluation Outcome:

Study 1
Child’s PTSD Symptoms
Deblinger, Lippman, and Steer (1996) found that children assigned to the child-only and parent–child conditions exhibited significantly fewer PTSD symptoms than children assigned to the parent-only and community conditions.

Parenting Skills of Mothers
Mothers of children assigned to the child-only and parent–child conditions reported significantly greater use of effective parenting skills than mothers of children assigned to the parent-only and community conditions.

Other Child Psychiatric Symptoms
Mothers of children assigned to the child-only and parent–child conditions reported significantly fewer externalizing behaviors and less depression among their children than mothers of children assigned to the parent-only and community conditions. Results of the follow-up evaluations indicated that improvements in externalizing behavior, depression, and PTSD were maintained over the 2-year follow-up period.

Study 2
General Behavior
Cohen and Mannarino (1996) found that children in the treatment condition scored significantly lower than children in the control condition on the Internalizing Behavior and Total Behavior Profile.

Sexualized Behavior
Children in the treatment condition scored significantly lower than children in the control condition on sexualized behaviors.

Problematic Behavior
Children in the treatment condition scored significantly lower than children in the control condition on problematic behaviors.

Study 3
Child’s PTSD
Cohen and colleagues (2004) found that children in the treatment condition scored significantly lower than control group children on the three PTSD subscales of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children: re-experience, hyperarousal, and avoidance.

Other Child Symptoms
Children in the treatment condition scored significantly lower than control group children on the Child Behavior Checklist total scale, the Child Depression Inventory, and the Shame Questionnaire.

Parents’ Symptoms
Parents in the treatment condition scored significantly lower than control group parents on the Beck Depression Inventory, lower on the Parent Emotional Response Questionnaire, and significantly higher on both the Parenting Practices Questionnaire and the Parent Support Questionnaire.

Child’s Diagnosis of PTSD Symptoms
Twenty-one percent of treatment children were diagnosed with PTSD at posttest, compared with 42 percent of control group children. This difference was statistically significant.

Other Information:

References:

Cohen, Judith A., and Anthony P. Mannarino. 1996. “A Treatment Outcome Study for Sexually Abused Preschool Children: Initial Findings.” Journal of the American Academy of Child and Adolescent Psychiatry 35(1):42–43.

———. 1997. “A Treatment Study for Sexually Abused Preschool Children: Outcome During a 1-Year Follow-Up.” Journal of the American Academy of Child and Adolescent Psychiatry 36(9):1228–36.

———. 1998. “Interventions for Sexually Abused Children: Initial Treatment Outcome Findings.” Child Maltreatment 3(1):17–27.

Cohen, Judith A., Anthony P. Mannarino, Lucy Berliner, and Esther Deblinger. 2000. “Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents: An Empirical Update.” Journal of Interpersonal Violence 15(11):1202–24.

Cohen, Judith A., Esther Deblinger, Anthony P. Mannarino, and Robert A. Steer. 2004. “A Multisite Randomized Trial for Children With Sexual Abuse–Related PTSD Symptoms.” Journal of the American Academy of Child and Adolescent Psychiatry 43:393–402.

Cohen, Judith A., Anthony P. Mannarino, and Esther Deblinger. 2006. Treating Trauma and Traumatic Grief in Children and Adolescents. Treatment Manual. New York, N.Y.: Guilford Press.

Cohen, Judith A., Anthony P. Mannarino, and Kraig Knudsen. 2004. “Treating Childhood Traumatic Grief: A Pilot Study.” Journal of the American Academy of Child and Adolescent Psychiatry 43:1225–33.

Cohen, Judith A., Anthony P. Mannarino, and Virginia R. Staron. 2006. “A Pilot Study of Modified Cognitive Behavioral Therapy for Childhood Traumatic Grief (CBT–CTG).” Journal of the American Academy of Child and Adolescent Psychiatry 43:1465–73.

Deblinger, Esther, Julie Lippman, and Robert A. Steer. 1996. “Sexually Abused Children Suffering From Posttraumatic Stress Symptoms: Initial Treatment Outcome Findings.” Child Maltreatment 1:310–21.

Deblinger, Esther, Robert A. Steer, and Julie Lippman. 1999. “Two-Year Follow-Up Study of Cognitive Behavioral Therapy for Sexually Abused Children Suffering From Posttraumatic Stress Symptoms.” Child Abuse and Neglect 23:1371–78.

Program Specification:

New Rating:

Effective

Re-reviewed Date:

June 2011

Program Type:

Cognitive Behavioral Treatment

Ethnicity:

African American

Hispanic or Latino (of any race)

White

Gender:

Both

Age:

3 - 18

Special Populations:

Mentally Ill Offenders

Target Settings:

Rural

Suburban

Urban

Problem Behaviors:

Family Functioning

Trauma Exposure

Risk & Protective Factors:

Risk

Community

Low community attachment

Family

Child victimization and maltreatment

Family history of problem behavior / Parent criminality

Family management problems / Poor parental supervision and/or monitoring

Family transitions

Family violence

Maternal depression

Parental use of physical punishment / Harsh and/or erratic discipline practices

Pattern of high family conflict

Poor family attachment / Bonding

Individual

Antisocial behavior and alienation / Delinquent beliefs / General delinquency involvement / Drug dealing

Early onset of aggression and/or violence

Early sexual involvement

Life stressors

Mental disorder / Mental health problem / Conduct disorder

Teen parenthood

Victimization and exposure to violence

School

Low academic achievement

Protective

Family

Effective parenting

Good relationship with parents / Bonding or attachment to family

Opportunities for prosocial family involvement

Individual

Healthy / Conventional beliefs and clear standards

Perception of social support from adults and peers

Positive / Resilient temperament

Self-efficacy

Social competencies and problem solving skills

Additional Information:

SAMHSA: NREPP

Status:

Program is in operation at this time.

Performance Measures:

Suggested OJJDP Performance Measures for the Program Types(s):

Mental Health Services
Cognitive Behavioral Treatment
Logic Model: PDF
Performance Matrix:PDF

Contact Information:

Program Developer:
Esther Deblinger, Ph.D.
Child Abuse Research Education and Service Institute
One Medical Center Drive
Stratford, NJ 08084
Phone: 856.566.7036
Email: Click Here
Website: Click Here

Anthony Mannarino, Ph.D.
Allegheny General Hospital, Department of Psychiatry
4 Allegheny Center, 8th Floor
Pittsburgh, PA 15212
Phone: 412.330.4312
Fax: 412.330.4377
Email: Click Here
Website: Click Here

Judith A. Cohen, M.D.
Center for Traumatic Stress in Children and Adolescents
Allegheny General Hospital
Pittsburgh, PA 15212
Phone: 4123304321
Fax: 4123304377
Email: Click Here
Website: Click Here

Training & TA Provider:
Judith A. Cohen, M.D.
Center for Traumatic Stress in Children and Adolescents
Allegheny General Hospital
Pittsburgh, PA 15212
Phone: 4123304321
Fax: 4123304377
Email: Click Here
Website: Click Here

Program Locations:
Lynn A. Brady
Mental Health Center of Dane County, Inc.
625 West Washington Avenue
Madison, WI 53703

Carrie Epstein
Safe Horizon
Two Lafayette Street, Third Floor
New York, NY 10007

Jenifer Wood
NCCTS—Duke University
905 West Main Street, Suite 24–E, Box 50
Durham, NC 27701

Susan Stewart
Child Trauma Treatment Network
50 N. Medical Drive
Salt Lake City, UT 84123

Jennifer Sigrest
Trauma Recovery for Youth
200 North Congress Street, Suite 100
Jackson, MS 39201

Barbara Ryan
Chadwick Center
3020 Children’s Way, MC 5016
San Diego, CA 92123