Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - Detailed Report

• P- Psycho-education and parenting skills
• R- Relaxation techniques: Focused breathing, progressive muscle relaxation, and teaching the child to control their thoughts (thought stopping).
• A- Affective expression and regulation: To help the child and parent learn to control their emotional reaction to reminders by expanding their emotional vocabulary, enhancing their skills in identification and expression of emotions, and encouraging self-soothing activities
• C- Cognitive coping and processing or cognitive reframing: Through this component, the child learns to think in new and healthier ways about the abuse and their role in it.
• T- Trauma narrative: Gradual exposure exercises including verbal, written and/or symbolic recounting (i.e., utilizing dolls, art, puppets, etc.) of abusive event(s) so the child learns to be able to discuss the events when they choose in ways that do not produce overwhelming emotions.
• I- In vivo exposure: Encourage the gradual exposure to innocuous (harmless) trauma reminders in child's environment (e.g., basement, darkness, school, etc.) so the child learns they can control their emotional reactions to things that remind them of the trauma, starting with non-threatening examples of reminders.
• C- Conjoint parent/child sessions: Held typically toward the end of the treatment. Sessions deal with psycho-education, sharing the trauma narrative, anxiety management, and correction of cognitive distortions. The family works to enhance communication and create opportunities for therapeutic discussion regarding the trauma.
• E- Enhancing personal safety and future growth: Provide training and education with respect to personal safety skills and healthy sexuality/ interpersonal relationships; encourage the utilization of skills learned in managing future stressors and/or trauma reminders.

Cohen, J.A., & Mannarino, A.P. (1997). A treatment study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36(9), 1228-1235.

Type of Study: Randomized controlled trial
Number of participants: 43 children
Population:

Age Range: 3-6 years at baseline
Race/Ethnicity: 56% Caucasian, 44% African American
Status (e.g., foster care, CW): Children with substantiated cases of sexual abuse.

Location/Institution: Pennsylvania
Summary: (To include comparison groups, outcomes, measures, notable limitations) Note: This study used the same sample as the Cohen & Mannarino (1996) report. Children and families were randomly assigned to receive either CBT or nondirective supportive therapy (NST). Parents completed the Child Behavior Checklist (CBCL) and the CSBI, which assesses sexualized behaviors. They also completed the Weekly Behavior Report (WBR). Scores on all measures improved significantly and were maintained over time for the CBT group. The CBT group also scored significantly better than the NST group on the Total Behavior Profile, Internalizing and Externalizing subscales of the CBCL and on the Weekly Behavior Reports.
Length of post-intervention follow-up: 1 year

Cohen, J.A., & Mannarino, A.P. (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35(1), 42-50.

Type of Study: Randomized controlled trial
Number of participants: 67 children and their parents
Population:

Age Range: 3 to 6 years
Race/Ethnicity: 54% Caucasian, 42% African American, 4% other.
Status (e.g., foster care, CW): Families recruited from rape crisis centers, CPS, pediatricians, psychologists, community mental health agencies, police or judicial system.

Location/Institution: Pennsylvania
Summary: (To include comparison groups, outcomes, measures, notable limitations)
Non-offending parents and children with documented sexual abuse were randomly assigned to received Cognitive Behavioral Therapy (CBT) or Nondirective Supportive Therapy (NST). Children’s symptoms were assessed at baseline and follow-up with the Pre-school Symptom Self-report (PRESS), the Child Behavior Checklist (CBCL), and the Child Sexual Behavior Inventory (CSBI). Parents also completed the Weekly Behavior Report (WBR), which was developed for this research project. At posttest the CBT group had improved significantly in comparison with the NST on the CSBI, the WBR total score, and on the Behavior Profile-Total and Internalizing subscales of the CBCL.
Length of post-intervention follow-up: None

Cohen, J.A., Mannarino, A. P., & Knudsen K. (2005). Treating sexually abused children: One year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29, 135-146.

Type of Study: Randomized controlled trial
Number of participants: 82, 56 females and 26 males
Population:

Age Range: 8-15 years
Race/Ethnicity: 49 (60%) Caucasian, 30 (37%) African American, 2 (2%) Biracial, and 1 (1%) Hispanic.
Status (e.g., foster care, CW): Not Specified

Location/Institution: Allegheny, Pennsylvania
Summary: (To include comparison groups, outcomes, measures, notable limitations) Eighty-two sexually abused children, 8-15 years old, and their primary caretakers were randomly assigned to TF-CBT or NST. Measures included the Children's Depression Inventory (CDI), Trauma Symptom Checklist for Children (TSCC), State-Trait Anxiety Inventory for Children (STAIC), Child Sexual Behavior Inventory (CSBI), and the Child Behavior Checklist (CBCL). Among treatment completers, TF-CBT resulted in significantly greater improvement in anxiety, depression, sexual problems and dissociation at 6-month follow-up and in PTSD and dissociation at 12-month follow-up. Intent-to-treat analysis indicated group X time effects in favor of TF-CBT on measures of depression, anxiety, and sexual problems.
Length of post-intervention follow-up: 12 months

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(4), 393-402.

Type of Study: Randomized controlled trial
Number of participants: 203
Population:

Age Range: 8-14
Race/Ethnicity: 60% Caucasian, 28% African American, 9% Hispanic, 7% biracial, 1% other.
Status (e.g., foster care, CW): Children with a confirmed report of contact child sexual abuse.

Location/Institution: Unknown
Summary: (To include comparison groups, outcomes, measures, notable limitations)
Children with documented sexual abuse histories were randomly assigned to received TF-CBT or Child Centered Therapy (CCT). Participants were used from two separate sites. Measures were administered at baseline and after treatment. Children’s psychiatric symptoms were measure using the Kiddie Schedule for Affective Disorders for School-age Children-Present and Lifetime Version (K-SADS-PL-PTSD) PTSD subscale. They also received the Children’s Depression Inventory (CDI), the State-Trait Anxiety Inventory for Children (STAIC), and the Children’s Attributions and Perceptions Scale (CAPS), which measures stigmatization, trust, self-blame and perceived credibility. Children and parents were also interviewed to assess PTSD, Psychosis and presence of substance abuse disorders, and parents filled out the Child Behavior Checklist (CBCL), Child Sexual Behavior Inventory (CSBI), Beck Depression Inventory (BDI), Parent’s Emotional Reaction Questionnaire (PERQ) and Parenting Practices Questionnaire (PPQ). Both groups were found to have improved significantly from pretreatment to posttreament. CBT group participants improved significantly in comparison to CCT group participants on the K-SADS-PTSD scales, the total CBCL, the CDI, the credibility and interpersonal trust subscales of the CAPS, the Shame Questionnaire, the BDI and the PERQ.  Limitations include a lack of no-treatment control group, lack of long-term follow-up and little ethnic diversity in the samples.
Length of post-intervention follow-up: None

Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1(4), 310-321.

Type of Study: Randomized controlled trial
Number of participants: 90 children and families
Population:

Age Range: 7-13
Race/Ethnicity: 72% Caucasian, 20% African American, 6% Hispanic and 2% other.
Status (e.g., foster care, CW): Referred by DYFS, prosecutor’s office or other community agency.

Location/Institution: New Jersey
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were randomly assigned child only, mother only, or mother and child treatment conditions, or to a standard community care control condition. The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-E) was used to initially evaluated children for psychopathology and for PTSD. They were also assessed with the State Trait Anxiety Inventory for Children (STAIC), and the Child Depression Inventory (CDI). Parents completed the Child Behavior Checklist (CBCL) and the Parenting Practices Questionnaire (PPQ). Children assigned to either treatment condition showed fewer PTSD symptoms after treatment than those assigned to parent-only treatment or community conditions. Mothers in either treatment condition reported more effective parenting behaviors on the PPQ and reported fewer externalizing behaviors for their children. Limitations include the large variation in treatment received by the community care control condition.
Length of post-intervention follow-up: None

Deblinger, E., Steer, R.A., & Lippmann, J. (1999). Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering from post-traumatic stress symptoms. Child Abuse & Neglect, 23(12), 1371-1378.

Type of Study: Randomized controlled trial
Number of participants: 75
Population:

Age Range: 7-13
Race/Ethnicity: 70% White, 21% Black, 7% Hispanic and 2% other.
Status (e.g., foster care, CW): Referred by DYFS, prosecutor’s office or other community agency.

Location/Institution: New Jersey
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study is a follow-up to Deblinger, Lippmann, & Steer (1996) and uses the same sample. Participants were reassessed at 3 months, 6 months, 1 year, and 2 years following treatment, using the K-SADS-E, the CDI, and the CBCL. Parents use of effective parenting practices was assessed with the PPQ. Scores on the measures of PTSD symptoms, depression and externalizing behaviors remained comparable to scores at the original post-treatment assessment.
Length of post-intervention follow-up: 2 years.

Deblinger, E., Stauffer, L.B., & Steer, R.A. (2001). Comparitive efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their non-offending mothers. Child Maltreatment, 6(4), 332-343.

Type of Study: Randomized controlled trial
Number of participants: 44 mothers and their children
Population:

Age Range: 2 - 8
Race/Ethnicity: 64% White, 21% Black, 2% Hispanic, and 14% other.
Status (e.g., foster care, CW): Recruited from mothers and children referred to the Regional Child Abuse Diagnostic and Treatment Center for a forensic medical examination.

Location/Institution: New Jersey
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participating mothers and children were randomly assigned to receive either cognitive behavioral group therapy or supportive counseling group therapy.  Mothers were assessed using the Miller Behavior Style Scale, which measures coping style; the SCL-90-R Posttraumatic Symptom Scale, and the IES, which measures intrusive and avoidant thoughts. They also completed the Parent Emotional Reaction Questionnaire (PERQ), the Parenting Practices Questionnaire (PPQ), and the Social Support Questionnaire (SSQ). Children were assessed with the Kiddie Schedule for Affective Disorders for School-age Children (K-SADS-E) to measure PTSD, the Child Behavior Checklist (CBCL), the Child Sexual Behavior Inventory (CSBI) and the What If Situations Test (WIFT), which measures ability to recognize and respond to abusive situations. Results showed improvements for both groups in all areas except social support. Effect sizes for the cognitive therapy group were larger, however. Children in the cognitive therapy group showed significantly greater gains in coping skill and knowledge and mothers in the cognitive group reported a greater reduction in intrusive thoughts and negative emotional reactions.
Length of post-intervention follow-up: 3 months

King, N.J., Tonge, B.J., Mullen, P., Myerson, N., Heyne, D., Rollings, S., Martin, R. & Ollendick, T.H. (2000). Treating sexually abused children with posttraumatic stress symptoms: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 39(11), 1347-1355.

Type of Study: Randomized controlled trial
Number of participants: 36 children
Population:

Age Range: 5-17
Race/Ethnicity: Unknown
Status (e.g., foster care, CW): Children referred from sexual assault centers, DHCS, mental health professionals, medical practitioners or school authorities.

Location/Institution: Australia
Summary: (To include comparison groups, outcomes, measures, notable limitations)
Children were randomly assigned to receive Child CBT, Family CBT or to a wait-list control group. PTSD symptoms were assessed using the Anxiety Disorders Interview Schedule for DSM-IV (ADIS). Children also reported their current level of emotional distress using the Fear Thermometer for Sexually Abused Children.  Coping skills were assessed with the Coping Questionnaire for Sexually Abused Children.  The Revised Children’s Manifest Anxiety Scale and the Children’s Depression Inventory were also completed.  Parents completed the Child Behavior Checklist and clinicians completed the Global Assessment Functioning (GAF) Scale for the children.  Treatment group children improved significantly over control group children on PTSD symptoms, although the two treatment conditions did not differ.  They also showed greater improvements on self-reported fear and anxiety, parent ratings on the CBCL and general functioning.  Limitations include a small sample size and possible bias due to measures being filled out by therapists who were not blind to the treatment conditions.
Length of post-intervention follow-up: 12 weeks

Cohen, J.A., & Mannarino, A.P. (1993). A treatment model for sexually abuse preschoolers. Journal of Interpersonal Violence, 8, 115-131.

Deblinger, E., Thakkar-Kolar, R., & Ryan, E. (2006). Trauma in Childhood. In Follette, V.M. & Ruzek, J. (Eds.) Cognitive behavioral therapies for trauma. New York: Guilford Press.

Cohen, J.A., & Mannarino, A.P. (2004). Treating childhood traumatic grief. Journal of Clinical Child and Adolescent Psychology, 33, 820-233.