Trauma-Focused Cognitive Behavioral . - Child Welfare
FACTSHEETOctober 2018Trauma-Focused CognitiveBehavioral Therapy: APrimer for Child WelfareProfessionalsTrauma-focused cognitive behavioral therapy (TF-CBT)is an evidence-based treatment approach shown tohelp children, adolescents, and their parents (or othercaregivers1) overcome trauma-related difficulties. It isdesigned to reduce negative emotional and behavioralWHAT’S INSIDEOverviewTarget populationKey componentsBenefits tousing TF-CBTWhat to look for ina TF-CBT therapistresponses following trauma, including child sexualConclusiontraumatic loss, mass disasters, multiple traumas,Additional resourcesdistorted or upsetting beliefs and attributions relatedReferencesabuse and other maltreatment, domestic violence,and other traumatic events. The treatment addressesto the traumas and provides a supportive environmentin which children are encouraged to talk about theirtraumatic experiences and learn skills to help themcope with ordinary life stressors. TF-CBT also helpsparents who were not abusive to cope effectivelywith their own emotional distress and developskills that support their children. This factsheet isintended to help child welfare professionals builda better understanding of TF-CBT, including whichclients should be referred for this approach, how it isimplemented, and resources for additional information.In this factsheet, the term “parent” includes birth parents as well as other types of primarycaregivers, including foster parents, kin caregivers, and adoptive parents.1Children’s Bureau/ACYF/ACF/HHS800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov
Trauma-Focused Cognitive Behavioral Therapy: A Primer for Child Welfare n the immediate as well as long-term aftermath ofexposure to trauma, including child maltreatment,children are at risk of developing significant emotional,behavioral, and other difficulties. Examples of theseharmful effects include depression, substance use,posttraumatic stress disorder (PTSD) symptoms (e.g.,upsetting and unwanted memories of the experience,avoidance, emotional numbing, hyperarousal), moodand anxiety disorders, suicide attempts, heightenedcortisol levels, and involvement with the justice system(Simonich et al., 2015). Victims also may experiencemaladaptive or unhelpful beliefs and attributions (e.g.,feeling powerlessness, believing they are responsible forthe abuse).TF-CBT is an evidence-based treatment that helpschildren address the negative effects of trauma, includingprocessing their traumatic memories, overcomingproblematic thoughts and behaviors, and developingeffective coping and interpersonal skills. It also includes atreatment component for parents or other caregivers whowere not abusive. Parents can learn skills related to stressmanagement, positive parenting, behavior management,and effective communication.TF-CBT combines elements drawn from multipleapproaches and theories: Cognitive therapy, which aims to change behaviorby addressing a person’s thoughts or perceptions,particularly those thinking patterns that createdistorted or unhelpful views Behavioral therapy, which focuses on modifyinghabitual responses (e.g., anger, fear) to nondangeroussituations or stimuli Family therapy, which examines patterns of interactionsamong family members to identify and alleviateproblems Attachment theory, which emphasizes the importanceof the parent-child relationship Developmental neurobiology, which provides insighton the developing brain during childhoodThe Children’s Bureau does not endorse anyspecific treatment or therapy. Before referring toor implementing a specific type of therapy in yourcommunity, consider its appropriateness basedon families’ needs, resource availability, and fitwithin the current service delivery system.Target PopulationAppropriate candidates for this treatment include thefollowing: Children and adolescents (ages 3–18) who rememberbeing exposed to at least one trauma (e.g., childmaltreatment, community violence, traumatic loss of aloved one) and who experience the following: PTSD symptoms Elevated levels of depression, anxiety, shame,or other dysfunctional abuse-related feelings,thoughts, or developing beliefs Trauma-related behavioral problems, including ageinappropriate sexual behaviors Nonoffending parents or other caregiversTF-CBT has demonstrated effectiveness in a variety ofenvironments (e.g., clinical settings, foster care, schools,in-home), with children and families from diverse culturalbackgrounds, and for individuals experiencing differenttrauma types (e.g., physical or sexual abuse, domesticviolence, disaster, traumatic grief), including multipletrauma types or exposures (Cohen & Mannarino, 2015).TF-CBT may not be appropriate or may need to bemodified for the following populations: Children and adolescents whose primary problemsinclude serious conduct problems (e.g., aggressive ordestructive behaviors) or other significant behavioralproblems that existed prior to the traumatic events andwho may respond better to an approach that focuseson overcoming these problems firstThis material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.This publication is available online at https://www.childwelfare.gov/pubs/trauma/.2
Trauma-Focused Cognitive Behavioral Therapy: A Primer for Child Welfare Professionalshttps://www.childwelfare.gov Children who inappropriately or illegally usesubstances on an extensive basisComponents of the TF-CBT protocol can be summarizedby the word “PRACTICE”: Children who are acutely suicidal P - Psychoeducation and parenting skills—Discussing and teaching about child abuse in generaland the typical emotional and behavioral reactionsto sexual abuse as well as skills training for parentsin positive parenting, child behavior managementstrategies and effective communication Adolescents who are currently exhibiting seriouscutting behaviors or engaging in other parasuicidalbehavior (i.e., nonfatal self-harming behavior)It is important to conduct meaningful assessments ofchildren who may be candidates for TF-CBT to ensurethey fit the profile of those in the target population andtherefore benefit from this intervention.Key ComponentsTF-CBT is a short-term treatment typically provided in 12to 16 weekly sessions, although the number of sessionscan be increased to 25 for youth who present withcomplex trauma (Cohen, Mannarino, & Deblinger, 2017).Most sessions last approximately 60 minutes, with thechild and parent separately seeing the therapist for about30 minutes each. There are some conjoint sessions inTF-CBT, particularly later in the treatment when the childshares his or her trauma narrative with the parent. TF-CBTis usually completed within 4–6 months. Some childrenmay benefit from additional services once the traumaspecific impact has been resolved.Each individual session is designed to build thetherapeutic relationship while providing education, skills,and a safe environment in which to address and processtraumatic memories. The therapist, parents, and child allwork together to identify common goals and attain them.Joint parent-child sessions are designed to help parentsand children practice and use the skills they learned andto assist the children in sharing their trauma narratives.These sessions can also foster more effective parent-childcommunication about the abuse and related issues. R - Relaxation techniques—Teaching relaxationmethods, such as focused breathing, progressivemuscle relaxation, and visual imagery, which maybenefit the parent as well A - Affective expression and regulation—Helpingthe child and parent manage their emotional reactionsto reminders of the abuse, improve their ability toidentify and express emotions, and participate in selfsoothing activities C - Cognitive coping and processing—Helping thechild and parent understand the connection betweenthoughts, feelings, and behaviors and exploring andcorrecting inaccurate and/or unhelpful attributionsrelated to everyday events T - Trauma narration and processing—Conductinggradual exposure exercises, including verbal, written,and/or other creative recounting of abusive events, andprocessing inaccurate and/or unhelpful thoughts aboutthe abuse I - In vivo exposure—Gradual exposure to traumareminders in the child’s environment (e.g., darkness,the setting where the trauma occurred), so the childlearns to control his or her own emotional reactions C - Conjoint parent/child sessions—Family work toenhance communication and create opportunities fortherapeutic discussion regarding the abuse and for thechild to share his/her trauma narration E - Enhancing personal safety and future growth—Education and training on personal safety skills,interpersonal relationships, and healthy sexuality andencouragement in the use of new skills in managingfuture stressors and trauma reminders2When children are living in a dangerous or high-risk environment (e.g.,presence of domestic violence or neighborhood violence), the therapist maymove safety planning to the beginning of the treatment and conduct safetycheck-ins throughout the therapy.2This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.This publication is available online at https://www.childwelfare.gov/pubs/trauma/.3
Trauma-Focused Cognitive Behavioral Therapy: A Primer for Child Welfare ProfessionalsBenefits to Using TF-CBTAt least 20 empirical investigations have been conductedevaluating the impact of TF-CBT on children who havebeen victims of sexual abuse or other traumatic events(Cohen & Mannarino, 2017). Research comparing TF-CBTto other tested models and services as usual (such assupportive therapy, nondirective play therapy, childcentered therapy) has shown that TF-CBT resulted insignificantly greater gains for children and parents.Follow-up studies (up to 2 years following the conclusionof therapy) have shown that these gains are sustained overtime. TF-CBT has been designated as an evidence-basedapproach by several organizations, including the CaliforniaEvidence-Based Clearinghouse for Child Welfare andthe National Registry of Evidence-Based Programs andPractices.Children participating in TF-CBT show a wide range ofimprovements, including decreases in PTSD symptoms,depression, anxiety, behavior problems, shame, cognitivedistortions, and relationship difficulties (Cohen &Mannarino, 2017; Cohen, Mannarino, & Iyengar, 2011;Lenz & Hollenbaugh, 2015). Research also demonstratesa positive treatment response for parents. Parentsexperience reductions in their own emotional distress anddepressive symptoms as well as improvement in how theycan support their children and manage their children’sbehavioral difficulties (Deblinger, Mannarino, Cohen,Runyon, & Heflin, 2015). Caseworkers may want to explorewhether this option is available in their community. (For alisting of certified TF-CBT therapists, visit https://tfcbt.org/members/.)What to Look for in a TF-CBT TherapistIf TF-CBT appears to be an appropriate treatment modelfor a family, you should look for a provider who hasreceived adequate training, supervision, and consultationin the TF-CBT model as well as TF-CBT certification (seehttps://tfcbt.org). If feasible, both you and the familyshould have an opportunity to interview potential TF-CBTtherapists prior to beginning treatment. The child andparents should feel comfortable with and have confidencein the therapist with whom they will work.https://www.childwelfare.govThe following are some specific questions to ask regardingTF-CBT: What is the nature of the therapist’s TF-CBT training(e.g., when trained, by whom, length of training)? Isthis person clinically supervised by someone trainedin TF-CBT or does the therapist participate in a peersupervision group with others who are TF-CBT trained?Is the therapist certified? Is there a standardized, objective assessment processused to gather baseline information on the functioningof the child and family and to monitor their progress intreatment over time? What techniques will the therapist use to help the childmanage his or her thoughts and emotions and relatedbehaviors? How and when will the therapist ask the child todescribe the trauma? Will the therapist use a combination of individual andjoint child-parent sessions? Is the practitioner sensitive to the cultural background ofthe child and family? How will cultural considerations beaddressed? Is there any potential for harm associated with treatment?For additional information about TF-CBT training andcertification, refer to https://tfcbt.org/ and tions/tfcbt trainingguidelines.pdf.ConclusionTF-CBT is an evidence-based treatment approach forchildren who have experienced sexual abuse, physicalabuse, exposure to domestic violence, mass disasters,multiple traumas, or similar traumas. It has a high level ofempirical support and can offer significant results in helpingchildren to process their trauma and overcome emotionaland behavioral problems following trauma. Caseworkersshould become knowledgeable about TF-CBT, as well asother commonly used treatments, to ensure they referchildren and families to the most appropriate communityproviders and treatment interventions. They should alsowork with parents to make sure they are informed about thetreatment options available to them.This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.This publication is available online at https://www.childwelfare.gov/pubs/trauma/.4
Trauma-Focused Cognitive Behavioral Therapy: A Primer for Child Welfare ProfessionalsAdditional ResourcesFor a comprehensive description of TF-CBT, refer to thefollowing book, whose authors are the developers of theapproach:Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017).Treating trauma and traumatic grief in children andadolescents (2nd ed.). New York: Guilford.For additional information about TF-CBT, view thefollowing resources:Trauma-Focused Cognitive Behavioral Therapy (TFCBT) [webpage]California Evidence-Based Clearinghouse for a-Focused Cognitive Behavioral TherapyNational Therapist Certification Program [webpage]Allegheny Health Networkhttps://tfcbt.orgTF-CBT Web 2.0 [web course]Medical University of South Carolinahttps://tfcbt2.musc.eduReferencesCohen, J. A., & Mannarino, A. P. (2017). Evidence basedintervention: Trauma-focused cognitive behavioraltherapy for children and families. In D. M. Teti (Ed.),Parenting and family processes in child maltreatmentand intervention (91–105). Cham, Switzerland: SpringerInternational Publishing.Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017).Treating trauma and traumatic grief in children andadolescents (2nd ed.). New York: Guilford.https://www.childwelfare.govCohen, J. A., Mannarino, A. P., & Iyengar, S. (2011).Community treatment of posttraumatic stress disorderfor children exposed to intimate partner violence.Archives of Pediatrics & Adolescent Medicine, 165(1),16–21.Cohen, J. A., & Mannarino, A. P. (2015). Trauma-focusedcognitive behavioral therapy for traumatized childrenand families. Child and Adolescent Psychiatric Clinicsof North America, 24(3), 557–570. doi: 10.1016/j.chc.2015.02.005Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon,M. K., & Heflin, A. H. (2015). Child sexual abuse: Aprimer for treating children, adolescents, and theirnonoffending parents (2nd ed.). New York: OxfordUniversity Press.Lenz, A. S., & Hollenbaugh, K. M. (2015). Meta-analysisof trauma-focused cognitive behavioral therapyfor treating PTSD and co-occuring depressionamong children and adolescents. CounselingOutcome Research and Evaluation, 6, 18–32. doi:10.1177/2150137815573790Salloum, A., Small, B. J., Robst, J., Scheeringa, M.S., Cohen, J. A., & Storch, E. A. (2017). Steppedand standard care for childhood trauma: A pilotrandomized clinical trial. Research on Social WorkPractice, 27, 653–663. doi: 10.1177/1049731515601898Salloum, A., Wang, W., Robst, J., Murphy, T. K.,Scheeringa, M. S., Cohen, J. A., & Storch, E. A. (2016).Stepped care versus standard trauma-focusedcognitive behavioral therapy for young children.Journal of Child Psychology and Psychiatry, 57, 614–622.doi: 10.1111/jcpp.12471Simonich, H. K., Wonderlich, S. A., Erickson, A. L.,Myers, T. C., Hoesel, Wagner, S., & Engel, K. (2015). Astatewide trauma-focused cognitive behavioral therapynetwork: Creating an integrated community responsesystem. Journal of Contemporary Psychotherapy, 45,265–274. doi: 10.1007/s10879-015-9305-4This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.This publication is available online at https://www.childwelfare.gov/pubs/trauma/.5
Trauma-Focused Cognitive Behavioral Therapy: A Primer for Child Welfare ProfessionalsSuggested Citation:Child Welfare Information Gateway. (2018). Trauma-focusedcognitive behavioral therapy: A primer for child welfareprofessionals. Washington, DC: U.S. Department of Healthand Human Services, Children’s Bureau.U.S. Department of Health and Human ServicesAdministration for Children and FamiliesAdministration on Children, Youth and FamiliesChildren’s Bureauhttps://www.childwelfare.gov
Primer for Child Welfare Professionals. Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment approach shown to help children, adolescents, and their parents (or other caregivers. 1) overcome trauma-related difficulties. It is designed to reduce negative emotional and behavioral
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
www.nctsn.org). As the developers of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT, Cohen, Mannarino & Deblinger, 2006), we proposed through this funding mechanism (Grant No SM54319-9) to evaluate how TF-CBT could be applied most effectively and culturally competently for trauma-affected military children and families.
In a recent review, trauma-focused cognitive behavioral therapy [29] was identified as being one of the most suc-cessful treatment protocols for trauma-related symptoms in children and adolescents [30]. However, this review did not focus on refugee children. Tyrer and Fazel [31
indicated that the most effective interventions are those that use cognitive-behavioral techniques to improve mental functioning. Cognitive-behavioral treatments have become a dominant therapy in clinical psychology, and analyses of cognitive-behavioral programs for offenders have come to positive conclusions. Chapter 2: What is Cognitive .
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Evidence-based treatment for traumatized children, adolescents and their parents/caregivers Short-term (12-20 sessions) Provided in parallel to child and surviving parent or caregiver, w
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