Evidence Based Therapy Models That Treat Children Adolescents and Families
Psychiatr Serv. Writer manuscript; available in PMC 2022 May 1.
Published in final edited form every bit:
PMCID: PMC4396183
NIHMSID: NIHMS669497
Trauma-Focused Cognitive Behavioral Therapy: Assessing the Evidence
Michael A. Ramirez de Arellano, Ph.D., D. Russell Lyman, Ph.D., 
Lisa Jobe-Shields, Ph.D., Preethy George, Ph.D., Richard H. Dougherty, Ph.D., A.Thou., Allen S. Daniels, Ed.D., Sushmita Shoma Ghose, Ph.D., Larke Huang, Ph.D., and Miriam Eastward. Delphin-Rittmon, Ph.D.
Michael A. Ramirez de Arellano
Mental Health Disparities and Variety Plan, National Crime Victims Research and Treatment Center, Section of Psychiatry and Behavioral Sciences, Medical Academy of South Carolina, Charleston, SC, ude.csum@amleraed
D. Russell Lyman
Senior Associate, DMA Wellness Strategies, ix Meriam Street, Suite 4, Lexington, MA 02420-5312, Phone: 781-863-8003, Fax: 781-863-1519, moc.htlaehamd@lssur
Lisa Jobe-Shields
National Crime Victims Research and Handling Heart, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, ude.csum@iehseboj
Larke Huang
Office of Behavioral Wellness Equity, Substance Corruption and Mental Health Services Administration, Rockville, Doc, vog.shh.ashmas@gnauh.ekraL
Abstract
Objective
Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a conjoint parent-child treatment developed past Cohen, Mannarino, and Deblinger that uses cognitive-behavioral principles and exposure techniques to forbid and care for posttraumatic stress, depression, and behavioral problems. This review divers TF-CBT, differentiated information technology from other models, and assessed the prove base.
Methods
Authors reviewed meta-analyses, reviews, and private studies (1995 to 2013). Databases surveyed were PubMed, PsycINFO, Practical Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, PILOTS, the ERIC, and the CINAHL. They chose from three levels of research evidence (high, moderate, and low) on the basis of benchmarks for number of studies and quality of their methodology. They also described the evidence of effectiveness.
Results
The level of show for TF-CBT was rated as loftier on the ground of ten RCTs, three of which were conducted independently (non by TF-CBT developers). TF-CBT has demonstrated positive outcomes in reducing symptoms of posttraumatic stress disorder, although information technology is less clear whether TF-CBT is effective in reducing behavior bug or symptoms of low. Limitations of the studies include concerns about investigator bias and exclusion of vulnerable populations.
Conclusions
TF-CBT is a viable handling for reducing trauma-related symptoms among some children who take experienced trauma and their nonoffending caregivers. Based on this evidence, TF-CBT should be bachelor every bit a covered service in health plans. Ongoing research is needed to further identify best practices for TF-CBT in various settings and with individuals from various racial and indigenous backgrounds and with varied trauma histories, symptoms, and stages of intellectual, social, and emotional development.
This article reviews the literature on TF-CBT as role of the Assessing the Show Base Series (run into box on next page). The objectives were to describe the components of TF-CBT, assess the level of prove (that is, methodological quality) of existing studies, and provide a concise summary of its overall effectiveness. The review included studies that investigated the use of TF-CBT with children exposed to a range of traumatic events who had experienced trauma-related mental health problems. The review also examined the effectiveness of TF-CBT in addressing specific symptoms, such as those of PTSD and low, and problem behaviors. Finally, the review highlighted the limitations and areas that need additional research. This information will aid payers and policy makers besides as families of children exposed to trauma make informed decisions about treatment.
Description of Trauma-Focused Cerebral-Behavioral Therapy
TF-CBT is defined in the 2006 treatment manual Treating Trauma and Traumatic Grief in Children and Adolescents (ane), although descriptions of the cardinal cognitive-behavioral components developed by Deblinger, Cohen, and Mannarino were described in earlier literature (9). The chief goal of TF-CBT is to reduce PTSD symptoms amidst children and adolescents. TF-CBT provides structure for the use of cognitive-behavioral principles in the context of two paramount developmental considerations: the role of the caregiver and the developing nature of a child's emotion regulation and coping capabilities. The model originally was designed to accost PTSD symptoms associated with sexual corruption: depressive symptoms, behavior bug (including assailment and inappropriate sexual behaviors), and unhelpful thoughts and feelings regarding the abuse, such every bit cognitive distortions, guilt, and shame. Subsequently the model has been adjusted to care for various types of abuse and other traumas, such as experiencing physical or emotional abuse or neglect and witnessing community or domestic violence, traumatic loss, state of war, or natural disasters. TF-CBT was designed to be delivered in 12–16 sessions of outpatient handling, depending on the needs and abilities of the child and caregivers.
The model too addresses the emotional reactions of nonoffending parents and caregivers. This population is defined as individuals who were not involved in perpetrating the abuse, although they may besides exist experiencing PTSD symptoms related to the abuse. Caregivers who may have been involved in causing the trauma (such as domestic violence or physical abuse) just who take subsequently received successful treatment or otherwise been found to be supportive of the child and able to ensure concrete and emotional safety may as well be involved in treatment, depending on the needs of the kid.
Over fourth dimension, TF-CBT has been applied to symptoms and behaviors associated with a broad range of traumas, such every bit other forms of child maltreatment, domestic violence, community violence, accidents, natural disasters, war, and other events involving traumatic loss (10–15). Key elements of the intervention are summarized in Tabular array 1. They include psychoeducation, gradual exposure, behavior modeling, coping strategies, and torso safety skills training. Each of these elements may be adjusted co-ordinate to the treatment needs of the child and family involved.
Table ane
Summary of Trauma-Focused Cerebral-Behavioral Therapy
| Service summary | |
|---|---|
| Service definition | Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a direct service for children and adolescents and their nonoffending caregivers. The arroyo uses cognitive behavioral principles and exposure techniques to accost symptoms of post-traumatic stress following trauma exposure as well as symptoms of depression, beliefs problems, and caregiver difficulties. Fundamental elements of the intervention include psychoeducation (eastward.g., common reactions to trauma exposure), coping skills (e.g., relaxation, feelings identification, cognitive coping), gradual exposure (e.g., imaginal, in-vivo), cerebral processing of trauma-related thoughts and beliefs, and caregiver involvement (eastward.thousand., parent preparation, conjoint child-parent sessions). To accommodate a multifariousness of traumatic experiences, TF-CBT includes general psychoeducational materials with recommendations for tailoring treatment for individuals who have experienced physical abuse, sexual abuse, interpersonal violence, or natural disasters. |
| | |
| Service goals |
|
| | |
| Populations | Children and adolescents who take experienced trauma and have trauma-related symptoms, including post-traumatic stress disorder |
| | |
| Settings for service delivery | Outpatient facilities, schools, client homes; individual and grouping therapy settings, (research was limited to outpatient settings) |
To help children and adolescents develop coping skills, treatment providers teach relaxation skills, affective modulation skills, and cognitive coping skills. In addition, TF-CBT uses exposure principles and cognitive-restructuring techniques that are specific to the traumatic experience. Exposure involves gradually introducing individuals to reminders of the trauma that may be tangible, such as places or people, or intangible, such as specific memories of traumatic events. The gradual exposure reduces distress associated with these reminders and decreases trauma-related reactions. Cognitive restructuring involves identifying inaccurate and unhelpful thoughts and beliefs (for example, self-blame) associated with traumatic events and developing more adaptive ways of understanding and drawing conclusions about the trauma and the victim's reactions to it.
Early versions of TF-CBT tended to place different levels of emphasis on certain components, such as exposure (xvi), and various means of naming the arroyo evolved. Two teams, i led by Deblinger and the other by Cohen and Mannarino, each created a structured manual for their approach. These two teams so collaborated, and in 1997 they integrated their like approaches to treatment. They coauthored a manual on TF-CBT, which was published in 2006 (1). In that manual, TF-CBT treatment components were summarized by using the acronym PRACTICE (1), and this summary forms the basis of our definition for TF-CBT as information technology appears in the research literature. The 8 components (the first of which has ii pieces) of PRACTICE are an elaboration of the original models and include Psychoeducation and Parenting skills, Relaxation, Affect modulation, Cognitive coping and processing, Trauma narrative, In-vivo mastery of trauma reminders, Conjoint child-caregiver sessions, and Enhancing condom and development.
A key focus of TF-CBT is to ensure an approach that is developmentally appropriate for the needs of children and their caregivers. This includes a developmentally sensitive assessment and fostering of coping strategies to help children better manage trauma-related distress and emotional reactions. After children learn coping skills, they participate in exposure-based components of handling. An case is the creation of a trauma narrative—a gradual exposure and cognitive-processing exercise that creates the private'due south story most the abuse. The narrative is intended to reduce distress and resolve maladaptive cognitions associated with trauma-related memories, which tin be affected by developmental factors such as level of cognitive and emotional maturity.
A second developmental consideration of TF-CBT is incorporating a nonoffending caregiver into the child'south recovery process. In the TF-CBT model, parents and children participate in parallel treatment sessions; for each component of treatment, the therapist spends part of the session with the child and role with the caregiver. In addition, the child shares the trauma narrative with the caregiver in the session. This allows the caregiver to provide support and helps the kid correct distortions in his or her understanding of the abuse, including those related to what happened and who is to blame. Caregivers frequently too participate in the session with the child to heighten the safe component, and then that the child tin receive adult support in regaining a sense of security and well-existence (one).
Clearly, the implementation of this model as outlined depends on the presence of a competent, child-focused caregiver at the time of handling, which cannot be presumed in all families affected by abuse and maltreatment. Many children are referred for TF-CBT via social services or other agencies that are involved with the kid because of concerns about the caregiver'due south capacity to provide care and safety, making total implementation of the caregiver components a challenge or impractical. For that reason, TF-CBT allows for a number of adaptations to the central components. The parallel-treatment components for caregivers can be provided to any available caregiver, such as a foster parent or another adult who tin can provide advisable parenting support and is involved in the child'southward daily life. During conjoint sessions, a child may cull to share the trauma narrative with an adult whom he or she identifies every bit supportive and trusted (for case, a grandparent, aunt, trusted teacher, or guidance counselor), regardless of whether this adult is involved in solar day-to-twenty-four hour period care. Sessions are besides held between the caregiver and the therapist throughout handling, including prior to conjoint sessions, to ensure the ability of the caregiver to reply in a caring and supportive fashion and to help prepare the caregiver for the sharing of the narrative.
V cadre elements of the TF-CBT model
Although other variations of CBT for traumatized children and adolescents take been reviewed in recent years (17,xviii), this review focused on what nosotros identified as five core elements of the electric current TF-CBT model and the iterations that preceded it. These are psychoeducation; coping strategies, such as relaxation, identification of feelings, and cognitive coping; gradual exposure, for example, through imagining or in-vivo exposure; cognitive processing; and caregiver participation, such equally parent training and conjoint sessions. Although studies that were conducted before publication of the well-nigh recent handling transmission used an earlier version of the manual, all the studies reviewed hither adhered to the five key elements we have identified.
We evaluated TF-CBT for the treatment of a broad range of traumatic events, rather than focusing on a specific type of trauma, as was the case for ii reviews published in 2013 by the Agency for Healthcare Research and Quality (AHRQ) (19,20). One of the AHRQ reviews provided a thorough comparative effectiveness study of cerebral-behavioral interventions for children and adolescents that address trauma other than maltreatment or family violence, only it did not cover the specific TF-CBT model defined here (nineteen). The literature search for this AHRQ review merged individual and schoolhouse group models (21,22) and included only one study of what was described as "cognitive-behavioral therapy" for trauma among children and adolescents (23). The 2nd AHRQ review targeted maltreatment (20). The authors reviewed two studies by TF-CBT developers that are covered here (24,25) but no others. Thus, in this review, we provide a different perspective on the TF-CBT literature.
Methods
Search strategy
We conducted a search for meta-analyses, research reviews, and individual studies from 1995 through July 2013. We searched major databases: PubMed (U.S. National Library of Medicine and National Institutes of Health), PsycINFO (American Psychological Association), Practical Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Centrolineal Health Literature. We too examined publications that had citations pertaining to the development of the model (1,sixteen,24,26). We used combinations of the following search terms: trauma-focused cognitive behavioral therapy, trauma therapy, treatment of trauma, cognitive behavioral therapy for trauma, cerebral behavior therapy for sexual corruption, cerebral behavior therapy for physical abuse, treatment for PTSD, and trauma-focused cognitive behavioral therapy for child traumatic grief. We also used truncated forms of these terms (such as "trauma") and alternative spellings and punctuation.
Inclusion and exclusion criteria
This review was express to U.S. and international studies in English and included the following types of articles: randomized controlled trials (RCTs), quasi-experimental studies, single-grouping fourth dimension-series design studies, and review articles, such equally meta-analyses and systematic reviews. We included only studies that investigated TF-CBT and its five central elements, as defined in a higher place in the clarification of the service. We too included review articles and meta-analyses that examined TF-CBT along with other cognitive-behavioral approaches (for example, manufactures that reviewed all cognitive-behavioral approaches, including TF-CBT). We excluded studies of other cerebral-behavioral–based interventions for traumatized children, such as Cerebral Behavioral Intervention for Trauma in Schools, which involves school-based prevention and handling groups with less caregiver involvement, and Narrative Exposure Therapy, which does not include other core components of TF-CBT.
Strength of the prove
The methodology used to rate the strength of the prove is described in detail in the introduction to this series (27). The inquiry designs of the studies that met the inclusion criteria were examined. Three levels of testify (high, moderate, and low) were used to signal the overall research quality of the drove of studies. Ratings were based on predefined benchmarks that considered the number and quality of the studies. If ratings were different, a consensus opinion was reached.
In general, high ratings indicate confidence in the reported outcomes and are based on iii or more RCTs with adequate designs or two RCTs plus two quasi-experimental studies with acceptable designs. Moderate ratings indicate that at that place is some acceptable inquiry to judge the service, although it is possible that hereafter enquiry could influence reported results. Moderate ratings are based on the following three options: two or more quasi-experimental studies with adequate design; one quasi-experimental report plus one RCT with adequate design; or at least two RCTs with some methodological weaknesses or at least three quasi-experimental studies with some methodological weaknesses. Low ratings indicate that research for this service is not acceptable to describe evidence-based conclusions. Low ratings indicate that studies accept nonexperimental designs, there are no RCTs, or in that location is no more than one fairly designed quasi-experimental study.
We accounted for other pattern factors that could increase or subtract the bear witness rating, such as how the service, populations, and interventions were defined; use of statistical methods to account for baseline differences between experimental and comparison groups; identification of moderating or confounding variables with appropriate statistical controls; examination of attrition and follow-up; use of psychometrically audio measures; and indications of potential research bias.
Effectiveness of the service
We described the effectiveness of the service—that is, how well the outcomes of the studies met the service goals. We compiled the findings for separate issue measures and study populations, summarized the results, and noted differences across investigations. Nosotros considered the quality of the research pattern in our conclusions near the strength of the evidence and the effectiveness of the service. Based on the evidence, we also evaluated whether the practice should be considered for inclusion every bit a covered service in public and individual wellness plans.
Results
Level of evidence
Our literature search resulted in xiii articles reporting on ten RCTs (11,xiii,14,24–26,28–34) and six review articles (10,12,xviii–20,35). On the ground of the criteria set forth in this review, the body of research on TF-CBT meets a high level of evidence. Three adequately designed RCTs were completed independently of the TF-CBT developers (xi,28,29), and vii RCTs and 3 follow-up studies completed by or involving the developers were otherwise determined to be of acceptable pattern (13,fourteen,24–26,xxx–34). We depict the findings of the publications by their blazon of research blueprint.
RCTs
Our literature search yielded ten RCTs that evaluated TF-CBT with the v cadre components as defined, too every bit a number of additional open up trials and dismantling studies that clarified the bear witness of its effectiveness. The brief summary here is complemented by additional study details summarized in Table 2. Of the ten RCTs we identified, seven compared TF-CBT with an agile control group (13,14,24–26,29,33), and three compared TF-CBT with a wait-list control group (11,28,31). Three additional articles, likewise listed in Table two, were follow-up studies to an original RCT; they included follow-upwardly periods of one year or longer (thirty,32,34). V RCTs evaluated TF-CBT exclusively with sexually abused children (24–26,29,33), one evaluated children who had been exposed to war and sexual exploitation (xi), ii evaluated a mixed-trauma sample of participants (29,31), one evaluated children exposed to intimate-partner violence (13), and one evaluated children exposed to a natural disaster (Hurricane Katrina) (14). Nine RCTs were administered in the individual or conjoint format (13,14,24–26,28,29,31,33); and one, an intervention with Congolese girls, was administered in a group format (11). Although we excluded group formats such equally Cerebral Behavioral Intervention for Trauma in Schools (which was specifically designed for school-based groups and did not fully adhere to the Practice protocol), we included the report with Congolese girls because clinicians used the TF-CBT transmission and adhered to the PRACTICE arroyo by involving parents in their group model.
Table 2
Randomized controlled trials of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), in chronological ordera
| Studyb | Comparison grouping | Sample | Findingsc | Effect sized | Selected methodological strengths and weaknesses |
|---|---|---|---|---|---|
| Cohen and Mannarino, 1996 (24); Cohen and Mannarino, 1997 (30) | Nondirective Supportive therapy | N=86; mean historic period, 4.7 years; age range, 2–vii; 58% females; experienced sexual corruption; 78% completed handling across groups | TF-CBT was related to greater improvement in trauma-reactive behaviors and sexual behavior problems, compared with nondirective supportive therapy; the treatment effects endured at 12- month follow-up. Significant pre- to posttreatment decreases in sexual behavior were noted, only the differences were not significant when TF-CBT was compared with an active control grouping, except at 12-calendar month follow-up. | Medium for sexual behavior at 12-month follow-up | There was an agile control group. Developers were authors of the study. Blinding procedures were insufficient or not properly described. The study excluded children with intellectual or developmental inability, children with psychosis, and children whose parents had psychosis or agile substance use. |
| Deblinger et al., 1996 (26); Deblinger et al., 1999 (32) | Therapy every bit usual | N=100; mean age, ix.eight years; age range, vii–13; 83% females; experienced sexual corruption; xc% completed treatment and posttest | TF-CBT was associated with decreases in externalizing behaviors, depression, and PTSD symptoms amidst children and with increases in effective parenting skills among mothers compared with those in therapy equally usual. | Medium for Posttraumatic stress symptoms, depression, and beliefs; medium for effective parenting practices | There was an active control group. Developers were authors of the written report. Blinding procedures were bereft or not properly described. The study excluded children with intellectual or developmental disability and children with psychotic symptoms. |
| Cohen and Mannarino, 1998 (33); Cohen et al., 2005 (34) | Nondirective Supportive therapy | Due north=82; hateful age, 11 years; age range 7–xv; 69% females; experienced sexual abuse; 60% completed treatment | TF-CBT was associated with greater improvements in depression, anxiety, beliefs problems, and sexual beliefs problems, compared with the command grouping. Significant pre- to posttreatment decreases in sexual behavior were noted, merely no significant differences were institute when TF-CBT was compared with an agile control grouping. | Medium for low | In that location was an agile control group. Developers were authors of the written report. Blinding procedures were insufficient or not properly described. The study excluded children with intellectual or developmental disability, psychotic symptoms, or an impairing substance use disorder and those whose parents had psychosis or agile substance use. |
| King et al., 2000 (28) | Look-list control grouping; also compared child-but condition with full model | Due north=36; mean age, eleven.4 years; age range, 5–17; 69% females; experienced sexual abuse; 75% completed handling | TF-CBT was associated with a significant reduction in PTSD symptoms of re- experiencing, abstention, and hyperarousal; lessened experiences of fear and anxiety; and improved global functioning, compared with the wait-listing control group. Caregiver involvement was non related to treatment outcomes. There was no main event for behavior problems. TF-CBT participants had a significant pre-post decrease in low, but no meaning between-groups divergence was noted when TF-CBT was compared with the control group. | Large for Posttraumatic stress symptoms | Authors were independent of model development. Blinding procedures were insufficient or not properly described. There was a wait-list control grouping. The study excluded children who were suicidal or extremely tearing and those with intellectual or developmental disability or psychotic symptoms. |
| Cohen et al., 2004 (25) | CCT | N=229; mean age, 10.eight years; historic period range, 8–fourteen; pct of females not reported; experienced sexual abuse; 88% completed at least iii sessions | TF-CBT was associated with greater improvement in PTSD symptoms, low, beliefs bug, shame, and abuse-related attributions amidst children and adolescents, compared with CCT. Among caregivers, TF-CBT was associated with greater improvement in low, abuse-specific distress, support of the child, and effective parenting practices. | Medium for Posttraumatic stress symptoms and for beliefs; medium for effective parenting practices | There was an active command group. Developers were authors of the study. Blinding procedures were insufficient or non properly described. The study excluded children with intellectual or developmental disability, psychotic symptoms, or impairing substance utilise disorder and those whose parents had psychosis or active substance use. |
| Jaycox et al., 2010 (14) | Cognitive- Behavioral Intervention for Trauma in Schools | N=118; mean age, 11.5 years; age range, 9–15.five; 66% females; experienced hurricane exposure; 60% received some treatment | Average PTSD scores improved in both interventions from baseline to 10 months: PTSD scores for the TF- CBT group moved to the normal range, and scores for the comparison group were in the low clinical range. A significant pre- to posttreatment decrease in low was noted for the TF-CBT group, but the between-group deviation was not significant. | No pregnant effects were noted compared with the control group. | At that place was an agile command group. Developers of the model were second and 3rd authors. Blinding procedures were insufficient or not properly described. No exclusion criteria were cited. |
| Cohen et al., 2011 (13) | CCT | N=124; mean historic period, nine.6 years; age range 7–14; 51% females; witnessed intimate-partner violence; lx% completed treatment | TF-CBT was associated with significant improvement of children'south PTSD symptoms and anxiety related to witnessing intimate-partner violence, compared with CCT, including greater decreases in hyperarousal and avoidance symptoms. A significant pre- to posttreatment decrease in depression was noted for the TF-CBT group, just the between-grouping difference was not meaning. | Medium for Posttraumatic stress symptoms | Developers were authors of the study. At that place was an active control group. The study excluded children with intellectual or developmental disability or psychotic symptoms or those whose parents had psychosis. |
| Scheeringa et al., 2011 (31) | Wait-list command | Due north=75; mean historic period, 5.three years; historic period range, three–half dozen; 34% females; experienced mixed trauma; retention non reported | Scores on PTSD improved over fourth dimension for TF-CBT group only not for the control group. Furnishings remained when the analysis deemed for type of trauma (acute injury, witnessed domestic violence, or victim of Hurricane Katrina). A meaning pre- to posttreatment subtract in depression was noted for the TF- CBT group, just the between-group deviation was not significant. | Big for Posttraumatic stress symptoms | The tertiary writer was a programmer of the model. Blinding procedures were bereft or not properly described. There was a wait-listing control group. The study excluded children with intellectual or developmental inability. |
| O'Callaghan et al., 2013 (11) | Look-list control | North=52; mean historic period, 16 years; age range, 12–17; 100% females; experienced state of war exposure and sexual violence; 88% completed follow-up assessments | TF-CBT was associated with greater improvements in symptoms of trauma, low, and anxiety; acquit issues; and prosocial behavior, compared with the command group. | Large for Posttraumatic stress symptoms | This study was the commencement demonstration of TF-CBT within the population of the Democratic Commonwealth of Congo. Authors were independent of the model evolution. Blinding procedures were insufficient or not properly described. In that location was a look-list control group. The study excluded children who were suicidal or extremely vehement, had intellectual or developmental disability, or had psychotic symptoms. Treatment was administered past individuals without a mental health or medical background. |
| Jensen et al., 2013 (29) | Therapy every bit usual | N=156; hateful age, xv.1 years; historic period range 10–xviii; 79% females; exhibited symptoms of trauma exposure; 78% completed 15 sessions and posttreatment assessment | TF-CBT was associated with lower levels of mental health symptoms (PTSD, depression, and full general symptoms) and greater improvements in functional impairment, compared with the control group. | Medium for Posttraumatic stress symptoms and depression | Authors were independent of model development. The study excluded children with psychotic symptoms or an impairing substance use disorder. |
Overall, the RCTs in our review included potent fidelity procedures coupled with very like definitions of the service. In addition, nigh assessment tools were well validated, including structured clinical interviews (for example, the Kiddie Schedule for Melancholia Disorders and Schizophrenia) and cocky- and parent-report measures (for example, the Academy of California, Los Angeles, PTSD Reaction Index).
Still, some studies had methodological weaknesses (Table 2). The master concern was investigator bias. Three RCTs with adequate designs were implemented past researchers who were independent of the developers of the handling (11,28,29). However, the remaining vii RCTs were conducted by the developers of TF-CBT (13,24–26,33) or included 1 of the developers in some capacity (14,31). Simply two of the vii RCTs conducted by the developers of the treatment met AHRQ's strict guidelines for inclusion regarding take chances of bias (24,25). Second, blinding procedures were not explicitly reported or were unclear or insufficient in six studies (14,24–26,28,33), and three studies had inactive control groups (eleven,28,31). Because these methodological concerns are common in the literature and in some cases may simply exist due to omissions in reporting, we included studies that had no more than ii perceived flaws. The only exception was 1 study that included multiple design flaws merely that provided new information on treatment of very immature children, a population rarely included in this research (35).
Review manufactures
The half dozen review articles included in this review (ten,12,18–20,35) are described in Table 3. Similarities and differences in inclusion and exclusion criteria must be considered when comparison these results with the results of our review, because none of the previous reviews assessed the level of prove in exactly the same way equally we take divers our evidentiary assessment protocol. The reviews examined the status of evidence for similar and overlapping bodies of research, including TF-CBT with maltreated children just (20); TF-CBT for traumas that are not related to corruption, maltreatment, or family unit violence (nineteen); and all cognitive-behaviorally oriented interventions applied to traumatized children (10,12,18,35).
Table iii
Review articles evaluating Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), in chronological order
| Study | Focus of review | Outcomes assessed | Findings |
|---|---|---|---|
| Silverman et al., 2008 (12) | Review. Psychosocial treatments for children and adolescents exposed to traumatic events (included 7 studies of CBT, 5 specifically of TF-CBT) | PTSD symptoms, depression, feet, behavior problems | TF-CBT met well-established criteria for methodological rigor. CBT approaches, including TF-CBT, were associated with greater improvements in all outcomes relative to non- CBT approaches. |
| Cary and McMillen, 2012 (ten) | Systematic review. CBT for children and adolescents who have survived trauma (included 14 studies of CBT, 6 specifically of TF-CBT) | PTSD symptoms, depression, behavior problems | TF-CBT was associated with reducing symptoms of PTSD (immediately and 12 months after treatment) as well as reducing depression and problem behaviors (immediately but not 12 months afterwards treatment) compared with the attention command group (a group that receives the same amount of attention as the experimental group only with a placebo approach not considered to be effective), standard customs care, and wait-list control atmospheric condition. |
| Gillies et al., 2012 (35) | Systematic review. Interventions for PTSD amidst children and adolescents (included v studies of CBT, 3 specifically of TF-CBT)b | PTSD symptoms, low, anxiety, adverse effects, dropout | "Fair testify" was cited that CBT (summarized together with TF-CBT) was associated with reduced PTSD symptoms compared with wait-list, usual care, and other therapies (supportive therapy, nondirective counseling, psychodynamic therapy, and hypnotherapy). |
| Macdonald et al., 2012 (xviii) | Systematic review. Cognitive- behavioral interventions for children who have been sexually abused (included ten studies of CBT, 6 specifically of TF-CBT) | PTSD symptoms, depression, feet, behavior problems | CBT, including TF-CBT, was associated with reducing symptoms of PTSD and feet, although effects were modest. CBT may take positive effects for children who take been sexually abused, but more than study is needed. |
| Forman- Hoffman et al., 2013 (xix) | Comparative effectiveness review. Interventions for traumatic stress other than maltreatment or family violence (included i study of CBT in a school setting, no studies of TF- CBT) | PTSD symptoms, depression, functional impairment, aggression, psychological difficulties, conduct problems, prosocial behavior | Show was depression for CBT interventions targeting children exposed to trauma, regardless of whether they were experiencing symptoms. Schoolhouse-based treatments with elements of TF-CBT showed promising furnishings for children exposed to trauma. |
| Fraser et al., 2013 (20) | Comparative effectiveness review. Interventions for children exposed to maltreatment (included 3 studies of CBT, 2 specifically of TF-CBTc) | Well-being (mental and behavioral health; caregiver-child relationship; cognitive, linguistic communication, and physical development; school-based functioning) and child welfare (prophylactic, placement stability, and permanency) | Authors stated that a potent conclusion in back up of any of the therapies, including CBT, could not exist drawn from the studies examined in the review. |
In contrast to the more often than not high rating of evidence found in our review and the reviews described below, the two reviews conducted by AHRQ found depression levels of bear witness for cognitive-behavioral interventions for trauma. Equally nosotros have noted, the get-go review focused on the treatment of children exposed to traumatic events that did not include maltreatment (that is, physical, sexual, emotional, or psychological abuse and neglect) or family violence (19). The authors identified only one study as TF-CBT—an evaluation of a cognitive-behavioral schoolhouse-based intervention for trauma-exposed adolescents (23). This written report had ane major exception to our definition of TF-CBT: information technology was implemented primarily in schoolhouse groups with little caregiver interest, whereas our model is implemented in individual and conjoint child-caregiver sessions. The second AHRQ review compared parenting interventions, trauma-focused treatments, and enhanced foster intendance approaches that address child maltreatment (twenty). Subsequently excluding a number of RCTs on the basis of the likelihood of author bias and other stringent criteria, the authors included three RCTs of TF-CBT. Two of these 3 RCTs are included in our review (24,25), along with some RCTs that met our inclusion criteria but were excluded past AHRQ because they were of the "wrong population" (xiii,29,33) or "wrong intervention" (26). The tertiary RCT reviewed by AHRQ compared group conditions for mothers of sexually abused children but did not assess TF-CBT for children because the children in both groups received TF-CBT (36); therefore, it is unclear why it was included in the AHRQ review (twenty), and we chose to exclude it from our review.
One review conducted by the Cochrane Collaboration determined that there was a moderate level of evidence for cognitive-behavioral approaches, including TF-CBT, for sexually driveling children (18). The authors concluded that although there was relatively consequent overall evidence that CBT is effective for this population, the body of research was weaker than in some other reviews because of the high gamble of bias (primarily due to lack of reporting on blinding procedures). In evaluating TF-CBT together with other cognitive-behavioral approaches, this Cochrane review provided useful data on cognitive-behavioral approaches in full general, just it confounded the testify in support of the effectiveness of TF-CBT every bit a distinct cognitive-behavioral approach.
The remaining three reviews we identified found that at that place was a high level of evidence for cognitive-behavioral approaches for traumatized children and adolescents, including TF-CBT (10,xx,35). In a review published in 2008, Silverman and colleagues (12) compared diverse psychosocial treatments for children exposed to trauma and included vii studies evaluating cognitive-behavioral therapies, including TF-CBT. This was the merely treatment approach determined to meet the criteria of a "well-established treatment." Another Cochrane Collaboration review that was near recently updated in 2012 examined 14 RCTs covering psychological therapies for the treatment of PTSD among children and adolescents. The authors concluded that compared with command atmospheric condition, the "merely therapy for which there was evidence" was CBT (including TF-CBT) (35).
Cary and McMillen (x) reviewed 10 RCTs published between 1990 and 2011 and concluded that the evidence for positive outcomes from cerebral-behavioral therapies for trauma (including TF-CBT) was consistently high. Six of the studies from this review met our inclusion criteria. The remaining 4 studies reviewed by Cary and McMillen focused on interventions for children and adolescents that were similar to TF-CBT (for example, Cognitive Behavioral Intervention for Trauma in Schools) but did non meet the criteria of all five cardinal components for inclusion in our review. Furthermore, although those authors excluded studies that did non measure PTSD symptoms, our review included two additional studies that assessed symptoms other than those of PTSD (24,30).
Although Cary and McMillen (10) specifically addressed TF-CBT, the other reviews drew their conclusions on the footing of cognitive-behavioral therapies in general, making it difficult to discern what the conclusions would have been had they focused on TF-CBT alone. Thus the conclusions regarding the show for TF-CBT reached by reviews of the literature over the past ii decades vary widely, non just considering of differences in the definition of TF-CBT (that is, whether all cerebral-behavioral interventions for traumatized children and adolescents are considered to be TF-CBT) but also because of differences in the types of trauma that were targeted and the vulnerable populations that were excluded.
Populations
A number of issues regarding sample composition and inclusion or exclusion criteria are of import to consider because they bear upon the generalizability of the findings. Eight of the x RCTs in this review were conducted in the United States (13,fourteen,24–26,28,31,33), and almost of the children who participated were Caucasian, followed by African American. Less than 10% of child participants were Hispanic. Every bit we have noted, i study was conducted with girls from the Autonomous Commonwealth of Congo (eleven). In addition, one study was conducted with children in Norway (73% Norwegian, 10% Asian) (29).
Table 2 notes the excluded populations for studies that reported this information. Eight studies excluded children with intellectual or developmental disabilities (11,13,24–26,28,33), nine excluded children with psychotic symptoms (xi,13,24–26,28,29,33), three excluded children on the basis of an impairing substance use disorder (25,29,33), and three excluded children who were suicidal or severely violent (11,26,28). All studies except one, which compared TF-CBT with a school-based intervention (12), required the participation of a broadly defined nonoffending caregiver. Several studies explicitly excluded parents with psychosis (13,24,25,33) or active substance abuse (24,25,33). Although exclusion criteria varied across studies, the criteria used signal that the findings are limited in their ability to be generalized to children with intellectual or developmental disabilities or children and families affected past more than serious forms of mental illness. Studies were as well limited to outpatient clinics, thus limiting generalizability to other settings.
Effectiveness of the service
TF-CBT has been associated with improved outcomes over time and in comparing with command groups, although findings are somewhat inconsistent. As 1 might expect, larger outcome sizes were reported when experimental groups were compared with inactive rather than active control groups (eleven,28). A majority of studies assessed posttraumatic stress symptoms and depressive symptoms, and some studies assessed behavior problems, including sexual behavior issues (24,33) and aggression (11,25,26,28,31). A few studies assessed caregiver outcomes (25,26).
The sections below summarize results from the 10 RCTs past targeted upshot. Effect sizes are based on comparing of the TF-CBT group with the comparing group, unless otherwise stated. Medium effects were defined as standardized hateful differences of Cohen's d ≥.40 and large effects were defined as d ≥.75.
Posttraumatic stress
All studies that included an assessment of posttraumatic stress symptoms reported significant differences between TF-CBT and comparison treatments at various posttreatment time points, primarily in the medium range of consequence sizes (xiii,25,26,29). Two studies that institute large issue sizes compared TF-CBT with a wait-listing control group (11,28). In the one report that compared TF-CBT with another cognitive-behavioral school-based intervention, both treatments were constructive in decreasing symptoms (14). In this written report, symptoms were (on boilerplate) in the nonclinical range after TF-CBT and in the depression-clinical range after the school-based intervention. Two studies suggested that TF-CBT differentially affects specific symptoms of posttraumatic stress (13,28). Immediately subsequently treatment, individuals receiving TF-CBT had greater reductions in hyperarousal and avoidance symptoms than in re-experiencing trauma-related symptoms, compared with a control group. I written report besides included an assessment of functional impairment as a result of trauma-related symptoms; TF-CBT outperformed therapy as usual with a medium effect size (29).
Low
Nine studies included assessments of depression (11,xiii,fourteen,25,26,28,29,31,33). Of 5 that reported statistically significant effects of TF-CBT compared with comparison treatment, iii had medium effect sizes (TF-CBT versus active comparison treatment) (26,29,33), one had a large effect size (TF-CBT versus expect-list control group) (11), and one had a modest effect size (TF-CBT versus child-centered therapy) (25). Four studies did not find TF-CBT to exist significantly more effective than a comparing treatment in decreasing depressive symptoms, although significant pre-postal service decreases in depression were found in the experimental group (13,14,28,31). Finally, ane study that compared TF-CBT with Cerebral Behavioral Intervention for Trauma in Schools found that the schoolhouse intervention was effective in decreasing depression, whereas TF-CBT was not (14).
Behavior problems (sexual and other)
Seven studies examined co-occurring behavior issues, such as aggression and disruptive behavior (11,24–26,28,31,33); two of these studies included specific measures of sexual behavior problems (24,33). Regarding general behavior problems, two studies did not find significant main effects for pre-postal service handling reductions in symptoms (24,28). Three studies found significantly greater symptom reduction for groups receiving TF-CBT than for comparison groups; comparison of TF-CBT with an active handling group yielded medium result sizes (25,26), whereas comparison with a wait-list control group yielded large effect sizes (xi). Regarding sexual behavior problems, the two studies that included this measure found pregnant decreases in sexual behavior problems in the TF-CBT group over fourth dimension (24,33). However, when the TF-CBT group was compared with an active control group, no meaning difference between the conditions was found, although a medium result emerged 12 months later on treatment in one written report (24).
Parenting practices
2 studies examined parenting behaviors and found significant improvements over time (25,26). TF-CBT was significantly more than effective in increasing effective parenting practices (with medium upshot sizes), compared with active control groups (that is, child-centered therapy and child-only treatment).
Individual treatment components
Several studies examined the effectiveness of specific handling components (37,38). A study by the treatment developers investigated treatment length (eight versus 16 sessions) and the inclusion or exclusion of a trauma narrative (38). A second report assessed symptoms at 6 and 12 months afterward treatment (37). Longer treatment was associated with increased improvements in PTSD re-experiencing and avoidance symptoms, but it was not related to viii other outcomes (38). Compared with handling without a narrative, inclusion of a narrative was associated with larger decreases in children's abuse-related fear and parents' corruption-specific distress; exclusion of a narrative was associated with larger decreases in behavior issues, perchance because of the increased amount of time focused on parent grooming rather than the narrative (38). Gains were sustained at the six- and 12-calendar month follow-upwardly, but the differences between weather condition (longer or shorter treatment and inclusion or exclusion of a narrative) were no longer meaning (37).
Retentivity
Several studies had a low retention rate in the TF-CBT group. For example, a study published in 2011 involving children exposed to interpersonal violence had a retentivity charge per unit of 67% (thirteen), which indicates a relatively high level of dropout. Other agile treatments for PTSD showed similar findings (35). In a field trial in the aftermath of Hurricane Katrina of clinic-based TF-CBT compared with school-based Cognitive Behavioral Intervention for Trauma in Schools, participants randomly assigned to TF-CBT were much less likely to attend their intake or complete handling than those receiving the more easily accessible school-based handling, suggesting that accessibility may be an important factor in treatment retention (fourteen). Some other study plant significant individual differences betwixt completers and noncompleters, with the attrition group beingness older and exposed to more traumas (29).
Conclusions
The treatment of trauma-related symptoms amid children and adolescents is an important component of the service array in a mod mental health and addiction treatment system. TF-CBT, as developed by Cohen, Mannarino, and Deblinger (1), has received attending considering of its applicability to diverse trauma types, growing bear witness base, and agile dissemination, which includes Web-based grooming. The purpose of this review was to examine the evidence associated with TF-CBT across trauma types, symptom presentation, and specific population characteristics. The results indicate a high level of show for TF-CBT for many types of trauma and some symptoms. However, this trunk of bear witness is not fully consistent beyond studies, and only three of the ten RCTs we plant were fully independent from the developers of this treatment approach.
The level of bear witness varied beyond four result measures: the master outcome of reduction in PTSD symptoms and the secondary outcomes of improvement in depressive symptoms, general and sexual beliefs bug, and parenting practices of the nonoffending parent (run across Table 4). The evidence is as well limited for highly vulnerable populations, such as for children at high gamble of suicidal or violent behavior; those with developmental disability, psychosis, or substance utilise; and parents or caregivers with psychosis or substance utilise disorders.
Table iv
Summary of show for the effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)
| Evidence for the effectiveness of Trauma-Focused Cerebral-Behavioral Therapy (TF-CBT): moderate to high |
|---|
| Compared with command conditions, TF-CBT demonstrates mixed but overall positive evidence for the following outcomes: |
| Posttraumatic stress disorder (PTSD) symptoms: high |
|
| Depressive symptoms: moderate |
|
| Behavior problems and sexual beliefs issues: moderate |
|
| Parenting practices for a nonoffending parent: moderate |
|
Acknowledgments
The authors acknowledge the valuable contributions of Suzanne Fields and Kevin Malone from the Substance Corruption and Mental Wellness Services Assistants; John O'Brien from the Centers for Medicare & Medicaid Services; Garrett Moran from Westat; and John Easterday, Linda Lee, Rosanna Coffey, and Tami Marker from Truven Health Analytics. The views expressed in this commodity are those of the authors and do not necessarily represent the views of the Substance Abuse and Mental Health Services Administration.
Sources of Funding
Development of the Assessing the Evidence Base serial was supported past Substance Abuse and Mental Health Services Administration contracts (HHSS283200700029I/HHSS28342002T, HHSS283200700006I; HHSS28342002T; HHSS28342003T, HSS2832007000171; HHSS28300001T) from 2010 through 2013. Preparation of the manuscript conducted by Lisa Jobe-Shields was supported by NIH Training Grant T32 {"type":"entrez-nucleotide","attrs":{"text":"MH018869","term_id":"1562690469","term_text":"MH018869"}}MH018869.
Footnotes
Disclosures of Conflicts of Involvement
There are no conflicts of interest for whatsoever author.
Contributor Information
Michael A. Ramirez de Arellano, Mental Health Disparities and Diversity Program, National Criminal offence Victims Enquiry and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical Academy of South Carolina, Charleston, SC, ude.csum@amleraed.
D. Russell Lyman, Senior Associate, DMA Health Strategies, ix Meriam Street, Suite 4, Lexington, MA 02420-5312, Phone: 781-863-8003, Fax: 781-863-1519, moc.htlaehamd@lssur.
Lisa Jobe-Shields, National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, ude.csum@iehseboj.
Preethy George, Westat, Rockville, Dr., moc.tatsew@egroegyhteerp.
Richard H. Dougherty, DMA Wellness Strategies, Lexington, MA, moc.htlaehamd@dkcid.
Allen Due south. Daniels, Westat, Cincinnati, OH, moc.liamg@sleinadsnella.
Sushmita Shoma Ghose, Westat, Appleton, WI, moc.tatsew@esohgamohs.
Larke Huang, Office of Behavioral Health Equity, Substance Abuse and Mental Health Services Administration, Rockville, Physician, vog.shh.ashmas@gnauh.ekraL.
Miriam E. Delphin-Rittmon, Function of Policy, Planning, and Innovation, Substance Abuse and Mental Health Services Administration, Rockville, MD, vog.shh.ashmas@nomttiR-nihpleD.mairiM.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396183/
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