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22 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013Trauma-Focused Cognitive Behavioral Therapy (CBT)for Youth in Child WelfareJudith A. Cohen, MD and Anthony Mannarino, PhDPracticeChildren show the negative effects of traumaexperiences in different ways. Let’s take a lookat a couple of case examples that illustrate thispoint. Six year old Maria was sexually abusedby her mother’s boyfriend while her mother,who was addicted to drugs, was unableto protect Maria. Mother was sometimespresent when her boyfriend, Jack, abusedMaria. Maria cries and clings to her fostermother when she sees a man who looks likeJack. (This is an example of responding to atrauma reminder—a person, place, situation,smell, feeling, or something else that remindsthe child of the original trauma experience.)Maria also has nightmares and is afraid togo to sleep alone at night (when Jack oftenabused her). She will only sleep if she isallowed to sleep in her foster mother’s bed.When asked about the abuse, Maria says shedoesn’t want to talk about it because it’s “tooscary.” Foster parents, teachers and mentalhealth professionals readily connect Maria’sproblems with her previous sexual abuse.Robert, 13 years old, also does not want todiscuss his past, which includes a long historyof physical and verbal abuse and neglect,witnessing domestic violence, and bullying atschool. Unlike Maria, Robert denies havingnightmares and being afraid and does notappear to the adults in his life to be negativelyaffected by his past trauma. He has beenremoved from four foster homes due to hisangry, aggressive behavior and refusing tocomply with rules. Typically Robert tells hiscaseworker that the foster parents “disrespect”him; the parents say that Robert is the onebeing disrespectful. In his current fosterhome, as Robert has become more defiant,his foster parents have become increasinglystrict, and are now giving him commandsin loud voices. His foster father has evenphysically restrained him to “teach him who’sthe boss.”. Like Maria, Robert is experiencingtrauma reminders (in his case, loud voices andphysical punishment from parent figures) andtrauma responses (problems regulating hisfeelings, thoughts and behaviors in responseTrauma-focused Cognitive Behavioral Therapy is the most tested EBT fortraumatized youth.to trauma reminders), but the adults in his lifedo not understand this; they see him as a kidwith bad behaviors who needs discipline.Maria, Robert, and thousands of otheryouth in the child welfare system needeffective treatment for their trauma problems.They currently have little chance of receivingsuch treatment because few therapists treatingthese youth learn evidence-based traumafocusedtreatments (EBTs).Figure 1: TF-CBT PRACTICE ComponentsP: PsychoeducationP: Parenting SkillsPRAC:R: Relaxation SkillsCoping Skills PhaseA: Affective Modulation SkillsC: Cognitive Coping SkillsT:Trauma Narrative andProcessing PhaseICE:Treatment Consolidationand Closure Phase(TG: Traumatic Grief Components as needed)T: Trauma Narrative and ProcessingI: In vivo Mastery of Trauma RemindersC: Conjoint Youth-Caregiver SessionsE: Enhancing SafetyEvidence-Based TraumaTreatmentsEvidence-based trauma treatments (EBTs)are trauma treatments that have been testedin scientific studies. The most rigorous kindof study to test a treatment’s effectiveness is arandomized controlled trial (RCT). In a RCTthe treatment being tested (Treatment A) iscompared to another treatment (Treatment B)to see which works best to help traumatizedchildren recover. In RCT studies, children arerandomly assigned (“randomized”) to receiveTreatment A or Treatment B. This is doneto eliminate the possibility of bias. In RCTstudies, both treatments are monitored (e.g.,by listening to audiotaped treatment sessionsor using a fidelity measure) to assure thatchildren are receiving the assigned treatment.Children’s outcomes are evaluated by peoplewho do not know which treatment thechildren have received (“blinded” evaluators).This is an additional step to prevent bias inthe outcome of the study.In order to be considered an EBT,Treatment A must produce significantlybetter outcomes than Treatment B in atleast one RCT study. For trauma-focusedtreatments, these outcomes may includePosttraumatic Stress Disorder (PTSD),externalizing or sexualized behavior problems,anxiety, depressive symptoms, shame, orthe child’s negative beliefs about himself.Other important outcomes may relate to thecaregiver, such as change in positive parentingpractices, caregiver support of the child,or resolving caregiver emotional distress.Outcomes specific to children in childwelfare may include prevention of placementdisruption or running away from the child’scurrent placement.Trauma-Focused CognitiveBehavioral Therapy (TF-CBT)Trauma-focused Cognitive BehavioralTherapy (TF-CBT, Cohen, Mannarino &Deblinger, 2006; www.musc.edu/tfcbt) isthe most tested EBT for traumatized youth.TF-CBT is comprised of several treatmentcomponents, summarized by the acronymPRACTICE. These components are dividedinto three modules or phases as shown inFigure 1: Coping Skills,; Trauma Narrativeand Processing, and Treatment Consolidationand Closure. Typically TF-CBT treatment is12-16 sessions, but for very complex trauma,this treatment may be 25-30 sessions. TF-CBT has been used for many youth in childwelfare and applications for these youth have
CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 23been described (Dorsey & Deblinger, inpress).During each subsequent TF-CBTcomponent youth use coping skills totolerate gradually increasing exposure to theirtrauma reminders, a process called “gradualexposure”. Caregivers (e.g., biological orfoster parents) participate in parallel parentingsessions throughout TF-CBT treatment.However, youth with frequent changes inplacement, youth without caregiver contact,or youth who refuse to allow the caregiverto participate in treatment can also receiveTF-CBT. For these youth, TF-CBT engagesthe youth in the youth-focused componentsof TF-CBT while simultaneously attemptingto create a supportive network from otheravailable adults (www.cdc.gov). If feasible,another supportive adult may eventuallyparticipate in the youth’s TF-CBT treatment.The early coping skills phase consists ofbuilding skills for the youth to use whenconfronted with trauma reminders and touse generally when experiencing regulationdifficulties. These skills are also importantfor the caregiver. Psychoeducation helps thecaregiver to view the youth’s problems asbeing related to his past trauma experiencesrather than simply as “bad” behavior.Parenting skills provide the caregiver withtools to more effectively respond to theyouth’s trauma-related regulation problems.For children like Maria, a step- by-step invivo (in real life) plan will help her masterher fear of sleeping in her own bed. Since thismay take several weeks, the in vivo masterywill begin early in TF-CBT. For youth likeRobert with serious behavioral problems, itmay take 10-12 sessions to achieve reasonablestability and self-regulation (Cohen, Berliner& Mannarino, 2010; Cohen, Mannarino,Kliethermes & Murray, in press).The next phase of TF-CBT is trauma narrativeand processing. During this phasethe youth develops and processes a detaileddescription of his trauma experiences. A youthwho has lived through chronic, multipletraumas may create a narrative focusing on histrauma theme (Cohen, et al, 2012). Creatingand processing the narrative typically takesabout 1/3 of the TF-CBT treatment.After the youth has created and come to a betterunderstanding of these experiences duringsessions with the therapist and the therapisthas shared this narrative with the caregiver inindividual sessions, the youth shares it withthe caregiver in conjoint youth-caregiversessions. With appropriate preparation thesesessions are highly rewarding and validatingsessions for youth and caregivers. Finally,re-establishing a sense of safety for youth inchild welfare is critical. For many youth inchild welfare this is the most critical componentand TF-CBT may begin and end withestablishing trust and safety.TF-CBT Effectivenessfor Youth in Child WelfareA dozen RCT studies have shown the effectivenessof TF-CBT in improving multipleoutcomes (e.g., PTSD, depression, anxiety,behavior problems, youth cognitions, parentingoutcomes) after traumas commonly experiencedby youth in child welfare (e.g., sexualabuse, domestic violence, multiple traumas).Two studies specifically focused on youth inchild welfare. The first study examined youthin care in Illinois, comparing TF-CBT toyouth receiving Systems of Care treatmentas usual (SOC). TF-CBT was significantlysuperior to SOC in improving PTSD symptoms,emotional and behavioral problems asmeasured by the Child and Adolescent Needsand Strengths (CANS) and in preventingplacement disruption and running awayfrom current placement (Weiner, Schneider& Lyons, 2009). The other examined theeffectiveness of TF-CBT with or withoutan additional module for engaging fosterparents. This study found that the engagementstrategy significantly improved fosterparents engagement in their youths’ TF-CBTtreatment but otherwise did not change youthoutcomes, with both groups experiencing significantimprovement after receiving TF-CBT(Dorsey, 2011).For more information about TF-CBT, therapistscan refer to the free TF-CBT trainingresources available at www.musc.edu/tfcbt,www.musc.edu/ctg and www.musc.edu/tfcbtconsult.Information about upcoming TF-CBT training is available at www.musc.edu/tfcbt under “Resources.” The location of over200 TF-CBT trained clinicians in Minnesotais available at www.ambitnetwork.org.Judith Cohen, MD is Medical Directorof the Center for Traumatic Stress inChildren & Adolescents at AlleghenyGeneral Hospital in Pittsburgh PA andProfessor of Psychiatry at the DrexelUniversity College of Medicine. She canbe reached at Jcohen1@wpahs.org.Anthony Mannarino, PhD is Chairman,Department of Psychiatry, and Directorof the Center for Traumatic Stress inChildren and Adolescents at AlleghenyGeneral Hospital, Pittsburgh, PA. Heis also Professor of Psychiatry at theDrexel University College of Medicine.He can be reached at amannari@wpahs.org.Practice
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