Trauma-Focused Cognitive Behavioral Therapy The National Child Traumatic Stress Network
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 effect sizes (13,25,26,29). Two studies that found large effect sizes compared TF-CBT with a wait-list control group (11,28). In the one study that compared TF-CBT with another cognitive-behavioral school-based intervention, both treatments were effective in decreasing symptoms (14). In this study, symptoms were (on average) in the nonclinical range after TF-CBT and in the low-clinical range after the school-based intervention. Two studies suggested that TF-CBT differentially affects specific symptoms of posttraumatic stress (13,28).
Treatment Sessions
CBT is typically a short-term intervention (8 to 12 sessions, sometimes up to 25), focusing on one specific issue. The short-term intervention was developed to help children and adolescents who have experienced a traumatic event. Evidence-based treatment for children and adolescents impacted by trauma and their parents or caregivers. Three RCTs with adequate designs were implemented by researchers who were independent of the developers of the treatment (11,28,29). However, the remaining seven RCTs were conducted by the developers of TF-CBT (13,24–26,33) or included one of the developers in some capacity (14,31).
Strength of the evidence
Caregivers often also participate in the session with the child to enhance the safety component, so that the child can receive adult support in regaining a sense of security and well-being (1). Early versions of TF-CBT tended to place different levels of emphasis on certain components, such as exposure (16), and various ways of naming the approach evolved. Two teams, one led by Deblinger and the other by Cohen and Mannarino, each created a structured manual for their approach. These two teams then collaborated, and in 1997 they integrated their similar approaches to treatment.
Five core elements of the TF-CBT model
Only two of the seven RCTs conducted by the developers of the treatment met AHRQ’s strict guidelines for inclusion regarding risk 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 (11,28,31). Because these methodological concerns are common in the literature and in some cases may simply be due to omissions in reporting, we included studies that had no more than two perceived flaws. The only exception was cbt interventions for substance abuse one study that included multiple design flaws but that provided new information on treatment of very young children, a population rarely included in this research (35). TF-CBT is a short-term intervention that generally lasts anywhere from eight to 25 sessions and can take place in an outpatient mental health clinic, group home, community center, hospital, school, or in-home setting. Often, the treatment will begin where the child and non-offending caregiver have separate therapy sessions and advance to engaging in joint sessions.
The therapist spends time with the child individually, the caregiver individually, and the child and caregiver together. 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 outcome measures and study populations, summarized the results, and noted differences across investigations. We considered the quality of the research design in our conclusions about 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 as a covered service in public and private health plans. TF-CBT may not be appropriate for children and adolescents who have significant conduct or other behavioral concerns that were present before the trauma may not receive significant benefit from TF-CBT and may see greater improvement with approaches in which they are first helped to overcome these difficulties.
If people cannot access TF-CBT where they are or would prefer to try something else, other types of therapy may help with trauma. TF-CBT has eight components, including psychoeducation, relaxation techniques, identifying and expressing emotions, and replacing negative thoughts with more helpful ones. The methodology used to rate the strength of the evidence is described in detail in the introduction to this series (27). Three levels of evidence (high, moderate, and low) were used to indicate the overall research quality of the collection of studies.
- The therapist incorporates individual child and parent sessions as well as joint sessions using family therapy principles.
- TF-CBT is effective at improving symptoms of post-traumatic stress disorder (PTSD) and preventing depression and behavioral challenges.
- Regarding sexual behavior problems, the two studies that included this measure found significant decreases in sexual behavior problems in the TF-CBT group over time (24,33).
- In addition, one study was conducted with children in Norway (73% Norwegian, 10% Asian) (29).
- The success of TF-CBT relies heavily on a trusting, genuine therapeutic relationship between therapist, child, and parent.