See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/260875420

Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents:

Assessing the Evidence

Article in Psychiatric services (Washington, D.C.) · March 2014

DOI: 10.1176/appi.ps.201300255 · Source: PubMed

CITATIONS READS

227 6,604

9 authors, including:

Michael Andrew de Arellano Lisa Jobe-Shields

Medical University of South Carolina University of Richmond
59 PUBLICATIONS 2,511 CITATIONS 35 PUBLICATIONS 1,127 CITATIONS

SEE PROFILE SEE PROFILE

Allen S Daniels
Westat
33 PUBLICATIONS 2,698 CITATIONS

SEE PROFILE

All content following this page was uploaded by Lisa Jobe-Shields on 22 March 2016.

The user has requested enhancement of the downloaded file.

Assessing the Evidence Base Series

Trauma-Focused Cognitive-Behavioral
Therapy for Children and Adolescents:
Assessing the Evidence
Michael A. Ramirez de Arellano, Ph.D. Allen S. Daniels, Ed.D.
D. Russell Lyman, Ph.D. Sushmita Shoma Ghose, Ph.D.
Lisa Jobe-Shields, Ph.D. Larke Huang, Ph.D.
Preethy George, Ph.D. Miriam E. Delphin-Rittmon, Ph.D.
Richard H. Dougherty, Ph.D.

T
Objective: Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is rauma-Focused Cognitive-
a conjoint parent-child treatment developed by Cohen, Mannarino, and Behavioral Therapy (TF-CBT)
Deblinger that uses cognitive-behavioral principles and exposure techniques is a manualized intervention for
to prevent and treat posttraumatic stress, depression, and behavioral prob- children who are exposed to trauma
lems. This review defined TF-CBT, differentiated it from other models, and and experience trauma-related men-
assessed the evidence base. Methods: Authors reviewed meta-analyses, tal health symptoms (1). Published
reviews, and individual studies (1995 to 2013). Databases surveyed were estimates indicate that 75% or more
PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Socio- of children and adolescents experience
logical Abstracts, Social Services Abstracts, PILOTS, the ERIC, and the some form of trauma by the age of 18
CINAHL. They chose from three levels of research evidence (high, moder- (2–4). A national survey of children
ate, and low) on the basis of benchmarks for number of studies and quality of aged 2–17 years or their caregivers
their methodology. They also described the evidence of effectiveness. conducted in 2008 found that more
Results: The level of evidence for TF-CBT was rated as high on the basis of than 69% had experienced at least one
ten RCTs, three of which were conducted independently (not by TF-CBT of 33 types of victimization (2). In a
developers). TF-CBT has demonstrated positive outcomes in reducing 2011 update with a nationally repre-
symptoms of posttraumatic stress disorder, although it is less clear whether sentative sample of individuals aged
TF-CBT is effective in reducing behavior problems or symptoms of de- one month to 17 years, the authors re-
pression. Limitations of the studies include concerns about investigator bias ported that in the past year over 57%
and exclusion of vulnerable populations. Conclusions: TF-CBT is a viable of participants had experienced at least
treatment for reducing trauma-related symptoms among some children who one of five types of victimization (phy-
have experienced trauma and their nonoffending caregivers. Based on this sical victimization or bullying, sexual
evidence, TF-CBT should be available as a covered service in health plans. victimization, child maltreatment, dam-
Ongoing research is needed to further identify best practices for TF-CBT in age to property, or witnessing victim-
various settings and with individuals from various racial and ethnic back- ization) (5). The authors interpreted
grounds and with varied trauma histories, symptoms, and stages of in- trends between 2008 and 2011 as
tellectual, social, and emotional development. (Psychiatric Services 65:591– suggesting more stability than change.
602, 2014; doi: 10.1176/appi.ps.201300255) The experience of trauma increases
a child’s risk of posttraumatic stress
Dr. de Arellano and Dr. Jobe-Shields are with the Mental Health Disparities and Diversity symptoms as well as depression and
Program, National Crime Victims Research and Treatment Center, Department of behavior problems (6). The lifetime
Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston. Dr. prevalence rate of diagnosable post-
Lyman and Dr. Dougherty are with DMA Health Strategies, Lexington, Massachusetts. Dr. traumatic stress disorder (PTSD)
George, Dr. Daniels, and Dr. Ghose are with Westat, Rockville, Maryland. Dr. Huang is among children and adolescents is
with the Office of Behavioral Health Equity and Dr. Delphin-Rittmon is with the Office of approximately 5% (7). However, be-
Policy, Planning, and Innovation, both at the Substance Abuse and Mental Health Services
tween 20% and 50% of children
Administration (SAMHSA), Rockville, Maryland. Send correspondence to Dr. Lyman
exposed to trauma experience some
(e-mail: [email protected]). This article is part of a series of literature reviews being
published in Psychiatric Services. The reviews were commissioned by SAMHSA through level of posttraumatic stress symp-
a contract with Truven Health Analytics and were conducted by experts in each topic area, toms (3). The high rates of trauma
who wrote the reviews along with authors from Truven Health Analytics, Westat, DMA among children and the potential
Health Strategies, and SAMHSA. Each article in the series was peer reviewed by a special long-term impact of PTSD and re-
panel of Psychiatric Services reviewers. lated conditions have necessitated the

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5 591
Table 1 limitations and areas that need addi-
tional research. This information will
Description of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)
help payers and policy makers as well
Feature Description as families of children exposed to
trauma make informed decisions about
Service definition TF-CBT is a direct service for children and adolescents and treatment.
their nonoffending caregivers. The approach uses cognitive-
behavioral principles and exposure techniques to address
symptoms of posttraumatic stress following trauma expo- Description of TF-CBT
sure as well as symptoms of depression, behavior problems, TF-CBT is defined in the 2006 treat-
and caregiver difficulties. Key elements of the intervention ment manual Treating Trauma and
include psychoeducation (for example, common reactions Traumatic Grief in Children and
to trauma exposure), coping skills (for example, relaxation, Adolescents (1), although descriptions
identification of feelings, and cognitive coping), gradual
exposure (for example, through imagination or in-vivo ex- of the key cognitive-behavioral compo-
posure), cognitive processing of trauma-related thoughts nents developed by Deblinger, Cohen,
and beliefs, and caregiver involvement (for example, par- and Mannarino were described in ear-
ent training and conjoint child-parent sessions). Treatment lier literature (9). The primary goal of
strategies such as behavior modeling and body safety skills TF-CBT is to reduce PTSD symptoms
training are also used. To accommodate a variety of trauma-
tic experiences, TF-CBT includes general psychoeducational among children and adolescents. TF-
materials with recommendations for tailoring treatment for CBT provides structure for the use of
individuals who have experienced physical abuse, sexual abuse, cognitive-behavioral principles in the
interpersonal violence, or natural disasters. context of two paramount develop-
Service goals To provide a process in which the child and his or her mental considerations: the role of the
nonoffending caregivers learn about trauma and develop
strategies to reduce related stress and modulate and con- caregiver and the developing nature of
trol associated feelings and thoughts; to provide structured a child’s emotion regulation and coping
opportunities for children and adolescents, with the support capabilities. The model originally was
of their nonoffending caregivers, to process the trauma and designed to address PTSD symptoms
learn to cope with stimuli that may lead to traumatic reac- associated with sexual abuse: depres-
tions; to support the child or adolescent in developing and
maintaining a secure sense of safety as well as adaptive sive symptoms, behavior problems (in-
social skills cluding aggression and inappropriate
Populations Children and adolescents who have experienced trauma and sexual behaviors), and unhelpful thoughts
have trauma-related symptoms, including posttraumatic and feelings regarding the abuse, such
stress disorder as cognitive distortions, guilt, and shame.
Settings of service Outpatient facilities, schools, client homes, individual and group
delivery therapy settings (research was limited to outpatient settings) Subsequently the model has been
adapted to treat various types of abuse
and other traumas, such as experiencing
physical or emotional abuse or neglect
development of interventions designed physical abuse, domestic violence, com- and witnessing community or domestic
specifically to meet the needs of chil- munity violence, and natural disasters) violence, traumatic loss, war, or natural
dren and adolescents in the aftermath occurs in a variety of settings that include disasters. TF-CBT was designed to be
of trauma, and this has been an im- university-affiliated and community- delivered in 12–16 sessions of outpatient
portant advancement in the field. based outpatient clinics. treatment, depending on the needs and
The Substance Abuse and Men- This article reviews the literature abilities of the child and caregivers.
tal Health Services Administration on TF-CBT as part of the Assessing The model also addresses the emo-
(SAMHSA) provides a general defi- the Evidence Base Series (see box on tional reactions of nonoffending parents
nition of TF-CBT as a treatment that next page). The objectives were to and caregivers. This population is de-
uses cognitive-behavioral principles, describe the components of TF-CBT, fined as individuals who were not
including exposure techniques, to ad- assess the level of evidence (that is, involved in perpetrating the abuse,
dress the various symptoms that chil- methodological quality) of existing although they may also be experiencing
dren and adolescents may experience studies, and provide a concise sum- PTSD symptoms related to the abuse.
after a traumatic event (Table 1). In mary of its overall effectiveness. The Caregivers who may have been involved
this review, we sought to augment that review included studies that investi- in causing the trauma (such as domestic
definition with specific information gated the use of TF-CBT with chil- violence or physical abuse) but who
about the key components of TF-CBT dren exposed to a range of traumatic have subsequently received successful
as described by its developers (1). TF- events who had experienced trauma- treatment or otherwise been found to
CBT has been widely used and dis- related mental health problems. The be supportive of the child and able to
seminated, including through the review also examined the effective- ensure physical and emotional safety
National Child Traumatic Stress Initia- ness of TF-CBT in addressing specific may also be involved in treatment, de-
tive (8). Treatment of trauma-related symptoms, such as those of PTSD and pending on the needs of the child.
symptoms secondary to a range of trau- depression, and problem behaviors. Over time, TF-CBT has been ap-
matic events (for example, sexual abuse, Finally, the review highlighted the plied to symptoms and behaviors

592 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5
associated with a broad range of trau-
mas, such as other forms of child
maltreatment, domestic violence, com-
About the AEB Series
munity violence, accidents, natural di- The Assessing the Evidence Base (AEB) Series presents literature reviews
sasters, war, and other events involving for 13 commonly used, recovery-focused mental health and substance use
traumatic loss (10–15). Key elements services. Authors evaluated research articles and reviews specific to each
of the intervention are summarized in service that were published from 1995 through 2012 or 2013. Each AEB
Series article presents ratings of the strength of the evidence for the service,
Table 1. They include psychoeducation,
descriptions of service effectiveness, and recommendations for future
gradual exposure, behavior modeling,
implementation and research. The target audience includes state mental
coping strategies, and body safety skills health and substance use program directors and their senior staff, Medicaid
training. Each of these elements may staff, other purchasers of health care services (for example, managed care
be adjusted according to the treat- organizations and commercial insurance), leaders in community health
ment needs of the child and family organizations, providers, consumers and family members, and others
involved. interested in the empirical evidence base for these services. The research
To help children and adolescents was sponsored by the Substance Abuse and Mental Health Services
develop coping skills, treatment pro- Administration to help inform decisions about which services should be
viders teach relaxation skills, affective covered in public and commercially funded plans. Details about the
modulation skills, and cognitive cop- research methodology and bases for the conclusions are included in the
introduction to the AEB Series (27).
ing skills. In addition, TF-CBT uses
exposure principles and cognitive-
restructuring techniques that are spe-
cific to the traumatic experience. include Psychoeducation and Parenting shares the trauma narrative with the
Exposure involves gradually introduc- skills, Relaxation, Affect modulation, caregiver in the session. This allows
ing individuals to reminders of the Cognitive coping and processing, Trauma the caregiver to provide support and
trauma that may be tangible, such as narrative, In-vivo mastery of trauma helps the child correct distortions
places or people, or intangible, such as reminders, Conjoint child-caregiver in his or her understanding of the
specific memories of traumatic events. sessions, and Enhancing safety and abuse, including those related to
The gradual exposure reduces distress development. what happened and who is to blame.
associated with these reminders and A central focus of TF-CBT is to Caregivers often also participate in
decreases trauma-related reactions. Cog- ensure an approach that is develop- the session with the child to enhance
nitive restructuring involves identify- mentally appropriate for the needs of the safety component, so that the
ing inaccurate and unhelpful thoughts children and their caregivers. This child can receive adult support in
and beliefs (for example, self-blame) includes a developmentally sensitive regaining a sense of security and
associated with traumatic events and assessment and fostering of coping well-being (1).
developing more adaptive ways of un- strategies to help children better Clearly, the implementation of this
derstanding and drawing conclusions manage trauma-related distress and model as outlined depends on the pre-
about the trauma and the victim’s emotional reactions. After children sence of a competent, child-focused
reactions to it. learn coping skills, they participate in caregiver at the time of treatment, which
Early versions of TF-CBT tended exposure-based components of treat- cannot be presumed in all families
to place different levels of emphasis ment. An example is the creation of affected by abuse and maltreatment.
on certain components, such as expo- a trauma narrative—a gradual expo- Many children are referred for TF-CBT
sure (16), and various ways of naming sure and cognitive-processing exer- via social services or other agencies that
the approach evolved. Two teams, cise that creates the individual’s story are involved with the child because of
one led by Deblinger and the other by about the abuse. The narrative is concerns about the caregiver’s capac-
Cohen and Mannarino, each created intended to reduce distress and re- ity to provide care and safety, making
a structured manual for their ap- solve maladaptive cognitions associ- full implementation of the caregiver
proach. These two teams then collab- ated with trauma-related memories, components a challenge or impracti-
orated, and in 1997 they integrated which can be affected by develop- cal. For that reason, TF-CBT allows
their similar approaches to treatment. mental factors such as level of cogni- for a number of adaptations to the key
They coauthored a manual on TF- tive and emotional maturity. components.Theparallel-treatmentcom-
CBT, which was published in 2006 A second developmental consider- ponents for caregivers can be provided
(1). In that manual, TF-CBT treat- ation of TF-CBT is incorporating to any available caregiver, such as a
ment components were summarized a nonoffending caregiver into the foster parent or another adult who can
by using the acronym PRACTICE (1), child’s recovery process. In the TF- provide appropriate parenting sup-
and this summary forms the basis of CBT model, parents and children port and is involved in the child’s
our definition for TF-CBT as it ap- participate in parallel treatment ses- daily life. During conjoint sessions, a
pears in the research literature. The sions; for each component of treat- child may choose to share the trauma
eight components (the first of which ment, the therapist spends part of the narrative with an adult whom he or
has two pieces) of PRACTICE are an session with the child and part with she identifies as supportive and trusted
elaboration of the original models and the caregiver. In addition, the child (for example, a grandparent, aunt,

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5 593
trusted teacher, or guidance counselor), provide a different perspective on the Intervention for Trauma in Schools,
regardless of whether this adult is in- TF-CBT literature. which involves school-based preven-
volved in day-to-day care. Sessions are tion and treatment groups with less
also held between the caregiver and the Methods caregiver involvement, and Narrative
therapist throughout treatment, includ- Search strategy Exposure Therapy, which does not
ing prior to conjoint sessions, to ensure We conducted a search for meta- include other core components of
the ability of the caregiver to respond in analyses, research reviews, and indi- TF-CBT.
a caring and supportive manner and vidual studies from 1995 through July
to help prepare the caregiver for the 2013. We searched major databases: Strength of the evidence
sharing of the narrative. PubMed (U.S. National Library of The methodology used to rate the
Medicine and National Institutes of strength of the evidence is described
Five core elements Health), PsycINFO (American Psy- in detail in the introduction to this
of the TF-CBT model chological Association), Applied So- series (27). The research designs of
Although other variations of CBT for cial Sciences Index and Abstracts, the studies that met the inclusion
traumatized children and adolescents Sociological Abstracts, Social Ser- criteria were examined. Three levels
have been reviewed in recent years vices Abstracts, Published International of evidence (high, moderate, and low)
(17,18), this review focused on what Literature on Traumatic Stress, the were used to indicate the overall
we identified as five core elements of Educational Resources Information research quality of the collection of
the current TF-CBT model and the Center, and the Cumulative Index to studies. Ratings were based on pre-
iterations that preceded it. These are Nursing and Allied Health Litera- defined benchmarks that considered
psychoeducation; coping strategies, ture. We also examined publications the number and quality of the studies.
such as relaxation, identification of that had citations pertaining to the If ratings were dissimilar, a consensus
feelings, and cognitive coping; gradual development of the model (1,16,24,26). opinion was reached.
exposure, for example, through imag- We used combinations of the fol- In general, high ratings indicate
ining or in-vivo exposure; cognitive lowing search terms: trauma-focused confidence in the reported outcomes
processing; and caregiver participation, cognitive behavioral therapy, trauma and are based on three or more RCTs
such as parent training and conjoint therapy, treatment of trauma, cogni- with adequate designs or two RCTs
sessions. Although studies that were tive behavioral therapy for trauma, plus two quasi-experimental studies
conducted before publication of the cognitive behavior therapy for sex- with adequate designs. Moderate rat-
most recent treatment manual used ual abuse, cognitive behavior ther- ings indicate that there is some ade-
an earlier version of the manual, all apy for physical abuse, treatment for quate research to judge the service,
the studies reviewed here adhered PTSD, and trauma-focused cogni- although it is possible that future re-
to the five key elements we have tive behavioral therapy for child trau- search could influence reported re-
identified. matic grief. We also used truncated sults. Moderate ratings are based on
We evaluated TF-CBT for the forms of these terms (such as “trau- the following three options: two or
treatment of a broad range of trau- ma”) and alternative spellings and more quasi-experimental studies with
matic events, rather than focusing on punctuation. adequate design; one quasi-experimental
a specific type of trauma, as was the study plus one RCT with adequate
case for two reviews published in 2013 Inclusion and exclusion criteria design; or at least two RCTs with
by the Agency for Healthcare Re- This review was limited to U.S. and some methodological weaknesses or at
search and Quality (AHRQ) (19,20). international studies in English and least three quasi-experimental studies
One of the AHRQ reviews provided included the following types of ar- with some methodological weaknesses.
a thorough comparative effectiveness ticles: randomized controlled trials Low ratings indicate that research for
study of cognitive-behavioral inter- (RCTs), quasi-experimental studies, this service is not adequate to draw
ventions for children and adolescents single-group time-series design stud- evidence-based conclusions. Low rat-
that address trauma other than mal- ies, and review articles, such as meta- ings indicate that studies have non-
treatment or family violence, but it analyses and systematic reviews. We experimental designs, there are no
did not cover the specific TF-CBT included only studies that investigated RCTs, or there is no more than one
model defined here (19). The litera- TF-CBT and its five key elements, as adequately designed quasi-experimental
ture search for this AHRQ review defined above in the description of study.
merged individual and school group the service. We also included review We accounted for other design
models (21,22) and included only articles and meta-analyses that ex- factors that could increase or decrease
one study of what was described amined TF-CBT along with other the evidence rating, such as how the
as “cognitive-behavioral therapy” for cognitive-behavioral approaches (for service, populations, and interven-
trauma among children and adoles- example, articles that reviewed all tions were defined; use of statistical
cents (23). The second AHRQ review cognitive-behavioral approaches, in- methods to account for baseline dif-
targeted maltreatment (20). The authors cluding TF-CBT). We excluded studies ferences between experimental and
reviewed two studies by TF-CBT de- of other cognitive-behavioral–based comparison groups; identification of
velopers that are covered here (24,25) interventions for traumatized chil- moderating or confounding variables
but no others. Thus, in this review, we dren, such as Cognitive Behavioral with appropriate statistical controls;

594 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5
examination of attrition and follow- Five RCTs evaluated TF-CBT exclu- odological concerns are common in
up; use of psychometrically sound mea- sively with sexually abused children the literature and in some cases may
sures; and indications of potential (24–26,29,33), one evaluated children simply be due to omissions in report-
research bias. who had been exposed to war and ing, we included studies that had no
sexual exploitation (11), two evaluated more than two perceived flaws. The
Effectiveness of the service a mixed-trauma sample of participants only exception was one study that
We described the effectiveness of the (29,31), one evaluated children exposed included multiple design flaws but
service—that is, how well the out- to intimate-partner violence (13), and that provided new information on
comes of the studies met the service one evaluated children exposed to treatment of very young children,
goals. We compiled the findings for a natural disaster (Hurricane Katrina) a population rarely included in this
separate outcome measures and study (14). Nine RCTs were administered research (35).
populations, summarized the results, in the individual or conjoint format Review articles. The six review articles
and noted differences across inves- (13,14,24–26,28,29,31,33); and one, included in this review (10,12,18–20,35)
tigations. We considered the quality an intervention with Congolese girls, are described in Table 3. Similarities
of the research design in our con- was administered in a group format and differences in inclusion and ex-
clusions about the strength of the (11). Although we excluded group clusion criteria must be considered
evidence and the effectiveness of the formats such as Cognitive Behavioral when comparing these results with the
service. Based on the evidence, we Intervention for Trauma in Schools results of our review, because none of
also evaluated whether the practice (which was specifically designed for the previous reviews assessed the level
should be considered for inclusion as school-based groups and did not of evidence in exactly the same way
a covered service in public and private fully adhere to the PRACTICE pro- as we have defined our evidentiary
health plans. tocol), we included the study with assessment protocol. The reviews
Congolese girls because clinicians examined the status of evidence for
Results used the TF-CBT manual and ad- similar and overlapping bodies of re-
Level of evidence hered to the PRACTICE approach search, including TF-CBT with mal-
Our literature search resulted in by involving parents in their group treated children only (20); TF-CBT
13 articles reporting on ten RCTs model. for traumas that are not related to
(11,13,14,24–26,28–34) and six re- Overall, the RCTs in our review abuse, maltreatment, or family violence
view articles (10,12,18–20,35). On included strong fidelity procedures (19); and all cognitive-behaviorally ori-
the basis of the criteria set forth in coupled with very similar definitions ented interventions applied to trauma-
this review, the body of research on of the service. In addition, most assess- tized children (10,12,18,35).
TF-CBT meets a high level of evi- ment tools were well validated, in- In contrast to the generally high
dence. Three adequately designed cluding structured clinical interviews rating of evidence found in our re-
RCTs were completed independently (for example, the Kiddie Schedule for view and the reviews described be-
of the TF-CBT developers (11,28,29), Affective Disorders and Schizophre- low, the two reviews conducted by
and seven RCTs and three follow-up nia) and self- and parent-report mea- AHRQ found low levels of evidence
studies completed by or involving the sures (for example, the University of for cognitive-behavioral interventions
developers were otherwise determined California, Los Angeles, PTSD Reac- for trauma. As we have noted, the first
to be of adequate design (13,14,24– tion Index). review focused on the treatment of
26,30–34). We describe the findings of Nonetheless, some studies had children exposed to traumatic events
the publications by their type of re- methodological weaknesses (Table 2). that did not include maltreatment
search design. The primary concern was investiga- (that is, physical, sexual, emotional,
RCTs. Our literature search yielded tor bias. Three RCTs with adequate or psychological abuse and neglect) or
ten RCTs that evaluated TF-CBT designs were implemented by re- family violence (19). The authors iden-
with the five core components as de- searchers who were independent tified only one study as TF-CBT—an
fined, as well as a number of addi- of the developers of the treatment evaluation of a cognitive-behavioral
tional open trials and dismantling (11,28,29). However, the remaining school-based intervention for trauma-
studies that clarified the evidence of seven RCTs were conducted by the exposed adolescents (23). This study
its effectiveness. The brief summary developers of TF-CBT (13,24–26,33) had one major exception to our defini-
here is complemented by additional or included one of the developers in tion of TF-CBT: it was implemented
study details summarized in Table 2. some capacity (14,31). Only two of the primarily in school groups with little
Of the ten RCTs we identified, seven seven RCTs conducted by the devel- caregiver involvement, whereas our
compared TF-CBT with an active opers of the treatment met AHRQ’s model is implemented in individual
control group (13,14,24–26,29,33), strict guidelines for inclusion regard- and conjoint child-caregiver sessions.
and three compared TF-CBT with ing risk of bias (24,25). Second, blind- The second AHRQ review compared
a wait-list control group (11,28,31). ing procedures were not explicitly parenting interventions, trauma-focused
Three additional articles, also listed in reported or were unclear or insuffi- treatments, and enhanced foster care
Table 2, were follow-up studies to an cient in six studies (14,24–26,28,33), approaches that address child mal-
original RCT; they included follow-up and three studies had inactive control treatment (20). After excluding a
periods of one year or longer (30,32,34). groups (11,28,31). Because these meth- number of RCTs on the basis of the

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5 595
 Table 2

596
Randomized controlled trials of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) included in the reviewa

Comparison Selected methodological

Studyb group Sample Findingsc Effect sized strengths and weaknesses

Cohen and Nondirective sup- N=86; mean age, 4.7 years; TF-CBT was related to greater improvement in Medium for sexual behav- There was an active control group. Developers were
Mannarino, portive therapy age range, 2–7; 58% trauma-reactive behaviors and sexual behavior ior at 12-month follow- authors of the study. Blinding procedures were
1996 (24); females; experienced sex- problems, compared with nondirective supportive up insufficient or not properly described. The study
Cohen and ual abuse; 78% completed therapy; the treatment effects endured at 12- excluded children with intellectual or develop-
Mannarino, treatment across groups month follow-up. Significant pre- to posttreatment mental disability, children with psychosis, and
1997 (30) decreases in sexual behavior were noted, but the children whose parents had psychosis or active
differences were not significant when TF-CBT was substance use.
compared with an active control group, except at
12-month follow-up.
Deblinger Therapy as usual N=100; mean age, 9.8 years; TF-CBT was associated with decreases in externalizing Medium for posttrau- There was an active control group. Developers were
et al., age range, 7–13; 83% behaviors, depression, and PTSD symptoms among matic stress symptoms, authors of the study. Blinding procedures were
1996 (26); females; experienced sex- children and with increases in effective parenting depression, and behav- insufficient or not properly described. The study
Deblinger ual abuse; 90% completed skills among mothers compared with those in therapy ior; medium for effec- excluded children with intellectual or develop-
et al., treatment and posttest as usual. tive parenting practices mental disability and children with psychotic
1999 (32) symptoms.
.
Cohen and Nondirective sup- N=82; mean age, 11 years; TF-CBT was associated with greater improvements Medium for depression There was an active control group. Developers were
Mannarino, portive therapy age range 7–15; 69% in depression, anxiety, behavior problems, and authors of the study. Blinding procedures were
1998 (33); females; experienced sex- sexual behavior problems, compared with the insufficient or not properly described. The study
Cohen et al., ual abuse; 60% completed control group. Significant pre- to posttreatment excluded children with intellectual or developmen-
2005 (34) treatment decreases in sexual behavior were noted, but no tal disability, psychotic symptoms, or an impairing
significant differences were found when TF-CBT substance use disorder and those whose parents had
was compared with an active control group. psychosis or active substance use.
King et al., Wait-list control N=36; mean age, 11.4 years; TF-CBT was associated with a significant reduction in Large for posttraumatic Authors were independent of model development.
2000 (28) group; also age range, 5–17; 69% fe- PTSD symptoms of re-experiencing, avoidance, and stress symptoms Blinding procedures were insufficient or not

PSYCHIATRIC SERVICES
compared child- males; experienced sexual hyperarousal; lessened experiences of fear and properly described. There was a wait-list control
only condition abuse; 75% completed anxiety; and improved global functioning, compared group. The study excluded children who were
with full model treatment with the wait-list control group. Caregiver involve- suicidal or extremely violent and those with
ment was not related to treatment outcomes. There intellectual or developmental disability or psy-
was no main effect for behavior problems. TF-CBT chotic symptoms.
participants had a significant pre-post decrease in
depression, but no significant between-groups dif-
ference was noted when TF-CBT was compared with
the control group.
Cohen et al., CCT N=229; mean age, 10.8 TF-CBT was associated with greater improvement in Medium for posttrau- There was an active control group. Developers were
2004 (25) years; age range, 8–14; PTSD symptoms, depression, behavior problems, matic stress symptoms authors of the study. Blinding procedures were
percentage of females not shame, and abuse-related attributions among and for behavior; me- insufficient or not properly described. The study
reported; experienced children and adolescents, compared with CCT. dium for effective par- excluded children with intellectual or develop-
sexual abuse; 88% com- Among caregivers, TF-CBT was associated with enting practices mental disability, psychotic symptoms, or
pleted at least 3 sessions greater improvement in depression, abuse-specific impairing substance use disorder and those
distress, support of the child, and effective whose parents had psychosis or active substance
parenting practices. use.
Continues on next page

' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5

 Table 2
Continued from previous page

Comparison Selected methodological

Studyb group Sample Findingsc Effect sized strengths and weaknesses

Jaycox et al., Cognitive-Behav- N=118; mean age, 11.5 Average PTSD scores improved in both interventions No significant effects There was an active control group. Developers of the

PSYCHIATRIC SERVICES
2010 (14) ioral Interven- years; age range, 9–15.5; from baseline to 10 months: PTSD scores for the TF- were noted compared model were second and third authors. Blinding
tion for Trauma 66% females; experienced CBT group moved to the normal range, and scores for with the control group. procedures were insufficient or not properly de-
in Schools hurricane exposure; 60% the comparison group were in the low clinical range. A scribed. No exclusion criteria were cited.
received some treatment significant pre- to posttreatment decrease in depres-
sion was noted for the TF-CBT group, but the
between-group difference was not significant.
Cohen et al., CCT N=124; mean age, 9.6 years; TF-CBT was associated with significant improvement Medium for posttrau- Developers were authors of the study. There was an
2011 (13) age range 7–14; 51% of children’s PTSD symptoms and anxiety related matic stress symptoms active control group. The study excluded children
females; witnessed inti- to witnessing intimate-partner violence, compared with intellectual or developmental disability or
mate-partner violence; with CCT, including greater decreases in hyper- psychotic symptoms or those whose parents had
60% completed treatment arousal and avoidance symptoms. A significant pre- psychosis.
to posttreatment decrease in depression was noted
for the TF-CBT group, but the between-group
difference was not significant.
Scheeringa Wait-list control N=75; mean age, 5.3 years; Scores on PTSD improved over time for TF-CBT Large for posttraumatic The third author was a developer of the model.
et al., age range, 3–6; 34% group but not for the control group. Effects stress symptoms Blinding procedures were insufficient or not
2011 (31) females; experienced remained when the analysis accounted for type of properly described. There was a wait-list control
mixed trauma; retention trauma (acute injury, witnessed domestic violence, or group. The study excluded children with in-
not reported victim of Hurricane Katrina). A significant pre- to tellectual or developmental disability.

' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5

posttreatment decrease in depression was noted for
the TF-CBT group, but the between-group differ-
ence was not significant.
O’Callaghan Wait-list control N=52; mean age, 16 years; TF-CBT was associated with greater improvements in Large for posttraumatic This study was the first demonstration of TF-CBT
et al., age range, 12–17; 100% symptoms of trauma, depression, and anxiety; stress symptoms within the population of the Democratic Re-
2013 (11) females; experienced war conduct problems; and prosocial behavior, com- public of Congo. Authors were independent of
exposure and sexual vio- pared with the control group. the model development. Blinding procedures
lence; 88% completed were insufficient or not properly described.
follow-up assessments There was a wait-list control group. The study
excluded children who were suicidal or extremely
violent, had intellectual or developmental dis-
ability, or had psychotic symptoms. Treatment
was administered by individuals without a mental
health or medical background.
Jensen et al., Therapy as usual N=156; mean age, 15.1 years; TF-CBT was associated with lower levels of mental Medium for posttrau- Authors were independent of model development.
2013 (29) age range 10–18; 79% health symptoms (PTSD, depression, and general matic stress symp- The study excluded children with psychotic
females; exhibited symp- symptoms) and greater improvements in functional toms and depression symptoms or an impairing substance use
toms of trauma exposure; impairment, compared with the control group. disorder.
78% completed 15 sessions
and posttreatment
assessment
a
Studies are listed in chronological order. Abbreviations: CCT, child-centered therapy; PTSD, posttraumatic stress disorder
b
Multiple publications in the same cell are based on the same RCT.
c
Findings presented were significant at p,.05.
d

597
Medium effect sizes were $.4; large effect sizes were $.75.
likelihood of author bias and other authors concluded that compared with Republic of Congo (11). In addition,
stringent criteria, the authors included control conditions, the “only therapy one study was conducted with chil-
three RCTs of TF-CBT. Two of these for which there was evidence” was dren in Norway (73% Norwegian,
three RCTs are included in our review CBT (including TF-CBT) (35). 10% Asian) (29).
(24,25), along with some RCTs that Cary and McMillen (10) reviewed Table 2 notes the excluded pop-
met our inclusion criteria but were ten RCTs published between 1990 ulations for studies that reported this
excluded by AHRQ because they were and 2011 and concluded that the information. Eight studies excluded
of the “wrong population” (13,29,33) evidence for positive outcomes from children with intellectual or develop-
or “wrong intervention” (26). The third cognitive-behavioral therapies for mental disabilities (11,13,24–26,28,33),
RCT reviewed by AHRQ compared trauma (including TF-CBT) was con- nine excluded children with psychot-
group conditions for mothers of sex- sistently high. Six of the studies from ic symptoms (11,13,24–26,28,29,33),
ually abused children but did not this review met our inclusion criteria. three excluded children on the basis
assess TF-CBT for children because The remaining four studies reviewed of an impairing substance use disor-
the children in both groups received by Cary and McMillen focused on in- der (25,29,33), and three excluded
TF-CBT (36); therefore, it is unclear terventions for children and adolescents children who were suicidal or severely
why it was included in the AHRQ that were similar to TF-CBT (for violent (11,26,28). All studies except
review (20), and we chose to exclude it example, Cognitive Behavioral Inter- one, which compared TF-CBT with
from our review. vention for Trauma in Schools) but a school-based intervention (12), re-
One review conducted by the did not meet the criteria of all five key quired the participation of a broadly
Cochrane Collaboration determined components for inclusion in our re- defined nonoffending caregiver. Sev-
that there was a moderate level of view. Furthermore, although those eral studies explicitly excluded parents
evidence for cognitive-behavioral ap- authors excluded studies that did not with psychosis (13,24,25,33) or active
proaches, including TF-CBT, for measure PTSD symptoms, our review substance abuse (24,25,33). Although
sexually abused children (18). The au- included two additional studies that exclusion criteria varied across studies,
thors concluded that although there assessed symptoms other than those the criteria used indicate that the
was relatively consistent overall evi- of PTSD (24,30). findings are limited in their ability to
dence that CBT is effective for this Although Cary and McMillen (10) be generalized to children with in-
population, the body of research was specifically addressed TF-CBT, the tellectual or developmental disabilities
weaker than in some other reviews other reviews drew their conclusions or children and families affected by
because of the high risk of bias on the basis of cognitive-behavioral more serious forms of mental illness.
(primarily due to lack of reporting therapies in general, making it diffi- Studies were also limited to outpatient
on blinding procedures). In evaluat- cult to discern what the conclusions clinics, thus limiting generalizability to
ing TF-CBT together with other would have been had they focused on other settings.
cognitive-behavioral approaches, this TF-CBT alone. Thus the conclusions
Cochrane review provided useful regarding the evidence for TF-CBT Effectiveness of the service
information on cognitive-behavioral reached by reviews of the literature TF-CBT has been associated with
approaches in general, but it con- over the past two decades vary widely, improved outcomes over time and in
founded the evidence in support of not only because of differences in the comparison with control groups, al-
the effectiveness of TF-CBT as a dis- definition of TF-CBT (that is, whether though findings are somewhat incon-
tinct cognitive-behavioral approach. all cognitive-behavioral interventions sistent. As one might expect, larger
The remaining three reviews we for traumatized children and adoles- effect sizes were reported when ex-
identified found that there was a high cents are considered to be TF-CBT) perimental groups were compared
level of evidence for cognitive-behavioral but also because of differences in the with inactive rather than active con-
approaches for traumatized children types of trauma that were targeted and trol groups (11,28). A majority of
and adolescents, including TF-CBT the vulnerable populations that were studies assessed posttraumatic stress
(10,20,35). In a review published in excluded. symptoms and depressive symptoms,
2008, Silverman and colleagues (12) Populations. A number of issues and some studies assessed behavior
compared various psychosocial treat- regarding sample composition and problems, including sexual behavior
ments for children exposed to trauma inclusion or exclusion criteria are problems (24,33) and aggression (11,25,
and included seven studies evaluating important to consider because they 26,28,31). A few studies assessed care-
cognitive-behavioral therapies, includ- affect the generalizability of the giver outcomes (25,26).
ing TF-CBT. This was the only treat- findings. Eight of the ten RCTs in The sections below summarize
ment approach determined to meet this review were conducted in the results from the ten RCTs by targeted
the criteria of a “well-established United States (13,14,24–26,28,31,33), outcome. Effect sizes are based on
treatment.” Another Cochrane Col- and most of the children who partic- comparison of the TF-CBT group
laboration review that was most re- ipated were Caucasian, followed by with the comparison group, unless
cently updated in 2012 examined 14 African American. Less than 10% of otherwise stated. Medium effects
RCTs covering psychological thera- child participants were Hispanic. As were defined as standardized mean
pies for the treatment of PTSD we have noted, one study was con- differences of Cohen’s d $.40 and
among children and adolescents. The ducted with girls from the Democratic large effects were defined as d $.75.

598 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5
Table 3
Review articles evaluating Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) included in the reviewa

Study Focus of review Outcomes assessed Findings

Silverman et al., Review. Psychosocial treatments PTSD symptoms, depression, anxi- TF-CBT met well-established criteria
2008 (12) for children and adolescents ety, behavior problems for methodological rigor. CBT ap-
exposed to traumatic events proaches, including TF-CBT, were
(included 7 studies of CBT, associated with greater improve-
5 specifically of TF-CBT) ments in all outcomes relative to
non-CBT approaches.
Cary and Systematic review. CBT for chil- PTSD symptoms, depression, be- TF-CBT was associated with reducing
McMillen, dren and adolescents who have havior problems symptoms of PTSD (immediately and
2012 (10) survived trauma (included 14 12 months after treatment) as well as
studies of CBT, 6 specifically of reducing depression and problem
TF-CBT) behaviors (immediately but not 12
months after treatment) compared
with the attention control group (a
group that receives the same amount
of attention as the experimental group
but with a placebo approach not con-
sidered to be effective), standard com-
munity care, and wait-list control
conditions.
Gillies et al., 2012 Systematic review. Interventions PTSD symptoms, depression, anxi- “Fair evidence” was cited that CBT
(35) for PTSD among children and ety, adverse effects, dropout (summarized together with TF-CBT)
adolescents (included 5 studies was associated with reduced PTSD
of CBT, 3 specifically of TF- symptoms compared with wait-list,
CBT)b usual care, and other therapies (sup-
portive therapy, nondirective coun-
seling, psychodynamic therapy, and
hypnotherapy).
Macdonald et al., Systematic review. Cognitive-be- PTSD symptoms, depression, anxi- CBT, including TF-CBT, was associated
2012 (18) havioral interventions for chil- ety, behavior problems with reducing symptoms of PTSD and
dren who have been sexually anxiety, although effects were modest.
abused (included 10 studies of CBT may have positive effects for
CBT, 6 specifically of TF-CBT) children who have been sexually
abused, but more study is needed.
Forman-Hoffman Comparative effectiveness review. PTSD symptoms, depression, func- Evidence was low for CBT interventions
et al., 2013 (19) Interventions for traumatic tional impairment, aggression, targeting children exposed to trauma,
stress other than maltreatment psychological difficulties, conduct regardless of whether they were ex-
or family violence (included problems, prosocial behavior periencing symptoms. School-based
one study of CBT in a school treatments with elements of TF-CBT
setting, no studies of TF-CBT) showed promising effects for children
exposed to trauma.
Fraser et al., 2013 Comparative effectiveness review. Well-being (mental and behavioral Authors stated that a strong conclusion
(20) Interventions for children ex- health; caregiver-child relation- in support of any of the therapies,
posed to maltreatment (in- ship; cognitive, language, and including CBT, could not be drawn
cluded 3 studies of CBT, 2 physical development; school- from the studies examined in the
specifically of TF-CBTc) based functioning) and child wel- review.
fare (safety, placement stability,
and permanency)
a
Reviews are listed in chronological order. Abbreviations: CBT, cognitive-behavioral therapy; PTSD, posttraumatic stress disorder
b
“CBT” was used to refer to all psychological treatments for children and adolescents that were based on cognitive-behavioral principles, whether or not
it was cited as TF-CBT. “TF-CBT” was used to refer to treatments including all core components as outlined in the present review.
c
See text for additional information; the third study did not test outcomes of TF-CBT for children because all children across conditions received the
treatment.

Posttraumatic stress. All studies TF-CBT with a wait-list control group based intervention. Two studies sug-
that included an assessment of post- (11,28). In the one study that com- gested that TF-CBT differentially
traumatic stress symptoms reported pared TF-CBT with another cognitive- affects specific symptoms of posttrau-
significant differences between TF- behavioral school-based intervention, matic stress (13,28). Immediately after
CBT and comparison treatments at both treatments were effective in de- treatment, individuals receiving TF-
various posttreatment time points, creasing symptoms (14). In this study, CBT had greater reductions in hyper-
primarily in the medium range of symptoms were (on average) in the arousal and avoidance symptoms than
effect sizes (13,25,26,29). Two studies nonclinical range after TF-CBT and in in re-experiencing trauma-related symp-
that found large effect sizes compared the low-clinical range after the school- toms, compared with a control group.

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5 599
One study also included an assess- Parenting practices. Two studies study found significant individual
ment of functional impairment as a examined parenting behaviors and differences between completers and
result of trauma-related symptoms; found significant improvements over noncompleters, with the attrition group
TF-CBT outperformed therapy as time (25,26). TF-CBT was significantly being older and exposed to more
usual with a medium effect size (29). more effective in increasing effective traumas (29).
Depression. Nine studies included parenting practices (with medium
assessments of depression (11,13, effect sizes), compared with active Conclusions
14,25,26,28,29,31,33). Of five that control groups (that is, child-centered The treatment of trauma-related symp-
reported statistically significant ef- therapy and child-only treatment). toms among children and adolescents
fects of TF-CBT compared with Individual treatment components. is an important component of the
comparison treatment, three had Several studies examined the effec- service array in a modern mental
medium effect sizes (TF-CBT versus tiveness of specific treatment compo- health and addiction treatment sys-
active comparison treatment) (26,29,33), nents (37,38). A study by the treatment tem. TF-CBT, as developed by Cohen,
one had a large effect size (TF-CBT developers investigated treatment Mannarino, and Deblinger (1), has re-
versus wait-list control group) (11), length (eight versus 16 sessions) and ceived attention because of its applica-
and one had a small effect size (TF- the inclusion or exclusion of a trauma bility to various trauma types, growing
CBT versus child-centered therapy) narrative (38). A second study assessed evidence base, and active dissemina-
(25). Four studies did not find TF- symptoms at six and 12 months after tion, which includes Web-based train-
CBT to be significantly more effec- treatment (37). Longer treatment was ing. The purpose of this review was to
tive than a comparison treatment in associated with increased improve- examine the evidence associated with
decreasing depressive symptoms, al- ments in PTSD re-experiencing and TF-CBT across trauma types, symp-
though significant pre-post decreases avoidance symptoms, but it was not tom presentation, and specific popula-
in depression were found in the ex- related to eight other outcomes (38). tion characteristics. The results indicate
perimental group (13,14,28,31). Finally, Compared with treatment without a high level of evidence for TF-CBT
one study that compared TF-CBT a narrative, inclusion of a narrative for many types of trauma and some
with Cognitive Behavioral Interven- was associated with larger decreases in symptoms. However, this body of
tion for Trauma in Schools found that children’s abuse-related fear and evidence is not fully consistent across
the school intervention was effective parents’ abuse-specific distress; exclu- studies, and only three of the ten
in decreasing depression, whereas sion of a narrative was associated with RCTs we found were fully indepen-
TF-CBT was not (14). larger decreases in behavior problems, dent from the developers of this
Behavior problems (sexual and possibly because of the increased treatment approach.
other). Seven studies examined co- amount of time focused on parent The level of evidence varied across
occurring behavior problems, such as training rather than the narrative (38). four outcome measures: the primary
aggression and disruptive behavior Gains were sustained at the six- and outcome of reduction in PTSD symp-
(11,24–26,28,31,33); two of these 12-month follow-up, but the differ- toms and the secondary outcomes of
studies included specific measures of ences between conditions (longer or improvement in depressive symp-
sexual behavior problems (24,33). shorter treatment and inclusion or toms, general and sexual behavior
Regarding general behavior problems, exclusion of a narrative) were no problems, and parenting practices
two studies did not find significant longer significant (37). of the nonoffending parent (see box
main effects for pre-post treatment Retention. Several studies had a low on next page). The evidence is also
reductions in symptoms (24,28). Three retention rate in the TF-CBT group. limited for highly vulnerable popula-
studies found significantly greater For example, a study published in tions, such as for children at high risk
symptom reduction for groups receiv- 2011 involving children exposed to of suicidal or violent behavior; those
ing TF-CBT than for comparison interpersonal violence had a retention with developmental disability, psycho-
groups; comparison of TF-CBT with rate of 67% (13), which indicates sis, or substance use; and parents or
an active treatment group yielded a relatively high level of dropout. caregivers with psychosis or substance
medium effect sizes (25,26), whereas Other active treatments for PTSD use disorders.
comparison with a wait-list control showed similar findings (35). In a field Compared with active control groups,
group yielded large effect sizes (11). trial in the aftermath of Hurricane TF-CBT groups showed consistent
Regarding sexual behavior problems, Katrina of clinic-based TF-CBT com- pre- to posttreatment decreases in
the two studies that included this pared with school-based Cognitive PTSD symptomatology, and these
measure found significant decreases Behavioral Intervention for Trauma improvements were sustained at
in sexual behavior problems in the TF- in Schools, participants randomly follow-up periods of up to 12 months.
CBT group over time (24,33). How- assigned to TF-CBT were much less The evidence and effectiveness esti-
ever, when the TF-CBT group was likely to attend their intake or com- mates were more moderate and mixed
compared with an active control group, plete treatment than those receiving regarding symptoms of depression
no significant difference between the the more easily accessible school- (especially when TF-CBT was com-
conditions was found, although a me- based treatment, suggesting that ac- pared with other cognitive-behavioral
dium effect emerged 12 months after cessibility may be an important factor treatments), behavior problems, and
treatment in one study (24). in treatment retention (14). Another parenting practices.

600 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5
 Sample sizes in most studies were
relatively small, so further research with
larger sample sizes would strengthen
Evidence for the effectiveness of
TF-CBT evidence. In addition, stud- Trauma-Focused Cognitive-Behavioral
ies investigating other factors that may Therapy (TF-CBT): moderate to high
influence the effectiveness of TF- Compared with control conditions, TF-CBT demonstrates mixed but overall
CBT—such as developmental stage, positive evidence for the following outcomes:
trauma type, and level of caregiver Posttraumatic stress disorder (PTSD) symptoms: high
engagement—should help advance • Robust findings indicate that TF-CBT reduces PTSD symptoms over time,
compared with control groups and other types of cognitive-behavioral
knowledge about the best way to treat interventions. This is the primary goal of the intervention.
children who have experienced trauma. Depressive symptoms: moderate
For example, future work may identify • Most studies found that TF-CBT reduced symptoms of depression, compared
additional steps in the TF-CBT ap- with control groups. However, several studies found significant pre- to
proach that could increase its ef- posttreatment reductions in depression in the experimental group but not in
the control groups.
fectiveness, particularly in addressing Behavior problems and sexual behavior problems: moderate
symptoms of depression as well as • In most studies, TF-CBT reduced general and sexual behavior problems over
co-occurring behavior problems. Fur- time; however, TF-CBT did not consistently show greater reductions compared
ther research addressing engagement with control groups.
and retention strategies should be Parenting practices for a nonoffending parent: moderate
• Two studies showed that TF-CBT increased effective parenting practices and
helpful, and one study suggests that improved the parent’s emotional reactions to the child’s abuse over time and, in
intervention in the aftermath of di- one study, compared with the control group at 12-month follow-up. Although the
saster may merit special attention in number of supporting studies is small, no other studies showed negative findings.
this regard (14).
Future research is also needed to
assess the applicability of TF-CBT to treatment outcomes is lacking. Fur- sis for determining whether studies are
more vulnerable populations affected thermore, although modifications have assessing TF-CBT as it has been
by trauma, including adolescents ex- been made to TF-CBT for use with defined by its developers.
periencing developmental disabilities, different ethnic minority groups (for The level of trauma and PTSD
substance use problems, homeless- example, Native American and La- symptoms experienced by U.S. chil-
ness, parental mental illness or sub- tino) and in different countries such dren and adolescents of all ages calls
stance dependence, juvenile justice as Zambia, Cambodia, and Pakistan, for further advancement in treat-
involvement, or psychotic symptoms. these modified treatments have not ment and empirical research. There
It will also be important to examine been evaluated rigorously; how- is room for improvement in the
the effectiveness of TF-CBT ap- ever, recent findings with girls evidence base for TF-CBT, espe-
proaches that have been adapted from the Democratic Republic of cially for highly vulnerable children
for relational work with very young Congo (11) suggest that this is an and their families, who are likely to
children and their parents. Open important direction for future re- have a high degree of need. In the
trials have been conducted regard- search. Research examining TF-CBT meantime, there is sufficient evi-
ing the adaptation of TF-CBT for across well-defined subgroups is also dence to include TF-CBT as a cov-
childhood traumatic grief (15,39), needed. ered service in the current behavioral
and the results are promising; how- Despite these limitations and the health care system.
ever, this area will benefit from more need for future research to refine and
rigorous evaluation in the future. establish the strongest possible evi-
Because much of the research on dence base for best practices, TF-CBT Acknowledgments and disclosures
TF-CBT was conducted by those who presents a viable treatment approach Development of the Assessing the Evidence
developed the intervention, addi- for children, adolescents, and families Base Series was supported by contracts
tional fully independent studies are who have experienced trauma. Com- HHSS283200700029I/HHSS28342002T,
needed to augment the three com- munities, policy makers, and other HHSS283200700006I/HHSS28342003T,
and HHSS2832007000171/HHSS28300001T
pletely independent RCTs that were stakeholders should consider TF- from 2010 through 2013 from the Substance
identified for this review (11,28,29). CBT when making decisions regarding Abuse and Mental Health Services Adminis-
Future research should also further the implementation of evidence-based tration (SAMHSA).The authors acknowledge
investigate the impact of treatment treatment for these populations. When the valuable contributions of Suzanne Fields,
M.S.W., and Kevin Malone, B.A., from
setting (for example, school or clinic) assessing which treatment models to SAMHSA; John O’Brien, M.A., from the
on outcomes, as well as the effects of fund, payers should ensure that all treat- Centers for Medicare & Medicaid Services;
barriers to treatment and to caregiver ments maintain fidelity to an evidence- Garrett Moran, Ph.D., from Westat; and John
Easterday, Ph.D., Linda Lee, Ph.D., Rosanna
involvement. Although several studies based model. The five core elements Coffey, Ph.D., and Tami Mark, Ph.D., from
included diverse samples from the we have identified—psychoeducation, Truven Health Analytics. The views expressed in
United States or international loca- coping strategies, gradual exposure, this article are those of the authors and do not
tions (11,29), close examination of cognitive processing, and caregiver necessarily represent the views of SAMHSA.
racial-ethnic and sex differences in participation—should form a good ba- The authors report no competing interests.

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5 601
References trial. Archives of Pediatrics and Adolescent stress symptoms: initial treatment outcome
Medicine 165:16–21, 2011 findings. Child Maltreatment 1:310–321,
1. Cohen JA, Mannarino AP, Deblinger E: 1996
Treating Trauma and Traumatic Grief in 14. Jaycox LH, Cohen JA, Mannarino AP, et al:
Children and Adolescents. New York, Children’s mental health care following 27. Dougherty RH, Lyman DR, George P,
Guilford, 2006 Hurricane Katrina: a field trial of trauma- et al: Assessing the evidence base for be-
focused psychotherapies. Journal of Trau- havioral health services: introduction to the
2. Finkelhor D, Ormrod RK, Turner HA: matic Stress 23:223–231, 2010 series. Psychiatric Services 65:11–15, 2014
Lifetime assessment of poly-victimization
in a national sample of children and youth. 15. Cohen JA, Mannarino AP, Staron VR: A 28. King NJ, Tonge BJ, Mullen P, et al:
Child Abuse and Neglect 33:403–411, pilot study of modified cognitive-behavioral Treating sexually abused children with
2009 therapy for childhood traumatic grief (CBT- posttraumatic stress symptoms: a random-
CTG). Journal of the American Academy of ized clinical trial. Journal of the American
3. Copeland WE, Keeler G, Angold A, et al: Child and Adolescent Psychiatry 45:1465– Academy of Child and Adolescent Psychi-
Traumatic events and posttraumatic stress 1473, 2006 atry 39:1347–1355, 2000
in childhood. Archives of General Psychi-
atry 64:577–584, 2007 16. Deblinger E, Hemn AH: Treating Sexually 29. Jensen TK, Holt T, Ormhaug SM, et al: A
Abused Children and Their Nonoffending randomized effectiveness study comparing
4. Kilpatrick DG, Ruggiero KJ, Acierno R, Parents: A Cognitive Behavioral Approach. trauma-focused cognitive behavioral ther-
et al: Violence and risk of PTSD, major Thousand Oaks, Calif, Sage, 1996 apy with therapy as usual for youth. Journal
depression, substance abuse/dependence, of Clinical Child and Adolescent Psychology,
and comorbidity: results from the National 17. Bisson J, Andrew M: Psychological treat- 2013; doi 10.1080/15374416.2013.822307
Survey of Adolescents. Journal of Consul- ment of post-traumatic stress disorder
ting and Clinical Psychology 71:692–700, (PTSD). Cochrane Database of Systematic 30. Cohen JA, Mannarino AP: A treatment
2003 Reviews 3:CD003388, 2007 study for sexually abused preschool children:
outcome during a one-year follow-up. Jour-
5. Finkelhor D, Turner HA, Shattuck A, et al: 18. Macdonald G, Higgins JP, Ramchandani P, nal of the American Academy of Child and
Violence, crime, and abuse exposure in et al: Cognitive-behavioural interventions Adolescent Psychiatry 36:1228–1235, 1997
a national sample of children and youth: an for children who have been sexually
update. JAMA Pediatrics 167:614–621, abused. Cochrane Database of Systematic 31. Scheeringa MS, Weems CF, Cohen JA,
2013 Reviews 5:CD001930, 2012 et al: Trauma-focused cognitive-behavioral
therapy for posttraumatic stress disorder in
6. Cohen JA, Mannarino AP: Predictors of 19. Forman-Hoffman V, Knauer S, McKeeman three- through six-year-old children: a ran-
treatment outcome in sexually abused J, et al: Child and Adolescent Exposure to domized clinical trial. Journal of Child
children. Child Abuse and Neglect 24: Trauma: Comparative Effectiveness of In- Psychology and Psychiatry, and Allied
983–994, 2000 terventions Addressing Trauma Other Than Disciplines 52:853–860, 2011
Maltreatment or Family Violence. Com-
7. Merikangas KR, He JP, Burstein M, et al: parative Effectiveness Review no 107. 32. Deblinger E, Steer RA, Lippmann J: Two-
Lifetime prevalence of mental disorders in AHRQ pub no 13-EHC054-EF. Rockville, year follow-up study of cognitive behavioral
US adolescents: results from the National Md, Agency for Healthcare Research and therapy for sexually abused children suffer-
Comorbidity Survey Replication—Adolescent Quality, 2013 ing post-traumatic stress symptoms. Child
Supplement (NCS-A). Journal of the American Abuse and Neglect 23:1371–1378, 1999
Academy of Child and Adolescent Psychi- 20. Fraser JG, Lloyd SW, Murphy RA, et al:
atry 49:980–989, 2010 Child Exposure to Trauma: Comparative 33. Cohen JA, Mannarino AP: Interventions
Effectiveness of Interventions Addressing for sexually abused children: initial treat-
8. TF-CBT: Trauma-Focused Cognitive Be- Maltreatment. Comparative Effectiveness ment outcome findings. Child Maltreat-
havioral Therapy. National Child Trau- Review no 89. AHRQ pub no 13-EHC002- ment 3:17–26, 1998
matic Stress Network, 2012. Available at EF. Rockville, Md, Agency for Healthcare
www.nctsnet.org/sites/default/files/assets/ Research and Quality, 2013 34. Cohen JA, Mannarino AP, Knudsen K:
pdfs/tfcbt_general.pdf Treating sexually abused children: 1 year
21. Goenjian AK, Karayan I, Pynoos RS, et al: follow-up of a randomized controlled trial.
9. Deblinger E, Cohen J, Mannarino A: Child Outcome of psychotherapy among early Child Abuse and Neglect 29:135–145,
and Parent Trauma-Focused Cognitive adolescents after trauma. American Journal 2005
Behavioral Therapy Treatment Manual. of Psychiatry 154:536–542, 1997
Pittsburgh, Pa, Allegheny General Hospital 35. Gillies D, Taylor F, Gray C, et al: Psy-
Center for Traumatic Stress in Children 22. Goenjian AK, Walling D, Steinberg AM, chological therapies for the treatment of
and Adolescents, 2003 et al: A prospective study of posttraumatic post-traumatic stress disorder in children
stress and depressive reactions among and adolescents. Cochrane Database of
10. Cary CE, McMillen JC: The data behind treated and untreated adolescents 5 years Systematic Reviews 12:CD006726, 2012
the dissemination: a systematic review of after a catastrophic disaster. American
trauma-focused cognitive behavioral ther- Journal of Psychiatry 162:2302–2308, 2005 36. Deblinger E, Stauffer LB, Steer RA:
apy for use with children and youth. Chil- Comparative efficacies of supportive and
dren and Youth Services Review 34: 23. Smith P, Yule W, Perrin S, et al: Cognitive- cognitive behavioral group therapies for
748–757, 2012 behavioral therapy for PTSD in children young children who have been sexually
and adolescents: a preliminary randomized abused and their nonoffending mothers.
11. O’Callaghan P, McMullen J, Shannon C, controlled trial. Journal of the American Child Maltreatment 6:332–343, 2001
et al: A randomized controlled trial of Academy of Child and Adolescent Psychi-
trauma-focused cognitive behavioral ther- atry 46:1051–1061, 2007 37. Mannarino AP, Cohen JA, Deblinger E,
apy for sexually exploited, war-affected et al: Trauma-focused cognitive-behavioral
Congolese girls. Journal of the American 24. Cohen JA, Mannarino AP: A treatment therapy for children: sustained impact of
Academy of Child and Adolescent Psychi- outcome study for sexually abused pre- treatment 6 and 12 months later. Child
atry 52:359–369, 2013 school children: initial findings. Journal of Maltreatment 17:231–241, 2012
the American Academy of Child and Ado-
12. Silverman WK, Ortiz CD, Viswesvaran C, lescent Psychiatry 35:42–50, 1996 38. Deblinger E, Mannarino AP, Cohen JA,
et al: Evidence-based psychosocial treat- et al: Trauma-focused cognitive behavioral
ments for children and adolescents ex- 25. Cohen JA, Deblinger E, Mannarino AP, therapy for children: impact of the trauma
posed to traumatic events. Journal of et al: A multisite, randomized controlled narrative and treatment length. Depression
Clinical Child and Adolescent Psychology trial for children with sexual abuse-related and Anxiety 28:67–75, 2011
37:156–183, 2008 PTSD symptoms. Journal of the American
Academy of Child and Adolescent Psychi- 39. Cohen JA, Mannarino AP, Knudsen K:
13. Cohen JA, Mannarino AP, Iyengar S: atry 43:393–402, 2004 Treating childhood traumatic grief: a pilot
Community treatment of posttraumatic stress study. Journal of the American Academy of
disorder for children exposed to intimate 26. Deblinger E, Lippmann J, Steer R: Sexually Child and Adolescent Psychiatry 43:
partner violence: a randomized controlled abused children suffering posttraumatic 1225–1233, 2004

602 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' May 2014 Vol. 65 No. 5
View publication stats