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Key overview details

Classification
  • Targeted
Mental Wellbeing Need
  • Supporting Behavioural Challenges
  • Anger/Aggression
  • Promoting Emotional Wellbeing
  • Anxiety / Worry / Stress
  • Depression/Low Mood
  • Emotion Regulation / Emotional literacy
  • Self Esteem / Resilience
  • Adjustment to life events (including separation or loss)
  • Trauma
Target Age
  • Preschool: 3 to 5 years
  • Primary school: 6 to 12 years
  • Adolescents: 13 to 18 years
Provision
  • Show only programmes known to have been implemented in Scotland
Usability Rating
4
Supports Rating
3
Evidence Rating
4

Evidence

4

Fit

Capacity

Supports

3

Usability

4

Need

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Trauma-Focused Cognitive Behavioural Therapy (Trauma Focused CBT)

Summary

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is a therapeutic intervention designed to help families with children/ adolescents (aged 3-18 years) who are showing trauma related symptoms in the aftermath of a traumatic experience (e.g. threatened death, serious injury, parental divorce, natural and man-made disasters, emotional/physical/sexual abuse or neglect). Trauma-Focused-CBT (TF-CBT) is also designed to help children/adolescents who are experiencing traumatic grief, and who have developed trauma related symptoms (that interfere with typical grief responses) and complicated/ maladaptive grief responses.

This individualised intervention is delivered over 8-25 sessions (typically over 12-15 sessions). Sessions are mostly delivered to non-offending parents and children separately over 25-40 minutes. Sessions are delivered in three phases; 1) stabilisation and skill-building phase; 2) trauma narration and processing phase; 3) integration and consolidation. Within these three programme phases, TF-CBT core programme components, summarised by the acronym PRACTICE, are delivered. PRACTICE represents P-Psychoeducation and parenting skills, R- Relaxation, A- Affect modulation, C- Cognitive processing, T- Trauma narration and processing, I- In vivo Mastery, C- Conjoint child-parent sessions, and E- Enhancing safety.

Website: https://tfcbt.org/

Usability - Rating: 4

Core Components

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is an individualised therapeutic intervention designed to help families with children/ adolescents (aged 3-18 years) who are showing trauma related symptoms in the aftermath of a traumatic experience (e.g. threatened death, serious injury, parental divorce, natural and man-made disasters, emotional/physical/ sexual abuse or neglect). TF-CBT does not include offending parents in cases of trauma that are caused by the parent. TF-CBT is also designed to help children/adolescents who are experiencing traumatic grief, and who have developed trauma related symptoms (that interfere with typical grief responses) and complicated/ maladaptive grief responses. TF-CBT is therefore used to address child/adolescent Post Traumatic Stress Disorder (PTSD) symptoms, anxiety, depression, emotional and behavioural difficulties that are associated with trauma and traumatic grief. The programme also aims to address parent’s distress about the child’s trauma, enhance parenting skills, and improve parent-child interactions.

An initial assessment is carried out to identify whether the child is experiencing symptoms of distress associated with traumatic exposure or traumatic grief. The assessment is also used by practitioners to tailor the intervention to individual needs. Summary findings of the initial assessment and intended treatment plan are provided to parents (and child when appropriate), after which the TF-CBT components are delivered.

TF-CBT sessions are typically delivered in three equally proportioned phases; 1) Stabilisation and skill-building phase: This first phase is typically delivered in 4-5 sessions. It focuses on trauma related education and developing skills needed to manage triggers/ trauma reminders; 2) Trauma narration and processing phase: This middle phase is typically delivered in 4-5 sessions. It involves the gradual elicitation and communication of details of child’s traumatic memories; 3) Integration and consolidation: This final stage is typically delivered in 4-5 sessions. It focuses on lessons learnt with attention to enhancing parent-child trauma associated communication, in-vivo mastery, and safety skills development. The components of these three phases are summarised by the acronym PRACTICE.

P-Psychoeducation and parenting skills

Stabilisation and skill-building phase

R- Relaxation

A- Affect modulation

C- Cognitive processing 

T- Trauma narration and processing

Trauma narration and processing phase

I- In vivo Mastery

C- Conjoint child-parent sessions

Integration and consolidation phase

E- Enhancing safety

The number of TF-CBF sessions delivered can range between 8-25 sessions, but the intervention is typically delivered over 12-15 sessions. Most sessions are delivered to parents and children separately, with each receiving 25-40 minutes individualised sessions. PRACTICE components in both parent and child sessions are delivered in parallel to help parents optimally model the skills and practice the taught skills with their child between sessions. Some joint sessions are also delivered to enhance trauma related communication, general communication, and parental support for the child. 

Informal assessments are carried out to guide the process, and a post-treatment assessment is conducted just before treatment completion.

Fidelity

Fidelity to the TF-CBT model is ensured by adherence to the following measures:

  • Sequential delivery of all PRACTICE components using TF-CBT brief practice checklist. In vivo mastery can be excluded when not clinically indicated.
  • Ensuring all three TF-CBT phases are delivered in appropriate proportion and duration

Modifiable Components

TF-CBT can be tailored to suit family’s needs. This includes an increased number of TF-CBT treatment sessions (up to 25 sessions) in complex trauma cases, and an increased focus on the stabilisation and skill-building phase (up to 8-12 sessions) also for complex trauma cases. In situations where parents’ needs differ from child’s needs, programme flexibility allows therapists to deliver non-parallel components to parent and child. Programme flexibility also permits delivery of the enhancing safety component of the intervention at the initial part of the intervention when clinically appropriate. TF-CBT has been modified for delivery in group format. It is delivered in outpatient clinic settings, schools, community centres, and via telehealth. Programme materials are available in English and Spanish.

Supports - Rating: 3

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) was developed in the USA by Drs. Anthony Mannarino, Judith Cohen and Esther Deblinger. Implementation support for TF-CBT is provided by programme developers and approved trainers. 

Support for Organisation / Practice

Implementation Support

Practitioners receive training and certification to support programme implementation. As part of the certification process, practitioners receive at least nine consultation calls. Consultation helps practitioners identify and overcome programme implementation challenges and barriers, increase fidelity to the programme model, and increase practitioners’ confidence in TF-CBT implementation. TF-CBT programme managers are available to help practitioners verify that their trainer, consultant, and/or supervisor are approved.

To support programme delivery, practitioners can purchase the TF-CBT programme guide. The guide contains detailed information on the programme framework, assessment, and intervention tools, as well as links to supporting resources. Links to games, practitioner training, participant workbooks (children and teens), TF-CBT brief practice checklist, and other supporting resources can also be found on the programme website.

Licence Requirements

Licence requirements for programme delivery not confirmed.

Start-up Costs

The Trauma-Focused CBT (TF-CBT) online self-paced training costs $35, the 3-day virtual training costs $299 (includes course materials), while the 3-day virtual training and twelve consultation calls cost $800. Certification application costs $125, and the TF-CBT certification test costs $125. All costs are charged per practitioner.

Building Staff Competency

Qualifications Required

TF-CBT is typically delivered by therapists and clinicians with a Master’s degree or above in a mental health discipline. Practitioners should also be licenced to practice in their mental health discipline.

Training Requirements

Practitioner training prior to programme delivery is required. Practitioner training includes a 10-hour TF-CBT web-based training and a 3-day live virtual training (via Zoom). Training covers the TF-CBT model and PRACTICE components. Following training, practitioners looking to become TF-CBT certified therapists receive twelve follow-up consultation sessions. These sessions are delivered twice monthly for six months, or once monthly for a year. Participation in at least nine of the twelve sessions is required. As part of the certification process, practitioners are also required to complete three TF-CBT treatment cases, use a minimum of one standardised tool to assess progress with the treatment cases, and pass the TF-CBT certification programme knowledge based test. Train-the-Trainer (TTT) and Train-the-Supervisor (TTS) programmes are available.

Supervision Requirements

Practitioners looking to become TF-CBT certified therapists receive twelve follow-up consultation sessions delivered over six months or one year.

Evidence - Rating: 4

Theory of Change

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is a hybrid approach that combines cognitive behavioural therapy, trauma-sensitive interventions, family therapy, humanistic models, attachment theory and developmental neurobiology. These integrated approaches/ models are used to re-regulate the areas of trauma impact (including cognitive problems, relationship problems, affective problems, family problems, traumatic behaviour problems, and biological problems) which helps address family’s needs in the aftermath of a traumatic experience.     

Preschool: 3 to 5 years - Rating: 4

Research Design & Number of Studies

The best evidence for TF-CBT for children aged 3-5 years old comes from two randomised controlled studies (RCT) conducted in USA in collaboration in programme developers. The first study included 64 children who had experienced a life-threatening traumatic event (e.g. suffered acute single blow trauma, chronic repeated events, or were victims of the Hurricane Katrina) (Scheeringa et al., 2011). They were aged 3-6 years, were majority male (66.2%), and from African American (59.5%), Caucasian (35.1%), and other ethnicities (5.4%). The second study included 67 sexually abused children (Cohen and Mannarino, 1996; 1997). They were aged 3-6 years, were majority female (58%), and from Caucasian (54%), African-American (42%), and other ethnicities (4%).

Outcomes Achieved

Compared to the control group who did not receive the intervention, the following outcomes were observed:

Child Outcomes

  • Significantly reduced PTSD symptoms at post-intervention (Scheeringa et al., 2011)
  • Significantly reduced total behaviour problems and internalising problems at post-intervention (Cohen and Mannarino, 1996)
  • Significantly reduced total behaviour problems, internalising problems and externalising problems observed at 12 months follow-up (Cohen and Mannarino, 1997)

Parent Outcomes

None

Key References

Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011) Trauma Focused Cognitive Behavioral Therapy for posttraumatic stress disorder in three through six year old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52(8), 853-860

Cohen, J. A., & Mannarino, A. P. (1997) A treatment study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36(9), 1228-1235.

Cohen, J. A., & Mannarino, A. P. (1996) A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35(1), 42-50

Primary school: 6 to 12 years - Rating: 4+

Research Design & Number of Studies

The best evidence for TF-CBT in children aged 6-12 years comes from two internal (Cohen et al, 2011; Cohen et al, 2004/ Deblinger et al., 2006) and two external (Goldbeck et al, 2016; Jensen et al, 2014) randomised controlled trials (RCTs). The first was an internal study conducted in USA, and included 229 children/ adolescents aged 8-14 years and their parents/ carers (Cohen et al, 2004; Deblinger et al., 2006). The children/adolescents had sexual abuse-related PTSD, were majority female (79%), and mostly Caucasian (60%). The second was an internal RCT conducted in USA and included 124 children/ adolescents aged 7-14 years and their parents/ carers (Cohen et al, 2011). The children/ adolescents had intimate partner violence (IPV) related PTSD symptoms, 49.2% were male, 50.8% were female, and were mainly of Caucasian (55.6%) or African American (33.1%) ethnicities. The third was an external RCT conducted in Norway, and included 156 young people aged 10-18 years and their parents/ carers (Jensen et al, 2014). The adolescents had PTSD symptoms, were mostly female (79.5%) and Norwegian (73.7%). The fourth study was an external RCT conducted in Germany, and included 159 children/ adolescents aged 7-17 years and their parents/ carers (Goldbeck et al, 2016). The children/adolescents had experienced one or more traumatic event(s), were mostly female (71.7%) and native German (89.9%).

Outcomes Achieved

Compared to the control group who did not receive the intervention, the following outcomes were observed:

Child Outcomes

  • Significantly reduced PTSD symptoms (Goldbeck et al., 2016; Jensen et al., 2014; Cohen et al., 2011; Cohen et al., 2004) and depressive symptoms post- intervention (Goldbeck et al., 2016; Jensen et al, 2014; Cohen et al., 2004)
  • Significantly reduced anxiety (Goldbeck et al., 2016; Cohen et al., 2011), and behaviour problems at post-intervention (Goldbeck et al., 2016; Cohen et al., 2004)
  • Significantly improved cognitive distortions and psychosocial functioning at four months post baseline (Goldbeck et al., 2016)
  • Significantly improved daily functioning at post-intervention (Jensen et al., 2013)
  • Significantly increased interpersonal trust and perceived credibility at post-intervention (Cohen et al., 2004)
  • Significantly reduced self-blame for negative events (Cohen et al., 2004)

Parent Outcomes

  • Significantly reduced depression and abuse-specific distress at post-intervention (Cohen et al., 2004)
  • Significantly increased parental support, parental practices at post-intervention (Cohen et al., 2004)

Key References

Goldbeck, L., Muche, R., Sachser, C., Tutus, D., & Rosner, R. (2016). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents: A Randomized Controlled Trial in Eight German Mental Health Clinics. Psychotherapy and Psychomatics 16, 159-170

Jensen, T. K., Holt, T., Silje, M., Ormhaug, K. E., et al. (2013). A randomized effectiveness study comparing Trauma-Focused Cognitive Behavioral Therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology. 43:3, 356-369

Cohen, J. A., Mannarino, A. P., & Iyengar, S. (2011). Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: A randomized controlled trial. Archives of Pediatrics & Adolescent Medicine, 165(1), 16-21.

Deblinger, E., Mannarino, A. P., Cohen, J. A. & Steer, R. A. (2006). Follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related PTSD symptoms: Examining predictors of treatment response. Journal of the American Academy of Child & Adolescent Psychiatry, 45, 12

Cohen, J., Deblinger, E., Mannarino, A. & R. Steer (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 393-402.

 

Adolescents: 13 to 18 years - Rating: 4+

Research Design & Number of Studies

Evidence outcomes for the age range 13-18 years are the same as for the 6-12 years evidence above.

Fit

Values

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is an individualised therapeutic intervention designed to help families with children and adolescents (aged 3-18 years) who are showing trauma related symptoms or are experiencing traumatic grief. TF-CBT applies a hybrid approach that combines several approaches/ models (including cognitive behavioural therapy, trauma-sensitive interventions, family therapy, humanistic models, attachment theory and developmental neurobiology) that aim to re-regulate the domains of trauma impact. This intervention is delivered to children/ adolescents and their non-offending parent(s).

  • Does this approach align with the key values of your organisation?

Priorities

TF-CBT is designed to address child/adolescent PTSD symptoms, anxiety, depression, emotional and behavioural difficulties that are associated with trauma and traumatic grief. The programme also aims to address parent’s distress about the child’s trauma, enhance parenting skills, and improve parent-child (general and trauma related) communications.

  • Is an individualised targeted intervention for families who child is experiencing traumatic grief or trauma symptoms a priority for your service?

Existing Initiatives

  • Does your organisation have existing programmes designed to help families with children/ adolescents who are showing symptoms associated with trauma or traumatic grief?
  • Are there components addressed by TF-CBT that are not met by existing programmes?
  • Are the existing initiatives effective?
  • Do existing initiatives fit your current and anticipated future requirements?
Capacity

Workforce

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is typically delivered by therapists and clinicians with a Master’s degree (or above) in a mental health discipline, and a licence to practice in their mental health discipline. Practitioner training prior to programme delivery is required. This involves a 10-hour TF-CBT web-based training, and a 3-day live virtual training (via Zoom). Practitioners can become TF-CBT certified therapists after completing the certification process. The intervention is typically delivered to families over 12-15 sessions.

  • Does your organisation have qualified practitioners who are available and interested in learning and delivering this programme?
  • Can your organisation support the time commitment required for practitioner training and programme delivery?
  • Will your service support practitioner certification?

Technology Support

Practitioner training and certification involves web-based training, live virtual training (via Zoom), follow-up consultation calls (over 6 or 12 months), and an online certification knowledge based test.

  • Does your organisation have technology to support practitioner training and certification?

Administrative Support

TF-CBT can be delivered in outpatient clinic settings, schools, community centres, and via telehealth.

  • In what setting will the programme be delivered?
  • Does your organisation have a venue (within this setting) to run programme sessions?
  • Does your organisation have administrative capacity and systems to support programme delivery?

Financial Support

TF-CBT web-based training costs $35, the 3-day virtual training costs $299 (includes course materials), while the 3-day virtual training and twelve consultation calls cost $800. Certification application costs $125, and the TF-CBT certification test costs $125. All costs are charged per practitioner.

  • How many practitioners will receive training to deliver TF-CBT?
  • Is practitioner certification desirable to your organisation?
  • Can practitioner training and certification (if desired) be financially supported?
  • How many families will the programme be delivered to in the first year? Can this be financially supported?
Need

Comparable Population

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is an individualised therapeutic intervention designed to help families with children and adolescents (aged 3-18 years) who are showing trauma related symptoms or are experiencing traumatic grief. Evidence of effectiveness with children and adolescents come from studies that included males and females who were African American, Caucasian, or from other ethnicities. All participants had experienced one or more traumatic event.

  • Is this comparable to the population your organisation would like to serve?

Desired Outcome

TF-CBT is designed to address child/adolescent PTSD symptoms, anxiety, depression, emotional and behavioural difficulties that are associated with trauma and traumatic grief. The programme also aims to address parent’s distress about the child’s trauma, enhance parenting skills, and improve parent-child (general and trauma related) communications. Programme delivery with children/adolescents has been associated with significant reductions across several outcomes, including PTSD symptoms, depressive symptoms, anxiety, self-blame, and behaviour problems. TF-CBT is also associated with significant improvements in cognitive distortions, psychosocial functioning, daily functioning, interpersonal trust and perceived credibility.

  • Is reducing PTSD symptoms and distress associated with trauma in children/adolescents a desired outcome for your service?
  • Does your organisation have other initiatives in place that effectively and efficiency address the above outcomes?
Developer Details

Dr. Judith Cohen
jcohen1@wpahs.org
https://tfcbt.org/