Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of]

Scientific Rating:
2
Supported by Research Evidence
See scale of 1-5
Child Welfare System Relevance Level:
High
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] has been rated by the CEBC in the area of: Sexual Behavior Problems Treatment (Children).

Target Population: Children (3-12) with a known trauma history who are experiencing sexual behavior problems and significant posttraumatic stress disorder (PTSD) symptoms, whether or not they meet full diagnostic criteria

For children/adolescents ages: 3 – 12

For parents/caregivers of children ages: 3 – 12

Brief Description

TF-CBT is a conjoint child and parent psychotherapy model for children who are experiencing significant emotional and behavioral difficulties related to traumatic life events. It is a components-based hybrid treatment model that incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles. TF-CBT is also rated a “1 – Well-Supported Research Evidence” in the Trauma Treatment - Client-Level Interventions (Child & Adolescent) and Anxiety Treatment (Child & Adolescent) topic areas for children with a known trauma history who are experiencing significant Post-Traumatic Stress Disorder (PTSD) symptoms, whether or not they meet full diagnostic criteria. The children can also be experiencing depression, anxiety, and/or shame. In addition, children experiencing Childhood Traumatic Grief can also benefit from the treatment. Please click here to go to that entry.


Program Goals:

The overall goal of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is:

  • Address symptoms resulting from a specific traumatic experience or experiences which includes:
    • Improving child PTSD, depressive and anxiety symptoms
    • Improving child externalizing behavior problems (including sexual behavior problems if related to trauma)
    • Improving parenting skills and parental support of the child, and reducing parental distress
    • Enhancing parent-child communication, attachment, and ability to maintain safety
    • Improving child's adaptive functioning
    • Reducing shame and embarrassment related to the traumatic experiences

Essential Components

The essential components of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) include:

  • PRACTICE:
    • Psycho-education and parenting skills
    • Relaxation techniques: Focused breathing, progressive muscle relaxation, and teaching the child to control their thoughts (thought stopping)
    • Affective expression and regulation: To help the child and parent learn to control their emotional reaction to reminders by expanding their emotional vocabulary, enhancing their skills in identification and expression of emotions, and encouraging self-soothing activities
    • Cognitive coping: Through this component, the child learns to understand the relationships between thoughts, feelings and behaviors and think in new and healthier ways
    • Trauma narrative and processing: Gradual exposure exercises including verbal, written and/or symbolic recounting (i.e., utilizing dolls, art, puppets, etc.) of traumatic event(s) so the child learns to be able to discuss the events when they choose in ways that do not produce overwhelming emotions. Following the completion of the narrative, clients are supported in identifying, challenging and correcting cognitive distortions and dysfunctional beliefs.
    • In vivo exposure: Encourage the gradual exposure to innocuous (harmless) trauma reminders in child's environment (e.g., basement, darkness, school, etc.) so the child learns they can control their emotional reactions to things that remind them of the trauma, starting with non-threatening examples of reminders.
    • Conjoint parent/child sessions: Held typically toward the end of the treatment, but maybe initiated earlier when children have significant behavior problems so parents can be coached in the use of behavior management skills. Sessions generally deal with psycho-education, sharing the trauma narrative, anxiety management, and correction of cognitive distortions. The family works to enhance communication and create opportunities for therapeutic discussion regarding the trauma.
    • Enhancing personal safety and future growth: Provide training and education with respect to personal safety skills and healthy sexuality/ interpersonal relationships; encourage the utilization of skills learned in managing future stressors and/or trauma reminders
  • TF-CBT is typically delivered in individual or conjoint therapy, however, it can be delivered in groups of 6 to 10 clients and their caregivers.

Child/Adolescent Services

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] directly provides services to children/adolescents and addresses the following:

  • Feelings of shame, distorted beliefs about self and others, acting out behavior problems (including sexual behavior), and PTSD and related symptoms

Parent/Caregiver Services

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] directly provides services to parents/caregivers and addresses the following:

  • Inappropriate parenting practices and parental trauma-related emotional distress

Delivery Settings

This program is typically conducted in a(n):

  • Birth Family Home
  • Community Agency
  • Community Daily Living Settings
  • Outpatient Clinic
  • Residential Treatment Center

Homework

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] includes a homework component:

Parents are given weekly assignments to practice the treatment components at home, both alone and to reinforce and practice these with their children.

Languages

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] has materials available in languages other than English:

German, Japanese, Korean, Mandarin, Polish, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Private space to conduct sessions
  • Waiting area for children when parents are being seen
  • Therapeutic books and materials

Minimum Provider Qualifications

  • Master's degree and training in the treatment model
  • Experience working with children and families

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contacts:
Training is obtained:

National Conferences; CARES Institute, Allegheny General Hospital and onsite by request

Number of days/hours:
  • Introductory Overview: 1–8 hours
  • Basic Training: 2–3 days
  • Ongoing Phone Consultation (twice monthly for 6-12 months): groups of 5-12 clinicians receive ongoing case consultation to implement TF-CBT for patients in their setting
  • Advanced Training: 1–3 days
Additional Resources:

There currently are additional qualified resources for training:

TF-CBTWeb, a ten-hour basic web-based training free of charge, is available at https://tfcbt.musc.edu/. A free web-based consultation product in implementing TF-CBT is available at http://etl2.library.musc.edu/tf-cbt-consult/ (completion of TF-CBTWeb is required prior to accessing this product). Information about training and consultation is available from the National TF-CBT Therapist Certification Program at https://tfcbt.org.

Implementation Information

Since Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] is rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

Show implementation information...

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] as listed below:

The TF-CBT Implementation Manual describes the organizational readiness process. It is available through the program representative listed at the end of the entry.

Formal Support for Implementation

There is formal support available for implementation of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] as listed below:

There is a formal structure for therapists to become certified in TF-CBT (https://tfcbt.org) as well as a structure for official training of TF-CBT trainers, organizational supervisors, and consultants to support large implementation programs.

Fidelity Measures

There are fidelity measures for Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] as listed below:

The TF-CBT Brief Practice Checklist is a self-report form that is available in Appendix 4 of the TF-CBT Implementation Manual. The manual is available through the program representative listed at the end of the entry.

Implementation Guides or Manuals

There are implementation guides or manuals for Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] as listed below:

The TF-CBT Implementation Manual describes the implementation process. It is available through the program representative listed at the end of the entry.

Research on How to Implement the Program

Research has not been conducted on how to implement Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of].

Relevant Published, Peer-Reviewed Research

This program is rated a "2 - Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The program must have at least one rigorous randomized controlled trial with a sustained effect of at least 6 months. The article(s) below that reports outcomes from an RCT showing a sustained effect of at least 6 months has an asterisk (*) at the beginning of its entry. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

Show relevant research...

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.

Type of Study: Randomized controlled trial
Number of Participants: 67

Population:

  • Age — 3-6 years
  • Race/Ethnicity — 58% Female and 42% Male
  • Gender — 54% Caucasian, 42% African American, and 4% Other
  • Status — Participants were families and children with histories of sexual abuse trauma who were recruited from rape crisis centers, Child Protective Services, pediatricians, psychologists, community mental health agencies, police, or judicial system.

Location/Institution: Pennsylvania

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Nonoffending parents and children with documented sexual abuse were randomly assigned to received Cognitive Behavioral Therapy (CBT) [now called Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)] or nondirective supportive therapy (NST). Children’s symptoms were assessed at baseline and follow-up with the Pre-school Symptom Self-report (PRESS), the Child Behavior Checklist for Ages 2-3 (CBCL/2-3), the Child Behavior Checklist for Ages 4-18 (CBCL/4-18), and the Child Sexual Behavior Inventory (CSBI). Parents also completed the Weekly Behavior Report (WBR), which was developed for this research project. Initial mean scores for both groups were in the clinical or borderline clinical range on the CSBI. At posttest, the CBT group had improved significantly in comparison with the NST on the CSBI, the WBR total score, and on the Behavior Profile-Total and Internalizing subscales of the CBCL. Note: Six children had to be removed from the NST group because of the persistence of sexually inappropriate touching of others, whereas no children had to be removed from the CBT group for this reason. Limitations include small sample size, reliability on self-reported measures and findings may only be generalizable to children with sexual abuse trauma.

Length of postintervention follow-up: None (a 1-year follow-up study was published separately - see Cohen & Mannarino 1997 below).

*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.

Type of Study: Randomized controlled trial
Number of Participants: 43 children

Population:

  • Age — 4-7 years at the time of the follow-up data collection
  • Race/Ethnicity — 56% Caucasian and 44% African American
  • Gender — 24 Female and 19 Male
  • Status — Participants were children with substantiated cases of sexual abuse.

Location/Institution: Pennsylvania

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study used the same sample as Cohen & Mannarino (1996). Children and families were randomly assigned to receive either CBT [now called Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)] or nondirective supportive therapy (NST). Parents completed the Child Behavior Checklist for Ages 2-3 (CBCL/2-3) or the Child Behavior Checklist for Ages 4-18 (CBCL/4-18) and the Child Sexual Behavior Inventory (CSBI), which assesses sexualized behaviors. Scores on all measures improved significantly and were maintained over time for the CBT group. There were clinically significant differences between the two groups on the CSBI at all post-treatment assessment points. Note: Throughout the course of the study, 14 NST subjects were either removed from the study during treatment (n = 6) or returned to treatment during the 12-month follow-up period (n = 8) because of persistent sexually inappropriate behaviors. Of the eight who returned for additional treatment, six required CBT interventions to resolve the sexually inappropriate behaviors. In contrast, no CBT subjects required removal during treatment, and only one CBT subject required a return to treatment during the follow-up period. Limitations include small sample size, high attrition, reliability on self-reported measures and findings may only be generalizable to children with sexual abuse trauma.

Length of postintervention follow-up: 1 year.

Stauffer, L. B. & Deblinger, E. (1996). Cognitive behavioral groups for nonoffending mothers and their young sexually abused children: A preliminary treatment outcome study.  Child Maltreatment, 1, 65-76.

Type of Study: One group pretest-posttest study
Number of Participants: 19

Population:

  • Age — Children: 2.3-6.5 years (Mean=3.46 years), Parents: 23-65 years (Mean=34.61 years)
  • Race/Ethnicity — Children: 84% Caucasian and 16% African American, Parents: 89% Caucasian and 11% African American
  • Gender — Children: 74% Female and 26% Male, Parents: 100% Female
  • Status — Participants were clients at the Center for Children’s Support, a resource for the medical and psychological evaluation and treatment of childhood sexual abuse victims and their nonoffending parents.

Location/Institution: New Jersey

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Non-offending mothers and young children (ages 2-6) some with documented sexual abuse behaviors received Cognitive Behavioral Therapy (CBT). Assessments at baseline, pretreatment (no treatment was provided between baseline and pre-treatment), post-treatment and follow-up time points included the Child Behavior Checklist for Ages 2-3 (CBCL/2-3), the Child Behavior Checklist for Ages 4-18 (CBCL/4-18), and the Child Sexual Behavior Inventory (CSBI). Maternal reports of sexualized behaviors as measured by the CSBI showed no change between baseline and pretreatment, significant improvements between pre-treatment and post-treatment and maintenance of the improvements at a 3-month follow up. Limitations include lack of randomization of participants, small sample size and length of follow-up.

Length of postintervention follow-up: 3 months.

The following studies were not included in rating Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] on the Scientific Rating Scale...

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

The randomized controlled trial evaluated the efficacy of child and caregiver participation through the use of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) in a sample of children age 8 to 14 years with histories of sexual abuse trauma and posttraumatic stress disorder (PTSD). Children were randomly assigned to receive TF-CBT or child-centered therapy (CCT). Participants were used from two separate sites. Measures administered to children at baseline and after treatment included the Kiddie Schedule for Affective Disorders for School-age Children-Present and Lifetime Version (K-SADS-PL-PTSD) PTSD subscale, Children’s Depression Inventory (CDI), State-Trait Anxiety Inventory for Children (STAIC), and the Children’s Attributions and Perceptions Scale (CAPS). Parents completed the Child Behavior Checklist for Ages 6-18 (CBCL/6-18), Child Sexual Behavior Inventory (CSBI), Beck Depression Inventory (BDI), Parent’s Emotional Reaction Questionnaire (PERQ) and the Parenting Practices Questionnaire (PPQ).  Results indicated that while both groups showed improvement, there was no significant difference on the CSBI between the intervention and control groups. Note: The children in this study did not have sexual behavior problems at a clinical level at baseline so this study could not be used in the rating process.

Cohen, J. A., Mannarino, A. P., & Knudsen K. (2005). Treating sexually abused children: One year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29, 135-146.

This randomized controlled trial evaluated the effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) in a sample of children ages 8 to 15 years with histories of sexual abuse trauma and posttraumatic stress disorder (PTSD). Participants were randomly assigned to one of two treatment groups: TF-CBT or non-directive supportive therapy (NST). Measures included the Children’s Depression Inventory (CDI), Trauma Symptom Checklist for Children (TSCC), State-Trait Anxiety Inventory for Children (STAIC), Child Sexual Behavior Inventory (CSBI), and the Child Behavior Checklist for Ages 6-18 (CBCL/6-18). Among treatment completers, TF-CBT resulted in significantly greater improvement in anxiety, depression, sexual problems, and dissociation at 6-month follow-up and in PTSD and dissociation at 12-month follow-up. Intent-to-treat analysis indicated group X time effects in favor of TF-CBT on measures of depression, anxiety, and sexual problems. Note: The children in this study did not have sexual behavior problems at a clinical level at baseline so this study could not be used in the rating process.

Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma-Focused Cognitive Behavioral Therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 28, 67–75.

This randomized controlled trial evaluated the effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) in a sample of children with histories of sexual abuse trauma and posttraumatic stress disorder (PTSD). Children were randomly assigned to one of the four treatment conditions: 8 sessions with no trauma narrative (TN) component, 8 sessions with TN, 16 sessions with no TN, and 16 sessions with TN. Measures included the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS), Beck Depression Inventory (BDI), Child Sexual Behavior Inventory (CSBI), Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5) or Child Behavior Checklist for Ages 6-18 (CBCL/6-18), and the Children’s Depression Inventory (CDI). Results indicated that TF-CBT, regardless of the number of sessions or the inclusion of a TN component, was effective in improving participant symptomatology as well as parenting skills and the children’s personal safety skills. Significant posttreatment improvements occurred with respect to 14 outcomes including child sexual behavior problems across all conditions.  The eight-session condition that included the TN component seemed to be the most effective and efficient means of reducing parents’ abuse-specific distress as well as children’s abuse-related fear and general anxiety. On the other hand, parents assigned to the 16-session, no narrative condition reported greater increases in effective parenting practices and fewer externalizing child behavioral problems at posttreatment. The major study limitation was the lack of a post-intervention follow-up. Note: The children in this study did not have sexual behavior problems at a clinical level at baseline so this study could not be used in the rating process.

References

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press.

Cohen, J. A., & Mannarino, A. P. (1993). A treatment model for sexually abused preschoolers. Journal of Interpersonal Violence, 8, 115-131.

Deblinger, E., Thakkar-Kolar, R., & Ryan, E. (2006). Trauma in Childhood. In Follette, V.M. & Ruzek, J. (Eds.) Cognitive behavioral therapies for trauma. New York: Guilford Press.

Contact Information

Name: Judith Cohen, MD
Agency/Affiliation: Allegheny General Hospital, Drexel University College of Medicine
Email:
Phone: (412) 330-4321
Fax: (412) 330-4377

Date Research Evidence Last Reviewed by CEBC: September 2015

Date Program Content Last Reviewed by Program Staff: June 2015

Date Program Originally Loaded onto CEBC: September 2011