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

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

See descriptions of 3 levels

Brief Description

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

  • Types of Maltreatment: Sexual Abuse, Exposure to Domestic Violence
  • Target Population: Children (3-12) with a known trauma history who are experiencing sexual behavior problems and significant Post-Traumatic Stress Disorder (PTSD) symptoms, whether or not they meet full diagnostic criteria.

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 (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.

The overall goal of TF-CBT is to address symptoms resulting from a specific traumatic experience or experiences. This 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

  • P – Psycho-education and parenting skills.
  • R – Relaxation techniques: Focused breathing, progressive muscle relaxation, and teaching the child to control their thoughts (thought stopping).
  • A – 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.
  • C – Cognitive coping: Through this component, the child learns to understand the relationships between thoughts, feelings and behaviors and think in new and healthier ways.
  • T – 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.
  • I – 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.
  • C – 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.
  • E – 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.

Child Component

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] (TF-CBT) was designed with a child component that addresses the following presenting problems and symptoms:

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

Age range: 3 – 12

Developmental Delays:

This program was not developed for children with developmental delays, and has not been tested for children with developmental delays.

Parent / Caregiver Component

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] (TF-CBT) was designed with a parent/caregiver component that addresses the following presenting problems and symptoms:

  • Inappropriate parenting practices and parental trauma-related emotional distress

Group Format

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) [Sexual Behavior Problems in Children, Treatment of] (TF-CBT) was not designed to be conducted in a group setting; but has been tested for use in a group setting.

Recommended group size:

6-10 children and their caregivers

Testing References:

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

Deblinger, E., Stauffer, L., & Steer, R. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for children who were sexually abused and their nonoffending mothers. Child Maltreatment, 6, 332-343.

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] (TF-CBT) 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] (TF-CBT) has materials available in languages other than English:

German, Japanese, Korean, Mandarin, 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 www.musc.edu/tfcbt. A free web-based consultation product in implementing TF-CBT is available at www.musc.edu/tfcbtconsult (completion of TF-CBTWeb is required prior to accessing this product).

Implementation Information

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

To be given to organizations or providers in order to measure organizational or individual readiness:

To be given to organizations or providers in order to measure organizational or individual readiness:

The Organizational Readiness and Capacity Assessment is a 29-item questionnaire designed to help agencies evaluate their readiness to implement evidence-based practices like TF-CBT.

Implementation Tools — for the program (e.g., implementation guides or manuals)

The TF-CBT Implementation Manual is for therapists, clinical supervisors, program administrators, and other stakeholders who are considering the use of TF-CBT for traumatized children in their communities. This manual was developed by the SAMHSA-funded National Child Traumatic Stress Network's (NCTSN) Sexual Abuse Task Force and is based on the experiences over many years in training community providers as to when, how, and with whom to use TF-CBT. It can be found at www.nctsnet.org/nctsn_assets/pdfs/TF-CBT_Implementation_Manual.pdf.

Fidelity Measures

  • Each TF-CBT component must be implemented for each child unless there are clinical reasons for deleting a component (for example, there are no trauma reminders the child is avoiding, so in vivo mastery is not needed).
  • The TF-CBT components must be implemented in the "PRACTICE" order unless there is a compelling reason to change the sequencing. (However, returning to a previously provided component to reinforce its use is permitted.)
  • Progression from one component to the next must occur within a reasonable time period (i.e., treatment is completed within 12 to 16 sessions for usual cases, and 16 to 20 sessions for complex cases).
  • The TF-CBT Brief Practice Worksheet is available to use to evaluate fidelity.

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 practice must have at least one rigorous randomized controlled trial with a sustained effect of at least 6 months. 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 range — 3 to 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)
Non-offending parents and children with documented sexual abuse were randomly assigned to received Cognitive Behavioral Therapy (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-SAP group for this reason.

Length of post-intervention 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 range — 4 years, 2 months to 7 years, 11 months at the time of the follow-up data collection
  • Race/Ethnicity — 56% Caucasian and 44% African American
  • Gender — 24 female and 19 male
  • Status — 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 the Cohen & Mannarino (1996) report. Children and families were randomly assigned to receive either 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. 

Length of post-intervention 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 range — 2.3 to 6.5 years (Mean = 3.46 years)
  • Race/Ethnicity — 89% Caucasian and 11% African American
  • Gender — Not Specified
  • 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 non-offending 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.

Length of post-intervention follow-up: 3 months.

The following studies were not included in rating TF-CBT 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 postreatment 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

Show references...

Cohen, J. A., & Mannarino, A. P. (2004). Treating childhood traumatic grief. Journal of Clinical Child and Adolescent Psychology, 33, 820-233.

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 Reviewed: September 2011