Child and Family Traumatic Stress Intervention (CFTSI)

Children ages 7-18 recently exposed to a potentially traumatic event, or having recently disclosed physical or sexual abuse, and endorsing at least one symptom of posttraumatic stress

For children/adolescents ages: 7 - 18

For parents/caregivers of children ages: 7 - 18

CFTSI is a brief early intervention model for children and adolescents 7-18 that is implemented soon after exposure to a potentially traumatic event, or in the wake of disclosure of physical and sexual abuse. Developed at the Yale Child Study Center, CFTSI fills a gap between acute responses/crisis intervention and evidence-based, longer-term treatments designed to address traumatic stress symptoms and disorders that have become established. The goal of this family-strengthening model is to improve the caregiver's ability to respond to, and support, a child who has endorsed at least one posttraumatic symptom. By raising awareness of the child's symptoms, increasing communication and providing skills to help master trauma reactions, CFTSI aims to reduce symptoms and prevent onset of posttraumatic stress disorder (PTSD). In addition, CFTSI offers an opportunity to assess which children and families need longer-term treatment. CFTSI is provided by master's-level clinicians who have been trained by CFTSI master trainers.

Hilary Hahn
Yale Childhood Violent Trauma Center

• Email: hilary.hahn@yale.edu
• Phone: (203) 737-6304

Carrie Epstien
Yale Childhood Violent Trauma Center

• Email: epstein.carrie@gmail.com

The goals of Child and Family Traumatic Stress Intervention (CFTSI) are:

• Improve screening and identification of children impacted by traumatic stress
• Reduce posttraumatic stress symptoms
• Enhance emotional support through increased caregiver-child communication
• Teach/practice coping skills to reduce trauma reactions
• Identify and address concrete external stressors (such as safety, legal issues, medical care)
• Assess child's need for longer-term treatment

The essential components of Child and Family Traumatic Stress Intervention (CFTSI) include:

• CFTSI grew out of two decades of responding collaboratively with law enforcement and child protective services partners to provide acute, on-scene, and follow-up post-event interventions to children and families who had been exposed to violence and other potentially traumatic events. As a result of this work, developers recognized the need for an evidenced-based early intervention that would fill the gap between the provision of standardized acute interventions and the evidenced-based, longer-term treatments that are required to deal with enduring posttraumatic reactions. CFTSI, a brief early intervention model, is designed to be implemented shortly after a potentially traumatic event or in the wake of later disclosure of traumatic events (typically sexual abuse) that occurred earlier in a child's life.
• Social and family support is one of the most important protective factors for children after exposure to potentially traumatic events. CFTSI attempts to increase the ability of caregiver(s) to support their child by helping to:
• Increase the child and parental understanding of the possible impact of exposure to potentially traumatic events on symptom formation, behavioral changes and daily functioning (psychoeducation).
• Increase the child's ability to communicate feelings and symptoms to caregiver(s).
• Increase the caregiver(s)' ability to observe and attend to the child's behavioral symptoms of distress.
• Increase caregiver(s)' ability to respond appropriately and supportively to the child's difficulties by teaching them:
• Specific strategies and interventions to do with their child.
• How to remind themselves and their child about the correlation between behavioral changes, internal feeling states, and the potentially traumatic event.
• By working with the child and family in these four areas, the goal of CFTSI is to help children feel more supported, which will lead to improved post-exposure outcomes.
• CFTSI Session Outline:
• Session 1 - Caregiver Meeting
• Provide psychoeducation about trauma and trauma symptoms.
• Assess caregiver(s)' and child's traumatic stress symptoms.
• Address case management issues.
• Session 2A: Meeting the child alone
• Provide psychoeducation about trauma and trauma symptoms.
• Assess child's traumatic stress symptoms.
• Session 2B: Family Meeting: Caregiver and child together (key session in CFTSI)
• Begin discussion by comparing child and caregiver's reports about child's trauma symptoms.
• Identify the specific trauma reactions that will be focused on and introduce coping skills.
• Session 3: Caregiver and child together
• Review progress and support communication attempts.
• Re-assess levels of distress and increased awareness.
• Practice coping skills and support efforts.
• Session 4: Caregiver and child together: Case disposition
• Re-assess levels of distress and increased awareness.
• Review progress made and support communication attempts.
• Review coping skills and support efforts.
• Assess and identify any additional treatment needs or case management needs.

Child/Adolescent Services

Child and Family Traumatic Stress Intervention (CFTSI) directly provides services to children and addresses the following:

• Early posttraumatic distressPosttraumatic adaptive difficultiesPre-existing psychiatric problems

Parent/Caregiver Services

Child and Family Traumatic Stress Intervention (CFTSI) directly provides services to parents/caregivers and addresses the following:

• Caregiver of child who has potentially been exposed to trauma

Recommended Intensity

Session 1: Accomplished in 1-2 meetings each 1 hour in length; Session 2a: 1 hour; Session 2b: Accomplished in 1-2 meetings each 1 hour in length; Session 3: 1 hour; Session 4: 1 hour. Additional sessions with child, caregiver or dyad are scheduled as necessary.

Recommended Duration

4-6 weeks

Delivery Settings

This program is typically conducted in a(n):

• Community-based Agency / Organization / Provider
• Hospital
• Outpatient Clinic

Homework

Child and parent/caregiver are asked to practice the coping skill taught in the session and are provided a Family Log to record efforts.

Languages

Child and Family Traumatic Stress Intervention (CFTSI) has materials available in the following languages other than English:

• Spanish

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

Resources Needed to Run Program

The typical resources for implementing the program are:

Private meeting space; copies of standardized instruments

Prerequisite/Minimum Provider Qualifications

Master's level trained therapists

Manual Information

There is not a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact

Training Type/Location:

Training is offered at a site of the trainee agency's choosing

Number of days/hours:

2 days for 12 hours total

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Child and Family Traumatic Stress Intervention.

Formal Support for Implementation

There is no formal support available for implementation of Child and Family Traumatic Stress Intervention.

Fidelity Measures

There are no fidelity measures for Child and Family Traumatic Stress Intervention.

Established Psychometrics

There are no established psychometrics for Child and Family Traumatic Stress Intervention.

Fidelity Measures Required

No fidelity measures are required for Child and Family Traumatic Stress Intervention.

Implementation Guides or Manuals

There are no implementation guides or manuals for Child and Family Traumatic Stress Intervention.

Implementation Cost

There are no studies of the costs of Child and Family Traumatic Stress Intervention.

Research on How to Implement the Program

Snyder, S. E., & Wenocur, K. (2023). ‘Meeting them where they are at’: A practice note on implementation of the Child and Family Traumatic Stress Intervention in an emergency family homeless shelter. Child & Family Social Work, 28(2), 302–310. https://doi.org/10.1111/cfs.12962

Child Welfare Outcome: Child/Family Well-Being

• Berkowitz, S. J., Stover, C. S. & Marans, S. R. (2011). The Child and Family Traumatic Stress Intervention: Secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry, 52(6), 676–685. https://doi.org/10.1111/j.1469-7610.2010.02321.x

  Type of Study: Randomized controlled trial

  Number of participants: 106

  Population:

  • Age — 7–17 years
  • Race/Ethnicity — 37% African American, 32% Caucasian, 22% Hispanic, 7% Multiethnic, and 2% Other Ethnicities
  • Gender — 48% Male
  • Status —

    Participants were children exposed to events that can lead to posttraumatic stress disorder (PTSD).

  Location/Institution: Yale Child Study Center

  Summary:

  The purpose of the study was to evaluate the efficacy of the Child and Family Traumatic Stress Intervention (CFTSI) to prevent the development of chronic posttraumatic stress disorder (PTSD) provided within 30 days of exposure to a potentially traumatic event. Participants were randomly assigned to CFTSI or a comparison group that received a psychoeducational intervention. Measures utilized include the Trauma History Questionnaire (THQ), the Parent Behavior Inventory (PBI), the Perceived Social Support-Family (PSS-Fa), the UCLA Posttraumatic Stress Disorder Index (PTSD-RI), the Behavior Assessment System for Children, Second Edition-Self Report (BASC-2), the Child Behavior Checklist (CBCL), the PTSD Checklist-Civilian Version (PCL-C) and the Trauma System Checklist for Children (TSCC). Results indicate that at follow-up, the CFTSI group demonstrated significantly fewer full and partial PTSD diagnoses than the control group; in addition, the CFTSI group had significantly lower posttraumatic and anxiety scores than the comparison group. Limitations include that the current study did not evaluate which elements of the CFTSI acted as the essential therapeutic mechanisms, length of follow-up, and high sample attrition.

  Length of controlled postintervention follow-up: 3 months.

• Note: The following studies were not included in rating Child and Family Traumatic Stress Intervention on the Scientific Rating Scale.

  Hahn, H., Putnam, K., Epstein, C., Marans, S., & Putnam, F. (2019). Child and Family Traumatic Stress Intervention (CFTSI) reduces parental posttraumatic stress symptoms: A multi-site meta-analysis (MSMA). Child Abuse & Neglect, 92, 106–115. https://doi.org/10.1016/j.chiabu.2019.03.010

  Type of Study: Other quasi-experimental

  Number of participants: 640 Child-caregiver dyads

  Population:

  • Age — Children: 7–17 years; Caregivers: Not specified
  • Race/Ethnicity — Children: 33% White, 28% Black, 18% Other, 11% Multiracial, 7% Unknown Ethnicity, 6% Native American/Alaska Native, 3% Asian; less than 1% identified as Native Hawaiian/Other Pacific Islander; Caregivers: Not specified
  • Gender — Children: 26% Male; 74% Female; Caregivers: 90% Female
  • Status —

    Participants were referred following formal disclosure of abuse in a Child Advocacy Center (CAC).

  Location/Institution: 10 community treatment sites along the Eastern Seaboard of the United States

  Summary:

  The purpose of the study was to evaluate the efficacy of the Child and Family Traumatic Stress Intervention (CFTSI) to reduce posttraumatic symptoms (PTS) in caregivers. Participants were from treatment sites that received CFTSI. Measures utilized include Part 1 of the Child PTSD Symptom Scale (CPSS) and the Posttraumatic Checklist–Civilian version (PCL-C). Results indicate that CFTSI was associated with significant changes in children's PTS and with clinically meaningful improvements in PTS for 62% of participating caregivers who had started CFTSI with clinical levels of PTS as measured by the PCL-C. Limitations include that the study cannot establish whether a given intervention is more efficacious than the passage of time or other interventions, and lack of follow-up. Note: This article was not used in the rating process due to the lack of a control group.

  Length of controlled postintervention follow-up: None.

• Note: The following studies were not included in rating Child and Family Traumatic Stress Intervention on the Scientific Rating Scale.

  Stover, C. S., Hahn, H., Maciejewski, K. R., Epstein, C., & Marans, S. (2022). The Child and Family Traumatic Stress Intervention: Factors associated with symptom reduction for children receiving treatment. Child Abuse & Neglect, 134, Article 105886. https://doi.org/10.1016/j.chiabu.2022.105886

  Type of Study: One-group pretest–posttest study

  Number of participants: 1190 Child-caregiver dyads

  Population:

  • Age — Children: 7–17 years
  • Race/Ethnicity — Children: 32% White, 28% Black, and 41% Other
  • Gender — Children: 82% Female
  • Status —

    Participants were referred following formal disclosure of abuse in a Child Advocacy Center (CAC).

  Location/Institution: 9 CACs and 4 hospital or community clinics from 7 different states

  Summary:

  The purpose of the study was to examine factors associated with changes in posttraumatic stress symptoms for children following completion of the Child and Family Traumatic Stress Intervention (CFTSI), an early and brief, trauma-focused mental health treatment that engages children together with their caregivers, with the child as the identified patient. Measures utilized include the Child PTSD Symptom Scale (CPSS), the Posttraumatic Checklist–Civilian version (PCL-C), and the Child Trauma History Questionnaire (CTHQ). Results indicate that there is a significant reduction in child reported posttraumatic stress scores from pre- to post-CFTSI. Scores on the CPSS declined an average of 8.74 points from pre- to post-CFTSI. There were no statistically significant differences in CPSS score changes based on age, gender, ethnicity, race, number of prior trauma types the child had experienced, caregiver posttraumatic stress symptoms, child relationship to the perpetrator, nature of event, or length of time to begin treatment. Limitations include the lack of a control group, study does not test acceptability or feasibility of CFTSI broadly in terms of assessing whether there are differences between those who engaged in treatment and those who did not or if there are differential rates of drop out from the intervention, lack of generalizability due to type of abuse, and lack of controlled postintervention follow-up. Note: This article was not used in the rating process due to the lack of a control group.

  Length of controlled postintervention follow-up: None.

• Note: The following studies were not included in rating Child and Family Traumatic Stress Intervention on the Scientific Rating Scale.

  Goslin, M. C., & Epstein, C. (2024). Telehealth delivery of the child and family traumatic stress intervention is associated with reduced posttraumatic stress in children and caregivers. Child Maltreatment, 29(3), 430–439. https://doi.org/10.1177/10775595241233230

  Summary:

  The purpose of the study was to evaluate whether telehealth delivery of the Child and Family Traumatic Stress Intervention (CFTSI) was associated with posttraumatic stress symptom reduction for children exposed to potentially traumatic events and their caregivers. Participants received a telehealth version of CFTSI. Measures utilized include the Child Trauma History Questionnaire (CTHQ), Adult Trauma History Questionnaire (ATHQ), Child PTSD Symptom Scale (CPSS-5), Posttraumatic Checklist-Civilian version (PCL-C), and a study-developed survey. Results indicate that there were significant reductions in child and caregiver posttraumatic stress symptoms from pre- to post-CFTSI. Effect sizes were large and consistent with or stronger than prior studies of CFTSI implemented in person. Preliminary findings also indicated high levels of caregiver satisfaction. Limitations include the lack of a control group and a lack of generalizability due to study demographics. Note: This article was not used in the rating process due to the lack of a control group.

• Marans, S., Epstein, C., & Berkowitz, S. (2011). The CFTSI provider manual: Adaptation for children in foster care. Yale Childhood Violent Trauma Center

• Marans, S., Hahn, H., Epstein, C., Arnow, N., & Roberts, L. (2012). The Safe Horizon-Yale Child Study Center Partnership: Offering hope for abused children. (White Paper). Yale Childhood Violent Trauma Center.