Trauma-Focused Cognitive Behavioural Therapy

Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1(4), 310-321. http://dx.doi.org/10.1177/1077559596001004003

Available at
http://journals.sagepub.com

Study design and sample 

The first study is a rigorously conducted RCT.

This study involved random assignment of 100 children and their parents to a parent-only treatment group (n=25); child-only treatment group (n=25); child and parent treatment group (n=25); or a community control group (n=25). For the purposes of the EIF assessment we primarily focused on the findings for the child and parent treatment group as this is how the intervention is normally delivered (although it can be delivered to the child only if it is not possible to work with the parents).

This study was conducted in the USA, with a sample of sexually abused children aged 7-13 years (mean = 9.84). 83% were female and 17% male. 72% were Caucasian, 20% African American, 6% Hispanic, 2% other ethnic origin. 76% of the children’s maternal caregivers were biological or adoptive, 4% were long-term foster mothers, 20% were other related female guardians (step-mothers, aunts, grandmothers, or older sister). The duration of the sexual abuse suffered by the children ranged from 1 day to more than 5 years of repeated abuse, 18% experienced 2-10 episodes, 22% experienced 11 to 50 abusive incidents.

Measures 

• Behavioural problems were measured using Child Behaviour Checklist (CBCL) (parent report).
• Situational specific anxiety was measured using the State/Trait ANXIETY Inventory for Children (STAIC) (Self-report).
• PTSD was measured using the Kiddie Schedule for Affective Disorders and Schizophrenia K-SADS (diagnostic interview).
• Child depression was measured using the Child Depression inventory (CD) (parent report).
• Parenting Practices were measured using the Parenting Practices Questionnaire (PPQ) (parent self-report).

Findings 

This study identified statistically significant positive impact on a number of child and parent outcomes.

This includes reduced PTSD (K-SADS), reduced child depression (CDI), and improved parenting practices (PPQ) for the parent and child intervention group. Reduced PTSD (K-SADS) for the child-only intervention group.

An additional paper (Deblinger et al., 1999) reported on the long term findings from this study. These outcomes did not however contribute to the overall programme rating as the study was not as robust as the Deblinger et al., (1996) study. 

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. http://dx.doi.org/10.1097/00004583-200404000-00005

Available at
http://www.sciencedirect.com

Study design and sample 

The second study is an RCT.

It involved random assignment of children and their carers to trauma-focused, cognitive behavioural therapy (TF-CBT) or Child Centred Therapy (CCT). The study took place in the United States. Participants were 229 children aged between 8 and 14 (mean age, 10.76 years) who were confirmed as having experienced contact sexual abuse. A parent or carer of each child participated in the parental treatment component of the study. All children met at least 5 criteria for sexual abuse-related DSMIV- defined posttraumatic stress disorder (PTSD). 180 (89%) met full criteria for current PTSD. 79% were female. 60% were Caucasian, with the next largest group represented (28%) being African American.

Measures

• PTSD was measured using the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL) (diagnostic interview).
• Child depression was measured using the Child Depression inventory (CD) (child self-report).
• Present (state) and trait anxiety symptoms were measured using the State-Trait Anxiety Inventory for Children (STAIC) (child self-report).
• Children’s stigmatization, interpersonal trust, self-blame for negative events, and perceived credibility were measured using the Children’s Attributions and Perceptions Scale (CAPS) (child self-report).
• Behavioural problems were measured using Child Behaviour Checklist (CBCL) (parent report).
• Normative as well as inappropriate sexual behaviours were measured using the Child Sexual Behaviour Inventory (CSBI) (parent report).
• Parental depression was measured using the Beck Depression Inventory II (BDI) (parent self-report).
• Parental emotional distress related to their children’s sexual abuse experience was measured using the Parent’s Emotional Reaction Questionnaire (PERQ) (parent self-report).
• Parental support of their sexually abused child and attributions about responsibility for the abuse was measured using the Parental Support Questionnaire (PSQ), (parent self-report).
• Parenting practices were measured using the Parenting Practices Questionnaire (PPQ) (parent self-report)

Findings 

This study identified statistically significant positive impact on a number of child and parent outcomes.

At post-intervention, child outcomes included reduced PTSD (K-SADS), reduced behavioural problems (CBCL), reduced symptoms of depression (CDI), increased perceived credibility and interpersonal trust (CAPS).

Parent outcomes include reduced parental depression (BDI), reduced parental emotional distress (PERFQ), improved parenting practices (PPQ), increased parental support (PSQ).

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. http://dx.doi.org/10.1097/01.chi.0000240839.56114.bb

Available at
http://www.sciencedirect.com

Deblinger et al., 2006 describes long term outcomes from study 2a described above. In this case:

• The study reported on 6 and 12-month follow-up findings.
• Positive findings for child outcome include reduced child internalising behaviour (CBCL), Reduced child externalising behaviour (CBCL).
• Positive findings for parent outcomes include reduced parental emotional distress (PERQ), improved parenting practices (PPQ), increased parental support (PSQ).

This study therefore identified statistically significant positive impact on a number of child and parent outcomes, at post-intervention, 6-month post-intervention and 12-month post-intervention. The conclusions that can be drawn from this study are limited by methodological issues pertaining to lack of ITT, unequivalent groups, and high attrition, hence why a higher rating is not achieved.

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. http://dx.doi.org/10.1001/archpediatrics.2010.247

Available at 
https://jamanetwork.com/journals

Study Design and Sample 

The third study is an RCT.

This study involved random assignment of 124 children to a treatment group (n=64; TF-CBT) and a control group (n=60; child centred therapy).

This study was conducted in the USA, with a sample of children aged 7-14 who have been exposed to intimate partner violence and were experiencing symptoms of PTSD. To be included, children had to have at least 5 IPV-related PTSD symptoms, including at least 1 in each of 3 PTSD symptom cluster on the Kiddie Schedule for Affective Disorders and Schizophrenia. 49% of the sample as male, 51% of the sample were female. 56% were white, 33% were Black, and 11% were biracial.

Measures

• Total child PTSD symptoms were measured using Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-PL) (Diagnostic interview).
• Child anxiety was measured using the Screen for Child Related Emotional Disorders (SCARED) (child self-report).
• Cognitive functioning was measured using The Kaufman Brief intelligence test (intelligence test).
• Total Behaviour Problems was measured using the Child Behaviour Checklist (parent report).

Findings

This study identified statistically significant positive impact on a number of child outcomes. This includes reduced PTSD (K-SADS-PL) and anxiety (SCARED).
This study identified statistically significant positive impact on a number of child outcomes. The conclusions that can be drawn from this study are limited by methodological issues pertaining to unequivalent groups post-attrition, and where attrition was over 10% these differences not being controlled for in the analyses.

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. http://dx.doi.org/10.1080/15374416.2013.822307

Available at
http://www.tandfonline.com

Study Design and Sample 

The fourth study is an RCT.

This study involved random assignment of 156 children to a treatment group (n=79, TF-CBT) or a control group (n=77, treatment as usual).
This study was conducted in Norway, with a sample of children aged 10-18 years who were experiencing PTSD symptoms. 79.5% of the sample were girls, 20.5% were boys. 73.7% were Norwegian, 10.9%.

Measures 

• PTSD symptoms were measured using CPSS (self-report) and the CAPS-CA (self-report, clinical judgement).
• Depression symptoms were evaluated using the Mood and Feelings Questionnaire (MFQ, child self-report).
• Anxiety symptoms were measured using the Screen for Child Anxiety-Related Disorders (SCARED) (child self-report).
• General mental health and conduct problems were measured using the Strengths and Difficulties Questionnaire (SDQ, parent report).

Findings 

This study identified statistically significant positive impact on a number of child outcomes.

This includes PTSD symptoms (CPSS, fCPSS), and depression symptoms (MFQ).

This study identified statistically significant positive impact on a number of child outcomes. The conclusions that can be drawn from this study are limited by methodological issues pertaining not reporting on equivalence between groups post-attrition, hence why a higher rating is not achieved.

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. http://dx.doi.org/10.1159/000442824

Available at 
https://www.karger.com

Study Design and Sample 

The fifth study is an RCT.

This study involved random assignment of 159 children to a treatment group (TF- CBT, n = 76) or a control group (waitlist; n = 83). It was conducted in Germany, with a sample of children aged 7-17 with PTSD symptoms. 28% of the sample was male, 72% were female. 90% were German natives, 6% were non-German natives, and 1% was unknown.

Measures 

PTSD Symptoms were measured using the PTSD Scale for Children and Adolescents (CAPS-CA) (independent assessor).

• The presence of comorbid mental disorders according to DSM-IV criteria was determined using the Schedule of Affective Disorders and Schizophrenia for School-Age Children Revised for DSM IV (K-SADS) (diagnostic interview).
• The level of psychosocial functioning was assessed using the Children’s Global Assessment Scale (CGAS) (independent assessor).
• PTSD symptoms was reported on the child and adolescent and caregiver versions of the UCLA-PTSD Reaction Index.
• The patients’ cognitive distortions related to the trauma were assessed by self-reports on the Child Posttraumatic Cognitions Inventory (CPTCI) (self-report).
• Symptoms of anxiety were assessed by self-reports and caregiver reports on the Screen for Child Anxiety-Related Emotional Disorders (SCARED) with repeatedly reported excellent psychometric properties (self-report).
• Symptoms of depression were assessed by patients’ self-reports on the Children’s Depression Inventory (CDI) (self-report).
• Child behaviour was measured using The Child Behaviour Checklist 4–18 (CBCL/4–18) [30] (parent report)
• The patients’ quality of life was assessed by self-reports and caregiver-reports on the Inventory of Quality of Life for Children (ILK) (parent and child reports).

Findings

This study identified statistically significant positive impact on a number of child outcomes. This includes:

• Reduced PTSD symptoms (CAPS-CA: total score, re-experiencing, avoidance, and hyperarousal; UCLA: self, care)
• Reduced cognitive distortions (CPTCI)
• Improved psychological functioning (CGAS)
• Reduced depression (CDI)
• Reduced anxiety (SCARED: self, care)
• Improved child behaviour (CBCL: Total, externalising, internalising).

This study identified statistically significant positive impact on a number of child outcomes. The conclusions that can be drawn from this study are limited by methodological issues pertaining to not reporting on equivalence between groups post-attrition, hence why a higher rating is not achieved.