1 , Vol. 46(3), 2009 Published online in Wiley InterScience (www.interscience.wiley.com) C 2009 Wiley Periodicals, Inc CHILDREN AND TRAUMATIC EVENTS: THERAPEUTIC TECHNIQUES FOR PSYCHOLOGISTS WORKING IN THE SCHOOLS STEVEN G. LITTLE Walden University ANGELEQUE AKIN-LITTLE Behavioral, Educational, & Research Consultants GABRIEL GUTIERREZ University of California, Riverside It is clear that exposure to traumatic events is not uncommon in childhood and adolescence, and psychologists working in schools should have some training in meeting the needs of this segment of the population. One intervention that has been empirically supported in the trauma field is Trauma- Focused Cognitive Behavior Therapy (TF-CBT). This article seeks to provide an overview of research on the efficacy of TF-CBT with children and adolescents who have experienced trauma with a primary focus on psychologists working in the schools. C 2009 Wiley Periodicals, Inc. Children and adolescents may experience a number of different types of trauma. These can include direct experience of abuse (e.g., sexual, physical), grief, domestic and/or community violence, natural disasters, or a combination of the above. In a retrospective study of more than 17,000 adults, Felitti and colleagues (1998) reported that more than one half of their sample had experienced at least one adverse event in childhood, with approximately one quarter reporting having experienced two or more. This included 10.6% who experienced emotional abuse, 28.3% who experienced physical abuse, and 20.7% who experienced sexual abuse. In 2005, 13.8 children per 1,000 aged were victims of serious violent crimes (aggravated assault, rape, robbery, and homicide). This rate was down from 43.8 per 1,000 in 1993 but it still represents 350,649 adolescents in the United States (Bureau of Justice Statistics, 2006). In addition, this figure does not include children and adolescents who may have been traumatized by witnessing violent acts. Finally, increasing numbers of children and adolescents have been victims of natural disasters. For example, more than one million people were displaced, at least temporarily, by Hurricane Katrina in 2005, and many remain displaced today (Akin-Little & Little, 2008). It is clear that exposure to traumatic events is not uncommon in childhood and adolescence, and psychologists working in schools should have some training in meeting the needs of this segment of the population. One intervention that has been empirically supported in the trauma field is Trauma-Focused Cognitive Behavior Therapy (TF-CBT). Although most of the research (i.e., controlled, randomized trials) have supported the efficacy of TF-CBT with sexually abused children (e.g., Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino, & Knudsen, 2005), this intervention has also proved efficacious for other types of trauma (Cohen, Mannarino, & Deblinger, 2006; Cohen, Mannarino, & Staron, 2006). It is the intent of this article to provide an overview of research on the efficacy of therapeutic techniques with children who have experienced trauma with a primary focus on TF-CBT for psychologists working in the schools. Psychological Impact of Trauma Unfortunately, stressful events are not an unusual occurrence in child and adolescent development. Parents divorce, grandparents die, children and others in their lives get injured. These examples may not be considered extreme trauma, however. According to the Diagnostic and Statistical Manual Correspondence to: Steven G. Little, 152 Shady Acres Road, Tupelo, MS edu 199
2 200 Little et al. of Mental Disorders-Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), an extreme traumatic stressor is one that involves direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one s physical integrity; or witnessing an event that involves death, injury, or threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (p. 463). Examples include sexual or physical abuse, severe accidents, cancer or other life-threatening illness, natural or man-made disasters, war, terrorism, or the sudden death of a parent, sibling, or peer (Cohen, Mannarino, & Deblinger, 2006). However, it should also be noted that not every child exposed to a traumatic event will develop trauma symptoms. Many children demonstrate resiliency, the ability to thrive and excel, even when exposed to severe stressors (Leckman & Mayes, 2007). Cohen, Mannarino, and Deblinger (2006) divide trauma symptoms into four main categories: affective, behavioral, cognitive, and physical. Affective symptoms include fear, depression, anger, and mood dysregulation (e.g., frequent mood changes). Behavioral symptoms center on the avoidance of things that remind the individual of the traumatic experiences. Although this avoidance may be an effective short-term coping mechanism, if these behaviors generalize, it may have a severe negative impact on the child s participation in normal age-appropriate activities. This type of coping in turn may exacerbate the affective symptoms. Cognitive symptoms involve distorted cognitions that the child may have about him- or herself, others, the event, or the world (e.g., the event is my fault ). There is not always a rational explanation for why bad things happen, so in an attempt to provide an explanation for the traumatic event, it is common for irrational beliefs to occur. These beliefs are generally dogmatic, rigid musts (e.g., this must be my fault ) and imperative demands (Dryden, DiGiuseppe, & Neenan, 2003). Most probably this type of coping appears to help the child develop a sense of control or predictability over the environment. Cohen and colleagues report that the most common irrational belief in children is blaming themselves. Finally, physical symptoms are related to the chronic stress that these children are experiencing. They include elevated resting pulse rates and blood pressure, greater physical/muscle tension, and hypervigalence. It has also been found that prolonged exposure to trauma and maltreatment can decrease brain size and functioning (DeBellis et al., 1999). TF-CBT: The Core Values TF-CBT is one of only three interventions that have been identified as meeting the criteria for evidence-based practice by the Kauffman Best Practices Project (Chadwick Center for Children and Families, 2004) and is the only trauma treatment for children with a scientific rating of 1, meaning it is well supported, effective practice by the California Evidence-Based Clearinghouse for Child Welfare ( ). TF-CBT consists of six core values (Cohen, Mannarino, & Deblinger, 2006). First, it is components based, meaning that it consists of a collection of core skills that build on one another. It is not a rigid session-by-session treatment approach but rather is designed to match the needs of the individual child and family. The second value is respect. For treatment to be effective, it must be consistent with the family s religious, community, and cultural values. The TF-CBT therapist works with the family to determine the optimal course of treatment. Third is adaptability, which denotes the need for flexibility and creativity on the part of the therapist in selecting and implementing TF-CBT components. The fourth core value is family involvement. Parents are a key component in treatment, and improving parent child interactions, communication, and intimacy is a major focus. Fifth is the idea that the therapeutic relationship is a key factor in restoring trust and functioning in the child. To accomplish this, the therapist must model trust, empathy, and acceptance throughout the course of treatment. The final core value is self-efficacy. The goal of TF-CBT is an
3 Children and Traumatic Events 201 optimally functioning individual and family well after treatment has been terminated. To accomplish this, the therapist attempts to establish a sense of self-efficacy in the client s affect, behavior, and cognitions. TF-CBT: The Specific Components TF-CBT is a short-term treatment that involves individual sessions with both children and parents as well as joint parent child sessions. It has been empirically validated for children ages 4 18 who have behavioral and emotional problems related to traumatic life events. The main components of TF-CBT include psychoeducation, parenting skills, relaxation, affective modulation, cognitive coping and processing, trauma narrative, in vivo mastery of trauma reminders, conjoint child parent sessions, and enhancing future safety and development. This article will summarize these components, and a more complete description of each component can be found in Cohen, Mannarino, and Deblinger (2006). Psychoeducation is the first component of the TF-CBT package, and it continues for the duration of therapy for both the child and parent. It is important to provide information about trauma, its effects, and its treatment. There is not any one set list of information that needs to be provided, however. It is important to individualize the information so that it is specific to the type of trauma that was experienced and the child s developmental level. Educating parents and children about what they should expect from treatment helps to enlist their cooperation and prepare them for the types of activities that will be conducted during therapy. Working with a child who has experienced a traumatic event can be difficult for even the most competent parents. The parenting skills included in TF-CBT have been found to be effective in helping parents with their child s behavior problems (Cohen, Deblinger, Mannarino, & Steer, 2004). Parenting skills taught include the use of praise, selective attention, time-out, and contingency management. Relaxation techniques are taught to the child in an effort to help him/her reduce the physiological symptoms of stress such as autonomic nervous system arousal, help the child sleep, and manage other behavioral manifestations of stress. There is no one relaxation technique that is recommended. Cohen, Mannarino, and Deblinger (2006) do, however, recommend some combination of focused breathing, meditation, and progressive muscle relaxation. They also recommend training parents in the relaxation techniques so that they can practice and reinforce these skills in their children. The authors also have found the relaxation program developed by Cautela and Groden (1978) useful when working with children and adolescents. Affective expression and modulation involves teaching children to manage their emotions and deal with their anxiety. Children who have experienced a traumatic event frequently have difficulty with these skills. They may find it hard to identify emotions, differentiate between emotions, or express their feelings appropriately. Additionally, if the children are able to express and control their feelings, they may be less likely to use avoidance as a coping strategy. Techniques that are used during this component include thought-interruption techniques, positive imagery, positive self-talk, and social skills building. Cognitive coping and processing involves teaching children and parents about the relationships among thoughts, feelings, and behavior and how they can identify and correct unhelpful thoughts. Initially the focus is on thoughts and beliefs in general; dealing with trauma-related cognitions comes later. The first step is recognition and sharing of internal dialogs, with the focus changing to inaccurate and unhelpful thoughts once they have developed initial skills in this area. Helping children create and discuss a narrative version of their traumatic experiences is essential in helping them cope. It is the most important step in helping to control intrusive and upsetting
4 202 Little et al. trauma-related imagery. The goal of the trauma narrative is to separate unpleasant associations among thoughts, reminders, or discussion of the trauma from overwhelming negative emotion. Over the course of several sessions, the child is encouraged to describe more and more details about what happened before, during, and after the trauma as well as the child s thoughts and feelings through these times. Eventually the child will share this narrative with his or her parent(s) or caregiver. In vivo mastery of trauma reminders is designed to help resolve generalized avoidant behaviors. Frequently innocuous cues in the environment remind the child of the trauma. They bring up unpleasant emotions, and one way of dealing with them is through avoidance. For example, a child who was abused in the basement of one home may avoid going into the basement of any home. This does not mean you want to desensitize the child to all perceived trauma cues. Many are legitimate and serve to help the child from being retraumatized. Part of this component is getting the child to recognize important cues from innocuous conditioned cues. TF-CBT also includes conjoint child parent sessions to review information, read the child s trauma narrative, and facilitate communication. The goal is to get the child comfortable in talking with the parent or caregiver about his or her traumatic experiences and other significant events that happen in his or her life. These sessions tend to occur toward the end of therapy as the child needs adequate time to cognitively process the trauma; however, there are times when it may be advisable to involve the parents earlier. The final component of TF-CBT is designed to enhance the child s future safety and development. In many cases the child will be unlikely to face a similar trauma in the future. Although it is acceptable to stress this, the therapist should never assure any child that he/she will not experience trauma again. Our goal, however, is to insure that they have the skills to minimize the likelihood of future trauma and cope with trauma effectively should it occur again. Empirical Support for TF-CBT As mentioned previously, TF-CBT has been empirically validated and is recognized by multiple sources as an empirically based intervention. The following section summarizes a representative sample of studies on TF-CBT for both trauma and grief. TF-CBT has consistently been demonstrated as an efficacious treatment for post-traumatic stress disorder (PTSD), depression, anxiety, and other related symptoms. There is also an abundance of evidence to support the efficacy of TF-CBT over treatments such as nondirective play therapy and supportive therapies for children who were the victims of sexual abuse (Cohen, Deblinger, & Mannarino, 2004). In addition, although the majority of studies have focused on child sexual abuse, evidence also suggests that it is effective for children exposed to other types of trauma as well as children who are multiply traumatized (Cohen, 2005). Cohen and Mannarino (1996) conducted the first treatment outcome study for sexually abused children using TF-CBT. In this study, TF-CBT was compared to a nondirective supportive therapy (NST) for 67 sexually abused preschool children and their parents. Treatment consisted of 12 individual sessions for both the child and parent. Results indicated that, whereas the NST group did not change significantly with regard to symptomology, the TF-CBT group demonstrated improvement on most outcome measures. These findings provided strong preliminary evidence for the effectiveness of TF-CBT for sexually abused preschool children and their parents. In a follow-up to their 1996 study, Cohen and Mannarino (1997) evaluated treatment outcome 6 and 12 months after initial treatment. Results indicated that the TF-CBT group exhibited significantly more improvement over time than the NST group. Results also indicated the superior effectiveness of TF-CBT over NST in reducing sexually inappropriate behavior. Cohen, Deblinger, Mannarino, and Steer (2004) compared the efficacy of TF-CBT with Child Centered Therapy (CCT) for the treatment of PTSD and related emotional and behavioral problems
5 Children and Traumatic Events 203 in children who have been sexually abused. A total of 203 children 8 14 years of age who had a verified case of sexual abuse were included in the study. Participants were randomly assigned to a manualized treatment consisting of TF-CBT or CCT. Therapists were trained in the modality they provided and received supervision. Treatment integrity was assessed by video and audiotape recording. Results indicated that parents in the TF-CBT reported lower levels on each of the outcome measures (except on parental support) than those who received CCT. That is, children and parents in the TF-CBT group reported improvement in PTSD symptoms, depression, shame, behavioral problems, and dysfunctional abuse attributions. Results also indicated that two times as many children in the CCT group continued to have PTSD based on DSM-IV-TR (APA, 2000) criteria. TF-CBT also appeared to improve children s feelings of trust, perceived credibility, and shame. This study is important because it supports the use of a shorter version of TF-CBT. Deblinger, Mannarino, Cohen, and Steer (2006) assessed the maintenance effects of TF-CBT and CCT of participants in the Cohen, Deblinger, Mannarino, and Steer (2004) study as well as to determine predictors of treatment responsiveness using sex, race, age, relationship to perpetrator, total number of traumas experienced before treatment, and pretreatment score on psychological measures. Participants from the Cohen, Deblinger, et al. study were followed for six additional months while providing booster sessions. Results indicated that children in the TF-CBT group maintained the gains made at posttreatment (6 months of maintenance with booster sessions). That is, the children who received TF-CBT continued to show fewer PTSD symptoms and fewer symptoms of shame compared to children in the CCT group. In addition, parents in the TF-CBT group reported less emotional distress than that of parents in the CCT group. This study is important because it provides support that a shortened version of the TF-CBT protocol has benefits that persist (at least for 6 months) after treatment has concluded. That children experienced less abuse-related shame during follow-up is also important to note as shame may mediate the impact of sexual abuse and hinder long term recovery. Cohen, Mannarino, and Knudsen (2004) examined a 16-session (eight sessions trauma based and eight sessions grief based) trauma-focused cognitive-behavioral therapy (CBT) for childhood traumatic grief (CTG). Traumatic grief occurs when trauma symptoms interfere with a child s ability to successfully deal with the normal grieving process. Twenty-two children and their primary caretakers received the CTG intervention. Results indicated that children experienced significant improvements in CTG, PTSD, depression, and anxiety symptoms and a reduction in behavior problems. PTSD symptoms improved only during the trauma-focused treatment components, whereas CTG improved during both trauma-focused and grief focused components. In addition, parents also experienced significant improvement in PTSD and depressive symptoms. In a follow-up study to Cohen, Mannarino, and Knudsen (2004), Cohen, Mannarino, and Staron (2006) examined the effectiveness of a 12-session CBT CTG model in treating trauma and grief symptoms. Despite the relative effectiveness of the 16-session approach, this study sought to examine the impact of a shortened version of the CBT CTG protocol used in Cohen, Mannarino, and Knudsen to match shorter bereavement treatment protocols serving children with trauma and grief. Participants included 39 children and adolescents ranging in age from 6 to 17 years who had experienced a loss of a parent or sibling because of accidental death, medical reasons, homicide, suicide, or drug overdose. Significant improvement in children s self-reported symptoms of CTG, PTSD, depression, and anxiety were reported. In addition, parents reported improvement in their child s PTSD, internalizing, and externalizing symptoms, and total behavior problems, but they themselves did not report improvement in their depressive symptoms. Similar to the results of Cohen, Mannarino, and Knudsen, a decline in PTSD symptoms and improvement in adaptive functioning was observed only during the trauma-focused phase of CBT whereas CTG symptoms improved for both the trauma- and grief-focused CBT interventions. The authors conclude that trauma-focused
6 204 Little et al. and a shortened version of a grief-focused CBT protocol is effective at reducing PTSD and CTG, and anxiety, behavioral problems, and depressive symptoms. This study has practical utility because it demonstrated that a shortened version of a trauma- and grief-focused CBT can be effective at improving childhood trauma and grief symptoms. This study also involved a collaborative approach with children and parents so that the information gained from therapy can be transferred between home and clinic and potentially improve generalization and maintenance. Kitchiner, Phillips, Roberts, and Bisson (2007) conducted a pilot study to evaluate the effectiveness of a TF-CBT educational training package coupled with a mental health practitioner clinical group supervision (CGS) component for the treatment of PTSD. Ten professionals ranging in experience levels from certified psychiatrists to a midwife with no experience participated as therapists. Therapists received between 6 and 23 sessions of TF-CBT training (e.g., education, case discussions, role plays, and manualized training). Each therapist provided services to at least one participant for a range of 5 16 hours of time spent in a dyad. Results indicated that PTSD symptoms improved significantly on the Beck Depression Inventory and a secondary measure. In addition, participants also reported slight increases in adjustment related to being alone and at work. Despite the improvements reported in the pilot study, these results may need to be viewed with a cautious eye because of minimal control and comparison groups. One would want to potentially assess the relative impact of the TF-CBT+CGS against TF-CBT alone to determine if CGS adds more strength to TF-CBT. In addition, this study did not provide the ages and gender of the participants and therapists. Further exploration should be conducted to assess the benefit of coupling GCS with TF-CBT. Schools often do not provide students with appropriate and necessary mental health services because they do not have the appropriate resources or because students are not triaged as needing such services (Walker, Ramsey, & Gresham, 2004). Indeed, TF-CBT should be evaluated with much more scrutiny to determine its relative effectiveness and practical utility with school-age children, as well as the social acceptability and habilitative properties for the student, teacher, and family members. In the only published study to date in schools, Kataoka et al. (2003) used group TF-CBT with Latino immigrant students who have been exposed to community violence. Participants included 198 students in Grades 3 8 with trauma-related depression and/or PTSD symptoms. The therapy was delivered in Spanish. Results indicated that students in the intervention group (n = 152) had significantly greater improvement in PTSD and depressive symptoms compared with waitlist controls (n = 47) at 3-month follow-up. Findings suggest that this program can be implemented in school settings and is associated with a decline in trauma-related mental health problems. Clearly, as discussed earlier, children and adolescents are experiencing traumatic events. However, most school psychologists are not receiving specific training in efficacious service delivery. TF-CBT is an effective therapeutic technique that can be used in many different types of traumatic situations (e.g., natural disaster; see Akin-Little & Little, 2008). It behooves school psychologists to take advantage of this free training to be able to meet the needs of children who may have been victims of a traumatic event and, in this way, insure the best possible prognosis for all children. REFERENCES Akin-Little, K. A., & Little, S. G. (2008). Our Katrina experience: Providing mental health services in Concordia Parish, Louisiana. Professional Psychology: Research and Practice, 39, American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author. Bureau of Justice Statistics. (2006). National crime victimization survey: Violent crime trends, U.S. Department of Justice Office of Justice Programs. Retrieved September 14, 2007, from viortrdtab.htm. California Evidence-Based Clearinghouse for Child Welfare ( ). Trauma treatment for children. Retrieved September 13, 2007, from
7 Children and Traumatic Events 205 Cautela, J. R., & Groden, J. (1978). Relaxation: A comprehensive manual for adults, children, and children with special needs. Champaign, IL: Research Press. Chadwick Center for Children and Families. (2004). Closing the quality chasm in child abuse treatment: Identifying and disseminating best practices. San Diego, CA: Author. Cohen, J., Mannarino, A. P., & Staron, V. R. (2006). A pilot study of modified cognitive-behavioral therapy for childhood traumatic grief (CBT-CTG). Journal of the American Academy of Child and Adolescent Psychiatry, 45, Cohen, J. A. (2005). Treating traumatized children: Current status and future directions. In E. Cardeña, & K. Croyle (Eds.), Acute reactions to trauma and psychotherapy: A multidisciplinary and international perspective. New York: Haworth Press. Cohen, J. A., Deblinger, E., & Mannarino, A. P. (2004, September). Trauma-focused cognitive-behavioral therapy for sexually abused children (pp ). Psychiatric Times, 21(10). Retrieved December 6, 2007, from Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multi-site, randomized controlled trial for sexually abused children with PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 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 & Adolescent Psychiatry, 35, 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 & Adolescent Psychiatry, 36, Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: The Guilford Press. Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood traumatic grief: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 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, DeBellis, M. D., Keshavan, M. S., Clark, D. B., Casey, B. J., Giedd, J. N., Boring, A. M., et al. (1999). Developmental traumatology: II. Brain development. Biological Psychiatry, 45, Deblinger, E., Mannarino, A. P., Cohen, J. A., & Steer, R. A. (2006). A follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 45, Dryden, W., DiGiuseppe, R., & Neenan, M. (2003). A primer on rational emotive behavior therapy (2nd ed.). Champaign, IL: Research Press. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, Kataoka, S. H., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P. Tu, W., et al. (2003). A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child Psychiatry, 42, Kitchiner, N. J., Phillips, B., Roberts, N., & Bisson, J. I. (2007). Increasing access to trauma focused behavioural therapy for post traumatic stress disorder through a pilot feasibility study of a group clinical supervision model. Behavioural and Cognitive Psychotherapy, 35, Leckman, J. F., & Mayes, L. C. (2007). Nurturing resilient children. Journal of Child Psychology and Psychiatry, 48, Walker, H. M., Ramsey, E., & Gresham, F. M. (2004). Antisocial behavior at school: Evidence-based practices. Belmont, CA: Wadsworth/Thompson Learning.