Evidence-based psychotherapies for children and adolescents by Weisz and Kazdin (third edition) – Chapter 15 summary

Trauma-focused cognitive behavioural therapy (TF-CBT) addressed problems specifically associated with traumatic events that children experience or witness (e.g. PTSD). TF-CBT targets PTSD symptoms and outcomes associated with trauma. A PTSD diagnosis is not required.

PTSD includes negative cognitions about oneself, others or the world and negative affective states. There may be dysregulation in affective, behavioural, cognitive and physiological areas of functioning. TF-CBT targets reregulation in each of these areas with the goal of optimizing children’s adaptive functioning after trauma.

The main goal of TF-CBT is to help children overcome traumatic avoidance (1), shame (2), sadness (3), fear (4) and other trauma-specific emotional and behavioural difficulties (5). TF-CBT is not a first line treatment but can help children after they have stabilized.

TF-CBT includes cognitive-behavioural, attachment, family, humanistic, and psychodynamic therapy principles. The overall level s of adjustment in all areas (e.g. physiological; emotional) impact each other and influence overall well-being. TF-CBT thus attempts to reduce the impact of trauma across these areas and this is believed to lead to overall improvements.

There are several pathways to PTSD after trauma:

1. Classical conditioning
   This holds that a learned association during the trauma leads to avoidance and this exacerbates the problem.
2. Emotional processing theory
   This holds that posttraumatic symptoms reflect the development of a problematic fear structure comprising many stimuli, responses and meaning representations. When this is triggered, there are maladaptive reactions.

These theories state that exposure is essential. The social-cognitive theory focuses on the impact of trauma on pre-existing or developing beliefs about one’s self, others and the world. It states that trauma-related feelings and thoughts should be reviewed to process the experience fully and correct dysfunctional beliefs and emotional reactions.

The family environment and the therapeutic relationship is also essential. TF-CBT may reduce parental distress and enhances parents’ support for their children.

Goals of TF-CBT include:

• Mastering skills to manage stress and improve affective, behavioural and cognitive  regulation early in treatment.
• Inclusion of parents or other caretaking adults in treatment whenever feasible.
• Mastering trauma reminders and traumatic avoidance.
• Making meaning and contextualizing traumatic experiences through affective and cognitive processing (i.e. moving beyond victimization).
• Enhance safety and optimizing future development.

TF-CBT focuses on children between the ages of 3 and 18. The treatment is adapted depending on the developmental stage of a child and parents receive TF-CBT in parallel individual or joint child-parent sessions.

TF-CBT consists of several components named PRACTICE:

• Psychoeducation
  This provides information to children and parents about the nature of traumatic experiences and common reactions to trauma (i.e. normalize experience and reactions). Psychoeducation occurs throughout treatment. Euphemisms are avoided.
• Parenting skills
  This provides parents with training to target the child’s symptoms and practice what the children are learning in treatment. Additionally, parents’ emotional responses to the child’s trauma are also addressed.
• Relaxation skills
  This includes focused breathing (1), progressive muscle relaxation (2) and yoga (3). It serves to distract the child from traumatic thoughts or from re-enactment of traumatic behaviours and to re-regulate the nervous system (e.g. HPA axis) as a result of physiological dysregulation. A relaxation plan is developed and this is done until the children are able to self-soothe with increasing skills in diverse settings.
• Affective expression and modulation skills
  Traumatized children may have affective dysregulation (e.g. expressing feelings is dangerous) an identifying and expressing feelings in therapy is thus essential. After affective expression, modulation skills are introduce to help children manage the disruptive feelings. Parents are trained to aid the children in this.
• Cognitive coping skills
  Children are taught cognitive coping skills after they have mastered affective expression. They learn alternative explanations for negative events.
• Trauma narration and cognitive reprocessing of traumatic experiences
  The therapist helps the child to develop and cognitively process a detailed narrative about their traumatic experiences during this component. Trauma narration refers to the interactive therapeutic process that occurs over several sessions during which therapists gradually encourage children to share their traumatic memories, including feelings, sensations, thoughts and increasing detail. The trauma experience is contextualized and fully processed. Therapists identify dysfunctional cognitions regarding the trauma. These are then replaced by more helpful thoughts.
• In vivo mastery of trauma reminders
  In vivo exposure should only be used when it is determined that the feared stimulus is truly innocuous as the stimulus is otherwise an appropriate cue to be vigilant to potential danger. If it is innocuous, in vivo desensitization should be used. The child uses PRAC skills to tolerate and process fear. Complete follow-through of exposure is needed as it may otherwise reinforce avoidance.
• Conjoint child-parent sessions
  TF-CBT is delivered as individual child and parent sessions and there can be brief joint parent-child sessions. The conjoint sessions are important to change the agency of change from therapist to parent. Safety planning begins during these sessions.
• Enhancing safety and future developmental trajectory
  Safety planning includes making sure that a trauma does not recur without implying that the child should have done something differently during the actual trauma.

Each component builds on the previously mastered skills. Each component includes interventions provided to both child and parent. TF-CBT typically lasts 8-20 sessions. It is completed when all components have been provided. Other interventions to consolidate the skills may be necessary.

TF-CBT enhances parental support (1), effective parenting practices (2) and reduces parental levels of depressive and trauma-related symptoms (3). Parental emotional distress and parental support were significant predictors of children’s symptoms for preschool children. Children’s abuse-related attributions and perceptions and parental support predict treatment outcome in older children with a history of sexual abuse. Multiple-trauma history and higher levels of pre-treatment depression are moderators of treatment outcome but only for children receiving child-centred treatment.

TF-CBT may be preferred for children with multiple traumas and those with more depressive symptoms. It may be especially useful to overcome trauma-related behavioural and depressive problems. TF-CBT appears to be useful for children in foster care as well. Therapeutic engagement at the start of the treatment and the importance of successful treatment completion are essential. TF-CBT may also be useful for treatment after disasters.

TF-CBT leads to 80-90% remission rates of PTSD diagnoses. It is efficacious.