Trauma focused CBT for children with co-occurring trauma and behavior problems

Abstract

Objective

Childhood trauma impacts multiple domains of functioning including behavior. Traumatized children commonly have behavioral problems that therapists must effectively evaluate and manage in the context of providing trauma-focused treatment. This manuscript describes practical strategies for managing behavior problems in the context of trauma-focused evidence-based treatment (EBT) using a commonly implemented EBT for traumatized children.

Methods

The empirical literature is reviewed and practical strategies are described for conducting trauma- and behavioral-focused assessments; engaging families in trauma- and behavioral-focused treatment; treatment-planning that includes a balance of both trauma and behavioral foci; managing ongoing behavioral problems in the context of providing trauma-focused treatment; managing behavioral crises (“crises of the week”); addressing overwhelming family or social problems; and steps for knowledge transfer.

Results

Trauma-focused EBT that integrate behavioral management strategies can effectively manage the behavioral regulation problems that commonly occur in traumatized children.

Conclusions

Addressing trauma-related behavioral problems is an important part of trauma-focused treatment and is feasible to do in the context of using common trauma-focused EBT.

Practice implications

Integrating effective behavioral interventions into trauma-focused EBT is essential due to the common nature of behavioral regulation difficulties in traumatized children.

Introduction

More than half of the children and adolescents (hereafter referred to as “children”) in the USA have experienced a potentially traumatic event such as child abuse, sexual assault, domestic violence, community violence, bullying, serious accidents, fires, disasters, medical trauma, or the traumatic death of a loved one. Approximately a quarter of exposed children develop significant symptoms of Posttraumatic Stress Disorder (PTSD) (Copeland, Keeler, Anglod, & Costello, 2007). Since PTSD places children at increased risk for other psychiatric and medical conditions and may derail normal developmental processes, it is important for these children to receive early and effective treatment (American Academy of Child and Adolescent Psychiatry, in press).

Effective treatments for PTSD symptoms and co-occurring psychiatric problems are available. One evidence-based treatment (EBT) for PTSD is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). TF-CBT is a structured individual and parent trauma-focused model that includes initial skills-based components followed by more trauma-specific components with gradual exposure integrated into each component (Cohen, Mannarino, & Deblinger, 2006; www.musc.edu/tfcbt). TF-CBT components are summarized in Fig. 1. Optimally TF-CBT is provided to children and parents or primary caretakers in parallel individual sessions with additional conjoint child-parent sessions included later in treatment. Flexible application of TF-CBT with early and specific focus on the positive parenting component can accommodate complex trauma presentations including significant behavior problems.

TF-CBT was initially tested in specialty trauma treatment clinics in which referred children primarily presented with PTSD symptoms. Inclusion criteria for these studies required the participation of a supportive parent or caregiver. However many of these children had histories of multiple trauma exposure and co-morbid conditions such as depression or behavior problems (Cohen, Deblinger, Mannarino, & Steer, 2004) TF-CBT worked well for children exposed to a variety of traumas, multiple traumas, both genders, and various ethnic and racial backgrounds.

There is considerable interest in transporting TF-CBT to routine clinical settings in which most children receive mental health care. In the USA, public mental health centers are a primary setting for child mental health service delivery. Many children exposed to trauma also initially present in domestic violence shelters, multi-service centers for refugee and immigrant children, or substance abuse programs. TF-CBT has recently been used with positive outcomes in usual care settings such as community mental health centers, for children living in foster care (Amaya-Jackson et al., 2009, Northwestern University, 2008) and in National Child Traumatic Stress Network Learning Collaboratives (NCTSN, www.nctsn.org) conducted in non-specialty settings.

Many traumatized children presenting for care in community settings are not seeking treatment for trauma-specific psychological impact. Sometimes the trauma history is known (e.g., domestic violence programs) but the focus is on other considerations such as establishing safety and stability. In other instances, the trauma history and related symptoms may not be known at the time of referral but be disclosed during the assessment.

In addition to trauma exposure, many of these children have experienced other significant adversities that affect emotional and behavioral adjustment. Children may have been neglected, unsupervised, or exposed to harsh or inconsistent parenting practices; many have problematic attachments. For example, approximately 50% of children seen in public mental health settings have had an open child welfare case within 2 years and many of these children are brought to treatment by their abusive or neglectful parent (Lau & Weisz, 2003).

Beyond their clinical conditions, a substantial proportion of these children continue to live in compromised circumstances. Many families are poor and disadvantaged and struggle with a whole array of difficulties in simply managing to meet basic survival needs. The parents often have their own psychiatric conditions. Others are involved with the criminal justice system. Of particular importance for helping children with trauma-related psychological impacts is that many children are still exposed to the sources of trauma impact. This may mean that they live with their abuser or an offender as is common in cases of child physical abuse and domestic violence, or they still live in the dangerous and violent communities that produced their traumatic stress symptoms. Thus most children exposed to potentially traumatic events who are referred for clinical care in public mental health have multiple problems, often including significant externalizing behavior problems (e.g., oppositional, noncompliant, physically aggressive, intrusive, destructive, or sexually inappropriate behaviors). These are often the problems for which their parents initially bring them for therapy, rather than PTSD or other trauma-related problems. If during assessment the clinician identifies the child's trauma impact as a clinically significant concern and offers trauma-focused therapy as an option, the behavior problems and other relevant considerations for the family must be a focus of treatment or the family will likely not be motivated to engage in treatment, since the behavior problems will likely persist or escalate if the clinician does not address them and effectively manage behavioral crises that arise during the course of trauma-focused treatment.

Evidence-based treatments exist for behavior problems. There is a substantial literature documenting the effectiveness of a variety of parent behavior management approaches (Eyeberg, Nelson, & Boggs, 2008). These interventions are primarily behavioral, target parenting skills, and are often fully parent-mediated. They do not address emotional problems that children with behavior problems may have. There is also a highly effective cognitive behavioral treatment for children with sexual behavior problems regardless of the cause of the behaviors (Carpentier, Silovsky, & Chaffin, 2006).

In contrast, TF-CBT addresses both trauma-related emotional and behavior problems. However, it is not clear that clinicians in routine practice settings are familiar with or skilled at delivering the parenting behavioral interventions that are the essential ingredients of this component of TF-CBT, especially in cases where the behavior problems are prominent. In order for TF-CBT to be effective with trauma-affected children who also have behavior problems, the parenting component will likely require a specific and sustained focus in therapy.

The parenting component of TF-CBT consists of the application of standard behavior management and skills training applied within the context of trauma-focused therapy. The parent management components include increasing positive parent-child encounters, reinforcement of positive behavior, ignoring minor irritating behavior, giving effective instructions and meting out consequences for misbehavior (e.g., time out, withdrawal of privileges). These strategies involve behavior monitoring and explicit behavior management plans. Core skills training for both children and parents involve teaching problem solving and communication. These are specific skills that require behavioral rehearsal and practice between sessions. The purpose of this paper is to describe how TF-CBT can be successfully implemented for children with coexisting trauma symptoms and significant behavioral problems, including frequent “crises of the week” (“COW”).