Practical strategiesTrauma focused CBT for children with co-occurring trauma and behavior problems
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”).
Section snippets
Assess for trauma exposure and trauma symptoms
Conducting a thorough assessment is critical to determining what problems to focus on during treatment. The first step in determining whether trauma-focused treatment is indicated is ascertaining the child's exposure and responses to trauma. Given the prevalence of exposure and the possibility of chronic PTSD, routine assessment of exposure and responses to trauma should become the standard of care in mental health settings. Although some clinicians have concerns about bringing up trauma
Present the assessment data and treatment options
The clinician can use the above information to decide whether trauma-focused therapy is appropriate for the child. Assuming the clinician has determined that TF-CBT may be appropriate for children with trauma impact and significant behavior problems, a first step would be for the clinician to present to the parent the information gathered during the assessment that supports the need to treat both trauma symptoms and behavior problems:
“From everything I have learned today it seems that your
Motivation and engagement strategies
The essence of therapy is that it is a change process. Two key components for successful behavior change have been identified. These processes are in addition to the availability of effective interventions. One is motivation. Motivation can be defined as problem recognition and readiness to change (Miller & Rollnick, 2002). In some cases such as substance abuse disorders it turns out that motivation for change can actually be as powerful as any intervention. The other process is engagement.
Addressing ongoing behavior problems
Behavior problems respond to training parents in behavioral skill interventions and teaching older youth TF-CBT skills such as relaxation, affective regulation and cognitive coping skills. When children's behavior does not improve it is usually because the behavioral interventions are not being implemented consistently or because they are being implemented incorrectly. It is the therapist's responsibility to ascertain why behavior problems are persisting by carefully analyzing why the agreed
Addressing crises of the week
Crises of the week (COW) are common in children with behavior problems. These typically take the form of episodes of disruptive behavior that the parents or others (e.g., schools) continue to be upset about or do not believe have been effectively resolved and therefore they are brought to the attention of the therapist as a pressing concern. Examples of serious COW are fire setting, stealing, initiating fights with peers, running away, alcohol or drug use, abusive behavior towards siblings or
Overwhelming family or social problems
Some children are brought to therapy to address behavioral or emotional problems even though there are more pressing problems in the family or environment that cannot be addressed through child psychotherapy. It is unfortunate but relatively common for well meaning providers and systems to recommend numerous services to troubled families in the hope of addressing their myriad problems and needs. For example in the child welfare system, parents are often expected to attend parenting classes,
Summary
TF-CBT is a highly versatile therapy model that targets trauma-specific emotional impacts and provides skills to children and families that are proven to be helpful in addressing behavior problems. When families of traumatized children present with behavior problems or complex situations, the therapist should decide whether the behavior problems can be effectively addressed by TF-CBT with the focus on the behavior problems being triaged up for immediate attention or whether the behavior is so
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Sleep in children exposed to adverse or traumatic events
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second EditionRole of Psychologists in Child Abuse Pediatrics
2022, Pediatric Clinics of North AmericaCitation Excerpt :However, there are still more than 650,000 US children in 2019 who were found to be victims of maltreatment, and more than 175,000 of them were physically or sexually abused.14 Maltreated children present with significantly more internalizing and externalizing problems than non-maltreated children and have greater risk for developing comorbid medical and/or psychiatric conditions that may further derail normal development.15–17 Clinical presentations may vary, regardless of the identified trauma.
Child and parent secondary outcomes in stepped care versus standard care treatment for childhood trauma
2022, Journal of Affective DisordersCitation Excerpt :While anger outbursts have not been studied as an outcome in trauma-focused treatment with children, children with PTSD are more likely to have anger outbursts than children without PTSD (Saigh et al., 2007). TF-CBT effectively integrates behavioral interventions to help children express emotions and control negative behavioral responses such that treatment is both trauma- and behavioral-focused (Cohen et al., 2010). Some of these same strategies, such as assisting the parent and child to develop a behavior plan, promoting emotion-regulation skills, and having parent-child meetings that facilitate communication and understanding of the traumatic experience, are used in Step One of SC-TF-CBT.
Emotional Dysregulation: A Trauma-Informed Approach
2021, Child and Adolescent Psychiatric Clinics of North AmericaCitation Excerpt :When trying to connect trauma to emotional dysregulation, it is critical to identify the temporal association of trauma and trauma reminders, while evaluating the presence of traumatic stress symptoms and clarifying historical comorbidity versus syndromic overlap. Furthermore, in stable patients, with emotional dysregulation associated with trauma, a trauma-focused outpatient treatment, such as TF-CBT, could be the definitive treatment to address the constellation of posttraumatic symptoms, including emotional dysregulation.7 As described by Layne and colleagues11 and demonstrated in Fig. 1, promotive, inhibitory and facilitative factors all are worth identifying when assessing the causative impact of traumatic experiences on poor outcomes, including emotional dysregulation.