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Review of Trauma-Focused Cognitive Behavioral Therapy Research
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was originally designed for children, adolescents, and non-offending caregivers facing the crisis of child sexual abuse. Early investigations evaluating the potential benefits of this model in individual and group formats were conducted via pre–post and quasi-experimental designs (Deblinger et al., 1990; Stauffer & Deblinger, 1996). Later, at independent sites in Pennsylvania (Cohen and Mannarino) and New Jersey (Deblinger and colleagues) very similar TF-CBT models were scientifically evaluated via randomized controlled trials. In a study evaluating the efficacy of TF-CBT as compared with non-directive supportive therapy for 67 preschool children with a history of child sexual abuse, Cohen & Mannarino (1996b) found that preschool children (2 to 7 years) randomly assigned to TF-CBT exhibited significantly greater improvements with respect to inappropriate sexual behaviors, as well as general behavior problems, than did children assigned to non-directive supportive therapy. The results of a similar investigation, examining the treatment responses of 49 older children who had experienced child sexual abuse, demonstrated that children (7 to 14 years) assigned to TF-CBT exhibited significantly greater improvement with respect to social competence and depression than did those assigned to the non-directive supportive condition (Cohen & Mannarino, 1998). Deblinger, Lippmann, & Steer (1996) conducted a randomized trial for 90 children (7 to 13 years) with a history of child sexual abuse in which the specific effects of the parent and child interventions associated with TF-CBT were examined. In this investigation children and their caregivers were randomly assigned to one of three TF-CBT conditions (i.e., child only; parent only; parent and child), or a community referral condition. The results of this study demonstrated that children randomly assigned to participate in the TF-CBT child intervention (i.e., child only or parent and child) showed significantly greater improvement with respect to PTSD than did children assigned to the community referral and/or parent only conditions. The non-offending parent’s participation in one of the TF-CBT conditions (i.e., parent only or parent and child), on the other hand, was associated with significantly greater improvements with respect to parenting practices, children’s levels of externalizing behavior problems, and child-reported depression. A randomized controlled trial also examined TF-CBT in the context of group treatment (Deblinger, Stauffer, & Steer, 2001). TF-CBT provided in group format in the aftermath of child sexual abuse led to significantly greater benefits for 44 young children (2 to 8 years) and their caregivers when compared with less structured support/educational groups. Within-group effect sizes were generally medium to large for the TF-CBT group as compared with small to medium within-group effect sizes for the support group. Caregivers in the TF-CBT groups as compared with those in the support groups demonstrated significantly greater improvement with respect to abuse-related emotional distress. Young children in the TF-CBT groups showed greater improvement with respect to body safety skills than did those assigned to the children’s support/educational groups. However, no differences were noted between the conditions with respect to children’s PTSD symptoms, potentially because young children in both conditions experienced exposure to child sexual abuse educational information, and the narrative component was not incorporated into the children’s TF-CBT groups due to the young age of the children and the group format.
In more recent years, the above researchers collaborated in refining the TF-CBT model for children and further evaluating its efficacy in multisite investigations. In their initial multisite investigation, 229 children (aged 8 to 14) were randomly assigned to TF-CBT or a child/client-centered approach. Children in the TF-CBT condition exhibited significantly greater improvement with respect to PTSD, depression, feelings of shame, dysfunctional attributions, and behavior problems (Cohen, Deblinger, Mannarino, & Steer, 2004). Likewise, non-offending caregivers participating in this study reported greater improvements with respect to their self-reported abuse-related distress, depression, parenting practices, and parental support of the child when they were assigned to TF-CBT compared with the client-centered condition (Cohen et al., 2004). Between-group effect sizes were generally within the medium range. In a recent multisite dismantling study, 210 children aged 4 to 11 were randomly assigned to one of four conditions in which TF-CBT was delivered in 8 versus 16 sessions, with and without the narrative component (Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011). The results of this investigation indicated that TF-CBT delivered with the narrative component in 8 sessions, appeared to be the most efficient and effective in helping children overcome abuse-related fear and generalized anxiety, whereas the 16-session skills-focused condition without the narrative seemed to be most effective in helping parents improve their parenting practices and in turn assisting their children in overcoming externalizing behavior problems. Effect sizes were large within the various conditions. It should also be noted that the clinical improvements reported in several of the above treatment outcome investigations have been maintained over 1- and 2-year follow-up periods (e.g., Cohen & Mannarino, 1997; Cohen, Mannarino, & Knudsen, 2005; Deblinger, Mannarino, Cohen, & Steer, 2006; Deblinger, Steer, & Lippmann, 1999). Finally, the results of the above studies by the original TF-CBT developers have been replicated by other researchers, further documenting the efficacy of TF-CBT with children who have experienced sexual abuse, as well as youngsters exposed to other traumas (i.e., Dorsey, Kerns, Trupin, Conover, & Berliner, 2011; King et al., 2000; Lyons, Weiner, & Scheider, 2006). In summary, TF-CBT has been evaluated in numerous scientific investigations, including over a dozen completed randomized controlled trials. Moreover, this treatment approach has received the highest ratings for its efficacy based on extensive reviews of the treatment outcome literature sponsored by the Department of Justice (Saunders, Berliner, & Hanson, 2004; www.musc/edu/cvc), the US Department of Health and Human Services (www.nrepp.samhsa.gov), and the California Evidence-Based Clearinghouse for Child Welfare (www.cebc4cw.org).