The National Children’s Alliance (2017) reports that more than 700,000 children

experience trauma annually and that more than two-thirds of children report at least one

traumatic event by the age of 16 in the United States. Children who experience trauma, or

traumatic events, become vulnerable to suffering from both short-term and long-term

consequences. As the rate of childhood trauma experiences increases so does the demand for

effective interventions. Trauma Focused Cognitive Behavioral Therapy is a successful

psychotherapy model that has been proven to be effective at treating trauma related symptoms in

children and adolescents.

Trauma

Traumatic events can include are interpreted and experienced by every person differently.

The more common occurrences involve physical abuse, sexual abuse, emotional abuse,

environmental disaster, war, loss of a loved one, or a car accident. Trauma, as defined by the

International Society for Traumatic Stress Studies (2017), is a term used to describe “negative

events that are emotionally painful and that overwhelm a person’s ability to cope” (“What is

Childhood Trauma,” para. 1). When these traumatic events happen frequently the impact of the

trauma becomes more severe and complex. Complex trauma has been defined as “the experience

of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often

of an interpersonal nature and early-life onset” (van der Kolk, 2005, p. 402).

Because the brain is not fully developed until the around the age of 25, exposure to

trauma have severe negative impacts on the brains of children. Enduring or witnessing abuse has

a unique, and severe, impact in the lives of toddlers as they cannot process their feelings with
others or talk to others about their experiences due to their lack of brain development,

independence, beneficial resources, and assistance from others. Therefore, they have a higher

likelihood of critical, long-term effects such as developmental delays, having unhealthy

attachments, and emotional dysregulation.

A large study involving over 17,000 people was conducted from 1995-1997 by Kaiser

Permanente and the Centers for Disease Control and Prevention that studied the long-lasting

effects of adverse childhood experiences, or ACEs, in adults by using a ten-question survey. The

survey questions were constructed to measure if the participant had experienced specific forms

of abuse, household challenges, and neglect before the age of 18 by responding “yes” or “no.”

According to the study, adverse childhood experiences have been linked to risky health

behaviors, chronic health conditions, low life potential, early death (CDC, 2017). The Kaiser and

CDC researchers reported that higher health risks were correlated with higher ACE scores.

Additional research has since been conducted to study the associations between behavioral

patterns and ACE scores. Perez, Jennings, Piquero, and Baglivio (2016) found that higher ACE

scores were predictive to traits of aggression and impulsivity, in addition to, higher rates of

substance abuse, suicidal behavior, and school difficulties.

Trauma symptoms may manifest as hyperarousal, mood changes, behavior and

relationship problems, avoidance, nightmares, decreased self-esteem, poor hygiene and overall

self-care, aggression, and depression. The most common psychiatric diagnosis’s in children with

histories of chronic trauma are separation anxiety disorder, oppositional defiant disorder, phobic

disorders, PTSD, depression, and ADHD. Evidence based practice treatment is imperative to

prevent the adverse, long-term effects of trauma.

Trauma Focused Cognitive Behavioral Therapy

 Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence based practice

that has been highly recognized for the effectiveness of treating children with trauma related

diagnoses. This psychotherapy model was originally formulated to address the treatment needs

of child sexual abuse victims by Dr. Anthony Mannarino, Dr. Judith Cohen, and Dr. Esther

Deblinger (Child Welfare Information Gateway, 2017). TF-CBT integrates cognitive, behavioral,

interpersonal, family, humanistic, attachment, and empowerment models of therapy, as well as,

the use of trauma-sensitive interventions to treat youth that have experienced trauma. TF-CBT

was designed to be flexible and creative as the therapist focuses on the direct needs of the client

based on strengths, age, interests, and developmental level.

The TF-CBT Treatment model has been modified from only treating child sexual abuse

victims and is now being used in a variety of trauma related treatment programs. TF-CBT has

been restructured over the last 15 years to treat children and adults with anxiety, depression,

PTSD, and even those with histories of chronic traumatic experiences. (National Child Traumatic

Stress Network, 2004). A new faith-based version of TF-CBT was developed by Walker, Lewis-

Quagliana, Wilkinson, and Frederick (2013) in which Christianity principles are implemented

into every intervention component. The therapy model has been contributed to decreasing the

amount of cognitive, relationship, and family difficulties, in addition to, somatic and high-risk

behaviors in trauma victims.

P.R.A.C.T.I.C.E. Components

This therapy model is comprised of three different phases; the stabilization phase, the trauma

narrative phase, and the integration/consolidation phase (The National Child Traumatic Stress

Network, 2008). The specific components of these three phases form the acronym PRACTICE.

The stabilization phase includes psychoeducation, parenting skills, relaxation and stress
management, affective expression and modulation, cognitive coping and processing. Trauma

narration and processing is also called the trauma narrative phase. Lastly, the integration and

consolidation phase entails in vivo mastery of trauma reminders, conjoint child-parent sessions,

and enhancing safety (The National Child Traumatic Stress Network, 2008). Gradual exposure is

a significant element in TF-CBT and is used throughout the entire treatment. In TF-CBT children

are gradually exposed to trauma reminders and memories throughout sessions so not to

overwhelm the child and ensuring that they are equipped with proper coping mechanisms feel

that thinking and talking about the trauma can be done safely.

Psychoeducation

Psychoeducation is employed at the onset of treatment to educate children and caregivers

on the impact of trauma, common child and caregiver reactions, the therapeutic process, and the

connection between thoughts, behavior, and feelings. During the first session, information about

the child’s diagnosis, the components of the treatment plan, and the structure of therapy should

be discussed (Cohen & Mannarino, 2008). The therapist might use statistics, such as one in four

girls are victims of sexual abuse, to normalize the traumatic experience decrease the stigma and

feelings of loneliness that are often associated with being a victim of trauma.

Parenting

Because children are highly dependent on parents, or caregivers, it is important to involve

them in the treatment process. This form of therapy recognizes the importance of the child’s

relationship with their parent as a central component in the effectiveness of the treatment

outcome. The main purposes of involving the parent, or caregiver, are to “increase the

caregiver’s ability to effectively parent the child, ensure that the caregiver recognizes the need
for gradual exposure, and address the caregiver’s own distress and cognitive distortions related to

the child’s trauma” (Kliethermes, Drewry, & Wamser-Nanney, 2017, p. 169) The parenting

component of the TF-CBT model teaches communication skills, parenting skills, behavioral

management skills, and stress management for the parent as they too are adapting to the

challenging behaviors that develop after trauma. Conjoint parent and child counseling sessions

are also aimed at enhancing communication and creating an alliance between the child and

parent as they both learn to adapt with the aftermath of the trauma. However, due to the number

of children that are in foster care due to neglect and abuse, a TF-CBT model has been formed

that tailors to the needs of this population.

Relaxation

Relaxation skills are necessary for the TF-CBT model as they “reverse physiological

arousal effects of trauma” and are especially useful to help children manage their emotions more

effectively when reminders of trauma occur. (The National Child Traumatic Stress Network,

2008, p. 9). Relaxation techniques can be taught through mindfulness, yoga, muscle relaxation,

deep breathing, and meditating. In addition to these techniques, coping skills are also

implemented and are tailored to the needs of the child. Coping skills can include activities such

as listening to music, blowing bubbles, singing, playing sports, drawing, and covering up with a

blanket. Teaching children simple relaxation techniques and coping skills help them self-soothe

and provides them with a sense of control to use when they begin to feel escalated (Cohen &

Mannarino, 2008).

Affect Expression and Modulation

 The Affect modulation process is essential for children to “identify and modulate

upsetting affective states including problem solving, anger management, present focus, obtaining

social support, and positive distraction activities” (The National Child Traumatic Stress

Network, 2008, p. 9). This also includes the parent and child learning to appropriately manage,

identify and express their emotions. Interventions may include a wide variety of feelings games

in which different feelings are discussed or acted out through role playing.

Cognitive Coping

By learning cognitive processing skills, the child and parent can better understand the

connections among thoughts, feelings, and behaviors and can allow the child to replace negative

thoughts with more accurate, positive thoughts. This also allows children, and parents, to learn

that they are in control of their own actions, thoughts, and feelings.

Trauma Narrative

The TF-CBT model requires the client to write a detailed narrative of their traumatic

experiences. According to the TF-CBT Implementation Manual that was distributed by The

National Child Traumatic Stress Network in 2008, the first chapter of the trauma narrative

focuses on the child’s identification factors, such as, name, age, grade, hobbies, and interests, the

second chapter focuses on what the child, and their life was like before the traumatic event, the

third chapter is the comprehensive description of the traumatic event using words and drawings,

while the fourth chapter concludes what the child has learned from the trauma and the treatment,

what advice the child would give others going through the same experience, and how their life is

different now.
 Critics argue that writing a trauma narrative is putting the child at risk for more trauma,

while TF-CBT trained therapists argue that it is a necessary step in overcoming the trauma.

Writing the trauma narrative and processing through it is especially helpful in learning cognitive

processing skills. Creating the trauma narrative aids in “overcoming avoidance of traumatic

memories, identifying cognitive distortions through the child’s telling of the story in his or her

own words, and contextualizing the child’s traumatic experiences into the larger framework of

the child’s whole life” (Cohen & Mannarino, 2008, p.160). During this time, the therapist will

help the child to identify emotions and specific details of the trauma, as well as, change themes

of cognitive distortions involving shame, self-blame, and low self-esteem that were expressed

through the trauma narrative. The process of the trauma narrative is much more important than

the final product (Kliethermes, Drewry, & Wamser-Nanny, 2017).

In Vivo Exposure

According to the California Evidence-Based Clearinghouse for Child Welfare (2017), in

vivo exposure encourages the “gradual exposure to innocuous trauma reminders in the child’s

environment so that the child learns they can control their emotional reactions to things that

remind them of the trauma” (“Essential Components,” para. 6). This is helpful for children to

reintegrate back into their normal routine and ending overgeneralizations of thoughts that involve

the traumatic event. For example, if a child was bitten by a dog that caused severe trauma, the

therapist and caregiver will work with and slowly introduce being around dogs for the child to

understand that all dogs are not dangerous

Conjoint Parent-Child Sessions

 The conjoint parent-child sessions are aimed at enhancing communication, developing a

safety plan, and sharing the trauma narrative with the parent. The therapist will have already

shared the trauma narrative with the parent in a previous individual session so that the parent

could process the information and subsequent feelings with the therapist alone. Because of this,

the parent can fully support the child during this process and praise them for sharing their

traumatic story, instead of dealing with their own emotions of hearing the detail for the first time.

After the child shares the trauma narrative, the child and parent can ask each other questions

regarding the narrative and discuss any ongoing fears while the therapist is observing in the

background (Cohen & Mannarino, 2008).

Enhancing Future Safety and Development

The final component of TF-CBT is designed to enhance personal safety and future

growth. At this point in the treatment model, the client is provided psychoeducation on personal

safety skills, healthy interpersonal boundaries in relationships, problem solving, social stressors,

and any additional skills that the family may need going forward and after treatment (National

Child Traumatic Stress Network, 2017).

Effectiveness

TF-CBT has been beneficial to children by decreasing the amount of intrusive thoughts

and avoidance behaviors. TF-CBT treatment research indicates that children “demonstrate

improved interpersonal trust and social competence, develop improved personal safety skills, and

show reductions in depression, anxiety, disassociation, behavior problems, sexualized behavior,

and trauma-related shame” upon finishing treatment (Child Welfare Information Gateway, 2012,

p.7). Jensen et al. (2014) found that TF-CBT was more effective in treating multi-traumatized
youth that displayed posttraumatic stress symptoms than other forms of therapy. Deblinger,

Pollio, Runyon, and Steer (2017) found that TF-CBT lead to significant improvements in

personal resiliency, in addition to, reduced emotional reactions to stressors. The improvements in

personal resiliency are significant to victims of childhood trauma as they tend to have higher

rates of risk for future victimization.

Conclusion

Traumatic events experienced by children have lasting effects on their overall well-being

well into adulthood. The ACE study has proven the significance of childhood trauma in relation

to health outcomes to which society members pay the price. Although there are many different

therapy models that can be used to treat post-traumatic stress symptoms and PTSD, TF-CBT is a

well-organized, evidence based practice that has been demonstrated to be effective at treating

trauma related disorders and building resiliency in trauma victims. The TF-CBT has also been

modified to treat numerous mental health disorders that will help millions of survivors live a

more fulfilling life.

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