More than two-thirds of American children will experience a potentially traumatic life event by age 16, according to psychologist Anthony Mannarino, PhD. That number might sound high. But "when you think about violence, abuse, traffic accidents, bullying, deaths in the family — you can get up to two-thirds pretty quickly," he says.
Decades ago, psychologists had little in the way of evidence-based help to offer these children, according to Mannarino, a professor at the Drexel University College of Medicine and vice chair of the department of psychiatry at Allegheny General Hospital in Pittsburgh. That's what inspired him and colleagues Judy Cohen, MD, a psychiatrist, and Esther Deblinger, PhD, a psychologist, to develop Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in the 1980s. The course of therapy — usually 12 to 18 sessions — has been shown to reduce PTSD, anxiety, depression and other symptoms in children and families.
Mannarino spoke to the Monitor about how Trauma-Focused Cognitive Behavioral Therapy works, and how he is using mobile technology to enable more children to benefit from it.
Who is this therapy for?
We've been studying Trauma-Focused Cognitive Behavioral Therapy, TF-CBT for short, for 25 years, and we have pretty good data showing its effectiveness with children as young as 3 and as old as 18.
We've studied the treatment with children who've been sexually abused, children exposed to domestic violence, children who've had traumatic losses, children exposed to multiple traumas. And it's been studied around the world at this point — in Japan, in Norway, in Germany, in the Netherlands, and even in some low-resource countries like Zambia and the Democratic Republic of Congo, where children have been exposed to civil war, to sex trafficking, to really complicated trauma backgrounds and histories.
Is it equally effective in all those situations?
Yes, fortunately, it has worked equally well with different traumas. There have been 16 randomized controlled trials that have been done, demonstrating the efficacy with a variety of populations of children. Eight have been conducted by our team and the other eight by other research teams around the world.
Maybe the biggest surprise was that it was effective even in the low-resource countries like Congo and Zambia, where some of these children have been exposed to as many as 10 different types of trauma experiences, and have had little or no access to mental health services. You wouldn't necessarily expect that it would work as effectively with children with such extensive trauma backgrounds. But the research that's come out from us and others has shown that some of the effect sizes, the actual size of the outcomes, are equal to if not greater than what we've found here in the United States with the populations we've studied.
How does the treatment work?
It's a phase-based treatment. The first part focuses on stabilizing a child's clinical symptoms, and includes psychoeducation. We work with families to help them understand the connection between the child's trauma exposure and current clinical presentation. We also educate the child and caretakers about the impact of the specific trauma that the child has experienced.
So for example, for a child who was sexually abused, the early part of the treatment might involve talking about what sexual abuse is and how often it happens — giving them information so they understand that they're not the only ones who've experienced this. We try to normalize this experience and tell them that lots of kids who've experienced it feel ashamed, or scared, or other things they're feeling.
Then we help the youngster with skills development, such as relaxation skills and other affective-regulation skills. For example, if they're having bad dreams or intrusive thoughts, they can use deep breathing or relaxation strategies. They also learn how to use feeling words to describe what's going on — like "I'm feeling really angry" or sad. Because we know that when children can describe their feelings, they're less likely to act out those feelings in destructive ways.
We also work with children to understand the basics of cognitive processing, so they begin to understand the relationships between thoughts, feelings and behaviors.
All of this is done early, to really help children stabilize their emotions and their behavior. During this early part, most children start to improve some.
Then, we launch into them sharing the details of what happened to them. That's the trauma narration and processing. As the child recounts the narration, the therapist might note distortions in the thoughts, such as, "It was my fault," and then help the child resolve those distortions.
Usually, TF-CBT takes 12 to 18 sessions. For children with really complex trauma backgrounds, it can be as long as 25 sessions.
How does this differ from cognitive behavioral therapy with adults?
In many ways it's kind of a hybrid. We're using cognitive behavioral interventions in the early part of treatment to help a child stabilize, but then we move on to trauma narration and processing.
That involves helping children slowly, incrementally, one step at a time, be able to tell their stories about the trauma they've experienced, their feelings about those experiences, and their thoughts about those experiences, and then helping to identify any distortions or unhelpful thoughts that they have about their trauma.
For example, when children have thoughts like, "It was my fault that this happened," the goal is to help them look at their trauma in a different way so that they have more accurate and more helpful thoughts about their trauma exposure.
Are there big differences in how this works for older children, teens and younger preschool-age children?
No. The outcomes with the younger children are as good as with the older children. But of course how you would implement the model with a young child — a 3-, 4-, or 5-year-old — is going to be very different than with a teenager.
With 3-, 4- and 5-year-olds, we use a lot of play materials in a structured way, to help the children learn how to identify feelings and more easily express feelings and progress through TF-CBT. With an older youth or adolescent, TF-CBT will include more typical verbal psychotherapy, although we try to incorporate interests and activities that the youth enjoys. So if a teen enjoys music, they might listen to music and talk about the emotions it evokes. And that gives them the opportunity to talk about emotions more generally, which they can transfer to talking about trauma.
Have you been able to follow any groups for the long term?
The longest we've been able to follow them is two years, which isn't a super-long time, but not bad for a treatment outcome study. In the follow-ups we've done, we've found that the treatment gains that children made at the end of TF-CBT were maintained two years out. Those gains include reductions in PTSD symptoms, depression, anxiety and behavior problems.
What's also really important is that parents who participated in the treatment make significant gains as well. They have reductions in their own depression, PTSD symptoms, and distress related to the child's trauma experience, and also significant increases in their support of the child.
Our research shows that the significant gains the parents have made correlate with children having reductions in their own symptoms, particularly with the younger children. If parents have made gains in their own PTSD and depression, they're going to be more available for their children in the aftermath of trauma, and that's going to make a big difference.
You've said that early on, one barrier to implementing this therapy was therapists' hesitancy to talk to children directly about trauma. Is this still a problem?
Sometimes therapists have been reluctant or worried that they would retraumatize children if they encouraged them to talk about it. But the truth is that whether we ask them to talk about it or not, those memories are living inside of these children and affecting their minds, bodies and brains in highly adverse ways.
So as therapists, we have to be brave enough to talk to children about it so that they can begin to externalize their feelings and their thoughts instead of those memories just living inside of them. The purpose of TF-CBT is to help families and children become less avoidant and be able to confront their feelings and their thoughts about the trauma experience.
Of course, trauma work can be painful for therapists because we're having to hear the stories that children tell us about their trauma backgrounds. Because of that, when therapists are learning TF-CBT, we strongly encourage them to make sure they're taking good care of themselves, having a life away from work and actually practicing some of these same relaxation skills that we're encouraging children to learn as part of therapy.
What are your future directions for research?
We hear with some frequency from therapists that the early cognitive processing part of the treatment — helping children understand the connections between thoughts, feelings, and behaviors — isn't easy for children to learn. And sometimes it's hard for therapists to teach, particularly therapists who aren't all that experienced with a cognitive behavioral approach.
Because of that, Judy Cohen and I teamed up with students and faculty from the Entertainment Technology Center at Carnegie Mellon University to develop a video game to help therapists teach children cognitive processing. The game is called TF-CBT Triangle of Life, and it's free through the Apple store or the Google Play store. The game is set in an African jungle, where a lion teaches other animals to connect thoughts, feelings and behaviors, and most importantly to modify thoughts to help them feel better. For example, a fish gets hit with a banana peel and immediately thinks the monkey threw it because he was mad at him. The lion helps this fish understand that maybe the monkey didn't purposely throw the banana peel at him, maybe it was an accident. And then the lion discusses how if you thought it was an accident, how would you think about that versus if you thought the monkey was actually trying to hit you with the banana peel?
Those kinds of situations help children learn to connect thoughts, feelings and behaviors, and also to help them see that if you change your thoughts, you can feel better as well. The game has been downloaded several thousand times, and we've gotten a lot of good feedback on it.
