Empirical Research

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As other chapters in this book demonstrate, the majority of trauma literature focuses on adults. Despite the high prevalence and seriousness of childhood traumatic experiences, the literature on childhood trauma and its sequelae and treatment is somewhat limited. Although adult-focused work has informed and assisted the understanding, assessment, and treatment of childhood trauma (Foa, Rothbaum, Riggs, & Murdock, 1992), it is not sufficient for professionals to extrapolate information from the adult trauma literature to their work with children.

Research with regard to the treatment of various types of childhood trauma is still very much in its infancy. To date, there are only a handful of studies examining the treatment efficacy of treating a range of childhood traumas, such as exposure to community violence, witnessing domestic violence, physical abuse, and traumatic grief. One study, conducted by March, Amaya-Jackson, Murray, and Schulte (1998), found that an intervention based on cognitive-behavioral therapy (CBT) significantly reduced PTSD symptoms in a small group of children exposed to community violence. In a review of treatment for childhood trauma, Cohen, Berliner, and Mannarino (2000a) reported that the available literature addressing domestic violence focused almost exclusively on the battered women or the offenders. Clinical descriptions and reports addressing children's reactions and possible treatment goals are available, but no empirical treatment outcome investigations have been published.

With regard to child physical abuse, several studies have documented significant reductions in PTSD symptoms using a variety of CBT programs. Swenson and Brown (1999) followed children in a 16-week CBT group focused on exposure, social skills, anger management, and relaxation training. Results from this project demonstrated a reduction in the children's level of anxiety, dissociation, anger, and PTSD. In a well-controlled design examining treatment for physically abusive parents, Kolko (1996) demonstrated that individual CBT treatment was superior to family therapy and standard community care in reducing parental anger and use of physical punishment. Both CBT and family therapy led to significant improvements in child behavior problems, parental distress, risk for future abuse, and family conflict. It appears that an integrated child and parent CBT treatment model would lead to greater gains in child and parent functioning (Runyon, Deblinger, Ryan, & Thakkar-Kolar, 2004).

A recent pilot study documents the successful use of CBT-based interventions for treating childhood traumatic grief. Cohen, Mannarino, and Knudsen (2004) examined the efficacy of a 16-week CBT-based program with sequential trauma and grief-focused interventions. Children in the study showed significant improvements in symptoms of depression, anxiety, PTSD, and behavioral problems. The caretakers, who were also included in the treatment program, also showed significant improvement in symptoms of PTSD and depression. In sum, although there are a few empirically based treatment outcome studies focused on a range of childhood traumas, research in the field needs to be expanded.

The treatment outcome literature specifically in regard to the treatment of children who have suffered sexual abuse has grown significantly in the last decade. Empirical treatment outcome data for children who have suffered sexual abuse experiences have received the most attention (Cohen et al., 2000a). Recent reviews of treatment outcome research in this area suggest that trauma-focused CBT has the strongest empirical support for the effective treatment of PTSD and related difficulties with this population of children (AACAP, 1998; Cohen, Berliner, & March 2000b; Saunders, Berliner, &

Hanson, 2003). This chapter offers a description of a trauma-focused treatment model that is rooted in, and supported by, empirical research.

Our trauma-focused CBT treatment model emerged from the assessment research documenting the wide array of difficulties faced by children who have suffered sexual abuse, with the most common diagnosis being PTSD (Finkelhor, 1995; McLeer, Deblinger, Henry, & Orvaschel, 1992). Thus a broad-based approach that could be tailored to children's individual needs and could address difficulties in behavioral, cognitive, affective, and physiological domains was warranted. in addition, research in the field had established the potentially significant influence of nonoffending parents on a child's recovery from the experience of sexual abuse (Conte & Schuerman, 1987; Deblinger, Steer, & Lippmann, 1999). Thus this model was designed to ameliorate the wide array of posttrauma difficulties experienced by children and also assist nonoffending parents in coping with their own distress and optimally responding to their children's difficulties. Toward these goals, this treatment approach involves the participation of the child and nonoffending caregiver in individual therapy sessions that ultimately build toward joint caregiver-child sessions as well as family sessions when appropriate.

Over the past 15 years studies have been conducted that examined the efficacy of trauma-focused CBT models in individual and group contexts with children who have suffered sexual abuse. Deblinger, McLeer, and Henry (1990) first reported the findings of a pilot investigation examining the effectiveness of individual CBT designed for children who had suffered sexual abuse and who met DSM-III-R criteria for PTSD. The results revealed no significant improvement during a 2- to 3-week pretreatment baseline period, but significant improvements on standardized measures of PTSD, anxiety, depression, and behavior problems at posttreatment. However, it was noted that at posttreatment, a significant proportion of the treated children continued to exhibit mild depressive symptoms. This finding led the investigators to combine exposure-based interventions with cognitive therapy techniques that might more effectively target depressive symptoms.

Building on the above preliminary data, a 5-year randomized controlled trial was conducted to evaluate the relative efficacy of the parent and child components of the CBT model with therapy offered in the community (Deblinger, Lippmann, & Steer, 1996). Children between 7 and 13 years of age were randomly assigned to standard community care or one of the following three CBT conditions: (1) a child-only intervention, (2) a parent-only intervention, or (3) a combined child and parent intervention. in the parent-only condition, therapists did not work directly with the children, but rather worked with the nonoffending parents to help them develop skills to serve as their children's therapeutic agents. in the combined parent-child condition, therapists used the same CBT interventions working initially with children and parents individually and later in joint parent-child sessions. The posttreatment results demonstrated significantly greater improvements in parenting practices, children's externalizing behavior problems, and chil dren's self-reported depressive symptoms when nonoffending parents participated in the CBT interventions (i.e., parent-only and parent-child conditions). On the other hand, children's PTSD symptoms were significantly more likely to improve when children received treatment directly from the CBT therapist (i.e., child-only or parent-child condition). Finally, the significant improvements children made in PTSD symptoms, depression, and externalizing behavior problems following treatment were maintained throughout a 2-year follow-up period (Deblinger et al., 1999).

Several investigations have documented the efficacy of this CBT model in group therapy settings as well (Stauffer & Deblinger, 1996; Deblinger, Stauffer, & Steer, 2001). Most recently, the findings of a group treatment investigation, examining the comparative efficacies of supportive and CBT groups designed for very young survivors of sexual abuse (ages 2-8) and their nonoffending mothers, demonstrated that children assigned to the CBT group exhibited greater improvements in body safety skills compared to those in the support group (Deblinger et al., 2001). That no differences were found in children's PTSD symptoms across conditions may be due to the fact that gradual exposure and processing interventions were not utilized in the CBT group with the children because of their young age and the group format. On the other hand, mothers assigned to the CBT group did participate in exposure and processing exercises, and they did demonstrate significantly greater reductions in intrusive, abuse-related thoughts and negative parental emotional reactions compared to mothers assigned to the support groups.

Simultaneous with the work of Deblinger and her colleagues, Cohen and Mannarino developed and tested a very similar CBT approach that also included an individual parent component. Cohen and Mannarino (1996a, 1997) first evaluated the efficacy of this trauma-focused CBT model in comparison to nondirective supportive therapy, another well-defined alternative treatment, with preschool children and their nonoffending parents. The results of this investigation demonstrated the superior effectiveness of the CBT model over the nondirective model with regard to general behavior problems, sexual behavior problems and trauma-related emotional difficulties. These differences were sustained over a 1-year follow-up.

Cohen and Mannarino (1998) used a similar randomized controlled design to evaluate the efficacy of CBT versus nondirective supportive therapy with school-age children. This study also demonstrated the superior effectiveness of CBT over the nondirective approach in reducing self-reported depressive symptoms and improving social competence. The 1-year follow-up findings revealed superior improvement in PTSD and dissociative symptoms for those children who had completed trauma-focused CBT compared to nondirective therapy. In addition, the findings of intent-to-treat analyses indicated superior response in depression, state and trait anxiety, and in sexual concerns among children assigned to CBT from pretreatment to 12-month follow-up (Cohen, Mannarino, & Knudsen, 2003).

A recent study conducted in Australia with children who had been sexually abused utilized the above described CBT model and documented its replicability: Superior outcomes were reported for children randomly assigned to the CBT as opposed to the waiting-list control condition (King et al., 2000). These investigators also compared children who received CBT with or without caregiver involvement (i.e., family CBT vs. child CBT) and found no differences at posttreatment, but one important difference emerged at follow-up: 3 months after completing treatment, children who had participated in family CBT reported significantly less fear related to the sexual abuse as compared to those who received child-only CBT.

Recognizing the similarities of their treatment models, Cohen and Mannarino collaborated with Deblinger and her colleagues (Cohen, Deblinger, & Mannarino, 2005; Cohen, Deblinger, Mannarino, & Steer, 2004) in conducting the largest and first two-site randomized treatment outcome trial in the field. In this investigation, children 8-14 years of age and their nonoffending parents were randomly assigned to receive CBT or client-centered treatment. The results of posttreatment analyses demonstrated that children assigned to trauma-focused CBT, as compared to client-centered treatment, showed significantly greater reductions in PTSD, depression, behavior problems, abuse-related attributions, and shame. Similarly, parents who received CBT, as compared to client-centered treatment, exhibited significantly greater improvement in depression, abuse-specific emotional distress, support of the child, and positive parenting practices. Thus these findings seem to replicate and expand on the results of earlier investigations that have supported the superior efficacy of the CBT model over less-focused approaches to treatment. The case study described later in the chapter focuses on the application of trauma-focused CBT with a child who has suffered sexual abuse.

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