1. Treating traumatized children with TF-CBT -
A study of process and outcome
Estonia, Tallin, October 3-4, 2012
Evidence-Based Practice in Working with Children and
Youth at Risk: The Norwegian Experience.
Tonje Holt, Tine K. Jensen, Randi Saur & Silje M. Ormhaug

2. The Research Group
- TF-CBT
Tine K. Jensen, Project leader
Karina Egeland, Research coordinator
Silje S. Hukkelberg, PhD. Post doctoral candidate
Silje M. Ormhaug, Research fellow/ PhD Candidate - assessments
Tonje Holt, Research fellow/ PhD Candidate - assessments
Shirley D. Stormyren, Specialist in psychology - training/treatment fidelity
Live E. C. Hoaas, Specialist in psychology – training /treatment fidelity
Lene B. Granly, Specialist in psychology – training /treatment fidelity
Tore Indregard – Statistics
ToRe Wentzel-Larsen - Statistics
Ingeborg Dittmann, Psychologist – treatment fidelity
Kristin Glad, Psychologist – treatment fidelity
Tor Iversen, Professor in Health economy, Faculty of Medicine,
Eline Aas, Accociate Professor in Health economy, Faculty of Medicine
+ 4 graduate students in Psychology
2

3. This Presentation:
• The Norwegian context
• What is TF-CBT?
• The NorwegianTF-CBT study
Design and Research q’s
Sample
Preliminary results
(main results and process results)
Satisfaction
• Implementing an EBT in ordinary clinics
• Asking about traumas

4. 4

5. The Norwegian Context I
• Population: 4.7 million (CO = 5.0 mill)
• 5 % subjected to violence every year
• Figures are stable

6. Explanations
Gender High Access to
equality employment education
A positive Equal
economy income

7. The historical development
From the private to the public sphere
“the personal is political”
• Women’s movement
• Mens violence against women, late 1970 -
• Political incentives; The past 10-15 years:
– Activities initiated and stimulated from a political
level
– Resources are allocated
– More knowledge
– New target groups

8. National action plans from 2000
The changing governments have presented
successively three action plans, entitled…
•Violence Against Women (2000 - 2003)
•Violence in Close Relationships (2004 - 2007)
•Turning Point; violence in Close Relationships
(2008 - 2011)
•Also released Action plans etc against; female genital
mutilation (2008 – 2011), forced marriage have been
presented (2008 – 2011), sexual and physical abuse of
children (2005 - 2009) and Reports NOU on Combating rape
(2008) & Rape- sexual assaults (2012-2014)

9. Objectives common to all action plans
• Attitudinal changes in society
• Strengthening professional communities and
expertise
• Assistance to victims of violence
• Development of therapeutic services for
perpetrators of violence

10. Two reports may be of interest
http://www.nkvts.no/biblioteket/Sider/brn.aspx
• Violence prevention in Norway. Activities and
measures to prevent violence in close
relationships (Saur, R., Hustad, A. E. & Heir, T. 2011)
• Research and education on prevention of violence
at the Norwegian Centre for Violence and
Traumatic Stress Studies (Saur, R., Hjemdal, O. K. &
Heir, T., 2011)
10

11. Overarching strategies in violence prevention
Prevention through…
• Teaching and knowledge dissemination
• Interventions and treatment
• Campaigns and information

12. However:
- A minority of the activities in our material
are evaluated by external research bodies.
- There is little systematic evidence of the
effects of violence prevention.

13. The Norwegian Context II
• ≈ 5-25% of youth population exposed
to interpersonal traumas in Norway
(Mossige and Stefansen, 2007)
• In 2007 4,5 % of the child population
received psychological
services (estimated need 5 %)
• Little is known about the quality of
interventions!
13

14. Trauma - Focused CBT (TF-CBT)
• Developers: Judy Cohen, Anthony Mannarino
& Esther Deblinger
• Short term, 12-15 sessions
• Based on theoretical principles from
cognitive, behavioral, interpersonal and
family therapy, in addition to trauma-theory
14
http://tfcbt.musc.edu/

15. TF-CBT Components
• PRACTICE
 Psychoeducation and Parenting Skills
 Relaxation
 Affective Modulation
 Cognitive Processing
 Trauma Narrative
 In Vivo Desensitization
 Conjoint parent-child sessions
 Enhancing safety and social skills

16. TF-CBT Cont.
• One of the most recommended treatments for
children who have experienced severe trauma and
present with significant post-trauma symptoms
• 11 RCT studies so far
• More improvement in child PTS symptoms,
depression, anxiety, shame and behavior problems,
compared to control groups
• More improvement in parental distress, support and
depression compared to control groups.
Deblinger et al., 1996, 1999; Cohen & Mannarino, 1996, 1997, 1998; King et al.,
2000; Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino,
Iyengar, 2011. 16

17. However
٥ No RCT studies in clinics outside the U.S. by
independent research groups
٥ Few effectiveness studies
٥ Can TF-CBT be implemented in regular
clinics, with “regular” clients, with therapists
that have ordinary case loads and that are
not trauma specialists.
٥ In Norway no special trauma clinics –
Can TF-CBT be used where the children
usually receive mental health services?
17

18. The Norwegian TF-CBT Study:
Overall Aim:
٥ Understand more of what treatment is beneficial for
traumatized youth and why (both effect and process)
Research questions
٥ Is TF-CBT more efficient than TAU in reducing trauma related
symptoms?
٥ What role does the therapeutic alliance play in treatment
outcome?
٥ What role does parents’ reactions and support play in
treatment outcome?
٥ What role does child post-trauma cognitions play in treatment
outcome?
٥ Is TF-CBT more cost effective?
٥ Do children and parents find the model useful?

19. The Norwegian TF-CBT study
Design
RCT design
In 8 regular child guidance clinics
156 child participants
28 therapists trained in TF-CBT
60 TAU therapists involved
19

20. The Norwegian TF-CBT study
Cont.
Inclusion criteria:
٥ Youths aged 10-18.
٥ Experienced a trauma
٥ Have PTSD symptoms over cut-off of 15 on CPSS
(clinical cut-off 11)
٥ Speak Norwegian
Exclusion criteria:
٥ Psychotic, suicidal
20

21. Treatment fidelity
check
Procedure
Therapy as usual
Assessed Assessment Assessment Assessment Follow-up
Referral for trauma T1 After 6. session after 15. session 12 &18 month
T2 T3 T4 & T5
TF-CBT
Treatment fidelity
check
21

22. Flow chart Assessed for eligibility
(n=454)
Met inclusion criteria (n=200)
Declined to participate (n=44)
Randomized
(n=156)
Allocated to Allocated to
TF-CBT (n=79) TAU (n=77)
Drop out Drop out
before session 6 before session 6
(n=14)
18% 25% (n=19)
22

23. Participants
• Gender: 80% girls, 20% boys
• Age: mean age 15 years
• 73 % Norwegian
• Mean no. of different traumatic events: 3.6
(SD = 1.7, range 1-10)
• Clinical population: multi-traumatized, high scores
on PTS, depression and anxiety
23

24. Worst trauma (n = 156)
20,5 %
Loss/accidents/
injury
20 %
Violence outside
30 %
Violence family
19 % SA outside
10,5 % SA family

25. Measures
• PTSD (CAPS + CPSS)
• Depression (MFQ)
• Anxiety (SCARED)
• Posttraumatic
cognitions (CPTCI)
• General mental
health (SDQ)
• Quality of life (16D)
• Therapeutic
Alliance (TASC-r)
• Parental emotions
and depr. (PERQ, CES)
• Parental support
(PSQ)
• Social support
(FFSQ)
25

26. Measures Interviews
• PTSD (CAPS + CPSS) • Children &
• Depression (MFQ) parents about
• Anxiety (SCARED) assessments
• Posttraumatic
cognitions (CPTCI) • Children &
• General mental parents about
health (SDQ) therapy
• Quality of life (16D) • TF-CBT
• Therapeutic therapists
Alliance (TASC-r) about using the
• Parental emotions model
and depr. (PERQ, CES)
• Parental support
(PSQ)
• Social support
(FFSQ)
26

27. Measures Interviews Other ifo
• PTSD (CAPS + CPSS) • Children & • Demographics
• Depression (MFQ) parents about • Other services
• Anxiety (SCARED) assessments provided
• Posttraumatic • Life changes
cognitions (CPTCI) • Children &
• General mental parents about • New traumatic
health (SDQ) therapy incidents
• Quality of life (16D) • TF-CBT • Therapist data
• Therapeutic therapists
Alliance (TASC-r) about using the
• Parental emotions model
and depr. (PERQ, CES)
• Parental support
(PSQ)
• Social support
(FFSQ)
27

28. Some preliminary Results:
Child Symptoms
28

29. PTS symptoms
30
TAU
26.88
TF-CBT
26.82 Effect size: .51
25
p= .001
20.68
CPSS Sum Score
20
18.90 16.87**
15
11.34
11
T1 T2 T3
Time
Results based on mixed effect analysis. Significant difference at T3. 29
n = 156

30. PTS - symptoms’ influence on daily functioning
11
10.33
Effect size: - .55
p= .001
10
FCPSS Sum Score
8.90
9
9.22**
8.03
8.47
8
7.99
TAU
TF-CBT
7
T1 T2 T3
Time
Higher values indicate less influence on daily functioning
Results based on mixed effect analysis. Significant difference at T3.
n = 156 30

31. % that met PTSD (diagnosis)
measured by CAPS
*
p = .035
n = 110

32. Depression
35 35.32
TAU
35.43 TF-CBT
Effect size: .54
30
27.82 p = .006
25
MFQ Sum Score
24.73
22.66**
20
15
14.40
11
T1 T2 T3
Time
Results based on mixed effect analysis. Significant difference at T3.
n = 156 32

33. 35 Anxiety
TAU
33.32 TF-CBT
Effect size: .30
34.12
p = .150
30.38
30
SCARED Sum Score
28.56
25
24.82
19.67
20
T1 T2 T3
Time
Results based on mixed effect analysis. No significant difference at T3.
n = 156 33

34. Preliminary results:
What do we know about the therapy
processes?
-any active ingrediens in therapy?
• 1) Parents
• 2) Post trauma cognitions
• 3) Therapeutic alliance

35. Preliminary Results
-active ingredients
1) Parental stress
Do the parents show less emotional
reactions at the end of therapy?
- And do the emotions have a mediating effect on
outcome?
Measurements: PERQ, CES-D
”I have felt upset about my child’s trauma»
“I felt that everything I did was an effort”
35

36. Parental depression
20
BOTH GROUPS
Parental distress
18
CESD Sum Score
16
22.5
14
BOTH GROUPS
PERQDistress Sum Score
20.0
12
10
17.5
T1 T2 T3
Time
15.0
T1 T2 T3
Time

37. PERQShame Sum Score
4.0 4.5 5.0 5.5
T1
Shame
T2
Time
BOTH GROUPS
T3
PERQGuilt Sum Score
8 9 10 11 12
T1
Guilt
T2
Time
BOTH GROUPS
T3

38. Baron & Kenny,
1986
Mediation
Parental
emotional
reactions
a b
Intervention C
Outcome
TF-CBT/ TAU
C’

39. Baron & Kenny,
1986
Mediation
Parental
emotional
reactions
B C
Intervention A
Outcome
TF-CBT/ TAU
D

40. Preliminary Results
-active ingredients?
2) Post-trauma cognitions
Measurement: CPTCI
“My reactions since the frightening event mean I
have changed for the worse”
“I am a coward”
“I don’t trust people”
40

41. Baron & Kenny,
1986
Mediation
Post trauma
cognitions
a b
β = .28, t(112) = 3.10, p < .001 β = .85, t(112) = 17.07, p < .001
C’
β = .01, t(112) = .11, p =.915
Intervention
TF-CBT/ TAU Outcome
C
β = .25, t(121) = 2.77 p < .001

42. Preliminary Results
-active ingredients
3) Therapeutic alliance
“The Alliance-Outcome Relationship in
Treatment of Traumatized Youths”
TF-CBT vs TAU (Ormhaug, 2012)
Measured by TASC
“The therapist and I have found a good way to work on the
difficult thoughts and feelings I got after what happened”
“The therapist tries to help me with the difficult thoughts and
42
feelings I got after what happened”

43. How is the alliance related to
outcome?
Therapeutic Aliiance Outcome

44. How is the alliance related to outcome?
Outcome
Est: -0.48**
Est: 0.05
TF-CBT
TAU Therapeutic alliance

45. Preliminary results:
What do we know about the processes?
-the active ingrediens in therapy?
• 1) The child’s improvement is not related to
parents’ reduction in emotional reactions/
stress.
• 2) Change in dysfunctional thoughts within
the child seems to be an important
explanatory variable.
• 3) Good results are dependent on WHAT
the therapist does, and HOW this is done
(tecnique and theraputic alliance)

46. Client satisfaction
What do the children think about the
treatment?
47

47. Children (TF-CBT n = 56, TAU n = 59)
I liked coming to the clinic
Not at all ----------------------------All the time

48. Children (TF-CBT n = 56 , TAU n = 59)
If I needed help again, I would come back to this clinic
Yes --------------------------------------------------No

49. Children (TF-CBT n = 56, TAU n = 59)
Coming to this clinic helped me with my problems
Not at all--------------------------------------All the time

50. Implementation an EBT in ordinary clinics
- challenges and experiences
• Resources
• Anchoring/ grounding in leadership/
management
• More than one therapists
• Fidelity
• Training
54

51. Therapists
 Training
2-6 days of training
session by session consultation – from audiotapes
web based training
 No. of cases per therapist: mean = 3 (1-6)
Learning the model as the study is being conducted
55

52. Initial challenges for
implementing an EBT
Resistance to manuals
Therapists with different educational
backgrounds
My cases are special – need longer time.
Hard to stay on track - COWs
Avoidance of trauma narrative
Stayed on the first (PRAC) components
56

53. “The importance of asking for
traumas”
Traumas are often omitted from the referrals
Trauma screening & assessments rarely done
Treated for other disorders (depression, ADHD, social
phobia)
Almost none receive trauma focused interventions
Therapists feel they are not giving adequate treatment
(Hjemdal, 2006; Ormhaug, Jensen, Hukkelberg, Holt & Egeland, in press)

54. What do the children think of being
asked about their trauma and trauma
problems
(in a research setting)
58

55. Children (n = 97)
Did you think it was upsetting or distressing to
answer questions about your trauma experience(s)?
60
49,5
50
40
30
19,6
20
10,3
10 7,2 8,2
3,1 2,1
0
Not 2 3 4 5 6 Very
distressing distressing
59

56. Children (n = 97)
Did you have a lot of feelings when you answered the questions?
40
35,1
35
30
25 21,6
20 18,6 18,6
15
10 6,2
5
0
No feelings Minimal Some, but Some Very strong
feelings not strong strong feelings
feelings
60

57. Children (n = 97)
Would you be willing to answer the same questions again?
60
50,5
50
40
30 27,8
20
12,4
9,3
10
0
Quite willing Might be Don't think be Definitely not
willing willing willing
61

58. Summary
• TF-CBT had a significant better improvement in child’s
trauma related symptoms
• Parents emotional reactions do also decline during the child's
therapy process, but in this study this was not related to the
child’s improvement
• Change in dysfunctional thoughts seem to be an important
active ingredient in therapy
• A good alliance is important, but there has to be something
more; not sufficient in TAU
• TF-CBT can, should and will be implemented in Norwegian
clinics: better outcomes, clients and therapists happy about it.
• Screening for trauma is important

59. Thank you for your attention!
tonje.holt@nkvts.unirand.no