January 7, 2011 — Children who witness domestic violence in the home and show signs of posttraumatic stress disorder (PTSD) can benefit from trauma-focused cognitive behavior therapy (TF-CBT) delivered in a community setting, results of a randomized controlled study suggest.

"This is the first study, to our knowledge, to document significant improvement in intimate-partner violence (IPV)–related PTSD and anxiety symptoms using a brief community TF-CBT compared with usual community treatment," the investigators, led by Judith A. Cohen, MD, medical director of the Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital, Pittsburgh, Pennsylvania, write.

"TF-CBT," she told Medscape Medical News, "is a relatively brief trauma-focused treatment for children and parents that helps children gain skills and talk directly about their trauma experiences in order to gain mastery over these experiences."

The study is published in the January issue of Archives of Pediatrics and Adolescent Medicine.

Key components of TF-CBT include the following:

Resiliency skills for child and parent (trauma education, relaxation, feeling and behavioral modulation skills);

Examining and changing unhelpful thoughts such as self-blame;

Creating a narrative about the trauma (in this case the domestic violence);

Helping the mother to understand how affected the child was by it;

Developing optimal ways of staying safe; and

Focusing on how children could feel safer in the face on ongoing danger.

Improvement in PTSD Symptoms

In a prior study, TF-CBT was superior to usual care, which comprises child-centered therapy and CCT for improving PTSD in sexually abused children, many of whom were also exposed to IPV. The current study assessed whether abbreviated TF-CBT (8 sessions rather than 12) would improve children's IPV-related PTSD symptoms to a greater extent than CCT.

A total of 124 children aged 7 to 14 years who had at least 5 IPV-related PTSD symptoms participated; 64 were randomized to TF-CBT and 60 to CCT. In both interventions, parents and children participated in eight 45-minute individual therapy sessions. For those in the TF-CBT group, parts of 2 sessions were spent with the child and parent together rather than separately.

The dropout rate was high (39.4%), the study authors note, which is not unexpected, given the study setting — a community domestic violence center "where people go when they are fleeing perpetrators," said Dr. Cohen. People who come to the center for help typically struggle with multiple safety issues, as well as emotional, financial, legal, and practical problems and often access "only time-limited therapy."

Actually, the dropout rate in the study was far lower than typical dropout rates in child community mental health settings, which may actually "support the project's external validity," the study team notes.

Children who received TF-CBT, relative to those who got usual care, showed statistically significant and clinically significant improvement in IPV-related PTSD symptoms, the investigators report, and outcomes did not differ by race.

In intent-to-treat analyses, "superior" outcomes were achieved with TF-CBT on a number of measures, including the following:

Total Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-PL; mean difference, 1.63; 95% confidence interval [CI], 0.44 – 2.82);

Self-reported PTSD symptoms (University of California at Los Angeles PTSD Reaction Index (mean difference, 5.5; 95% CI, 1.37 – 9.63);

K-SADS-PL hyperarousal (mean difference, 0.71; 95% CI, 0.22 – 1.20);

K-SADS-PL avoidance (mean difference, 0.55; 95% CI, 0.07 – 1.03); and

Screen for Child Anxiety Related Emotional Disorders (SCARED, anxiety; mean difference, 5.13; 95% CI, 1.31 – 8.96).

In completer analyses, those completing TF-CBT had significantly greater improvement than those completing CCT on these measures as well.

TF-CBT also had clinical benefit. For example, the PTSD remission rate was significantly higher in TF-CBT completers relative to CCT completers (75% vs 44%; P = .03). In addition, the average scores for the TF-CBT group moved from the clinical range to the reference range on the SCARED and the Child Behavior Checklist while remaining in the clinical range on these measures in the CCT group.

"This study did not examine which components of TF-CBT are most critical," said Dr. Cohen. She mentioned, however, that her team recently completed a different "dismantling" study that examined that question, which will be published in Depression and Anxiety later in 2011.

Finding the 'Active Ingredients'

Asked for his perspective on the study, Christopher M. Layne, PhD, of the UCLA National Center for Child Traumatic Stress in Los Angeles, California, noted the challenges inherent in implementing treatment outcome studies capable of producing significant effects under such conditions.

Speaking of challenges that currently face the broader child and adolescent mental health field, Dr. Layne noted that leading figures have recently issued challenges to "move beyond the study of evidence-based treatment alone to also address evidence-based explanations of how and why treatments work."

Dr. Layne noted that developing a deeper understanding of the essential elements and "active ingredients" of psychotherapy will enhance the field’s ability to intervene effectively with youth who show signs of treatment nonresponse. "In some cases, youth may simply need more sessions of the same treatment. In other cases, standard evidence-based treatment may need to be supplemented with other components in order to produce positive outcomes."

Dr. Layne noted that the effectiveness of some treatment components, such as psychoeducation or trauma processing, can be effectively studied using dismantling designs because they can be modularized and added vs dropped. Other, more "pervasive" treatment elements (such as the therapeutic alliance or group cohesion), although they explain large proportions of variance in treatment outcomes, usually cannot be studied using dismantling designs because they cannot be modularized. Such elements require other types of "active ingredient" study designs, such as designs that test their role as mediators of therapeutic change over time.

Dr. Layne also noted that the general treatment outcome literature indicates that therapy is "quite effective at what is often its primary aim — reduce mental distress (batting about 2 clinically improved cases out of 3 who receive treatment in well-designed studies that offer a standard course of evidence-based treatment). However, the evidence suggests that even a full standard course of treatment does not necessarily work for everyone who receives it — some patients simply do not significantly improve."

Stopping Family Violence

Dr. Layne was not involved in the study but wrote an accompanying commentary in which he focuses on progress to date in developing interventions for trauma-exposed children and offers recommendations for further advancing the field.

The findings in the current study, Dr. Layne writes, help "shed light on treatment practices that may significantly benefit children exposed to interpersonal violence, many of whom live under circumstances of ongoing threat and adversity."

Dr. Cohen emphasized that treatment is no substitute for action. "Ongoing domestic violence is detrimental to children's optimal development, and mental health treatment cannot take the place of protecting children from ongoing family violence," she said.

Of concern, among treatment completers in the study, 89% reported contact with IPV perpetrators and 66% reported experiencing new traumas during treatment.

More information on TF-CBT can be found on the TF-CBT Website.

The study was supported by the National Institutes of Mental Health. Dr. Cohen and Dr. Layne are members of the National Child Traumatic Stress Network (NCTSN). Dr. Cohen and a coinvestigator are authors of the book Treating Trauma and Traumatic Grief in Children and Adolescents, published by Guilford Press, which describes the TF-CBT treatment model, and they have financial interest in the publication of this book. Dr. Layne has disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011;165:16-21.