Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

Trauma-focused cognitive behavioral therapy for

children and families

Judith A. Cohen, Esther Deblinger & Anthony P. Mannarino

To cite this article: Judith A. Cohen, Esther Deblinger & Anthony P. Mannarino (2016): Trauma-
focused cognitive behavioral therapy for children and families, Psychotherapy Research, DOI:
10.1080/10503307.2016.1208375

To link to this article: http://dx.doi.org/10.1080/10503307.2016.1208375

Published online: 22 Jul 2016.

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Psychotherapy Research, 2016
http://dx.doi.org/10.1080/10503307.2016.1208375

EMPIRICAL PAPER

Trauma-focused cognitive behavioral therapy for children and families

JUDITH A. COHEN1, ESTHER DEBLINGER2, & ANTHONY P. MANNARINO3

1
Allegheny General Hospital, Allegheny Health Network, Temple University School of Medicine, Pittsburgh, PA, USA;
2
CARES Institute, Rowan University-School of Osteopathic Medicine, Stratford, NJ, USA & 3Department of Psychiatry,
Allegheny General Hospital, Allegheny Health Network, Temple University School of Medicine, Pittsburgh, PA, USA
(Received 28 April 2016; revised 13 June 2016; accepted 24 June 2016)

Abstract
Objective: This article provides information about trauma-focused cognitive behavioral therapy (TF-CBT), an evidence-
based treatment for traumatized children, adolescents, and families. Method: The evolution of the TF-CBT model is
described from the perspective of the treatment developers, including population of focus, conceptual and methodological
features of the research, critical challenges and design issues that have been confronted, and how they have been
addressed. Major research findings and their implications for clinical practice are also described, as well as future research
challenges and directions for young researchers starting out in this field. Results: The TF-CBT model has been been
tested in a variety of challenging research settings and has strong evidence for improving trauma symptoms across diverse
populations of traumatized children. Conclusions: TF-CBT is an effective and widely used treatment for addressing
childhood trauma.

Keywords: child psychotherapy; cognitive behavior therapy; trauma

Introduction
Trauma-focused cognitive behavioral therapy (TF-
CBT, Cohen, Mannarino, & Deblinger, 2006;
Cohen, Mannarino, Kliethermes, & Murray, 2012;
Deblinger, Mannarino, Cohen, Runyon, & Heflin,
2015; www.musc.edu/tfcbt) is an evidence-based
treatment for children and adolescents who have sig-
nificant trauma-related problems and their parents or
caregivers. This paper describes our perspective on
some aspects of the model and our future research
directions.
The TF-CBT Model
The TF-CBT model is a brief (8–25 session),
cognitive-behavioral, resiliency-building, com-
ponents- and phase-based model for trauma-
impacted children or adolescents and their parents
and caregivers. The nine TF-CBT components,
summarized by the acronym “PRACTICE” are
contained within three phases that are typically pro-
vided in equal length: Phase 1, Stabilization Skills
include the following components: Psychoeducation
about trauma impact; Parenting skills to address chil-
dren’s traumatic behavior responses and enhance
support, understanding and communication with
the child; Relaxation skills to reverse physiological
trauma responses; Affective skills to address
emotional trauma dysregulation; and Cognitive pro-
cessing skills to understand connections among
thoughts, feelings and behaviors and generate more
accurate and helpful thoughts. Phase 2 is Trauma
Narration and Processing which contains only one
component, Trauma narration and processing, to
describe and cognitively process the child’s personal
trauma experiences. Phase 3, Consolidation,
includes the following components: In vivo mastery
to address overgeneralized fear and avoidance of
innocuous trauma reminders; Conjoint child–parent
sessions to enhance communication about the
child’s trauma experiences and general parent–child

Correspondence concerning this article should be addressed to Judith A. Cohen, Professor of Psychiatry, Allegheny General Hospital, Alle-
gheny Health Network, 4 Allegheny Center, 8th Floor, Pittsburgh, PA 15212, USA. Email: judith.cohen@ahn.org

© 2016 Society for Psychotherapy Research

2 J. A. Cohen et al.
communication; and Enhancing safety and future
development to address these issues. During each
TF-CBT session, the therapist meets for about half
of the session with the child and about half of the
session with the parent or caregiver (during the con-
joint sessions, most of the session is spent with the
child and parent together). Since trauma involves loss
of safety and often, loss of trust that the parent can
keep the child safe, the therapeutic relationship is con-
sidered central to TF-CBT in enabling the child and
parent to optimally recover after trauma (Cohen, Man-
narino, & Deblinger, 2006).
The Focus of Our Research
Trauma Impact
Trauma exposure is pervasive: more than two-thirds of
children experience a potentially traumatic event
during childhood, one-third experience multiple
traumas, and at least 20% of trauma-exposed children
develop significant posttraumatic stress disorder
(PTSD) symptoms or related clinically important pro-
blems (Copeland, Keeler, Angold, & Costello, 2007).
Children who experience sexual abuse, domestic vio-
lence, or multiple traumas are particularly vulnerable
to long-lasting negative impacts such as PTSD. Our
interest in child trauma arose from our respective
experiences in pediatrics, child and adolescent psy-
chiatry, child psychology, consulting to child protec-
tive services, and collaborating on treatment studies
designed to address the therapeutic needs of those
impacted by sexual abuse. These varied experiences
made us aware of the scope of the problem of child
sexual abuse, and that more empirical research was
needed. When we began our clinical research careers
(in the early 1980s), empirical evidence about the
prevalence and impact of child trauma was sparse,
but our clinical experience and that of our colleagues
who worked in the field of child maltreatment
suggested that child abuse and other forms of child
trauma were far more pervasive and potentially dele-
terious than commonly appreciated at that time.
Developing Our Treatment Approach
Our conceptual framework (described below)
suggested that a collaborative treatment model in
which children and parents or primary caregivers (here-
after referred to as “parents”) were integrally included in
treatment was necessary for optimal outcomes. This
was confirmed by our initial work, which began by doc-
umenting the diverse types of clinical problems evi-
denced by children who experienced sexual abuse
including PTSD as well as anxiety, depressive and
behavioral problems (e.g., Mannarino, Cohen, &
Gregor, 1989; McLeer, Deblinger, Atkins, Foa, &
Ralphe, 1988). We also found that significant factors
that mediated the development of these problems
included children’s maladaptive cognitions about the
abuse, and family factors such as family cohesion, par-
ental support of the child, and parental distress related
to the child’s abuse (e.g., Deblinger, Hathaway, Lipp-
mann, & Steer, 1993; Mannarino & Cohen, 1996a,
1996b; Mannarino, Cohen, & Berman, 1994). Since
non-offending parents often co-experience their chil-
dren’s trauma (e.g., during domestic violence, in
which the parent is the direct victim; the death of the
child’s sibling, the child experiencing a dog bite that
the parent witnessed, etc.), we developed an instrument
to assess parental distress related to their child’s trauma
(Holt, Cohen, & Mannarino, 2015; Mannarino &
Cohen, 1996a). We specifically focused on factors that
could potentially be modified by treatment, since our
goal was ultimately to design and test a treatment
model for these children. This confirmed our belief
that including both children and parents in treatment
was the best approach to treating children following
sexual abuse.
Simultaneously, we were directing clinical treatment
programs in Pittsburgh and New Jersey, respectively,
for children who had experienced sexual abuse as well
as other traumatic experiences. At that time, no treat-
ment had evidence of efficacy for any type of child
trauma. We developed the best model that we could
come up with, combining elements of evidence-based
treatments for adult rape victims, evidence-based treat-
ments for child anxiety, behavioral and other problems
that our studies documented these children experi-
enced (e.g., Cohen & Mannarino, 1988; Deblinger,
McLeer, Atkins, Ralphe, & Foa, 1989; Mannarino,
Cohen, & Gregor, 1989); and our clinical judgment
based on treating many of these children. We initially
began these efforts as two independent teams (Cohen
& Mannarino; Deblinger & colleagues); however,
during collaborative meetings sponsored by the
National Center for Child Abuse and Neglect
(NCCAN, later OCAN), we became increasingly
aware of the similarities of our perspectives and thera-
peutic approaches toward treating this population. In
the mid-1990s, we became a collaborative team and
renamed our model TF-CBT. Deciding to work
together in this regard has been one of the most gratify-
ing and rewarding choices of our professional careers.
Expanding Our Focus
We initially chose to focus specifically on sexual
abuse because it was severely stigmatized and our
clinical impressions were that it was associated with
particularly negative outcomes; this has been

confirmed by subsequent research (e.g., Nelson et al.,
2002). As it became increasingly clear that the children
in our studies who had experienced sexual abuse had
also experienced multiple other forms of trauma
(Cohen, Deblinger, Mannarino, & Steer, 2004a), we
expanded our focus to include other types of child
trauma such as child traumatic grief (Cohen, Mannar-
ino, & Knudsen, 2004), disasters (CATS Consortium,
2010; Jaycox et al., 2010), domestic violence (Cohen,
Mannarino, & Iyengar, 2011), and multiple/complex
traumas (e.g., Cohen et al., 2016).
Conceptual and Methodological Features of
Our Research
Core Concepts Underlying Our Research
The distinct conceptual features of our research are
grounded in understanding the core concepts of
child trauma and how intervention might effectively
reverse these processes. Core concepts related to
PTSD briefly include the failure of fear extinction;
the role of maladaptive cognitions; the role of par-
ental distress/psychopathology, the importance of
parental support and the use of effective parenting
strategies in reversing trauma-related behavioral dys-
regulation; the role of developmental neurobiology
and the importance of practicing new skills in order
to build “resiliency brain pathways” and to reverse
the adverse neurobiological effects of trauma; and
the role of the therapeutic alliance in effecting positive
therapeutic change. These are described in more
detail elsewhere (Cohen, Mannarino, & Deblinger,
2012; Cohen, Mannarino, Perel, & Staron, 2006;
Craske et al., 2008; Deblinger et al., 2015).
Methodologic Features of Our Research
Important methodologic features of our research are
related to the fact that childhood trauma is inherently
complex, and childhood trauma responses are not
limited to one diagnostic entity such as PTSD
(National Child Traumatic Stress Network, 2012).
Specifically, child trauma impacts virtually all
domains of functioning, including affective, cogni-
tive, behavioral, interpersonal, and social. Due to
this complexity, we have always attempted to
examine a variety of outcomes. However, this has
often complicated research design issues. For
example, both in recognition of the complexity of
children’s trauma responses and the fact that the
PTSD diagnosis is imperfect for assessing children’s
trauma responses, we have rarely required a full
PTSD diagnosis for inclusion in our studies.
Instead, our inclusionary criteria have generally
required that children have a minimum number of
Psychotherapy Research 3
PTSD symptoms (e.g., at least five symptoms with
one in each cluster). In one randomized controlled
treatment outcome study of children who had experi-
enced sexual abuse, we did not require symptom
elevation in any single instrument, but rather
required only that in order to participate, a child
who had experienced sexual abuse needed to have
an elevated score on at least one of five assessment
instruments (Cohen, Mannarino, & Knudsen,
2005). While this closely replicated a community
sample of children who had experienced sexual
abuse and TF-CBT still outperformed the compari-
son condition, since fewer children had elevated
scores on instruments assessing pre-treatment levels
of PTSD, anxiety, anger, depression, sexual behavior
problems, social competence, or internal or external
behavioral problems, it decreased the likelihood and
power of finding significant group differences. As
expected, the effect sizes in that study were lower
than in other TF-CBT studies.
Comparison Treatment Conditions
Another important methodological feature of our
treatment outcome studies has been the nature of
the comparison conditions that we chose to use in
these studies. Since we have always directed clinical
programs that serve large numbers of traumatized
children and our primary goal has been for all chil-
dren treated in our programs to experience significant
improvement, we have not used wait list or “sham”
comparison designs. We instead have used compari-
son conditions intended to represent the best of what
was commonly provided by community therapists
such as Nondirective Supportive Therapy (NST)
(Cohen & Mannarino, 1996c) or Child Centered
Therapy (CCT) (Cohen & Mannarino, 2001),
which we believed would be at least as effective as
treatment available elsewhere in our respective com-
munities. In other words, while evaluating the relative
efficacy of TF-CBT, our commitment was for all chil-
dren in our studies to receive effective treatment
(Duncan, Miller, Wampold, & Hubble, 2010). Our
studies documented that children receiving NST or
CCT experienced significant improvement, albeit
less than those who received TF-CBT, and that
families were equally satisfied with these conditions
and TF-CBT. However, using effective comparison
conditions also necessarily decreased the effect size
differences found in our studies.
Including Siblings in Treatment Studies
Another methodological issue was whether to include
siblings in studies. We often encountered the situation
4 J. A. Cohen et al.
where several siblings in the same family experienced
the index trauma required for study inclusion (e.g.,
sexual abuse; domestic violence). Parents typically
wanted all affected siblings to participate in the
study if they met inclusionary criteria. Although our
research designs would have been “cleaner” if we
had included only one sibling per family and had not
needed to control for potential family confounds,
the realities of recruiting patients to participate in
research studies from a community clinic required
that we include all siblings that met inclusionary cri-
teria in families that were willing to participate in
research, using post hoc statistical methods to
control for family factors. It should be noted that in
many of our studies, the referrals came from child pro-
tection workers serving children and families in impo-
verished urban settings as well as more rural areas.
Thus, we believe that the diverse participants in
these studies were representative of the populations
served by many community mental health clinics
across the nation.
Research Challenges in the Real World
The above-described methodologic issues became
increasingly prominent as we began to conduct
studies outside of our own clinics such as a commu-
nity domestic violence program, foster care agencies,
and residential treatment facilities for adjudicated
youth. Balancing tensions between the demands of
“pure research” design considerations and funding
agencies, on the one hand, and the “real world” on
the other hand, has been an ongoing feature of our
research. This extended to how many instruments
to include for assessing symptoms. Any clinician or
administrator who practices in a community setting
can understand this issue, since community prac-
titioners must complete many instruments for
insurers, county funders, and so on, and neither
they nor their patients welcome additional demands
on the child’s or parent’s time, even when they are
paid (albeit minimally) to participate in research.
We believe these types of issues may have contributed
in part to diminishing the overall effect size of TF-
CBT in some studies, but they have also contributed
to the generalizability of TF-CBT in real-world set-
tings. For example, the effect size of TF-CBT
versus usual care in a community domestic violence
center, where families received only eight treatment
sessions and most families had ongoing contact
with domestic violence perpetrators, was .3 (Cohen
et al., 2011). In contrast, the effect size of TF-CBT
versus usual care in Norwegian community settings,
where families received 15 treatment sessions was
.51 (Jensen et al., 2014).
Critical Conceptual and Methodological
Challenges that We Have Addressed in Our
Research
Assessing PTSD: Its Own Challenge
Assessing the multiple domains of trauma outcome in
a standardized and reliable manner has been an
ongoing methodological challenge itself. For
example, PTSD is one of the most challenging dis-
orders to accurately assess in children, particularly
younger children who have limited ability to accu-
rately report their internal states and may not under-
stand some of the diagnostic criteria. There was no
instrument to assess PTSD in young children when
we conducted our first treatment outcome study
(1993–1996), so we created a parent questionnaire
to capture core features of this disorder in preschool
children who had experienced sexual abuse (Cohen
& Mannarino, 1996b). Diagnostic accuracy signifi-
cantly improves when trained interviewers ask both
child (in a developmentally appropriate manner)
and parent about the child’s symptoms. Additionally,
PTSD diagnostic criteria have changed with sub-
sequent iterations of DSM, requiring that assessment
instruments be revalidated and making it difficult to
directly compare results using different versions to
each other. For example, the introduction of a new
cluster of symptoms in DSM-5 that includes negative
alteration of mood and cognitions, while likely to
improve diagnosis of PTSD in children who were
previously under-identified with this disorder, will
mean that the DSM-5 version of child self-report
instruments such as the Child PTSD Symptom
Scale (Foa et al., 2016) will have more items than
the previous version, different cut-off scores, and
thus clinicians will not be able to easily compare
DSM-IV to DSM-5 scores.
Assessing Multiple Outcomes
As noted earlier, due to the complexity of children’s
trauma responses, PTSD has not been the only
outcome we have assessed. An important methodo-
logical challenge has been balancing the need to
assess multiple domains of trauma impact, with the
practical limits of time, cost, and children’s tolerance
for and reliability of completing multiple instruments
during assessments. We have included multiple
outcome instruments that assessed child depressive,
anxiety, internalized, and/or externalized behavioral
symptoms; maladaptive cognitions as well as feelings
of shame related to trauma experiences. Since we
have also believed that including parents was critical
to changing children’s outcomes, in various studies,
we have assessed changes in positive parenting

practices, parental support of the child, parental
distress about the child’s trauma, and parental
depression and/or PTSD.
Design Challenges That We Have Confronted
in Our Research and How We Have
Addressed These
Legal Challenges
We have encountered many design challenges in con-
ducting research for traumatized children. Child
sexual abuse is a crime, reporting requirements
apply, an investigation must occur, and there must
be documentation that the abuse occurred. Perpetra-
tors of child maltreatment are subject to criminal and/
or civil penalties (e.g., loss of child visitation or
custody), making it unlikely that they would admit
to such acts. These legal issues have complicated
our research designs in several ways. Prior to includ-
ing children in a sexual abuse study, there had to be
documentation that abuse had occurred; if an
alleged case was not indicated by Child Protective
Services (CPS) or police did not believe that the
child had been abused, we could not include the
child in the study. This may have biased our
samples, but given the focus of the studies, we
included only those children who were found cred-
ible by CPS and/or police. For our domestic violence
study, a Pennsylvania law that required divorced
parents to give permission for children to receive psy-
chotherapy caused some divorced mothers to refuse
to participate since understandably, they did not
want to ask their ex-spouse (the domestic violence
perpetrator) for permission for their child to receive
TF-CBT. Thus, it is possible that this sample was
also biased, in that families with highly contentious
divorces did not participate in the domestic violence
study. We could not bypass these legal requirements,
but we recognize that, as with all research involving
maltreated children, our samples may not be repre-
sentative of all children who experience maltreat-
ment. Still, we believe we were able to manage the
legal and therapeutic complications in working with
this population in the course of conducting treatment
outcome research using the same general guidelines
we have followed in our respective clinics for those
not participating in research.
Collaborating with Community Agencies
Design challenges also arose in conducting research
in collaboration with community agencies. For
example, we worked closely and collaboratively
with a community domestic violence center, the
Psychotherapy Research 5
Women’s Center and Shelter of Greater Pittsburgh
(WCS) and are greatly indebted to them for allowing
us to conduct research in their setting. Several design
issues needed to be addressed in order to implement
TF-CBT for children in this setting, including the
following. Since the standard number of child treat-
ment sessions at the WCS was eight, we modified
TF-CBT to be provided in eight sessions. Although
TF-CBT was originally developed to address past
dangers (i.e., for children who were no longer living
in dangerous situations), these children were often
living with ongoing danger, since many families had
ongoing contact with a domestic violence perpetra-
tor. In order to address this challenge, we modified
TF-CBT to address ongoing danger by moving the
enhancing safety component to the beginning of
treatment, working with the mother throughout treat-
ment to develop a feasible safety plan for the child,
and helping the child to differentiate between real
danger and trauma reminders (Cohen et al., 2011;
Cohen, Mannarino, & Murray, 2011).
Defining Treatment Dropout
How to define treatment dropouts has been another
interesting design challenge. Our IRBs have defined
“study participants” as children who signed assents
(with parental consents) to participate in the study
and who completed the initial assessment instru-
ments, regardless of whether they participated in
any treatment sessions; we have therefore defined
treatment dropouts as “early dropouts” (e.g., those
who discontinued the study before starting treat-
ment) and “late dropouts” (e.g., those who discontin-
ued the study after completing 1–3 treatment
sessions). Other studies have not included individuals
as participants until they have been randomized to
treatment and/or have completed a certain number
of pre-treatment sessions; using this approach
would have substantially lowered the proportion of
dropouts in our studies since the majority of our
families that drop out do so early. Families receiving
treatment for child abuse or domestic violence often
are chaotic, have many challenges, and drop out for
reasons unrelated to treatment. We have learned
that perspectives differ with regard to dropping out
of treatment. For example, the study we conducted
at the WCS resulted in a higher dropout rate than
found in any previous TF-CBT study, which was dis-
appointing to us but delighted the WCS staff since
this same dropout rate was far lower than their
usual dropout rate when treating children. Also,
relating to treatment length, when conducting a
study comparing 8 versus 16 TF-CBT treatment ses-
sions with families impacted by childhood sexual
6 J. A. Cohen et al.
abuse, we were surprised to find that many parents
seemed pleased when assigned to the eight-session
conditions. Moreover, the eight-session TF-CBT
condition that incorporated the written narrative pro-
duced excellent results with respect to reductions in
abuse-related fear and anxiety, suggesting that the
eight-session TF-CBT protocol seems to be a viable
alternative when necessary (Deblinger, Mannarino,
Cohen, Runyon, & Steer, 2011).
Major Research Findings of Our Research
and Their Implications for Clinical Practice
TF-CBT Efficacy in Randomized Controlled
Trials
At the time of writing, thirteen randomized con-
trolled treatment trials have been completed compar-
ing TF-CBT to other active psychosocial treatment
or wait-list control conditions. These studies have
included children aged 3–18 years, whose index
traumas have included sexual abuse (Cohen &
Mannarino, 1996a; Cohen et al., 2005; Cohen
et al., 2004a, 2004b; Deblinger, Lippmann, &
Steer, 1996; Deblinger, Stauffer, & Steer, 2001;
King et al., 2000), domestic violence (Cohen et al.,
2011), disaster (Jaycox et al., 2010), commercial
sexual exploitation (O’Callaghan et al., 2013), war
(McMullen et al., 2013), and multiple/complex or
mixed traumas (Goldbeck et al., 2016; Jensen et al.,
2014; Murray et al., 2015). The studies were con-
ducted in diverse settings, including in the USA,
Europe, Australia, and Africa, and were provided in
individual and group settings, contributing to the
generalizability of the findings. Across studies,
results have consistently demonstrated that TF-
CBT was superior to comparison conditions in
improving PTSD symptoms and related problems
such as child depressive, anxiety, behavioral and/or
cognitive symptoms and parental distress, and posi-
tive parenting. Several studies have also addressed
questions of particular interest to clinicians who
treat traumatized children, such as addressing the
needs of youth with complex PTSD (also known as
complex trauma); the needs of children in the child
welfare or juvenile justice systems, the issue of medi-
cation versus psychotherapy, and how to treat chil-
dren with co-occurring PTSD and maladaptive
grief responses (which we refer to as “traumatic
grief”).
TF-CBT for Complex Trauma
Complex PTSD is not formally included in the
DSM-5 but is proposed for inclusion in the
International Classification of Diseases (ICD). In
addition to having core PTSD features of re-experi-
encing, avoidance, and sense of threat, youth with
Complex PTSD must have (1) experienced chronic
trauma (typically interpersonal trauma such as child
abuse or domestic violence) and (2) have significant
features of affect dysregulation, negative self-
concept, and interpersonal disturbances. Through
our work with the SAMHSA-funded National
Child Traumatic Stress Network (www.nctsn.org),
we have developed several products and resources
for applying TF-CBT for youth who have complex
trauma including papers and chapters that describe
these applications in detail (e.g., Cohen et al., 2012;
Cohen et al., 2011; Kliethermes & Wamser, 2012).
Several TF-CBT studies have included youth with
complex trauma experiences and responses (e.g.,
Cohen et al., 2004a, 2004b; Goldbeck et al., 2016;
McMullen et al., 2013; O’Callaghan et al., 2013)
and documented that TF-CBT led to significantly
greater improvement than the comparison or
control condition in both core PTSD symptoms
and multiple other domains related to complex
PTSD. Effect sizes for PTSD symptoms were
medium to large in several of these studies (.5–2.5).
One study documented that youth who met the
ICD definition of Complex PTSD experienced com-
parable improvement from receiving TF-CBT to
youth who had typical PTSD (Goldbeck et al., per-
sonal communication, December 21, 2015), docu-
menting comparable efficacy of TF-CBT for youth
with complex PTSD.
TF-CBT for Youth in Foster Care or Juvenile
Justice Systems
Many youth in child welfare or juvenile justice
systems would meet the proposed criteria for
Complex PTSD. Three studies have specifically
addressed the effectiveness and application of TF-
CBT treatment for children in these respective
systems. The first evaluated the benefit of adding
evidence-based engagement strategies to standard
TF-CBT for foster families, versus standard TF-
CBT. Although there were no differences between
the two conditions in child outcomes, the additional
engagement strategies led to increased retention in
treatment through four sessions and prevention of
premature treatment dropout (Dorsey et al., 2014).
The second quasi experimental study compared
three trauma-focused evidence-based treatments—
TF-CBT, Child Parent Psychotherapy (Lieberman
& Van Horn, 2008), and Structured Psychotherapy
for Adolescents Recovering from Chronic Stress
(DeRosa et al., 2005)—to Systems of Care (SOC)

treatment as usual in the State of Illinois. The overall
goal of SOC is to increase the stability of foster care
placements and it is known to be effective for children
impacted by trauma. Using propensity analysis, after
adjusting for baseline characteristics, TF-CBT
achieved significantly greater results than SOC in
the domains of improving traumatic stress symptoms
and child behavioral/emotional needs; youth in TF-
CBT were about 1/10 as likely to run away from a
foster placement and ½ as likely to experience any
type of foster placement disruption as youth who
received usual SOC (Weiner, Schneider, & Lyons,
2009). A third study evaluating two alternative
implementation strategies for therapists treating
youth in residential treatment facilities documented
that across these implementation strategies, youth
who received TF-CBT while adjudicated to residen-
tial treatment facilities experienced significant
improvement in PTSD and depressive symptoms
(Cohen et al., 2016). These findings indicate that
TF-CBT can be implemented with positive out-
comes for youth with complex trauma, including
those who engaged in child welfare or juvenile
justice systems.
TF-CBT and Pharmacologic Treatment of
Traumatized Youth
There is growing attention to the issue of the off-label
use of psychotropic medication for children and ado-
lescents, particularly for those who are in foster care
and who may lack adequate parental involvement in
decision-making and oversight about this issue
(Lee, Fouras, Brown and AACAP Committee on
Quality Issues, 2015). Even after controlling for
trauma exposure, mental health diagnoses, and
other likely reasons for medication use, a study of
Medicaid-funded children across five states found
that children in foster care were 2–4.5 times more
likely than those in other settings to receive psycho-
tropic medications, often receiving up to five different
medications including multiple anti-psychotic medi-
cations (GAO, 2011). Despite lack of empirical evi-
dence indicating the efficacy of pharmacologic
interventions for treating pediatric PTSD, medi-
cation is often used for traumatized children, particu-
larly those in foster care. We conducted one of the
early studies examining the relative efficacy of
adding a commonly used psychotropic medication,
sertraline, versus placebo, to TF-CBT for youth
who had sexual abuse-related PTSD. The addition
of sertraline did not have a significant impact over
that of TF-CBT on improving PTSD or depressive
symptoms (Cohen et al., 2006). However, the study
was limited by being underpowered (n = 24) to
Psychotherapy Research 7
detect significant differences between the groups.
More research is needed in this regard.
TF-CBT for Children’s Maladaptive Grief
Reactions
There is ongoing debate about how to define and
measure maladaptive versus typical grief across devel-
opment. We functionally define childhood traumatic
grief as a condition in which children develop PTSD
symptoms related to the death of an attachment
figure that interfere with typical grief response,
leading to maladaptive grief responses. Thus, these
children have both PTSD and maladaptive grief
symptoms. We have explored the feasibility and effec-
tiveness of sequentially providing TF-CBT trauma-
and grief-focused components. Three effectiveness
studies have documented that using TF-CBT in
this manner leads to significant improvements in chil-
dren’s PTSD and maladaptive grief symptoms
(Cohen, Mannarino, & Knudsen, 2004; Cohen,
Mannarino, & Staron, 2006; O’Donnell et al.,
2014). A randomized controlled trial is currently
nearing completion comparing this application of
TF-CBT to usual care for orphaned Tanzanian chil-
dren (Whetton & Dorsey, PIs).
The clinical implications of these findings are that
TF-CBT is effective in addressing many of the
common problems that traumatized children and
adolescents develop, across developmental levels,
trauma types, cultures, and settings. As a result,
TF-CBT is being widely implemented across the
USA and internationally.
Major Challenges Ahead for Our Research
Program
TF-CBT Implementation and Dissemination
One of the challenges of developing an evidence-
based treatment model is getting therapists who
most commonly treat the intended recipients to use
the model with appropriate fidelity. In this case, the
initial challenge was to convince community clini-
cians to use TF-CBT for traumatized children.
Thanks to our long and productive collaboration
with the National Crime Victims Center at the
Medical University of South Carolina (MUSC), our
colleagues at MUSC selected TF-CBT as their
initial evidence-based treatment for which to
develop a distance learning course. We collaborated
with them to develop this course, TF-CBTWeb
(www.musc.edu/tfcbt), which was launched in
2005. In the first 7 years of its availability, more
than 125,000 professionals accessed the course
8 J. A. Cohen et al.
from more than 130 countries, with a greater than
70% completion rate (Heck, Saunders, & Smith,
2015). At the time of writing this paper, more than
280,000 professionals have accessed the course,
with registration rates showing no sign of decreasing
over time (B. Saunders, personal communication,
July 6, 2016).
Balancing Fidelity with Flexibility
As dissemination and implementation of the TF-
CBT model have grown, one of the challenges we
face is how to balance our desire to reach as many
traumatized children as possible, with the need to
ensure appropriate fidelity to the treatment model.
In order to address this issue, we have developed
TF-CBT Train the Trainer, Train the Consultant
and Train the Supervisor programs to ensure conti-
nuity in TF-CBT training, consultation, and supervi-
sion across programs. We have also introduced a
National TF-CBT Therapist Certification program,
available at https://tfcbt.org. Our international trai-
ners have worked to encourage the dissemination of
TF-CBT across the world with research results
suggesting considerable success in implementation
with fidelity reflected in results comparable to those
found in the USA In addition, international trainers
working in low-resource countries are developing
standards for training international lay counselors in
the TF-CBT model through an “apprentice model.”
The increasing focus on the biological basis for
mental illness may represent another challenge to the
availability of funds to engage in ongoing research to
optimize the development and dissemination of psy-
chosocial interventions to address children’s mental
health difficulties in the aftermath of trauma.
However, as concerns have grown about the overuse
of psychiatric medications particularly with trauma-
tized child populations such as children in foster care,
it is our hope that interest in evidence-based practices
that have documented effectiveness will continue to
grow. In fact, recent research has documented the
cost effectiveness of TF-CBT as compared to treat-
ment as usual, in that during the year following outpa-
tient treatment, children who received TF-CBT were
significantly less likely to require costly inpatient treat-
ment as compared to those who received treatment as
usual (Greer, Grasso, Cohen, & Webb, 2014). Thus,
the long-term therapeutic and cost benefits of utilizing
TF-CBT appear to outweigh the greater short-term
costs associated with training and delivering TF-CBT
and/or other evidence-based practices. These findings
certainly support the need for continued research in
the area. Moreover, the continued funding of the
National Child Traumatic Stress Network with its
focus on the dissemination of evidence-based treat-
ments for childhood trauma seems to bode well for
future dissemination efforts.
Advice for Young Researchers Entering Our
Research Domain
Trauma Remains a Great Field for Research
Although we have made great strides in developing,
implementing, evaluating, and disseminating TF-
CBT, an evidence-based treatment designed to help
children and families positively recover in the after-
math of trauma, much remains to be learned to
ensure optimal outcomes for all children and their
families. Given the prevalence of childhood trauma,
we urge future researchers to work closely and coop-
eratively with child-serving systems to develop
improved, culturally competent, and developmentally
appropriate methods to sensitively and efficiently
screen and identify children negatively impacted by
trauma engaged in the various child-serving systems.
Moreover, we encourage researchers to familiarize
themselves with all of the applicable state laws, local
law enforcement practices, child protection policies
as well as medical and psychiatric organizations that
serve this vulnerable population to enhance working
relationships that can be critical to successful research.
In general, it behooves researchers in this field to col-
laborate with professionals in the fields of child protec-
tion, law enforcement, medicine and mental health to
access the multidisciplinary service systems and
address the diverse needs of this population.
Potential Future Research Directions
Understanding the mechanisms of trauma impact on
children’s various domains of functioning, including
social, emotional, interpersonal, behavioral, physio-
logical, and neurobiological, continues to be critical
to our ability to successfully serve this population.
While many of our treatment outcome studies have
focused on these areas from a symptom reduction per-
spective, the TF-CBT treatment model is a strength-
based model and thus we urge greater research focus
on the measurement of positive outcomes and
strengths developed in the face of adversity. Several
of our studies, for example, have documented
improvements with respect to parenting practices
and children’s personal safety skills (e.g., Cohen
et al., 2004a, 2004b; Deblinger et al., 1996, 2011;
Deblinger, Stauffer, & Steer, 2001). However, other
important areas of individual and parent child relation-
ship strengths as well as family functioning (for
example, parental relationships, child–parent

attachment, neurobiological functioning, etc.) may be
critical to assess as well. Such a focus may help to
expand our understanding of ingredients critical to
effective treatment, while also identifying factors that
may support population-based resilience in the face
of widespread disasters. Complementary approaches
have been integrated into TF-CBT treatment, such
as using yoga or music when implementing the TF-
CBT components (Griffin, Wozniak, & Cohen,
2016). More research should be conducted to evaluate
the value of such complementary approaches, either
alone or when integrated into evidence-based treat-
ments such as TF-CBT. In addition, it should be
noted that assessment research has documented the
far-reaching impact of childhood trauma on adoles-
cent and adult development. Though follow-up
research has been conducted documenting the sus-
tained benefits of TF-CBT at 1-year and 2-year
follow-up assessments (Deblinger, Mannarino,
Cohen, & Steer, 2006; Deblinger et al., 1999; Man-
narino et al., 2012), the field would benefit from
longer term treatment outcome follow-ups to deter-
mine if our current treatment methods interrupt the
very negative life trajectories commonly associated
with complex childhood trauma.
Treatment Non-Responders
We are pleased to report that several treatment
outcome studies have documented that the majority
of children have been highly responsive to the TF-
CBT model with several investigations documenting
that 80% of children no longer meet PTSD criteria at
post-treatment (Cohen et al., 2004a, 2004b; Jensen
et al., 2014). However, we remain concerned about
the minority of children who have been less than
optimally responsive and thus research directed at
identifying this subset of children early on is of
paramount importance. Despite concerns of some clin-
icians that children with comorbid PTSD and ADHD
might be difficult to treat, these children have typically
responded well to TF-CBT (e.g., Diehle, Opmeer,
Boer, Mannarino, & Lindauer, 2015), possibly
because of the overlap in symptoms between these dis-
orders and the propensity to misdiagnose younger trau-
matized children as having ADHD (Cohen et al.,
2010). Children exhibiting depressive symptoms and/
or comorbid symptomatology respectively at pre-treat-
ment have been found to be more likely to exhibit
ongoing PTSD at post-treatment than others (Gold-
beck et al., 2016; Mannarino, Cohen, Deblinger,
Runyon, & Steer, 2012). Thus, further research exam-
ining this subpopulation is of great import. Recent
research suggests that the development and impact of
the therapeutic alliance, for example, may be a fruitful
Psychotherapy Research 9
area to explore to uncover means of enhancing out-
comes for those children who are less than optimally
responsive to treatment (Ormhaug, Jensen, Wentzel-
Larsen, & Shirk, 2014).
Dissemination and Implementation
Research
Another critical area for future research relates to the
evaluation of training methods designed to encourage
large-scale TF-CBT dissemination in terms of its
success in producing positive outcomes, while also
demonstrating fidelity to the model. Fidelity is critical
given the recent research suggesting that fidelity to
the model appears to predict more positive outcomes
(Amaya-Jackson et al., 2012). In addition to initial
training, future researchers are encouraged to
examine factors that may enhance the sustainability
of these evidence-based practices beyond the period
of training. Thus, research that examines training,
supervision and organizational support that helps
clinicians to learn to implement the model with fide-
lity over longer follow-up periods is an important area
of further research as well.
Secondary Traumatic Stress and
Professional Fulfillment
We would be remiss if we did not acknowledge the
stressors associated with this area of research in
terms of the legal and child protection issues as well
as the repeated exposures to descriptions of child-
hood trauma and abuse. For these reasons, it is
important to monitor oneself and one’s colleagues
on an ongoing basis for the possibility of developing
secondary traumatic stress However, it is equally
important to acknowledge the great professional sat-
isfaction that comes from seeing children and their
families draw closer and stronger as they heal in the
context of treatment. Thus, despite the challenges,
we encourage researchers to embrace this field of
study. We end by enthusiastically recommending
positive collaborations and acknowledge the pro-
fessional benefits we have experienced as a result of
our collaboration. Moreover, we strongly urge all
those engaged in this critically important field to
remain committed to their own professional growth
and personal self-care and that of their colleagues.
Acknowledgments
We gratefully acknowledge the funding agencies,
project officers and research staff who supported
our research; the clinical and support staff at the Alle-
gheny General Hospital Center for Traumatic Stress
10 J. A. Cohen et al.
in Children and Adolescents and the Rowan Univer-
sity CARES Institute; and the children and families
who have taught us so much and made all of our
research possible.
Funding
Funding for the preparation of this manuscript was
provided in part from the Substance Abuse and
Mental Health Services Administration [grant
number SM 61257].
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