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Integrating tf -CBT and Sexual offense specific treatments for Teens. By Adam H. Benton, PhD. (TF-CBT) Trauma-Focused Cognitive-Behavior Therapy. Traumatic Stress in Children Assessment of Trauma Symptoms Development and Research On TF-CBT Treatment Using TF-CBT Components

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tf cbt trauma focused cognitive behavior therapy
(TF-CBT)Trauma-Focused Cognitive-Behavior Therapy
  • Traumatic Stress in Children
  • Assessment of Trauma Symptoms
  • Development and Research On TF-CBT
  • Treatment Using TF-CBT Components
  • Trauma-Informed Care in Juvenile Justice and Residential Settings
  • The AR BEST Program
what is child traumatic stress
What is Child Traumatic Stress?

Child Maltreatment

Domestic Violence

Natural Disasters

Community and School Violence

Medical Trauma

Traumatic Loss


War-Zone Trauma

how big is the problem the epidemiology of child traumatic stress
How Big is the Problem?The Epidemiology of Child Traumatic Stress

General population studies

Disaster studies

  • Terrorism
  • Natural disasters

Child maltreatment studies

general population studies of child traumatic stress
General Population Studies of Child Traumatic Stress

National Survey of Adolescents(Kilpatrick & Saunders, 1997)

  • Representative US sample: 12-17 yrs
  • Serious physical assault: 5 million
  • Sexual assault: 1.8 million

Youths in Urban America study(Breslau et al., 2004)

  • Mid-Atlantic US city
    • Baseline 6 yrs; follow-up 20-22 yrs
  • 82.5% one or more lifetime traumatic events: 87.2% males, 78.4% females
  • Exposure to violent assault
    • Increase after 15 years, peaked @ 16-17 yrs
    • Major decrease by age 21
general population studies of child traumatic stress1
General Population Studies of Child Traumatic Stress

Developmental Victimization Study(Finklehor et al., 2005)

  • Representative US sample: 2-17 yrs
  • 1 in 8 experienced a form of child maltreatment
  • 1 in 3 witnessed violence

The Great Smoky Mountains Study(Copeland, et al., 2007)

  • A majority of children (67.8%) were exposed to one or more traumatic events by age 16.
  • Children exposed to trauma had almost double the rates of psychiatric disorders of those not exposed.
disaster studies
Disaster Studies

New York City, NY Department of Education Study(Hoven et al., 2005)

  • At 6 months post World Trade Center attack, the prevalence of:
    • PTSD was 10.6%
    • agoraphobia was 14.8%
    • conduct disorder was 12.8%
    • separation anxiety was 12.3%
    • alcohol problems was 4.5%
  • Over 60% experienced at least one major traumatic event prior to the attacks.

Gulf Coast Child & Family Health Study(Abramson et al., 2007)

  • At 2 years after Hurricane Katrina.
    • 46,000 children were displaced
    • 51% of displaced children had at least 1 risk factor for poor long term outcomes
posttraumatic stress disorder
Posttraumatic Stress Disorder

C. Persistent Avoidance (3+)


Experienced or witnessed…actual or threatened injury or death

Responded with intense fear, helplessness, or horror

B. Reexperiencing

Intrusive recollections

Recurrent dreams

Acting or feeling as if the event were recurring

Intense distress triggered by internal or external cues

Physiological reactivity

Avoiding thoughts, feelings etc

Places, activities, or people

Inability to recall events

Diminished interests in significant activities

Detachment or estrangement from others

Restricted affect

Foreshortened future

posttraumatic stress disorder1
Posttraumatic Stress Disorder

D. Persistent Increased Arousal (2+)

Duration of 1 month or more

Clinical impairment

Difficulty sleeping


Difficulty concentrating


Exaggerated startle response

what is the impact of child traumatic stress
What is the impact of Child Traumatic Stress?
  • Capacity to regulate emotion and attention
  • Social development
  • Cognitive development: IQ and language
  • Academic performance
  • Substance use/abuse
  • Numbness, desensitization to threat
  • Re-victimization
  • Recklessness and reenacting behavior
  • Posttraumatic stress and other disorders (depression, anxiety, phobia, panic)
  • Developmental Trauma Disorder
  • Health effects
traumatic stress symptoms in children
Traumatic Stress Symptoms in Children

Compared to adults…

  • Less numbing and difficulty recognizing avoidance
  • More overt aggression, destructiveness, and reenactment (also in play and drawings)
  • Older children – foreshortened future
  • Over the age of 10 – react more like adults

Dyregrov & Yule, 2005

Effect of increasing trauma exposures on cumulative rates of psychiatric diagnoses by age 16 years (Copeland et al., 2007)
incidence of ptsd in children
Incidence of PTSD in Children

6% life-time prevalence in older adolescents

Natural Disasters

30-50% moderate symptoms

5-10% full criteria

Traffic Accidents

29% at 4 wks

36% at 6 wks

6 – 25% at 12-15 wks

14% at 9 months

Exposure to war

25 – 70%

Diseases or hospitalization

X < 15%

Sexual and Physical Abuse

11 – 20%

Symptoms often remain for years without treatment (15-29% still meet criteria 5- 33 years later)

Dyregrov & Yule, 2005

predictors of ptsd reactions in children
Predictors of PTSD Reactions in Children
  • Level of Exposure
  • Lack of social support
  • Female gender
  • Previous trauma exposure
  • Prior psychiatric problems
  • Strong acute response
  • Family history of mental illness
  • Cognitive variables
    • Negative appraisal
    • Unfairness
    • Rumination
    • Thought suppression
    • Confusion during the event
trauma the brain
Trauma & the Brain

Vertical Organization

Cortex: the thinking brain; Prefrontal cortex- reasoning, executive functions, decision making, social control, impulse control, personality

Limbic: Amygdala evaluates threats; Hippocampus encodes memories and facilitates conscious memory; Thalamus –relay station; Hyposthalamus- homeostasis, brain-body exchange of info

Brain Stem: Cardiovascular, arousal, some reflexes

trauma the brain1
Trauma & the brain

Hemispheric Organization

Right Hemisphere

Non-verbal communication

Imagery, visual spatial info

General, big picture perspectives

Negative emotions

Withdraw and avoid

Left Hemisphere

Analytic thinking

Language, words and numbers

Detail perspectives

Positive emotions

Motivation to approach tasks

neurobiology of trauma
Neurobiology of Trauma
  • Limbic Irritability
    • Increase activation of the Amygdala- hypervigilence, scanning for threat cues, over interpreting innocuous cues as significantly threatening
    • Difficulty regulating emotions and emotionally charged situations
    • Decreased activation of speech centers….expressive/receptive language difficulties
    • Social and relational problems related to reading social cues
    • Attention problems due to hyper-focused on perceived threat and missing dismissing non-threatening information
neurobiology of trauma1
Neurobiology of Trauma
  • Hippocampus
    • Smaller hippocampal volume due to persistent threat: reduced short-term memory, verbal memory, dissociation, and context dependent memory
    • Lack of development of left hippocampus area, contributes to language difficulties
    • Deficient Left Hemisphere Development
      • Difficulty analyzing and understanding their own and others behavior
      • Decreased verbal skills
      • Pathological responses involving anger, fear avoidance, withdrawal, and depression
      • Decreased adaptive coping responses
neurobiology of trauma2
Neurobiology of Trauma
  • Cerebellar Vermis
    • Difficulty with emotional stability, controlling activation,
    • Observed by physiological soothing, such as rocking, swinging, when experiencing trauma trigger.
trauma attachment
Trauma & Attachment
  • Secure- responds specifically to situations, flexible, adaptive
  • Avoidant- Over-modulate…limited, rigid with emotions, less specific responses, less flexible and responsive to context
  • Anxious- under-modulate, respond more quickly and greater intensity to fear eliciting stimuli, responses bypass cortex. poor coping, less specific appraisals, less flexible in response to context

“Studies have shown that tram experiences impact significantly the level of neural integration in the brain…..leading to neurological obstacles to creating and sustaining secure relationships.” (Creeden 2009, citing Teicher et al., 2002)

trauma implications for treatment
Trauma & Implications for treatment
  • “Neglect and chronic states of mis-attunement lead to an over-prunning of synapses in the prefrontal cortex, leaving individuals with an impaired capacity to modulate and regulate emotion in response to threat.” (Creeden 2009, from Lott 2003)
  • Children and teens with chronic trauma histories have problems with arousal in general, rather than with sexual arousal specifically.
  • Treatment providers should consider a focus on broad-based arousal control and regulation, rather than solely sexual arousal.
  • Clients with language deficits may benefit less from our typical language dependent styles of counseling
trauma implications for treatment1
Trauma & Implications for treatment
  • Executive Functioning Problems, - ADHD
    • Impulsivity, disorganization, rigid problem-solving approaches, misreading social cues
    • Interventions to address these deficits are important to treatment
    • Our clients trauma experiences are intertwined strongly with their abusive behavior and not just from a social-learning perspective…but through the link to their experience of anxiety, fear, abandonment, anger, shame and other overwhelming affect states. Creeden 2009.
    • “Not addressing the impact of the client’s own trauma, will simply impede the learning and effective use of skills we are teaching them to control/change their inappropriate and abusive behavior.” Creeden 2009
trauma histories of those in juvenile justice system
Trauma histories of those in Juvenile Justice system
  • Several studies estimate that 75-93 percent of youth entering the system have experienced some degree of traumatic victimization.
  • Males who experience trauma prior to the age of 12….50-79 percent become involved in serious juvenile delinquency
  • Young boys who engaged in sexual offenses, 95 percent reported some type of trauma exposure, 77.5 percent reported more than one type. More than half reported both physical and sexual abuse
  • Incarcerate women are more likely than non-incarcerated women to report sexual or physical abuse
  • Pre-teens and adolescents who participated in homicide offenses have histories of severe childhood maltreatment
  • Only 20 percent of states provide evidence-based or standardized assessment tools.
                  • Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense, July 2010. Justice Policy Institute
the system can be traumatic
The system can be traumatic
  • Long-term separation from parents and family
  • Violence among peers
  • In 2007, 10 deaths in JJ facilities
  • 10.7 percent report sexual contact by staff
  • Physical and emotional abuse by staff and peers
  • With youth who have experienced trauma and have PTSD or mental illness, treatment is more effective than incarceration at reducing recidivism
                • Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense, July 2010. Justice Policy Institute
assessment of trauma symptoms
Assessment of Trauma Symptoms
  • “The development of the abused or neglected child seldom follows a predictable course, because child maltreatment is characterized by many other

negative socialization forces, such as family instability, parental inconsistency, and socioeconomic disadvantage.”

Wolf & McEachran, In Mash & Terdal, 1997)

assessment process
Assessment Process
  • Assess existing risk and safety
  • Identify general strengths and problems areas for family (marital problems, Family Stressors, etc.)
  • Identify parental needs (support, child rearing, etc)
  • Identify child needs (behavior, cognitive, social, mental health symptoms, etc)
  • Reporting issues
assessment process1
Assessment Process
  • Cognitive problems: Maladaptive patterns of thinking about self, others and situations, including distortions and unhelpful thoughts, like self-blame or rumination about the trauma
  • Relationship problems: Difficulties getting along with peers, poor problem-solving or social skills, hypersensitivity in interpersonal interactions, maladaptive strategies for making friends, impaired ability to trust.
  • Affective problems: Sadness, anxiety, fear, anger, poor ability to tolerate or regulate negative affective states, inability to self-soothe.
assessment process2
Assessment Process
  • Family problems: Parenting skills deficits, poor parent-child communication, disturbances in parent-child attachment, disruption in family relationships or functioning due to abuse.
  • Traumatic behavior problems: Avoidance of trauma reminders; trauma-related, sexualized, aggressive, or oppositional behaviors; unsafe behaviors
  • Somatic problems: Sleep difficulties, physiological hyperarousal and hypervigilance toward possible trauma cues, physical tension, somatic symptoms.

Cohen, Mannarino, & Deblinger, 2006

assessment instruments
Assessment Instruments
  • Family Adjustment
    • Family Adaptability , Cohesion and Expression Scale
    • Family Environment Scale
  • Cognitive / Learning Ability
    • WISC, WPPSI, Stanford Binet, KBIT, WASI
    • WIAT, Woodcock-Johnson, WRAT,
  • Social Functioning
    • Harter Self-Perception Profile for Children
    • Harter Social Support Scale for Children
    • Adolescent Interpersonal Competency Questionnaire
    • Children’s Attributional Style Questionnaire
  • Emotional /Behavioral
    • Child Behavior Checklist
    • Behavior Assessment Scale for Children
    • Roberts Apperception Test – 2
    • Child Depression Inventory
    • Manifest Anxiety Scale for Children
    • Strengths & Difficulties Questionnaire
  • Traumatic Stress Symptoms
    • UCLA Posttraumatic Stress Index
    • Trauma Symptom Checklist for Children
    • Child PTSD Screen
    • Child Report of Posttraumatic Symptoms
    • Children’s Impact of Traumatic Events Scale
    • Child Dissociative Checklist
    • Traumatic Events Screening Inventory
sample assessment battery for teens
Sample Assessment Battery for Teens
  • Screener
    • Behavior Assessment System for Children, Second Edition
    • Strengths and Difficulties
  • Traumatic Events Screener
    • Childhood Trust Events Survey
  • PTSD Specific Measure
    • UCLA PTSD Reaction Index
    • Video Training:
using assessment to guide tx
Using Assessment to Guide tx


  • Overall Score
    • Cut-off = 37+ Strong Specificity / Sensitivity of Meeting Criteria for PTSD
    • 30-37 needs treatment
  • Clusters may indicate specific treatment interventions to focus on
    • Re-experiencing - Cognitive
    • Avoidance - Exposure
    • Increased Arousal – Affect regulation / relaxation
development of tf cbt
Development of TF-CBT

Judith A. Cohen, M.D.

Anthony P. Mannarino, Ph.D.

Allegheny General Hospital, Pittsburgh, PA

Center for Traumatic Stress in Children and Adolescents

Esther Deblinger Ph.D.

New Jersey Child Abuse Research Education and Services Institute

research on tf cbt
Research On TF-CBT
  • TF-CBT is the most rigorously tested treatment for traumatized children

– 6 randomized trials

  • Improved PTSD, depression, anxiety, shame and behavior problems compared to supportive treatments
  • Improved parental distress, parental support, and parental depression compared to supportive treatment
  • Successful with diverse ethnic and racial populations
what is tf cbt
What is TF-CBT?

A hybrid treatment model that integrates:

  • Trauma sensitive interventions
  • Cognitive-behavioral principles
  • Attachment theory
  • Developmental neurobiology
  • Family therapy
  • Empowerment therapy
  • Humanistic therapy
core values
Core Values



Respectful to Cultural Values

Adaptable and Flexible

Family Focused

Therapeutic Relationship is Central

Self-efficacy is Emphasized

tf cbt treatment structure
TF-CBT Treatment Structure
  • Average 12 – 18 sessions
  • 1 to 1 ½ hour weekly sessions
  • Each session is divided into individual child and parent sessions
  • The length of the child and parent portions may vary by topic
  • Similar topics in most parent and child sessions
  • Same therapist for both child and parent(s)
  • Combined parent-child time in some to many sessions
treatment using tf cbt components
Treatment Using TF-CBT Components
  • Psychoeducation and Parenting Skills
  • Relaxation
  • Affect Modulation
  • Cognitive Coping
  • Trauma Narrative and Processing
  • In Vivo Mastery of Trauma Reminders
  • Conjoint Child-Parent Sessions
  • Enhancing Future Safety and Development
tf cbt components
TF-CBT Components



Skill Building




Skill Building


Behavior Management

1996 Deblinger & Heflin



  • Begins during first session and continues throughout treatment
  • Provide information about the specific trauma, common psychosocial reactions to trauma, etc.
  • Review benefits of early, effective tx
  • Explain treatment plan and theoretical rationale for skills, exposure and processing
parenting skills
Parenting Skills
  • TF-CBT views parents as central therapeutic agent for change
  • Establish parent as the person the child turns to for help in times of trouble
  • Explain the rationale for parent inclusion in treatment
    • Not because parent is part of the problem but because parent can be the child’s strongest source of healing
  • Emphasize positive parenting skills, enhance enjoyable child-parent interactions, maximize perception/reality effective parenting
parenting skills praise
Parenting Skills (Praise)
  • Focus on actively praising the child
    • Praise a specific behavior
    • Provide praise ASAP after behavior occurs
    • Be consistent
    • Do not qualify your praise
    • Provide praise with same level of intensity as criticism
  • “Catch your child being good!”
parenting skills selective attention
Parenting Skills (Selective Attention)
  • No reaction to certain negative behaviors
    • Defiant or angry verbalizations to parent
    • Nasty faces, rolling eyes, smirking
    • Mocking, mimicking
  • Walk away, busy oneself with an activity
  • Remain calm, dispassionate
  • Expect a reactions of more provocative behavior
  • Praise “the opposite”- wanted behavior
parenting skills time out
Parenting Skills (Time Out)
  • Purpose: Interrupt child’s negative behaviors and allow him/her to regain control
  • Explain to child
  • Location: quiet, least stimulating
  • Once in time out, parent should refrain from comments, and maintain calm demeanor.
  • Be consistent!
parenting skills1
Parenting Skills
  • Time out: Interrupt child’s negative behaviors and allow him/her to regain control
  • Contingency reinforcement programs: Decrease unwanted behaviors and increase desired behaviors
  • Other behavior management issues as needed
relaxation affective modulation
Relaxation/Affective Modulation

Feeling Identification

  • Accurately identify and express a range of different feelings
    • Board games
    • Feeling brainstorm
    • Color My Life or person
  • Physiological responses to different feelings (spaghetti, robot/ragdoll, etc.)
  • Can ask directly about feelings experienced during traumatic event.
  • End on a positive note
relaxation affective modulation1
Relaxation/Affective Modulation
  • Reduce physiologic manifestations of stress and PTSD
  • Explain body responses to stress
  • Shallow breath, muscle tension, headaches
  • Focused breathing/mindfulness/meditation
    • Bubble breaths, diaphramatic breathing
  • Progressive Muscle Relaxation
  • Physical Activity
  • Positive Visual Imagery
  • Anything that helps relax (e.g., art, reading, etc.)
relaxation affective modulation2
Relaxation/Affective Modulation

Thought Interruption and Positive Imagery

  • Use when overwhelmed with trauma reminders
  • Temporary measure early in treatment
  • Teaches child control over their thoughts
  • “Changing the channel”
  • Saying “go away” or “snap out of it”
  • Imagining a stop sign
  • Replace unwanted thought with a positive one
relaxation affective modulation3
Relaxation/Affective Modulation

Positive Self-talk

  • Focus on child’s strengths
  • Remind child to verbalize these

Enhancing Sense of Safety

  • Ask about child’s sense of safety right now
  • Develop a safety plan
relaxation affective modulation4
Relaxation/Affective Modulation

Problem Solving / Impulse Control

  • STOP Technique
  • Turtle Technique
cognitive coping
Cognitive Coping
  • Help children and parents understand the cognitive triad: connections betweenthoughts, feelings and behaviors, as they relate to everyday events
  • Help children distinguish betweenthoughts, feelings, and behaviors
  • Help children and parents view events in more accurate and helpfulways
  • Encourage parents to assist children in cognitive processing of upsetting situations, and to use this in their own everyday lives for affective modulation
cognitive coping2
Cognitive Coping

Types of Inaccurate Thoughts

  • Personal, Pervasive, Permanent
    • All or Nothing Alan
    • Again and Again Agnes
    • Catastrophic Cassie
    • Negative Ned
trauma narrative and processing
Trauma Narrative and Processing
  • Reasons we avoid this with children:
    • Child discomfort
    • Parent discomfort
    • Therapist discomfort
    • Legal issues
trauma narrative and processing1
Trauma Narrative and Processing
  • Reasons to directly discuss traumatic events:
    • Gain mastery over trauma reminders
    • Resolve avoidance symptoms
    • Correction of distorted cognitions
    • Model adaptive coping
    • Identify and prepare for trauma/loss reminders
    • Contextualize traumatic experiences into life
    • Gradual Exposure
trauma narrative and processing2
Trauma Narrative and Processing
  • Introduce the child to the rationale for the narrative
  • Can introduce the idea by reading a book about a child who told their trauma story and felt better
  • Use analogies:
    • Cleaning a wound
    • Rollercoaster
  • Help the child to identify how they would like to tell their trauma story (e.g., book, poem, story, song, drawing, painting, video, audiotape, typing on computer, cartoon, talk show)
trauma narrative and processing3
Trauma Narrative and Processing
  • Chapter 1: Innocuous information about the child (name, age, school, hobbies, etc)
  • Chapter 2: “Before” (for example, what the relationship was like with the person before the trauma started or what life was like before the traumatic event occurred)
trauma narrative and processing4
Trauma Narrative and Processing
  • Chapter 3: Encourage the child to “tell what happened” during the trauma itself
    • If multiple episodes, let the child choose one (example: first, last, one most remembered)
    • Typically, children proceed from first to last episode
    • Include disclosure, legal procedures, medical exams, removal from home, etc.
    • For the first telling, allow the child to tell the story with minimal interruption and little questioning.
trauma narrative and processing5
Trauma Narrative and Processing
  • Identify “hot spots” or “worst moments”
  • Rate distress (SUDS scale) before, during, and after narrative
  • Review the child’s description at subsequent sessions
  • Help the child to describe more details
  • Encourage child to describe thoughts and feelings related to trauma
trauma narrative and processing6
Trauma Narrative and Processing
  • Ask broad, open-ended questions
    • What were you thinking?
    • What were you saying to yourself?
    • How were you feeling?
    • What happened next?
  • Make clarifying and reflective statements
    • Tell me more about it…
    • I wasn’t there, so tell me…
    • I want to know all about…
    • Repeat the part about…
    • So, your uncle began touching your vagina…
trauma narrative and processing7
Trauma Narrative and Processing
  • Include the following in the final chapter:
    • What have you learned?
    • What would you tell other children who experienced this?
    • How are you different now from when it happened/when you started treatment?
trauma narrative and processing8
Trauma Narrative and Processing
  • Common negative distortions
    • Self-blame
    • Overestimating danger
    • Changed world view
trauma narrative and processing9
Trauma Narrative and Processing
  • Sexuality
    • “Am I gay?” “I was abused because I dress sexy.”
  • Body Concerns
    • “I might die of AIDS.” “I might be pregnant.”
  • Interpersonal Concerns
    • Family
      • “I tore apart my family.”
    • Friends
      • “My friends think I’m a slut.”
  • Safety Concerns
    • “I will never trust another man.” “I can’t go anywhere alone.”
  • Self Image
    • “I am so stupid.” “I am unlovable.”
trauma narrative and processing10
Trauma Narrative and Processing
  • Examine contradictory evidence/facts
  • Test the accuracy of thoughts
  • Use the Socratic method
  • Use role plays (e.g. best friend)
trauma narrative and processing11
Trauma Narrative and Processing
  • Examine thoughts which are permanent, pervasive, or too personalized
    • Permanent: “ My child will never be happy again.”
    • Pervasive: “No one can be trusted with my child.” “The world is not a safe place.”
    • Personalized: “This happened because I am a terrible parent.” “I should have known that man was a sex offender.”
  • "If my best friend had a child who experienced a similar traumatic experience, would I say to him or her what I am saying to myself?“
  • "Would I want my child to overhear me making this statement out loud?"
conjoint sessions
Conjoint Sessions

Format of sessions

  • Meet individually with parent and child prior to joint part of session
  • Meet together after child and parent prepared for session
conjoint sessions1
Conjoint Sessions
  • Sharing the narrative
  • Parent may not know details of what happened
    • Avoidance
    • Legal issues
  • Explore what parent knows about the traumatic event
  • Monitor their reactions
  • Prepare them before
  • Share with parent what child has said in therapy
    • Confidentiality
    • Developmental issues
conjoint sessions2
Conjoint Sessions

When NOT to have joint sessions:

  • Parent unable to provide appropriate support
  • Child adamantly opposed (evaluate how realistic objections are)
  • Parent(s) continue to be disbelieving or unsupportive
  • Parent(s) feel emotionally incapable of hearing narrative
  • Child is refusing to participate in joint parent child sessions
in vivo desensitization
In Vivo Desensitization
  • Resolve generalized avoidant behaviors

– Gradually help the child get used to the feared situation

  • Identify the feared situation
  • Design the in vivo desensitization plan
  • Praise and reinforce in vivo work
  • Therapist MUST have confidence that this will work or it won’t
enhancing safety and future development
Enhancing Safety and Future Development

Sex Education

  • Dependent on the age of the child
  • Start young and continue through adolescence
  • Model open communication beginning use of accurate terms for private parts
  • Broad or specific
    • Puberty
    • Sex vs. sexual abuse
    • Relationship issues
  • Talk with caregiver first
  • Identify resources
enhancing safety and future development1
Enhancing Safety and Future Development

Increasing Awareness

  • Develop a safety plan which is responsive to the child’s and family’s circumstances and the child’s realistic abilities (No-Go-Tell, private part or sexual behavior rules, etc.)
  • Improve problem solving skills in stressful situations
  • Increase awareness (Boundaries, Hula Space, Personal Bubble, etc.)
  • Counteract shame by enhancing confident body language
  • Increase assertive communication skills (mouse/lion)
enhancing safety and future development2
Enhancing Safety and Future Development
  • Coach child to make verbal and nonverbal communication congruent (Mouse/Lion)
    • Look the person in the eye
    • Neutral facial expression
    • Confident body posture
    • Firm voice
    • Tell the person what you want
comparing tx components
Comparing Tx Components

Offense-Specific Tx

  • Assessment of protective and potentiating factors
  • Create a safety plan
  • Sexual behavior rules & Sex Laws
  • Right touching and wrong touching
  • Sexual history
  • Emotion / Self-regulation, self-control
  • Sex education and healthy sexual behavior
  • Healthy relationships, friendships and romance
  • Right / Wrong Thinking
  • Engaging in new social activities
  • Triggers / Danger zones
  • Empathy, taking responsibility and restitution
  • Relapse prevention plans
  • Parent Involvement
  • Follow-up

Trauma-Focused Tx

  • Psychoeducation(5, 2,4,3,13) and Parenting Skills (5,14,13,15,6,10)
  • Relaxation (6)
  • Affect Modulation (6, 7)
  • Cognitive Coping (6, 7, 9, 11,12)
  • Trauma Narrative and Processing (5,6)
  • In Vivo Mastery of Trauma Reminders (6)
  • Conjoint Child-Parent Sessions (14, 12)
  • Enhancing Future Safety and Development (2,4,)
terminating therapy
Terminating Therapy
  • Review skills and progress achieved
  • Fade out and/or plan booster sessions
  • Discuss and plan for natural setbacks
  • Encourage clients’ confidence in managing setbacks
  • Emphasize parents’ role as a continued therapeutic resource for the child
  • Celebrate clients’ therapy graduation
applying tf cbt in real life
Applying TF-CBT in Real Life
  • First things first
  • Provide crisis response (usually for parents)
  • Know what your setting can do
  • Triage for priority focus
    • Basic needs (e.g., place to live)
    • Response to system activities (e.g., placement, legal processes)
  • Psychiatric emergencies/active substance abuse
  • Severe behavior problems
  • Sexual behavior problems
applying tf cbt in real life1
Applying TF-CBT in Real Life
  • Match length and intensity to child presentation
  • Focus on what is most distressing for child
  • Incorporate into interventions for other concerns/problems
  • Be flexible
strategy for less affected children
Strategy for Less Affected Children
  • Psychoeducation
  • Identification of potential areas of problems
  • Review of coping strategies
  • Revictimization prevention
children with history of multiple traumas
Children with History of Multiple Traumas
  • Integrate trauma treatment into broader intervention
  • Be prepared to offer longer term relationship based therapy
  • Provide assistance with managing every day life
trauma informed care in juvenile justice
Trauma informed care in Juvenile Justice

10 Key Principles

  • A traumatic experience is an event that threatens someone’s life, safety, or well-being.
  • Child traumatic stress can lead to Post Traumatic Stress Disorder (PTSD).
  • Trauma impacts a child’s development and health throughout his or her life.
  • Complex trauma is associated with risk of delinquency.
  • Traumatic exposure, delinquency, and school failure are related.
  • Trauma assessments can reduce misdiagnosis, promote outcomes, and maximize
  • resource.
  • There are mental health treatments that are effective in helping youth who are

experiencing child traumatic stress.

  • There is a compelling need for effective family involvement.
  • Youth are resilient.
trauma informed care in residential facilities
Trauma informed care in Residential facilities

Hummer, Dollard, Robst, Armstrong, 2010. Univ. of S. Florida

Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Organizational Change

  • Organizational Readiness
  • Competent Trauma-Informed Organizational, Clinical, and Mileu Practices
  • Youth and Family Engagement in Trauma-Informed Care
trauma informed care
Trauma Informed Care


  • Trauma-specific Treatment: Facilitates recovery through individual or group treatment directly focused on the trauma and recovery
  • Trauma-Informed Care: Addresses dynamics and impact of complex trauma on youth through a focus on avoiding inadvertently re-traumatizing them when providing assistance within the mental health system

Hummer, et al., 2010

“Residential programs that serve traumatized youth should be first and foremost a “sanctuary” with an abundance of environmental and relational safeguards to prevent further re-traumatization.” (Bloom et al., 2003, in Hummer, 2010)

trauma informed care1
Trauma informed care

Organizational Readiness

  • Capacity and readiness to adopt a new practice model
    • Leadership expressed commitment to implementing trauma informed care
    • Leadership has a addressed cultural and policy barriers that may impeded implementation
  • Provide support and structure to monitor and evaluate practices and outcomes on an ongoing basis
    • Systematic monitoring of outcomes
    • Organization incentives for staff change
    • Leadership allows time for focus on implementation of trauma-informed care
    • Agency provides resources to implement and monitor outcomes
trauma informed care2
Trauma informed care

Competent Trauma-Informed Organizational, Clinical, and Milieu Practices

  • Demonstrate organizational practice standards
    • Agency has a trauma informed task force/workgroup endorsed by leaderships
    • Agency identifies and monitors trauma informed care values (safety, Trustworthiness, choice, collaboration, and empowerment)
    • Agency utilizes one or more debriefing methods for all involved after a incident
    • Formal policies and procedures reflect language and practice of trauma-informed care
trauma informed care3
Trauma informed care
  • Demonstrate program standards for implementation of trauma-informed care
    • Clinical and direct care staff are integrated into treatment teams that allow for targeted training and supervision.
    • Opportunities for staff to recognize, acknowledge, and address vicarious traumatization
    • Trauma Screening, assessment, and service planning designed to identify and address trauma while avoiding re-traumatization
    • The program offers trauma-specific evidence-based practices
    • Treatment planning and interventions are individualized, include skill building, and are developmentally suited to each youth
    • Each youth has a safety or crisis plan plan individualized choices for calming, de-escalation, and avoidance of seclusion and restraint.
    • The physical environment is attuned to safety, calming, and de-escalation
    • Milieu staff uses a strengths-based, person-centered approach in all their interactions with youth
    • Staff have systematic opportunities to seek support or assistance from their peers
trauma informed care4
Trauma informed care

Youth and Family Engagement in Trauma-Informed Care

  • Staff are effective in engaging youth and families in trauma-informed care practices
    • The agency demonstrates, in philosophy and in practice, intent toward increasing comfort, involvement, and collaboration of youth and caregivers
    • The agency regularly trains all staff on how to engage caregivers and monitors extent of engagement
    • Youth and their caregivers are aimed at addressing dynamics and building skills to effectively identify and address trauma related needs and symptoms.
    • Youth and caregivers are actively involved in treatment, discharge planning, and transition to the next placement
arkansas best for children
Arkansas BEST for Children

Clinical Care & Training – Provide state-of-the-art training, supervision and learning environments that will maximize the adoption of evidence-based interventions for traumatized children and adolescents.

  • Website
  • List serve
  • Free on-line assessments and feedback reports (CBCL, UCLA)
  • 2 Day Conference April 15 & 16 with one of the developers of TF-CBT
  • Post-conference Consultation 6 – months
  • Yearly conference
  • On-line trainings
  • Tele-video Conferences
  • Certification of completion of TF-CBT training

Brown, L. K. & Brown, M. (1997). What’s the big secret? Talking about sex with girls and boys. Boston: Little, Brown and Company.

  • Colblentz, J. (1992). God’s will for my body; Guidance for adolescents. Harrisonburg: Christian Light Publications, Inc.
  • Gravelle, K., Castro, N., & Castro C. (1998). What’s going on down there? Answers to questions boys find hard to ask. New York: Walker and Company.
  • Gravelle, K., & Gravelle, J. (2006). The period book: Everything you don’t want to ask (but need to know). New York: Walker and Company.
  • Haffner, D.W. (1999). From diapers to dating; A parent’s guide to raising sexually healthy children. New York: Newmarket Press.
  • Harris, R. H. (1994). Changing bodies, growing up, sex and sexual health; It’s perfectly normal. Cambridge: Candlewick Press.
  • Harris, R. H. (1999). It's So Amazing!: A Book about Eggs, Sperm, Birth, Babies, and Families. Cambridge: Candlewick Press.
  • Harris, R. H. (2006). It’s not the stork; A book about girls, boys, babies, bodies, families, and friends. Cambridge: Candlewick Press.
  • Hummer, Dollard, Robst, Armstrong, (2010). Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Organizational Change, 89, No. 2. Child Welfare
  • Jones, S. & Jones B. (1995). What’s the big deal? Why God cares about sex (Ages 8 – 11). Colorado Springs: Navpress Books & Bible Studies.
  • Jones, S. & Jones, B. (1995). Facing the facts; The truth about sex and you (Ages 11-14). Colorado Springs: Navpress Books & Bible Studies.
  • Jukes, M. (1998). Growing up it’s a girl thing; straight talk about first bras, first periods, and your changing body. New York: Alfred A. Knopf.
  • Kirberger, K. (2003). No body’s perfect; Stories by teens about body image, self-acceptance, and the search for identity. New York: Scholastic.

Langford, L. (1998). The big talk; Talking to your child about sex and dating. New York: John Wiley & Sons.

  • Lasser, M. (1999). Talking to your kids about sex; how to have a lifetime of age-appropriate conversations with your children about healthy sexuality. Colorado Springs: WaterBrook Press.
  • Leman, K. & Bell, K.F. (2004). A chicken’s guide to talking turkey with your kids about sex. Grand Rapids: Zondervan.
  • Madaras, L. (2003). Ready, set, grow! A “what’s happening to my body?” Book for younger girls. New York: Newmarket Press.
  • Madaras, L. & Madaras, A. (2000). The what’s happening to my body? Book for boys. A growing up guide for parents and sons. New York: Newmarket Press.
  • Marsh, C.S. (1991). Sex stuff for Connecticut parents and teachers of kids 7-17. Atlanta: Carole Marsh/Gallopade.
  • Marsh, C.S. (1998). Sex stuff for kids: A book of practical information & ideas for kids 7-17. Atlanta: Carole Marsh/Gallopade.
  • Mayle, P. (2000). “Where did I come from?” A guide for children and parents. New York: Kensington Publishing Corp.
  • Mayle, P. (1975). “What’s happening to me?” An illustrated guide to puberty. New York: Kensington Publishing Corp.
  • Richardson, J. & Schuster, M.A. (2003). Everything you never wanted your kids to know about sex (but were afraid they’d ask). New York: Crown Publishers.
  • Roffman, D.M. (2001). Sex & Sensibility; The thinking parents guide to talking sense about sex. Cambridge: Perseus Publishing
  • Royston, A. (1996). Where do babies come from? New York: DK Publishing.
  • Schwartz, P. & Cappello, D. (2000). Ten talks parents must have with their children about sex and character. New York: Hyperion.
contact info
Contact Info

Adam H. Benton, PhD, LPP

Behavior Management Systems, Inc.

2402 Wildwood Ave., Suite 140

Sherwood, AR 72120