In the video above, Joan Kaufman, PhD, of the Department of Psychiatry at Yale University, discusses the different stages of trauma-focused cognitive behavior therapy, or TF-CBT, the best evidence-based intervention for children who have impairing reactions to traumatic events. One key insight, she says, is that caregivers and children must work together, and that clear communication and understanding can make all the difference.
Trauma-focused CBT is the treatment that’s been developed for children with post-traumatic stress disorder that has the strongest evidence base to date. It has multiple components. The first component is psychoeducation, and it involves both the parent and the child. The first thing is both the parent and the child need to learn what are normal trauma responses. For individuals with a history of trauma who might meet criteria for post-traumatic stress disorder, it can be a very unnerving experience. You frequently have flashbacks, you may hear the perpetrator’s voice, you have trouble sleeping, trouble concentrating, you may feel cranky and irritable. And to understand that these are all part of a syndrome, and common experiences for people who have been through the type of things that you went through, in and of itself is therapeutic. And it also helps the parent make sense of what the kid is experiencing, and understanding that trauma triggers often elicit some negative behaviors. So if a child has been exposed to domestic violence, yelling can be a trigger. Running into a perpetrator is often going to elicit extreme anxiety and might also elicit irritability. So starting to get a catalog of what are those things that elicit these symptoms helps you begin to get control of it. So psychoeducation is the first component.
The second is skills-building. Being able to develop a sense of skills to deal with extreme anxiety: Relaxation training, thought-stopping techniques for recurrent memories. And the training and skills the parent wants are, how do I manage the child when they get irritable or they may be oppositional or they don’t want to sleep. What are some skills I can use that will help them manage those behaviors and not have things escalate?
Once there’s a set of skills and feeling like some sense of mastery, then the next major component is the trauma narrative, which is basically a revisiting of the trauma: Telling the story, and also the cognitions and the thoughts that go along with it. One of the core symptoms of PTSD is avoidance, and there’s that sense of, “I’ll be fine if I just don’t think about it.” But the reality is, it comes back, and our experiences shape us. And by taking it out of the box and examining it, it allows us to pack it up and really put it away. If we just shove it in there, you can’t really close the suitcase. And it’s important that oftentimes when things have happened to you, how you make sense of it affects how you feel about yourself.
I remember one adult saying to me she couldn’t remember what she did that made her father want to choke her. And the reality is that there’s nothing that justifies a parent choking a child. But yet she had this sense of, “I’m really not worthwhile.” And so, taking out and examining what are the thoughts you have as to why things happened, is really — it’s called trauma-focused CBT because it does have cognitive behavior therapy elements, where you look at the cognitions and how that affects your emotions and how that affects your behaviors. You make those links and then lots of times you can realize that the way you made sense of the horrible things that happened to you — it’s not because you were a bad person, it’s not because you deserved it, it’s not because you should have been able to stop it and you couldn’t have. That you can then put these things away without all those negative thoughts about yourself.
After the trauma narrative is created (and it can be done in multiple ways — actually writing a story, or some children do it with cartoons or drawings), it’s something that’s shared with the caregiver. And it’s a really important process, that these are not experiences and thoughts that are alone in the child’s head, but that the parent and the child have a way of talking and communicating about these things.
So over time, TF-CBT has been found to lead to reduction not just in PTSD symptoms, but in behavioral symptoms with these gains really maintained over time. In the state of Connecticut, since we have implemented trauma-focused CBT, the number of kids in the Child Protective Services system needing inpatient psychiatric care has gone down enormously. Before system-wide we were offering this treatment, about 65% of child psychiatric inpatients were kids who were involved in the system due to abuse or neglect. It’s now down to about 30%, and I think addressing the trauma symptoms really has allowed an enormous number of children to kind of get back on track and be kids again.