Development of Stepped Care Trauma-Focused Cognitive-Behavioral Therapy for Young Children

doi:10.1016/j.cbpra.2013.07.004

Cognitive and Behavioral Practice

Volume 21, Issue 1, February 2014, Pages 97-108

https://doi.org/10.1016/j.cbpra.2013.07.004 Get rights and content

Highlights

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Stepped Care TF-CBT is designed to address treatment barriers.
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Considerations for the development of Stepped Care TF-CBT are discussed.
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Parent-led therapist-assisted treatment is used as a first-line treatment.

Abstract

Young children who are exposed to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). While effective psychosocial treatments for childhood PTSD exist, novel interventions that are more accessible, efficient, and cost-effective are needed to improve access to evidence-based treatment. Stepped care models currently being developed for mental health conditions are based on a service delivery model designed to address barriers to treatment. This treatment development article describes how trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established evidence-based practice, was developed into a stepped care model for young children exposed to trauma. Considerations for developing the stepped care model for young children exposed to trauma, such as the type and number of steps, training of providers, entry point, inclusion of parents, treatment components, noncompliance, and a self-correcting monitoring system, are discussed. This model of stepped care for young children exposed to trauma, called Stepped Care TF-CBT, may serve as a model for developing and testing stepped care approaches to treating other types of childhood psychiatric disorders. Future research needed on Stepped Care TF-CBT is discussed.

Section snippets

Stepped Care

Generally, there are two guiding principles underlying stepped care models. First, the initial step needs to be intensive enough to lead to likely improvements and least restrictive in terms of the therapist time. Other factors that minimize clients’ time and inconveniences may also be considered as least restrictive when developing the steps. Provider cost (i.e., therapist time) is a major factor when developing stepped care with health care costs a major concern. Second, stepped care models

Therapeutic Approach

The therapeutic approach should be one of the first considerations in developing a stepped care model for children exposed to trauma. Treatment modalities may differ within a stepped care model but there must be supporting evidence for the therapeutic methods being delivered. TF-CBT is the most well-established treatment for childhood PTSD (Silverman et al., 2008). CBT for childhood trauma has demonstrated efficacy with children of all ages, from diverse backgrounds, in individual or group

Stepped Care TF-CBT Components

Figure 1 provides a graphic representation of the assessment and treatment flow of Stepped Care TF-CBT. The following section describes the components of Stepped Care TF-CBT.

Conclusion

This treatment development article describes the considerations that were taken into account when developing a stepped care model for young children exposed to trauma. These considerations included therapeutic approach, types of steps, number of steps, training of providers, entry point, and inclusion of parents. A specific stepped care model called Stepped Care TF-CBT, which includes Step One, Maintenance Phase, and Step Two, was described. In addition, issues such as noncompliance,

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The bidirectional associations between caregiver and child symptoms in the parent-led treatment stepping together for children after trauma
2024, Behaviour Research and Therapy
An innovative approach to child trauma treatment in which caregivers are allocated treatment tasks has shown promising results, but less is known about the bidirectional associations between caregiver and child symptoms during treatment.
Eighty-two child-caregiver dyads who participated in the parent-led therapist-assisted Stepping Together for Children after Trauma (ST-CT) were included (child age: 7–12 years, mean = 9.9 years). Caregivers' emotional reactions and anxiety/depression and children's posttraumatic stress (PTS) and depression were assessed pretreatment, mid-treatment, and posttreatment. We investigated the possible directional associations between caregivers' emotional reactions and anxiety/depression and children's PTS and depression using random intercept cross-lagged panel models.
Symptoms improved in both caregivers and children. Lower levels of caregiver emotional reactions at pretreatment predicted improved child PTS at mid-treatment; lower levels of caregiver emotional reactions at mid-treatment predicted improved child depression at posttreatment; and lower levels of child PTS at mid-treatment predicted improved caregiver emotional reactions at posttreatment.
These findings suggest that caregivers and children can impact each other's responses to a parent-led child trauma-focused treatment. Notably, children with caregivers who were less affected by their own emotional reactions exhibited greater improvement in both PTS and depression. Supporting the caregivers may benefit both children and caregivers.
ClinicalTrials.gov NCT04073862; https://clinicaltrials.gov/ct2/show/NCT04073862.
Study protocol for a hybrid 1 effectiveness-implementation trial of Brief Skills Training in Affective and Interpersonal Regulation (Brief STAIR) and web-administered STAIR (webSTAIR) for posttraumatic stress disorder in integrated primary care
2023, Contemporary Clinical Trials
Posttraumatic stress disorder (PTSD) disproportionally affects low-income, racial and ethnic minoritized communities, where prevalence is high, yet access to evidence-based treatments (EBTs) is low. As such, there is a need to identify effective, feasible, and scalable interventions for PTSD. Stepped care approaches that include brief, low-intensity treatments are one approach to improving access yet have not been developed for adults with PTSD. Our study aims to test the effectiveness of a step one PTSD treatment in primary care while gathering information on implementation to maximize sustainability in the setting.
This study will be conducted in integrated primary care in the largest safety net hospital in New England using a hybrid type 1 effectiveness-implementation design. Eligible trial participants are adult primary care patients who meet full or subthreshold criteria for PTSD. Interventions include Brief clinician-administered Skills Training in Affective and Interpersonal Regulation (Brief STAIR) versus web-administered STAIR (webSTAIR) during a 15-week active treatment period. Participants complete assessments at baseline (pre-treatment), 15 weeks (post-treatment), and 9 months (follow-up) post-randomization. We will assess feasibility and acceptability post-trial using surveys and interviews with patients, study therapists, and other key informants, and will assess the preliminary effectiveness of interventions in terms of PTSD symptom change and functioning.
This study will provide evidence for the feasibility, acceptability, and preliminary effectiveness of brief, low-intensity interventions in safety net integrated primary care, with the aim of including these interventions in a future stepped care approach to PTSD treatment.
Clinical Trial Number: NCT04937504
Stepped Care Versus Standard Care for Children After Trauma: A Randomized Non-Inferiority Clinical Trial
2022, Journal of the American Academy of Child and Adolescent Psychiatry
Trauma-focused cognitive-behavioral therapy (TF-CBT) is an evidence-based therapist-led treatment for children after trauma. Parents often experience barriers to treatment engagement, including cost. Stepped care TF-CBT (SC-TF-CBT) was developed as an alternative delivery system. Step One is a parent-led therapist-assisted treatment. Step Two provides therapist-led TF-CBT for children who did not benefit from Step One and require more intensive treatment. This study compared SC-TF-CBT to standard TF-CBT in a community-based non-inferiority trial.
A total of 183 children (aged 4-12 years) experiencing posttraumatic stress symptoms (PTSS) and their caregivers were randomly assigned to SC-TF-CBT or standard TF-CBT within 6 community clinics. Assessments occurred at baseline, mid- and posttreatment, and 6 and 12 months. Primary outcomes included PTSS and impairment. Secondary outcomes included severity, diagnostic status, remission, and response. Treatment cost, acceptability, and satisfaction were measured. Difference and non-inferiority tests were applied.
SC-TF-CBT participants changed at rates comparable to participants in TF-CBT for primary and secondary measures. SC-TF-CBT was non-inferior to TF-CBT for PTSS, impairment, and severity at all time points except for impairment at the 6-month assessment. Attrition did not differ between treatment arms (132 participants were completers). Baseline treatment acceptability was lower for SC-TF-CBT parents, although there was no difference in expected treatment improvements or treatment satisfaction at posttreatment. Based on regression estimates, total costs were 38.4% lower for SC-TF-CBT compared to TF-CBT, whereas recurring costs were 53.7% lower.
Stepped Care TF-CBT provides an alternative way to deliver treatment for some children and parents, with reduced cost for providers and parents.
Stepped Care for Children after Trauma: Optimizing Treatment; https://clinicaltrials.gov; NCT02537678.
Development and Implementation of a Transdiagnostic, Stepped-Care Approach to Treating Emotional Disorders in Children via Telehealth
2021, Cognitive and Behavioral Practice
Citation Excerpt :
We drew on several sources of information to inform these decisions, including the designs of previously conducted stepped-care trials for youth emotional disorders, findings on trajectories of change from previous treatment trials, and the research team’s prior clinical experiences in implementing the UP-C. Crucially, the first step needed to be long enough for a substantial proportion of youth to demonstrate meaningful improvement, and the entire length of the UPC-SC needed not to exceed the length of the full treatment protocol. A review of previous stepped-care intervention trials for youth revealed that most trials included either two or three steps, and the number of sessions included in Step 1 ranged from 4 to 14 “sessions” facilitated by either a parent or clinicians, with a mean number of sessions of 8.60 (Mufson et al., 2018; Pettit et al., 2017; Rapee et al., 2017; Salloum et al., 2014; van der Leeden et al., 2011). Although this range is quite large, many of the Step 1 interventions in the trials reviewed contained at least some sessions composed of low-intensity interventions, such as brief parent and/or adolescent phone consultations, parent–child review and practice of therapeutic content at home (Rapee et al., 2017; Salloum et al., 2014), or 15-minute attention bias modification training sessions (Pettit et al., 2017).
Stepped-care interventions may increase the accessibility of evidence-based treatments but remain relatively underexplored in the child mental health literature. Further, while the feasibility and efficacy of stepped-care interventions have been examined for specific diagnoses or classes or disorders, transdiagnostic stepped-care interventions have not yet been developed. We discuss the development and initial implementation of a transdiagnostic approach to emotional disorders using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2018). A case series is presented to illustrate the delivery of UP-C stepped care (UPC-SC) via telehealth, using a collaborative decision-making process to inform step-up/step-down decisions. Lessons learned are discussed to guide refinements of UPC-SC and inform a larger trial.
Symptom trajectories of early responders and remitters among youth with OCD
2020, Journal of Obsessive-Compulsive and Related Disorders
This study examined the phenomenology and predictors of early response and remission among youth with obsessive-compulsive disorder (OCD) receiving cognitive-behavioral therapy (CBT).
One hundred and thirty-nine youth with a current primary diagnosis of OCD participated in this study. Participants received 10 sessions of CBT augmented by either placebo or d-cycloserine (DCS) as part of a randomized double-blind multi-site clinical trial. Early response and remission status were determined by clinician-rated global symptom improvement (CGI-I) and severity (CGI-S), respectively.
At the mid-treatment assessment, 45.3% of youth were early responders, and 28.1% were early remitters. At post-treatment assessment, 79.1% of youth were responders and 67.6% were remitters. Early response predicted a higher likelihood of post-treatment response and remission; early remission significantly predicted a higher likelihood of post-treatment remission. Bivariate logistic regressions showed that early response was predicted by lower baseline clinician-rated global severity (CGI-S) and lower depression severity; however, only depression severity remained a significant predictor in the multivariable logistic regression model. Furthermore, bivariate logistic regressions showed that early remission was predicted by lower baseline clinician-rated global severity (CGI-S), lower depression severity, and lower obsessive-compulsive symptom severity (CY-BOCS); however, only global severity remained a significant predictor in the multivariable logistic regression model.
Lower OCD and depression symptom severity predicted a greater likelihood of early treatment response and remission to CBT. Findings suggest that low OCD and depression symptom severity could serve as baseline characteristics to identify potential candidates for lower-intensity initial interventions in a stepped care approach. The modest predictive value of the variables examined suggests that additional factors could add to prediction of treatment response and remission.
clinicaltrials.gov Identifier: NCT00864123.
Dialectical behavior therapy stepped care for hospitals
2020, The Handbook of Dialectical Behavior Therapy: Theory, Research, and Evaluation
Stepped care is a health service delivery model aimed at enhancing access to care and cost-effectiveness. This approach involves initially assigning patients to receive the lowest level of care still expected to yield benefits, repeatedly monitoring patient progress, and accordingly adjusting the intensity of care throughout the course of treatment. Stepped care models have been increasingly applied to treatments targeting a wide range of mental health concerns. This chapter proposes a stepped care model for dialectical behavior therapy (DBT) for suicidality based on existing research and describes an ongoing study testing a DBT-based stepped care model for suicide prevention among adolescents and young adults within a hospital setting, highlighting the promise of stepped care as a scalable, sustainable, cost-effective strategy, for improving patient outcomes and expanding access to mental health services.

View all citing articles on Scopus

^☆: The authors would like to thank David Tolin, Ph.D., Anxiety Disorders Center, The Institute of Living and Yale University School of Medicine, for his consultation on the development of the stepped care model for young children after trauma; and Crisis Center of Tampa Bay and Mary Lee’s House in Tampa, Florida, where Stepped Care TF-CBT is being developed and tested.

^☆☆: The project was supported by National Institute of Mental Health award R34MH092373 to Dr. Salloum. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.

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Development of Stepped Care Trauma-Focused Cognitive-Behavioral Therapy for Young Children☆,☆☆

Highlights

Abstract

Section snippets

Stepped Care

Therapeutic Approach

Stepped Care TF-CBT Components

Conclusion

Children and Youth Services Review

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Anxiety Disorders

Child Abuse and Neglect

Behavior Therapy

Cognitive and Behavioral Practice

Journal of the American Academy of Child and Adolescent Psychiatry

Behaviour Research and Therapy

Evaluation and Program Planning

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Clinician knowledge and utilization of empirically-supported treatments for maltreated children

Child Maltreatment

In demand: Therapeutic services for children and young people who have experienced sexual abuse

Child Abuse Review

Treatment considerations for therapists in applying evidence-based practice to complex presentations in child trauma

Journal of Traumatic Stress

Trauma Symptom Checklist for Young Children: Professional Manual

Stepped Care in psychological therapies: Access, effectiveness and efficiency

The British Journal of Psychiatry

Remote treatment of panic disorder: A randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls

The American Journal of Psychiatry

Treatment of social phobia: Randomized trial of internet-delivered cognitive behavioural therapy with telephone support

The British Journal of Psychiatry

Implementing CBT for traumatized children and adolescents after September 11: Lessons learned from the child and adolescent trauma treatments and services project

Journal of Clinical Child and Adolescent Psychology

Clinical implications of traumatic stress from birth to age five

Annual Review of Clinical Psychology

Trauma-focused cognitive behavioural therapy for children and parents

Child and Adolescent Mental Health

Disseminating and implementing trauma-focused CBT in community settings

Trauma, Violence Abuse

Treating trauma and traumatic grief in children and adolescents

Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings

Child Maltreatment

The victimization of children and youth: A comprehensive, national survey

Child Maltreatment

The effectiveness of eye movement desensitization and reprocessing in the treatment of traumatized children and youth

Journal of EMDR Practice and Research