Stepped Care Versus Standard Care Trauma-Focused Cognitive Behavioral Therapy for Elementary Age Children

Purpose: Between 68 to 80% of children are exposed to potentially traumatic events with an estimated one-third exposed to more than one type of trauma. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a well-established evidence-based practice designed for children exposed to traumatic events. TF-CBT has demonstrated to be superior to active treatments and wait-list conditions, however TF-CBT lasts three to six months and relies on therapist delivered treatment with weekly, usually in-office, face-to-face sessions. This current approach to providing treatment makes it difficult for many families to access care, and as a consequence treatment for those most in need is underutilized. Due to the prevalence of trauma and barriers to treatment, new service delivery approaches are needed, such as stepped care models that incorporate effective interventions. Recently, a stepped care intervention (called Stepped Care TF-CBT) was developed from TF-CBT. Step One is a 6-week parent-led treatment with therapist assistance (3 sessions).  Step Two is 9 sessions of therapist-led TF-CBT. The current pilot study aims to compare Stepped Care TF-CBT to standard TF-CBT with school-age children (ages 8 to 12) on child outcomes, parental distress and parent satisfaction.

Methods: Using a 2:1 ratio, 33 children with at least five symptoms of posttraumatic stress (PTSS) as a result of various types of traumas were randomly assigned within a community-based agency to receive Stepped Care (n = 22) or standard TF-CBT (n =11).  A blind evaluator administered baseline, after Step One, post- and 3-month follow-up assessments with parents and children.  Measures included the Anxiety Disorders Interview Schedule Child/Parent Version PTSD module, UCLA PTSD Index for DSM-IV, Clinical Global Impression-Severity and Improvement, Child Behavior Checklist, Parenting Stress Index, and the Client Satisfaction Questionnaire. Treatment fidelity via therapist fidelity checklist and ratings of audio recorded therapy sessions resulted in inter-rater agreement of .89 for Stepped Care and .92 for standard care. End point analysis (Wilcoxon Rank-Sum tests), repeated measures (generalized linear mixed effects modeling), and a more rigorous non-inferiority testing (20% of the treatment effect of Standard TF-CBT as the equivalence margin) were used to analyze data.

Results: The majority (58%) of children experienced more than one type of trauma.  Twenty-seven percent of the children were Hispanic, and 21.2% were African American with 78.8% Caucasian. Of the 17 parents and children that completed Step One, 14 responded (82.35%) and did not require further treatment, and three stepped up to Step Two. Change scores and repeated measures suggest that there were no differences between the conditions in PTSD, PTSS, severity, improvement, internalizing and externalizing behaviors, parenting stress, and satisfaction at post and follow-up assessments. However, using the non-inferiority tests, there was evidence to reject inferiority between the conditions on treatment improvement and parent satisfaction at post- and follow-up assessment.

Implications: Stepped Care TF-CBT may be a viable service delivery approach that is more accessible and efficient than standard care. However, more research is needed, including comparisons in treatment delivery costs.  Clinical implications and future research will be discussed.